Urineif I am asked to mention the most
common symptom of an Arab patient, I shall quote
burning urine ("Harrara"
Try asking the patient for this symptom. He will
never say "No". if he does say
"No", ask him "sometimes or off
and on ("Saa Aad"
or "Baadal Aao Kaat")
does he experience this symptom"? The answer
is bound to be "Yes" ("Naam").
Any doctor would straight think of urinary
Duration of this symptom is
more important. Longer the history more are the
chances of this symptom not being due to
infection, although urine examination would
easily diagnose the latter.
these patients have "No" evidence of
urinary infection. This symptom appears to be
climate with excessive sweating.
urine often with less water intake.
type of food and Chillies consumed
attention focussed on genitals.
But some of
these factors will not explain the same complaint
in female patients in whom this symptom is
sometimes heard of. Male patients definitely
complain of burning urine more often.
my opinion, like the oesophagus, urethra in
very sensitive and a slightly concentrated or
acidic urine leads to "burning"
most common cause of this symptom is what I label
as "cystourethritis syndrome of
when I started seeing Arab patients, keeping in
mind the etiological factors of this syndrome,
history of multiple deliveries, and sex habits of
their husbands, I expected to find a high
incidence of this syndrome in females. I was
surprised to see that this is not so.
impression is that Arab females (except a few
westernised Bahrainis) are the most 'shy'
patients. They would not like to mention urinary
symptoms to a doctor.
few female patients agree to some of the symptoms
of cystourethritis syndrome and stricture
urethra, I remember to have referred very few
female Arab patients for cystoscopic examination
as compared to a large number of Indian women.
And if I did, they were more often Westernized
Bahraini women! In the latter there was often a
history of either "loop" or
"pills" being used.
amazing is the very high incidence of urethritis
syndrome in males. This syndrome is seen in
increasing order of frequency from Bahrain,
Qatar, Saudi, Oman, U.A.E. to Yemenit being
highest in Yemenis.
A few of
these patients, after being investigated turn out
to have chronic prostatitis. Rarely stricture of
urethra is noticed. But the fact is, that in
majority of them no organic cause is detected to
explain the symptoms.
you see an Arab, more often a Yemeni wincing his
face, while showing you the penile areas where he
feels burning sensation in addition to complaint
of burning urine. Burning is felt either in the
whole penile urethra, at the tip (which they
often show by compressing the tip of penis),
perineum or sometimes even in the testicles.
Often the symptoms increase after sexual
intercourse. There is associated frequency of
urine, more often during day time ("Finhaar").
is a very frequent symptom, specially in Yemenis.
Some of the patients complain of passing sticky
mucous like substance ("Shaaham")
in the urine off and on.
these symptoms are "kept going"
by the extensive investigations ordered by the
doctors. In fact most of the patients want
"invasive" or "painful"
prostatic massage although
"appreciated" by many Arab patients
sometimes increases neurosis. Many pathologists
report presence of an "occasional"
leucocyte or pus cell in the prostatic secretion
even when the culture of this secretion is
negative. The presence of "occasional"
pus cell mentioned in the report becomes an
obsession in the mind of the Arab patient. When
he now goes to the next specialist, his dialogue
changes whilst the history taking session takes
place. He "now" complains of
"Prostate trouble" or pus cells ("Dood")
in prostatic fluid ("Mani").
cystoscopic examination, once in a way Bilharzia
cystitis is detected. I have a feeling that even
when the organic part of this illness is treated,
the functional part remains. I can compare it to
Bilharzia, Giardia or Amoebic infection of the
colon where symptoms of irritable bowel syndrome
persist after the disease is cleared.
Most of the
patients of urethritis syndrome proudly present
their normal report of cystoscopy. Though a few
of them show improvement in their symptoms
(psychogenic) after cystoscopy (atleast
temporarily), in majority the symptoms persist.
The interesting part of the picture is that in
spite of administration of large doses of
Pyridium (local anaesthetic dye excreted in urine
to soothe urethra), urine alkalinising agents,
long term antibiotic therapy and advice regarding
consumption of plenty of fluids, it needs a
heroic effort to get rid of the symptom of
burning urine in an Arab patient!
FugaxSimilar to the pain of proctalgia
fugax, I have come across Yemeni patients
complaining of severe pain inside the whole
penile urethra ("Daakhal Bole").
Some of them get severe exacerbations resembling
proctalgia fugax. And yet on urethroscopic
examination (done under anaesthesia), findings
are more or less normal. I wonder if I can label
these patients as suffering from "Urethra/gia
Fugax", especially since
urethritis syndrome (equivalent of irritable
bowel syndrome) is so common in this population .
common symptom is that of passing sticky
in the urine. In some of these patients,
phosphaturia is detected.
presence of a few sperms is reported on urine
examination. "Wastage" of sperms
the urine is something which an Arab cannot
tolerate!! He is usually not impressed by the
explanations of a helpless physician and somehow,
wants to get rid of this "symptom".
