Unmet Surgical Need among Adults in A Mixed Urban-Rural Community in Nigeria: A Survey of 1,993 Adults Using the Sosas Survey Tool.

INTRODUCTION: Community-based prevalence studies are known to be more accurate than hospital-based records. However, such community-based prevalence studies are uncommon in low- and middle-income countries including Nigeria. Allocation of resources and prioritization of health care needs by policy makers require data from such community-based studies to be meaningful and sustainable. This study aims to assess the prevalence of common surgical conditions amongst adults in Nigeria. METHODS: A descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions in adults in a mixed rural-urban area of Lagos was conducted. The study population comprised resident members in the Ikorodu Local Government Area (LGA) of Lagos State. Data was collected using a modified version of the interviewer-administered questionnaire, the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool. Data was analysed using the REDCap analytic tool. RESULTS: Eight hundred and fifty-six households were surveyed with a yield of 1,992 adults. There were 95 adults who complained of surgical conditions giving a prevalence rate of 5%. Vast majority of reported conditions were acquired deformities (n=94) while only 1 congenital deformity was reported. Others included breast lumps, anterior neck swelling, and groin swellings. CONCLUSION: The most common surgical complaints in our setting among adults were acquired conditions of the extremities and open wounds/sores. With an estimated population of 90 million adults and approximately 1,200 orthopaedic and general surgeons respectively, the surgeon-to-affected population ratio is 1:10,000. There is a large gap to be filled in terms of surgical manpower development.

INTRODUCTION: Les études de prévalence communautaires sont connues pour être plus précises que les dossiers hospitaliers. Cependant, de telles études de prévalence communautaires sont rares dans les pays à revenu faible et intermédiaire, y compris le Nigeria. L'allocation des ressources et la priorisation des besoins de santé par les décideurs nécessitent des données issues de telles études communautaires pour être significatives et durables. Cette étude vise à évaluer la prévalence des affections chirurgicales courantes chez les adultes au Nigeria. MÉTHODES: Une étude descriptive transversale basée sur la communauté pour déterminer la prévalence des conditions chirurgicales congénitales et acquises chez les adultes dans une zone rurale-urbaine mixte de Lagos a été menée. La population étudiée comprenait des membres résidents de la zone de gouvernement local (LGA) d'Ikorodu, dans l'État de Lagos. Les données ont été collectées à l'aide d'une version modifiée du questionnaire administré par un enquêteur, l'outil d'enquête Surgeons OverSeas Assessment of Surgical Need (SOSAS). Les données ont été analysées à l'aide de l'outil analytique REDCap. RÉSULTATS: Huit cent cinquante-six ménages ont été enquêtés, ce qui a donné 1 992 adultes. Quatre-vingt-quinze adultes se sont plaints de conditions chirurgicales, donnant un taux de prévalence de 5 %. La grande majorité des conditions rapportées étaient des déformations acquises (n=94) tandis qu'une seule déformation congénitale a été signalée. Les autres incluaient des nodules mammaires, des gonflements antérieurs du cou et des gonflements inguinaux. CONCLUSION: Les plaintes chirurgicales les plus courantes dans notre cadre parmi les adultes étaient des conditions acquises des extrémités et des plaies ouvertes/ulcères. Avec une population estimée à 90 millions d'adultes et environ 1 200 chirurgiens orthopédiques et généralistes respectivement, le ratio chirurgien-population affectée est de 1:10,000. Il y a un grand écart à combler en termes de développement de la main-d'œuvre chirurgicale. MOTS CLÉS: Prévalence, Charge de morbidité, Chirurgie, Plaies.

The costs of surgical site infection after abdominal surgery in middle-income countries: Key resource use In Wound Infection (KIWI) study.

BACKGROUND: Surgical site infection (SSI) is the most common complication of abdominal surgery, with substantial costs to patients and health systems. Heterogeneity in costing methods in existing SSI studies makes multi-country comparison challenging. The objective of the study was to assess the costs of SSI across middle-income countries. METHODS: Centres from a randomized controlled trial assessing interventions to reduce SSI (FALCON, ClinicalTrials.gov, NCT03700749NCT) were sampled from two upper-middle- (India, Mexico) and two lower-middle- (Ghana, Nigeria) income countries. The Key resource use In Wound Infection (KIWI) study collected data on postoperative resource use and costs from consecutive patients undergoing abdominal surgery with an incision >5 cm (including caesarean section) that were recruited to FALCON between April and October 2020. The overall costs faced by patients with and without SSI were compared by operative field contamination (clean-contaminated vs contaminated-dirty), country and timing (inpatient vs outpatient). FINDINGS: A total of 335 patients were included in KIWI; SSI occurred in 7% of clean-contaminated cases and 27% of contaminated-dirty cases. Overall, SSI was associated with an increase in postoperative healthcare costs by 75.3% (€412 international Euros) after clean-contaminated surgery and 66.6% (€331) after contaminated-dirty surgery. The highest and lowest cost increases were in India for clean-contaminated cases (€517) and contaminated-dirty cases (€223), respectively. Overall, inpatient costs accounted for 96.4% of the total healthcare costs after clean-contaminated surgery and 92.5% after contaminated-dirty surgery. CONCLUSION: SSI was associated with substantial additional postoperative costs across a range of settings. Investment in health technologies to reduce SSI may mitigate the financial burden to patients and low-resource health systems.

