Top 10 Causes of Bleeding After Sex

by Dr. Norashikin Mokhtar

There are a few things that can ruin a pleasant post-coital haze – one of them is if your partner immediately rolls onto his back and begins snoring. This can be frustrating, but it is surely not as frightening as going to the bathroom and discovering that you are bleeding!

Bleeding after sex can be due to a number of causes, and usually means that either the skin lining the cervix or vagina is thin or inflamed, or that there is a lesion on the cervix.

It is not to be taken lightly, so if you discover that you are bleeding after intercourse, do see a doctor as soon as possible. Below are the ten most common causes of bleeding after sex.

No. 10 Cervical Dysplasia

One cause of the bleeding could be cervical dysplasia, which means that there are abnormal cells growing on the surface of the cervix. This is a pre-cancerous condition and could lead to cancer if the abnormal cells are not removed.

You may be at risk of cervical dysplasia if you have multiple sexual partners, have sex before age 18, give birth before age 16, or have had a sexually transmitted disease.

Cervical dysplasia can be detected early if you go for regular pap smears. It can be treated with cryosurgery or conisation.

No. 9 Chlamydia

Bacteria is a common culprit of vaginal bleeding. Chlamydia is a type of bacterial infection that is usually sexually transmitted. Apart from bleeding, women with chlamydia may also have abnormal vaginal discharge or feel a burning sensation while urinating.

Chlamydia infection must be treated with antibiotics, or it may lead to future problems like pelvic inflammatory disease and even infertility. To prevent being infected, be sure to practise safe sex and use condoms.

No. 8 Gonorrhoea

Another sexually transmitted bacterial infection that could cause post-intercourse bleeding is gonorrhoea, sometimes called 'the clap'. Just like chlamydia, it can also cause other symptoms like vaginal discharge, burning and pain while urinating, and increased urination.

If the infection spreads, it can cause fever and severe pain in the lower abdomen.

Gonorrhea should be treated with the right type of antibiotics so that it does not cause complications that could lead to infertility.

No. 7 Vaginitis or Cervicitis

Inflammation and infection of the vagina, or of the cervix, could also lead to some bleeding. These conditions could be caused by a bacterial or fungal infection, which can be treated with antibiotics or antifungals.

Sometimes, cervicitis occurs after inserting a foreign device like a cervical cap or a diaphragm into the pelvic area. It can also be caused by an allergic reaction to contraceptive spermicides or to latex in condoms.

No. 6 Cervical Polyps

Sometimes you may have growths in your cervix called polyps. These are smooth finger-like growths that are red or purple in colour. They grow out of the mucous layer of the cervix or the cervical canal, and are extremely fragile.

The good news is, cervical polyps can be removed easily and painlessly by tying a surgical string around the base and cutting it off. The base can be then be removed with electrocautery or with a laser.

No. 5 Trichomoniasis

Another sexually transmitted culprit of bleeding after sex is trichomoniasis, a disease caused by a parasite. It can also cause discomfort during sex, vaginal itching, a greenish-yellow, frothy or foamy vaginal discharge with a foul or strong smell, swelling of the labia and itching of the inner thighs.

Rarely, trichomoniasis can be transmitted through tap water, hot tubs, urine, on toilet seats, and in swimming pools.

This infection can be treated with antibiotics. To prevent from getting it, practise safe and healthy sex.

No. 4 Yeast Infection

Occasionally, the bleeding could be due to a very common condition in women – a yeast infection caused by a fungus called Candida albicans. This infection occurs when the normal fungi that lives in the vagina overgrows and upsets the healthy balance of microorganisms in the vagina.

You may note that you have a yeast infection by the other symptoms, like itching and burning in the vaginal area, as well as an odourless, white vaginal discharge with a cheese-like texture.

You should see your doctor or gynaecologist for proper treatment, especially if it is your first yeast infection.

