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Things to know about ‘Dhat’ syndrome (Nocturnal emission/Nightfall)

What is meant by nightfall or nocturnal emission or wet dreams?

Spontaneous involuntary loss of semen while the person is in sleep is called as nightfall or nocturnal emission. It is most common in young boys (adolescent age group).

Is there any side effects of night fall ?

There is no evidence that nightfall (wet dreams/nocturnal emission) cause any bodily side effect in men.

What is Dhat disease or Dhat Syndrome ?

Dhat syndrome is the clinical entity seen primarily in Indian subcontinent and present with a features of depression, anxiety, multiple nonspecific body symptoms, sexual dysfunction, fatigability, and impairment of concentration, which are attributable to semen loss. Loss of semen irrespective of the mechanism (during urination, defecation, masturbation, nightfall or nocturnal emission, and even sexual intercourse) is considered worrisome by patients suffering from Dhat syndrome.  

Which age group are mainly affected with Dhat syndrome ?

Patients with Dhat syndrome are often young males in second to third decade of life. Majority of the patients belong to south east Asia continent and belong to low socio-economic groups with orthodox culture. Families with poor education have higher chances of having this entity.

What are the symptoms of Dhat syndrome ?  

The most common presenting symptoms in patients with Dhat syndrome are weakness of the body, tiredness, low energy, low mood and mental stress. It can also be described as the abnormal illness behavior and bodily symptoms due to semen loss, as well as heightened emotional (depression and anxiety) response. These symptoms often get amplified with the stress.

How the symptoms of Dhat syndrome develop ?

At the time of onset of Dhat syndrome, these people get excessively worried with having nightfall or semen discharge and gives lot of significance to this semen loss. Every time they loss semen, they experience stress (as it is not acceptable in their culture). This abnormal thinking leads to stress response which further gets amplified with each time person have semen loss and hence this vicious cycle goes on. Further exaggeration of this stress response leads to the symptoms of anxiety, depression and other body (somatic) symptoms. This anxiety feature can lead to sexual dysfunction seen in few men with Dhat syndrome. Nearly 20% of patients diagnosed with Dhat syndrome do harbour some underlying depression, anxiety disorder.

How to treat Dhat syndrome ?

The patient with Dhat syndrome approach a variety of medical practitioners and specialists with their complaints. Since this culture originated disease entity is rare in western countries, the presentation and management knowledge is deficient in western medical practitioners. Patients with Dhat syndrome require comprehensive assessment to assess clinical severity. Integration of various medical specialities such as Urology, Psychiatry, Psychologists, general medicine, psychiatric nurses, alternative medicine (Ayurvedic/Siddha) can lead to better patient management. Psychosocial therapy, cognitive behavior therapy (imparting sex education and resolving sexual myths is very important), antianxiety and antidepressant therapy are helpful. Educating the traditional healers may help in resolving the sexual myths that they carry and dissipate to the people in the society.

Prostate cancer – Part I

What is prostate ?

Prostate is a lemon sized reproductive gland, found only in men, below the bladder. Its function is to produce fluid which helps providing nourishment to sperms in semen. Urinary passage goes through prostate, before reaching the penis.

What all diseases can occur in prostate ?

BPH (BPH (Enlarged prostate) Symptoms), Prostatitis (Infection in prostate), Prostate cancer (Prostate cancer)are the most common diseases that originate from prostate.

What is prostate cancer ?

Like rest of the body cancers, prostate can harbour cancer in it. Malignant growth inside the prostate is called prostate cancer. Most of the prostate cancers are slow growing.

What are the risk factors for prostate cancer ?

Older age, African – American race, family history of ovarian/breast and prostate cancer increases the likelihood of a man being diagnosed with prostate cancer. As men increase in age, the risk of prostate cancer increases. About 60% of prostate cancers are diagnosed in men over the age of 65 years. Besides these, diet high in animal fat has been associated with risk of developing prostate cancer.

What are the symptoms of prostate cancer ?

Prostate cancer can be asymptomatic; meaning there can be no symptoms of cancer. If it does causes symptoms, these can be urinary symptoms or more generalised symptoms, depending upon the stage of prostate cancer. Most common symptoms include- urinary symptoms such as frequency or weak urinary stream, blood in urine (hematuria), erectile dysfunction (ED), Hematospermia (Blood in semen), urinary and bowel incontinence, pain in hips/back/legs etc.

Can we detect prostate cancer in patient who does not have symptoms ?

Prostate cancer can be easily screened with combination of Digital rectal examination (DRE), conducted by doctor and blood test called PSA (Prostate specific antigen). (Prostate cancer and PSA testing). These tests are recommended annually in men over 50 years of age. Combination of these tests can diagnose prostate cancer in men, in whom there are no symptoms of this disease.

What is PSA test ?

The PSA is a blood test which is commonly used to detect possible prostate cancer in a person. Elevated PSA levels may indicate the presence of prostate cancer, but it can be also elevated in certain conditions of prostate such as BPH, prostate infections (prostatitis), UTI (Urinary tract infection), retention urine etc.

If initial tests shows risk of prostate cancer, what happens next ?

The final diagnosis of prostate cancer is made after prostate biopsy done most commonly by ultrasound guidance called TRUS (Trans rectal Ultrasound). Sometimes doctor orders MRI called mpMRI (multiparametric MRI) prostate before undertaking biopsy. Once biopsy shows evidence of prostate cancer, the cancer is staged to look for the extent of cancer spread into the body. This is done by combination of various modalities such as CT scan, MRI , Bone scan and more recently PSMA PET scan.