Changing the pathologist is a good solution,
liked by the patient and the doctor!
these patients, however, turn out to be suffering
from chronic prostatitis. Since this disease is
very difficult to cure, many of them visit two to
three specialists without obtaining relief. Then
start the superadded symptoms of anxiety and
("Asfar") urineis another
common symptom. The point is that an average Arab
has plenty of spare time at his disposal
So his main
hobby is to watch the normal physiological
functions of the body (incidentally most of the
physicians have forgotten their physiology). Thus
the patients would misguide the doctor by their
symptoms of observing the heart beats in a
particular position, talk about the entry of food
into oesophagus, borborygmi, look at the stool
and the detailed contents of it, the saliva,
urine and the semen which they pass at different
times of the day and night.
urine colour ("Laon Boal")
changes from time to time depending on the amount
of sweating, water intake and possibly on the
type of food and drugs consumed. Sometimes it is
bound to be concentrated and yellow. This yellow
colour upsets them because most of them have fear
of yellow ("Asfar")
Since the Arab patients are fond of getting
investigated, routine semen examination is often
asked for. I have frequently had
patientsmore often Yemeniswho, among
other symptoms complained of presence of less
sperms in the semen! An Arab would develop severe
depression and anxiety with neurosis if the sperm
count is even slightly low! Often they associate
it with future chances of sex weakness.
Frequently they already have three to five
children and yet oligospermia frightens them.
Also when I see a semen report I find that the
period of abstinence was hardly a day! This
factor is more often responsible for the slight
oligospermia which these patients are worried
about. 'It also explains the symptoms of thin
semen complained of by many patients.
Off and on
I do come across cases of Azoospermia the
incidence of which is same as in Indian
community. These patients need detailed
investigations and testicular biopsy. Many of
them turn out to have obstructive Azoospermia.
This can be corrected by surgery. It should
therefore be investigated even in an elderly Arab
because he may have a newly wedded young wife,
from whom he would like to continue producing
children, in order to satisfy her.
symptoms of sex weakness are discussed elsewhere.
the testicles ("Kaolaa")it is
interesting that the diseases of testicles are
more rare in Arab patients than what I see in
Indian population. Hydrocele is a rare disease in
an Arab! I cannot find any explanation for this
observation. Similarly orchitis is rare.
Testicular atrophy is seen off and on.
kidney stones are common, constant pain of
ureteric calculus referred to testicles is
interestingly less common. Thus, when the
patient, usually a Yemeni, complains of pain in
both the testicles and the loins, often this pain
turn out to be part of a psychoneurosis.
due to enlarged prostateEnlarged
prostate does not appear to be more common in
Arab countries. Yet, we see so many patients
having this disease coming to Bombay. The reason
is that a lot of elderly population visits this
city. Secondly most of them do not trust their
own surgeons in their respective countries.
observation is that even an elderly patient is
fit for the "T.U.R."
surgery for prostate. Also post-operatively, with
the selfretaining catheter in their bladder,
Arabs grumble so little. You can see them smiling
from the next day of the operation. Even if they
come to the hospital with infected urine or
develop post-operative urinary infection and
pyrexia, surprisingly they complain of very few
symptoms! An Arab patient, from the next day of
operation, has only to say "Zein
Insha Allah" or "Tamam"
or "Kuvez" or
(all equivalents of "very well"). This
is in striking contrast to the symptoms of
neurosis and anxiety which we see in the same
population. Willingness to undergo surgery is to
be seen to be believed!!
stonesin my experience the above entity
is extremely common in Arab population. As a
physician, while recording the past illness in a
male patient, if I have to ask for a common
condition, I would ask the history of kidney
in Yemenis, the frequency of stones is less
(Bilharziasis is the commonest), while in
Bahrainis perhaps it is the most common
(Bilharziasis hardly ever). Also the incidence of
this disease in Qatar (and other Arab countries)
is high. My experience about high frequency of
kidney stones is not shared by all. Thus, I
compare the statistics in my cosmopolitan
practice. Even in Indian population, the
frequency of this disease varies from place to
place, and in different communities, yet I have
not come across any community with such high
incidence of this disease.
incidence has created two problems. First is that
neurotic patients are afraid of this disease. I
have mentioned elsewhere that the moment a Yemeni
gets pain in the loin, he presumes he has kidney
disease, most likely a stone.
problem is that symptoms due to another disease
may be attributed to this condition, because the
stone can easily be picked up on plain X-ray.
Therefore, I have made it a point that unless
urine examination shows evidence of haematuria or
infection or the symptoms are typical of kidney
stone (loin pain more posteriorly) or of ureteric
colic radiating down to the testicle, I would
look for other causes of pain, especially if
there are multiple symptoms involving more than
would look for evidence of
infection (proved by urine culture) and
uropathy (seen on l.V.P.)
I often ask
for the following investigations as well , namely
four hours urine calcium and uric acid
load test to exclude renal tubular
asking for the above tests in hundreds of
patients especially with history of repeated
kidney stones, I find that in majority of them,
most of the investigations are normal. In some of
them, the only abnormality detected is increased
24 hour excretion of either urine calcium or uric
acid. In others, mild hyperuricaemia is noted,
but they have no evidence of "uric acid
stones". Hyperparathyroidism is a verv rare
disease and hardly ever seen in Arab patients.
hundreds of "female" Arab patients,
whom I have seen in rny practice during the last
fifteen years, I do not remember to have seen
kidney stones (or elicited a past history of
kidney stones) in more than a dozen patients. I
cannot find any adequate explanation for this
much disparity in sex distribution, though the
same is also observed in Indian population.