No. 3 Endometritis or Adenomyosis

Endometritis is the inflammation of the endometrium, which is the innermost layer of the uterus. Adenomyosis occurs when the tissue of the endometrium attaches itself to the uterus or the ovaries, and grows outside of the uterus.

Endometritis can cause other symptoms like general discomfort, fever, lower abdominal or pelvic pain, abnormal vaginal discharge, discomfort with bowel movement (constipation may occur) and an enlarged abdomen. Adenomyosis causes prolonged, heavy and painful menstrual bleeding.

Endometritis can be treated successfully with antibiotics, but adenomyosis may require a hysterectomy.

No. 2 Uterine Polyps

Polyps may also grow in the uterus, which occurs when the endometrium overgrows and protrudes into the uterus. Besides bleeding after sex, you may experience bleeding between periods, excessive or prolonged menstrual bleeding, bleeding after menopause and breakthrough bleeding during hormone therapy.

Uterine polyps can be removed surgically, where the doctor will use a hysteroscope to see inside your uterus and cut away the polyps.

No. 1 Fibroid Tumours

Although the word 'tumour' often means cancer, this is not the case with fibroid tumours. These are solid masses of fibrous tissue that grow in the uterus and are usually benign (non-cancerous).

Although these fibroids can cause post-intercourse bleeding, some women do not experience any symptoms at all.

Fibroid tumours may disappear on their own after menopause. However, they can be treated with various methods such as uterine artery embolisation (cutting off the fibroids’ blood supply), focused ultrasound surgery (using high frequency sound waves to destroy the fibroids), or myomectomy (surgical removal of the fibroids).

Bleeding after sex is nothing to be afraid or ashamed about. It could be caused by just a simple infection or it could be a symptom of another problem that needs to be investigated.

So, do go and see your doctor or gynaecologist immediately; do not wait and hope that the bleeding will go away on its own.


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FAQ On Menopause

I am experiencing irregular periods now. I am in my mid-forties. Am I having menopause? My friends say I cannot be having menopause because menopause comes with 'hot flashes'.

Every woman experiences menopause differently, and menopause isn't a single one-off event. It’s an accumulation of transitory events.

It can start as early as in the 30s or as late as the 60s. Most women experience it during their 40s or 50s. There are grandmothers in kampungs at the age of 60 still getting pregnant and giving birth!

You cannot say you are having menopause now because you have only one symptom of menopause. A woman may experience signs and symptoms of menopause well before her periods stop permanently. But it’s safe to say that once you don’t have your period for 12 months, you’ve had menopause.

Why does menopause occur?

When you age, your ovaries make decreasing amounts of the hormones oestrogen and progesterone, the ones which regulate your menstrual cycle, ovulation and pregnancy.

Menopause is divided into:

Perimenopause – beginning from the time when you start experiencing menopausal signs and symptoms. You may still be ovulating during this time. Your hormone levels are uneven and your periods are irregular. This part may last four to five years or longer.

Postmenopause – When you have had 12 months of no period, you are considered to have reached menopause. Then the years that follow are called postmenopause.

Other than irregular periods, what kind of symptoms will I experience with menopause?

Every woman experiences menopause differently, so her signs and symptoms are also going to be very different. You cannot compare what your mother or sister went through with what you are going through now.

Some women have very few symptoms. Other women suffer greatly. But the things you generally have to look out for are :

Irregular periods – Some women stop menstruating suddenly. Some find their menstruation tapering off. Yet other women find their menstruation getting heavier for a while, and then stopping altogether.

But it’s safe to say that if your periods have been regular and predictable, and they suddenly become irregular and unpredictable, this might be the first sign you are going through menopause.

Decreased fertility – You become less likely to become pregnant. Anyway, this happens with age.

Vaginal and urinary changes - Your vaginal and urethral tissues become drier, thinner and less flexible. This is caused by decrease of the hormone oestrogen. You may experience burning or itching in the area because there is decreased vaginal fluid to lubricate it.

Sexual intercourse may become painful or difficult. There is also an increased risk of vaginal or urinary tract infections. Not all women will experience this.