Testosterone and Testosterone deficiency syndrome

What is testosterone ?

Testosterone is the male hormone which helps in the physical, sexual and psychological well being of the person.

What is the role of testosterone hormone in male body ?

Testosterone helps in development of male secondary characters at puberty such as growth of facial hairs, penis and testes enlargement, deepening of voice, bony and muscle growth etc. In grown adults, this hormone helps in maintaining muscle and fat mass, safeguarding cardiovascular health and producing blood cells, keeping emotional stability, maintaining sexual life while keeping libido, sexual desire, penile erection and fertility normal.

What are sign and symptoms of testosterone deficiency in men ?

Sexual symptoms – Decreased libido; erectile dysfunction; decreased frequency of
morning erections; decreased performance

Physical symptoms – Increased visceral body fat/obesity; decreased lean muscle mass;
decreased strength; fatigue/loss of energy; decreased physical activity/
vitality; low bone mineral density; anemia; flushes; loss of facial, axillary
and pubic hair/slow beard growth; decline in general feeling of well-being

Psychological symptoms – Depression/depressed mood; mood changes; irritability;
inability to concentrate; insomnia/sleep disturbances

Which persons are at risk of developing testosterone deficiency syndrome ?

Persons with poorly controlled diabetes, high BMI, kidney failure on dialysis, chronic alcohol consumer, liver disease, on cancer chemotherapy , drug addicts, COPD etc are at risk for testosterone deficiency and its symptoms.

How to check and evaluate for the testosterone deficiency ?

Testosterone is checked by the blood sample, taken in fasting state early morning between 8 am to 11 am. Normal levels of total testosterone in adult male is usually between 275 ng/dl – 875 ng/dl. Level below this range suggests testosterone deficiency.

How to treat if someone having low testosterone levels ?

If someone is having low serum testosterone levels, complete history and examination for sign and symptoms is must for such patients, as only low testosterone levels does not warrants its treatment. If there are corroborative sign and symptoms along with low testosterone level, the treatment is usually initiated with either intramuscular (i.m.), oral and gel preparations.

Whom to consult for if someone has low testosterone levels ?

You should meet Andrologist for the evaluation and treatment of low testosterone levels.

Ten signs and symptoms of low testosterone levels in adults

  1. Sexual symptoms – Most prominent symptom, Decreased erections, loss of erectile function (erectile dysfunction), decreased semen volume, decreased frequency of ejaculations
  2. Hair loss
  3. Cognitive symptoms – Low mood, low sexual desire, memory impairement, sleep disturbances, concentration difficulties, decreased motivation
  4. Reduced muscle mass, increase in body fat
  5. Decreased physical strength/activity, decreased energy
  6. Increased risk of heart diseases
  7. Hot flushes
  8. Gynecomastia/increased breast tissue
  9. Persistent fatigue
  10. Loss of bone tissue, increased risk of osteoporosis

Read more about testosterone and testosterone deficiency syndrome at Testosterone and Testosterone deficiency syndrome

Short Frenulum (Tight Frenulum, Frenulum Breve)

What is frenulum ?

Frenulum is the elastic fold of skin that joins the underside of the glans of the penis with the inner surface of the foreskin.

What are risks of having short frenulum ?

short frenulum (also called frenulum breve) is when the frenulum is so short in length that there is restriction in free and smooth retraction of the foreskin. This often leads to the pain and discomfort during sexual intercouse. Also, it can increase the risk of infections, as it is difficult to clean under the foreskin. Short frenulum can also get torn while sexual activity and hence can lead to bleeding. Read how this condition is different from Phimosis

What is the treatment for short frenulum ?

It can be managed conservatively if not causing any discomfort or pain. In some cases, steroid creams and stretching exercises can be enough to sufficiently elongate the frenulum. However in majority of cases, surgery is required to alleviate the symptoms. Frenuloplasty (Frenular release) is the mainstay of surgery. Sometimes, the resection of the frenulum (frenulectomy) or circumcision (removal of foreskin) is required. This surgery is done on day care basis with same day discharge of the patient after surgery.

Whom to consult for short frenulum ?

Urologist and Andrologist are the doctors, who look after such problems.

Frequently asked questions about phimosis

What is phimosis ?

Phimosis is the inability to completely retract the prepuce, otherwise called foreskin. It is normal in newborn child and upto 2-3 years of age.

What are the causes of phimosis ?

It can be congenital (present since birth) or secondary due to the infections or lichen sclerosis (foreskin becomes whitish and hard).

With what symptoms phimosis present with ?

Children with phimosis present with crying episode while passing urine or there is ballooning of foreskin while passing urine. Adult person with phimosis usually present with the difficulty in passing urine or painful intercourse. In cases of infection, patient may present with pus discharge or redness over the penis.

What is the treatment of phimosis in young children ?

In children after 2-3 years, if foreskin remain non retractile, mother may be taught to gently retract foreskin during every bath after applying lubricating jelly such as petroleum jelly.

What is the treatment of phimosis ?

Phimosis is a surgical curable disease. Children after 3-4 years with non retractile foreskin may be surgically treated with removal of foreskin called circumcision. Adult patient may similarly be undertaken for circumcision if there is no infectious cause of phimosis. In cases of infections leading to phimosis, such patient are treated with antibiotics and maintenance of local hygiene.

What is circumcision surgery ?

Circumcision is a day care procedure and may be done safely under local anesthesia in adults. There is no significant post operative complications associated with this surgery or any problems in attaining erection or sexual performance in adults.

Whom to consult if someone having phimosis ?

You should visit nearby Urologist or Andrologist for the treatment of phimosis.