“The evil that men do lives after them…”

“The evil that men do lives after them; the good is oft interred with their bones.” These insightful words were spoken by Marc Antony in Shakespeare’s Julius Caesar.

This quote often comes to mind whenever I see elderly men trooping to the urology clinic. Don’t get me wrong, there are plenty reasons for men to visit the clinic, chief of which is the common culprit- Mr Prostate. Prostate enlargement usually rears its ugly head usually from the fourth decade of life and is the commonest cause of lower urinary symptoms in men in their prime. So, while women come to terms with the symptoms of menopause, men usually have to contend with having urinary issues.

However, Mr prostate is not the subject of discussion today.

It is as if, by some grand design, ‘the bro code’ maybe, doctors do not like to blow the trumpet about another important condition, urethral strictures, that occur after men have lived a life of reckless sexual proclivities. They mention the condition in passing, when teaching medical students and residents, but fail to advocate to the public in general about the dangers of having repeated sexually transmitted Infections.

Malnutrition, threat to Nigerian children’s survival – FG

Malnutrition, threat to Nigerian children’s survival – FG

More than sixteen years ago, as a young impressionable medical student scavenging the emergency wards with my friends, looking for interesting cases, we chanced upon an elderly man sitting quietly on a chair crying in pain.

It was the first time in my adult life that I was seeing an old man crying like a baby complete with red eyes and mucous running down his nostrils. His screaming attracted our attention but when asked what the matter was, he would only shake his head, and mutter something incoherent. When the crying became too much, we looked for the most approachable doctor and asked him to please attend to the old man among the sea of people demanding attention.

Do you know what the old man was saying that we could not decipher?

‘Pitsari’. Piss.

The elderly man could not urinate to save his life. He must have been in so much pain that day. The doctor, realizing a teaching moment, gathered us around and proceeded to take a quick history trying to find the cause of the urinary retention. The old man had been unable to pass urine since in the morning despite all his straining. He had gone from one private hospital to another, and all were unable to pass a catheter. The doctor examined his abdomen and felt his distended bladder, while the man continued to howl like a banshee. It was a horrible experience.

The first step in this type of emergency, acute urinary retention, is to attempt to relieve the bladder by catheterization. We watched as the doctor tried to pass the tube (catheter) through the penis but was met with resistance. The catheter could not pass through. The next step was to pass do a suprapubic catheterization which involved making a small incision in the lower abdomen so that the catheter could be put directly into the bladder to drain it. Suprapubic catheterisation (SPC) is a useful procedure that provides bladder drainage when urethral access is not possible in conditions like urethral disruption, severe urethral stricture disease or inaccessible urethra owing to traumatic catheterisation.

By that time, the old man was too traumatised to care what was being done to him and so gave his consent willingly. We (medical students) watched as the procedure was done in under ten minutes after which clear urine was drained into a urine bag. As the catheter drained the man’s urine, the relief on the man’s face was instant. Tears of pain became tears of joy.

Wallahi, fifteen minutes later, the old man was asleep with his catheter attached to his urine bag by his side!

That night, the doctor on duty in the A&E took his time to teach us about urethral strictures, the types, causes and treatment options. I went back to my room determined to clerk the old man, myself, the next day.

Urethral stricture is a narrowing of the urethra. The urethra is the tube that carries urine out of the body. This tube can become narrow and causes difficulty and discomfort when a man urinates. Some patients, like that old man, with severe urethral strictures are completely unable to urinate. This is referred to as urinary retention, and is a medical emergency requiring attention. Men are more likely to have urethral injury than women because of their longer urethra. For this reason, urethral strictures are hardly seen in women and children.

The old man’s history was typical. Tests showed he had extensive urethral strictures which is just medical jargon for a blocked urethral passage (the passage in the penis through which urine comes out). The blockage was what prevented the urine from coming out which caused accumulation of urine in his bladder thereby distending it and causing unbearable pain. The cause of the strictures was from excessive scarring caused by repeated sexually transmitted infections (STI) in his youth. The most common infections that cause stricture are sexually transmitted infections, such as gonorrhea and chlamydia.

The 73-year-old man confessed to having led a promiscuous lifestyle until old age caught up with him. Many premarital and extra marital affairs had exposed him to many STIs which at the time was either ignored or treated with over-the-counter antibiotics. Fortunately for him his HIV status negative.

Years later, I continue to hear his story through many, many patients I have seen. The gist is always the same, albeit less dramatic. Elderly men with difficulty in passing urine from strictures caused by years of STIs. Unfortunately, or maybe fortunately, because of the popularity HIV has gained, many men are more worried about HIV than any other infection. They are not aware that the ‘less significant’ infections like Gonorrhoea and Chalamydia (which can be asymptomatic) will predispose you to scarring and fibrous tissue formation which will come back to haunt you in old age.

“The evil that men do shall live after them”.

A caveat- there are other causes of urethral strictures, globally, but in Africa, the commonest causes are chronic inflammation  caused by infections, most often sexually transmitted infections like chlamydia.

Health care workers continue to advocate against the ABC safe sexual practices: Abstinence, Being faithful to one partner and the use of Condoms but only in the context of immediate diseases like HIV and hepatitis B. We forget that those simple STIs that we treat in the clinic or by the patients themselves in chemists, have far reaching consequences and complications. These young men, go away ignorant and continue to score ‘goals’ hailed by their fellow men.

We don’t counsel them appropriately and warn them about how strictures can significantly reduce the quality of the lives; how they might have to live with urine bags tucked into the deep pockets of their baban-riga because they cannot afford a urethroplasty, or how they may end up weeping like babies at the mercy of medical students and doctors young enough to be your children and grandchildren.

Young people, stay Woke and practice the ABC of safe sex.