Hot flashes – Again, this is caused by dropping levels of oestrogen. Your blood vessels may expand, causing more blood to rush to your skin. This can lead to a feeling of warmth that moves upwards from your chest to your shoulders, neck and head (“hot flash”).

Your face is flushed, and red blotches may appear on the affected skin. This may be associated with sweating (including night sweats), chills and weakness. Some women even feel slightly faint. Most hot flashes last from 30 seconds to several minutes.

Sleep disturbance – Some women experience difficulty falling asleep or sleeping well through the night.

Weight gain – Some women gain about 3kg on average during menopause. The fat that was once in your hips and thighs may settle around your waist instead. Your breasts may sag. Your hair may thin and your skin may wrinkle. All this is because of dropping oestrogen.

Emotional and memory changes – Some women are irritable, tired and have problems with memory and concentration.

My mother says that if I don’t have children, I will get menopause earlier. Is this true?

No. But there are some conditions that can hasten menopause.

If you have your womb and ovaries removed for any reason at all, the removal of your ovaries will hasten menopause simply because oestrogen is not produced anymore. When you remove your womb alone, it doesn’t cause menopause.

If you have had chemotherapy and radiotherapy for cancer, this can induce menopause.

About 1% of women also experience menopause before age 40 due to genetic factors or autoimmune disease. This is called premature menopause.

Is there anything I can take for menopause?

Yes. Hormone therapy relieves the symptoms of menopause. The newer hormone therapies are safer than the older ones. Ask your doctor to tell you your options.

As for your diet, you should eat plenty of vegetables, grains, fruits, and calcium. This will help combat osteoporosis.

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Avoid Using Washable Masks

2009/09/04
NST Online
by Annie Freeda Cruez

KUALA LUMPUR : The Health Ministry does not recommend the use of washable face masks to stop the spread of influenza A (H1N1).

Health director-general Tan Sri Dr Ismail Merican said the mask, sold at 'pasar malam' for RM5 each, had not been evaluated by the ministry.

"People should use 3-ply and N95 masks if they have influenza-like illness (ILI)."

N95 masks fit tightly over the face, filtering out 95% of small particles.

Studies show that people can cut the risk of getting sick by 60 to 80% by using masks in combination with frequent hand-washing and avoiding close contact with sick persons.

Dr. Ismail said masks should be used once and then thrown away.

"Wearing masks is not the solution. It helps, of course, especially if you are sick and want to move around. Malaysians should also observe strict personal hygiene, washing hands with soap and water, use of alcohol rubs or sanitisers, practise cough and sneeze etiquette and stay home if unwell."

The official death toll now stands at 73, as the ministry's mortality review committee has yet to confirm 3 deaths reported earlier.

Dr. Ismail said there were still many people with ILI symptoms who out in public without wearing masks or adhering to cough and sneeze etiquette.

"Please follow our advice as by not doing so, you are spreading the virus to others, especially those who fall under the high risk category. Because of you, they may suffer complications and some may even die," he said.

The World Health Organisation has reported 246,221 confirmed cases of H1N1 with 2,958 deaths in 182 countries.


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How to Manage Insomnia

by Dr. Milton Lum

The body rests and recovers from previous activities during sleep. Normal sleep comprises cycles of non-rapid eye movement (NREM) and rapid eye movement (REM). NREM sleep is followed by REM sleep, which occurs 4 to 5 times during the usual 8-hour sleep period.

The first REM period of the night may be last less than 10 minutes, while the last may exceed an hour. The NREM and REM cycles vary in length from 70 to 100 minutes initially, to 90 to 120 minutes later in the night.

During the first third of the night, deep NREM sleep predominates, while REM sleep predominates in the last third of the night. REM sleep takes up 20% to 25% of total sleep time.

Insomnia

Insomnia refers to the disturbance of a normal sleep pattern. The different types of insomnia are:

* Difficulty getting to sleep (sleep onset insomnia) which is most common in young people.

* Waking up in the night which is most common in older people.

* Waking up early in the morning, which is least common.

* Not feeling refreshed after sleeping, leading to irritability, tiredness and difficulty concentrating during the day.

* Waking up due to disturbances such as noise or pain.

The duration of insomnia varies. It may be :

# Transient, lasting 2 to 3 days

# Short-term, lasting more than a few days, but less than 3 weeks

# Chronic, that is, it occurs on most nights for 3 weeks or more.

Everyone has experienced insomnia. It is generally accepted that about one-third of the population has insomnia.

How Much Sleep?

The need for sleep varies with age. A newborn may sleep 16 to 20 hours, and an infant 12 to 14 hours. Toddlers may sleep 10 hours or more. Primary school children need 9 to 10 hours of sleep, while normal adults need 6 to 10 hours of sleep.

It takes an adult about 10 to 20 minutes to fall asleep. Most of those who have less than 5 to 6 hours of sleep are probably not getting enough sleep.

After a good sleep, a person would feel refreshed on waking and can stay alert throughout the day, without the need for naps or sleeping in on weekends.

Symptoms and Causes

The symptoms of insomnia vary. They include lying awake for a long period at night prior to sleeping, waking up several times at night, waking up early in the morning and not being able to go back to sleep, feeling tired and not refreshed, inability to function properly during the day, and feeling irritable.

The causes of insomnia :

* Physiological : working at night, light, noise, snoring, partner's movements, and jet lag.

* Medical : pain or discomfort caused by arthritis, headaches, back pain, menopausal hot flushes, gastrointestinal disorders and pruritus (excessive itching).

* Psychological and psychiatric : examination stress, work worries, relationship problems, anxiety, depression, bereavement and dementia.

* Sleep disorders : sleep apnoea and sleep walking.

* Medicines : antidepressants, appetite suppressants, beta-blockers, corticosteroids and decongestants.

* Alcohol.

Management

Consult a doctor. He will look into the history of your condition and conduct a physical examination. The doctor will enquire about your sleeping routines, previous and current medical conditions, psychological or psychiatric conditions, if any, consumption of caffeine, medicines and alcohol, substance abuse including narcotic drugs, diet and exercise. The cause may be detected through this approach in many instances.

If the cause is not obvious, the doctor will ask for a sleep diary to be kept. This involves recording the time when one goes to sleep, when one wakes up in the morning and when one wakes up at night.

A referral to a specialist may be necessary if the cause is still not obvious. Laboratory tests and polysomnography may be carried out. The latter is used in the diagnosis of sleep apnoea and sleep disorders. This involves recording many parameters when one is asleep, including brain electrical activity; movements of the eye, jaw and leg muscles; and heart and lung functions. The doctor will discuss with the patient prior to any videotaping which may be considered necessary.

Once a diagnosis of the underlying condition has been made, the cause will be treated. For example, if the cause is anxiety or depression, the problem will go away once it is treated.

General measures which do not involve the use of medicines are preferred. It may involve counselling if the insomnia is due to stress or bereavement. Cognitive behavioural therapy which involves changes in thinking and behavioural patterns is useful. Measures like limiting caffeine or alcohol intake, exercise and keeping to a regular sleep routine are helpful.

Sleeping pills may be considered by the doctor for severe or short-term insomnia if general measures do not work. Doctors are usually reluctant to prescribe sleeping pills as they relieve the symptoms but do not address the underlying cause. An individual can also become dependent on sleeping pills, which are not without side effects.

Many of the sleeping pills available belong to a group of medicines called benzodiazepines which require a doctor's prescription. Benzodiazepines are anxiolytics and hypnotics, that is, they reduce anxiety and promote calmness and sleep. Benzodiazepines can lead to dependence and side effects like a hangover and drowsiness during the day. This can lead to accidents when driving. Examples of benzodiazepines include lormetazepam and temazepam.

The short-acting 'Z-pills' that is, zopiclone and zolpidem, act on the same receptors as benzodiazepines but are not classified as such because their molecular structures are different. They were initially thought to be less addictive and habit forming than benzodiazepines but this view has changed with reports of addiction in the past few years. The side effects are similar to benzodiazepines.

The lowest possible dose of sleeping pills should be taken for the shortest possible time. One should only take them under medical supervision. There is no place for self-medication. Do not stop intake abruptly as this may cause withdrawal effects. The doctor's advice is crucial here.

Melatonin is a hormone that is involved in the regulation of the sleep cycle or circadian rhythm. It is a short-term medicine for insomnia and cannot be consumed for more than 3 weeks. Although side effects are uncommon, they include dizziness, migraines, irritability, constipation and abdominal discomfort.

Getting Good Sleep

Getting a good night's sleep is vital. This can be achieved by various means :

* Having a routine facilitates sound sleep. This means going to bed and getting up at about the same time every day. It is important to relax before getting into bed as activity just before bedtime may keep one awake.

* Having an early dinner helps. The digestive system goes to sleep at about 7 o'clock. A light dinner is helpful.

* Avoid caffeine after lunch as caffeine keeps one awake.

* Avoid alcohol as its breakdown produces chemicals that stimulate the individual. It also increases the likelihood of snoring as it relaxes the muscles. This leads to lighter and less refreshing sleep.

* Avoid naps. The afternoon nap may keep one awake at night.

* Avoid light. This is because melatonin, the hormone that helps a person sleep, is produced in the dark.


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Vaginal Yeast Infection

by Dr. Nor Ashikin Mokhtar

A vaginal yeast infection is one of the most irritating yet common conditions that affect women.

In fact, it is so common that about 75% of women will have a yeast infection at some point in their lives. Of these, almost half will have recurrent infections, meaning 2 or more infections later on in life.

What Is a Yeast Infection?

Yeast infection is also called candidiasis, and is due to the fungus Candida albicans that infects the vagina.

You must be wondering why yeast would grow in the vagina. In fact, it is natural to find small amounts of yeast living in the vagina under normal conditions. However, the natural acidity of the vagina can be unbalanced, causing the yeast to overgrow and cause an infection.

The infection will then cause irritation of the vagina and the vulva (the area around the vagina). This may cause you to suffer extreme itchiness in and around the vagina. This may be accompanied by a thick, white, odourless vaginal discharge that has the texture of cottage cheese.

You may also notice other symptoms like burning, redness and swelling of the vagina and vulva, pain upon urinating, and pain or discomfort during sex.


What Causes It?

Vaginal yeast infections are usually caused by a weakened immune system that can lead to changes in the acidity of the vagina. The various conditions that can lower a woman's immune defences are stress, lack of sleep, sickness, poor diet, extreme intake of sugary foods, pregnancy, menstruation and disease such as poorly-controlled diabetes and HIV infection.

You may also find that taking certain medications can increase your risk of getting a yeast infection, such as birth control pills, antibiotics and steroid medicines.

What about sex? Some women believe that they can get yeast infections through sexual intercourse with their partners. However, this is actually very rare.

A woman could be at higher risk if she has unprotected intercourse with a partner who has a yeast infection, but this condition is rare in men. There is a slightly higher risk following oral sex given by men who carry yeast organisms in their mouth.

Nonetheless, yeast infections are not likely to be transmitted from partner to partner. Having said that, however, other infections can be contracted sexually, and women should always practise safe sex with their partners.

Don't Be Shy – See a Doctor

It can be embarrassing to admit that you have symptoms of a vaginal infection. However, it is important that you overcome your shyness and see your GP or gynaecologist.

Sometimes, the signs of a yeast infection are similar to that of sexually transmitted diseases, such as chlamydia and gonorrhoea. Getting a medical check-up could help you determine whether you have a yeast infection or something more serious.

A yeast infection is easily diagnosed. Your doctor will examine you to look for swelling and discharge. He or she may also take a sample from your vagina and examine that under the microscope to look for yeast organisms.

Treatment is often in the form of antifungal creams, tablets, ointments or suppositories (inserted into the vagina).

Do not attempt to treat the infection yourself – always get your doctor's advice, even if you want to use over-the-counter medicines. Taking antifungal medications when you do not have a yeast infection could make your condition worse and increase your risk of getting a resistant strain of infection in the future.

Avoiding Repeat Infections

It is very common for women to develop recurrent yeast infections, even several in one year. Here are some tips to prevent another yeast infection from occurring :

* Don't use douches.

* Avoid scented hygiene products like bubble bath, sprays, pads and tampons.

* Change tampons and pads frequently when you are menstruating.

* Don't wear clothing or underwear that are tight in the crotch.

* Wear cotton underwear or pantyhose with a cotton crotch.

* Change out of wet swimsuits and exercise clothes as soon as possible.

* Keep your vaginal area clean.

* After a shower or bath, dry the vaginal area completely before getting dressed.

* After using the toilet, always wipe from front to back.

* Avoid sharing towels with others.

* Don't take antibiotics unless prescribed by your doctor.

* Eat a diet high in vegetables, protein and grains, and avoid processed foods, sugars and alcohol.

* Abstain from sex while undergoing treatment for a yeast infection.

* If you are experiencing chronic yeast infections and are using birth control pills, consider changing your birth control method.

Finally, see your doctor for more advice about avoiding repeat yeast infections. Ignoring it will not make it go away.


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Urinary Bladder Cancer

by Dr. Clarence Lei Chang Moh and Datuk Prof. Dr. Tan Hui Meng

The urinary bladder is a reservoir which stores and discharges urine at the appropriate time. Urine itself is produced from the 2 kidneys. Urothelial cancer may occur anywhere along the urinary tract, from the kidney to the proximal part of the prostatic lining. The most common site for urothelial cancer is in the bladder.

Symptoms

The most common symptom is that of blood in the urine. Other conditions such as urinary stones and infection can also give rise to blood in the urine, but these conditions are usually associated with some amount of pain or discomfort at urination.

Therefore, if one passes blood in the urine without any pain (a condition known as painless haematuria), one must rule out cancer of the urinary tract.

In the early stages, there are no other symptoms nor signs. Of course, the bleeding can be diluted by taking more fluids or diuretics. Haematuria detected during microscopic analysis also has similar implications and warrants a full medical evaluation. The bleeding from the tumour can be intermittent. Therefore, one must be ever vigilant, even if there is only one episode of painless haematuria.

Causes

Bladder cancer is commoner in the older age group (above 60 years of age) and is very rare in children. It is more common in males compared to females, with a ratio of 4 to 1. It is the 6th most common cancer in the US.

According to the National Cancer Registry of Malaysia 2002, it ranks as the 10th commonest cancer in males. For Malaysian men, it comprises 4.1% of all new cancers, with a peak incidence of 33.5 per 100,000 for men in the age group of 60 to 69 years of age.

Other than the above epidemiological factors, the most well known cause is smoking. Smoking increases the incidence of bladder cancer by 3-fold, and also worsens the outcome of bladder cancer patients who continue to smoke.

Certain chemicals (eg aromatic amines) used in industry (eg dye in textile or rubber) and in agriculture may increase the incidence of bladder cancer. Hence, workers in the rubber, chemical, leather, textile, metal, and printing industries are exposed to substances such as aniline dye and aromatic amines that may increase their risk for bladder cancer. However, such occupational hazards take up to 20 years to manifest.

Chronic infections and irritation (eg by kidney stones) may predispose to certain types of bladder cancers, eg squamous cell carcinoma (SCC).

Diagnosis

If you have blood in the urine, you should consult a doctor who specialises in the urinary tract, namely, a urologist. Based on the clinical features, he will be able to determine the relevance of your symptoms and decide on further tests.

Blood in the urine can be confirmed by a simple urine dipstix test. The red blood cells can also be quantified with microscopy.

The urologist will usually arrange for appropriate imaging studies of the urinary tract. A minimum screening test is that of an ultrasound of the urinary tract. A full urinary bladder would give a better image on ultrasound.

Nowadays, multi-slice computerised tomography (MSCT) give good pictures not only of the urinary tract but also any extension of the growth to any other areas, eg outside the bladder or the lymph nodes.

Intravenous urography, which can pick up a space-occupying growth along the urinary tract, can be done if the patient has a normal kidney function. The excretion of the radiocontrast material will indicate the functioning of the kidneys as well as the blood supply to the kidneys.

Initial Treatment

All suspected bladder tumours require endoscopic assessment which can be easily carried out by a urologist. A special endoscope called a cystoscope is used to examine the urinary bladder. Any tumour seen is then biopsied with a forceps, together with any other suspicious areas of the bladder.

Most bladder tumours are cancerous and biopsy alone (which may cause bleeding or tumour seedling) is insufficient. Endoscopic treatment is carried out, immediately after the biopsies, with another endoscopic instrument known as a resectoscope.

All the tumours that protrude into the bladder are resected. The base of the tumour is also resected as deep as possible, without making any perforation of the urinary bladder.

The bladder tumours are then sent separately for histological examination and staging. A dose of chemotherapy (usually Mitomycin-C) is then instilled into the bladder immediately to reduce the risk of tumour cells seedling to other parts of the urothelium.

Staging of Urinary Bladder Cancer

The staging system used is usually TNM staging (Tumour, Node, Metastasis). The T stage is divided into T1, T2, T3, T4 with T1 tumour being confined to the mucosa and T4 tumour invading the surrounding organs, eg the prostate.

About 70% of bladder tumours are confined to the mucosa at presentation. Many patients in Malaysia tend to procrastinate and eventually have treatment only when the tumours have already invaded the bladder muscle layers.

Another important feature of bladder cancer is that of the grade of cells of the cancer, with grading (1) indicating well differentiated cells, grade (2) moderately differentiated and grade (3) poorly differentiated.

Bladder cancers in the higher T stage, with nodal involvement, metastasis and poorly differentiated bladder cancers are more aggressive and more likely to spread to adjacent or other parts of the body.

Definitive Treatment

After the initial endoscopic treatment by the urologist, definitive treatment is then stratified according to its stage and grade.

For patients whose cancer is localised to the mucosa, the treatment remains that of endoscopy. A second cystoscopy with a view to further biopsies and endoscopic resection is undertaken at around 6 weeks. This is to ensure that the previous endoscopic treatment is adequate and there is no understaging of the bladder cancer.

Thereafter, the patient can be followed up with 3-monthly cystoscopy for 2 years, 6 monthly cystoscopy for another 2 years and then yearly cystoscopies. In the event the patient has recurrent gross haematuria or if there is progression of the cancer earlier, a change of treatment is necessary.

For such superficial bladder tumours who tend to recur, a more intensive chemotherapy into the bladder is necessary to control the cancer. This may be in the form of chemotherapy (eg Mitomycin-C, MMC) or immunotherapy with BCG (Bacillus Calmette-Guerin).

MMC or BCG ± Interferon are usually given into the bladder on a weekly basis for 6 weeks. BCG has been used in the prevention of tuberculosis (TB) for a long time. When BCG is given into the bladder, it induces a very strong reaction in the body's immune system to kill the bladder cancer cells.

Cancer Invade Deep Into the Bladder Muscle

Such cancers are not amendable to endoscopic resection as this would create a hole in the bladder. If the patient is fit and there is no evidence of spread to the lymph nodes or metastasis (eg to the liver, lung or bone), the standard treatment is to remove the entire urinary bladder. This is known as radical cystectomy.

A new urinary bladder has to be constructed from the segments of isolated intestines. A simple one is that of the ileal conduit. In the ileal conduit, one end of the intestines is joined to both urinary tubes (ureters) draining the kidney, and the other end comes up to the abdomen as a stoma.

For suitable patients, the new constructed bladder may be reconnected to the urethra and the patient may be able to empty his or her urine normally or taught to empty with a clean catheter.

If the patient is not fit for radical long surgery, another option is external radiotherapy.

Tumour Spread Beyond the Bladder

If the patient is reasonably fit, then intravenous chemotherapy has been shown to be of some benefit. However, the benefits of chemotherapy have to be weighed against that of its side-effects.

For bladder cancers which are limited to the mucosa, the prognosis is good. However, these patients do require close monitoring.

For cancers which have spread outside the bladder and require radical cystectomy or radiotherapy, the prognosis is moderate. The mean 5-year survival of such bladder cancers is about 85%.

For patients who have bladder cancers extending to the lymph nodes or metastasis to other organs, the prognosis is poor. Such patients should go for good palliative treatment. If the patient continues to smoke, the outcome or prognosis is worsened.


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Care For Your Joints

Cycling is a low-impact exercise that is good for the joints.
When you reach a certain age, the aches and pains will begin, especially in the joints.

While it may not be possible to prevent ageing, there are certain do's and don'ts that you can adhere to so that the pain in the joints will be minimal.

Do’s

1. Exercise at least 30 minutes a day as it helps to strengthen the muscles that protect our joints.

It does not have to be a workout, but it can include chores such as gardening, washing the car or even an evening stroll around your neighbourhood.

If you are already suffering from joint pains, you can try low-impact activities, such as biking or swimming, that are gentle on the joints but still help burn calories.

2. Protect your joints from injuries. Remember to warm up before exercising and cool down after your workout.

This precaution is not restricted to sports or exercise alone. Even physical activities such as lifting a box should be done properly. For example, when lifting, be sure to carry the box as closely to your body as possible. Also, use your arms instead of just your hands to support the weight.

3. Respect your body's fitness level. If you work out in the gym, do not feel pressured to keep up with the people around you as everyone has different levels of stamina.

Always remember that what is tolerable for someone else might not be tolerable for you.

4. Try and maintain a healthy weight. Being overweight will put unnecessary stress on your joints as every 2.2kg gained puts as much as 4 times the stress on your knees.

Even minimal weight loss can do wonders to ease the pressure and your joints will thank you for it.

5. Supplement your diet with essential fatty acids (EFAs) such as Omega-3 which can be found in cod liver oil. When taken in high concentrations, cod liver oil has been scientifically proven to reduce inflammation and help slow down the progression of cartilage destruction.

As EFAs are not produced by the body, the only way we can get it is from eating EFA-rich foods or, more conveniently, from supplements.

Don'ts

1. Do not ignore muscular aches and pains. If your body aches after a workout, you might be working out the wrong way.

Consult exercise instructors or follow home exercise videos which will be able to lead you in a proper workout. If you are a gym member, try to book a session with a trainer who can then tell you where you might be going wrong.

2. Always make sure to seek medical attention if you have a muscular ache that will not go away as it may be a sign that your joints are injured.

Humans generally have a tendency to develop a tolerance to pain that we experience every day. The same can be said for joint pain. Bear in mind though, that any lingering pain could be a symptom of something more serious, so take note of it and seek treatment.

3. Do not forget to always eat balanced meals and try and cut down on fatty foods. If you need energy to keep you going throughout the day, stock up on more fibre-rich foods like whole-meal bread, cereals and nuts.

4. Do not wait until you are thirsty to drink water. This is because by the time we get thirsty, we are already mildly dehydrated. Be sure to drink at least 8 glasses of water every day, especially before and after exercising.

75% of our muscles and 22% of our bones consist of water. Water also helps in cushioning joints. Drink up as water loss can be detrimental to joints, robbing them of their ability to lubricate. Staying well hydrated is the simplest way to minimise unnecessary joint pain.

5. Do not forget to treat your muscles and joints from time to time by going for a good body massage. The benefits are known to include decreased pain and increased circulation, energy and flexibility. A warm bath can also relieve muscle tension and ease aching joints.


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