Ivermectin shows clinical benefits in mild to moderate COVID19: a randomized controlled double-blind, dose-response study in Lagos.

INTRODUCTION: In vitro studies have shown the efficacy of Ivermectin (IV) to inhibit the SARS-CoV-2 viral replication, but questions remained as to in-vivo applications. We set out to explore the efficacy and safety of Ivermectin in persons infected with COVID19. METHODS: We conducted a translational proof of concept randomized, double blind placebo controlled, dose response and parallel group study of IV efficacy in RT-polymerase chain reaction proven COVID 19 positive patients. Sixty-two patients were randomized to three treatment groups. (A) IV 6 mg regime, (B) IV 12 mg regime (given Q84 h for 2 weeks) (C, control) Lopinavir/Ritonavir. All groups plus standard of Care. RESULTS: The Days to COVID negativity (DTN) was significantly and dose dependently reduced by IV (P = 0.0066). The DTN for Control were, = 9.1+/-5.2, for A 6.0 +/- 2.9 and for B 4.6 +/-3.2. Two way repeated measures ANOVA of ranked COVID 19 +/- scores at 0, 84, 168 and252h showed a significant IV treatment effect (P = 0.035) and time effect (P < 0.0001). IV also tended to increase SPO2% compared to controls, P = 0.073, 95% CI-0.39 to 2.59 and increased platelet count compared to C (P = 0.037) 95%CI 5.55-162.55 × 103/ml. The platelet count increase was inversely correlated to DTN (r = -0.52, P = 0.005). No SAE was reported. CONCLUSIONS: 12mg IV regime given twice a week may have superior efficacy over 6mg IV given twice a week, and certainly over the non IV arm of the study. IV should be considered for use in clinical management of SARS-COV2, and may find applications in prophylaxis in high risk areas.

Two-stage flap repair of severe hypospadias: Usefulness of the tubularized incised plate urethroplasty.

PURPOSE: The use of flaps in the two-stage repair of posterior hypospadias associated with severe chordee has been well established. Despite the almost certain guarantee of flap take, complications such as diverticuli are still relatively high. While different applications of the tubularized incised plate have been described, experience with the application of the technique to the two-stage flap repair is very limited. A previous local review of 15 cases performed at the present institution during the period 1998-2003, using the technique as described by Rekit, revealed fistulae and diverticulum rates of 20% and 27%, respectively. With the primary objective of improving surgical outcome, the midline incision was incorporated into the two-stage flap repair. MATERIALS AND METHODS: Between 2004 and 2015, 35 boys (aged 2-15 years) with severe hypospadias that required excision of the urethral plate were operated using the two-stage flap technique. The first stage involved mobilization of preputeal or dorsal penile skin (if circumcised) to the ventral surface, as described by Retik. After a minimum interval of 6 months, the second-stage operation was performed in a way similar to the technique of tubularized incised plate urethroplasty, as popularized by Snodgrass, and involved a preliminary midline incision on the neo-urethral plate followed by tubularization and multilayered closure. RESULTS: All but one flap took successfully. The outcome was satisfactory in 80% of patients, and there was a fistula rate of 14% ( Summary Table). One patient had a complete breakdown of the flap and was successfully treated about 12 months later by repeating the second stage of the operation. No case of diverticulum or stricture was recorded. DISCUSSION: Even though there was a marginal improvement in the fistula rate, the most striking observation was the complete absence of diverticulum or stricture. With a reported incidence rate of 20-63%, different authors have reported diverticulum formation (despite the absence of distal obstruction) to be a major problem of the two-stage flap technique. Attempts by these authors at reducing the risk of diverticulum by reducing flap size have tended to increase the risk of strictures. This has been the main reason given by some authors for abandoning the technique. The main limitations of the present study included the wide age range of the patients and the small sample size. CONCLUSION: The inclusion of a midline incision in a two-stage flap urethroplasty for proximal hypospadias appears to prevent the development of diverticulum.

Routine hemoglobin electrophoresis for pediatric surgery day case in at-risk populations: Suggested algorithm for screening using clinical risk factors.

BACKGROUND: Hemoglobin electrophoresis (HBE) is a part of the preoperative routine requested by anesthetists. However, the prevalence of hemoglobinopathy in the population is low. This study aims to determine the clinical risk factors for hemoglobinopathies and propose clinical guidelines for preoperative screening of patients for pediatric day care surgery. PATIENTS AND METHODS: A prospective study carried out over 12 months. Consecutive patients aged 6 months and older who had day case surgery were recruited to the study. Biodata and relevant clinical data were collated and documented in a proforma and analyzed using a statistical package for social sciences version 17. RESULTS: There were 124 patients106 boys and 18 girls. The median age was 3 years. Scrotal lesions were the most common conditions managed (71.7%). Seventy-eight percent of patients had HbAA, 15.3% had HbAS, and 4.8% had HbAC while 0.8% each had both HbSC and HbSS. At least one parent of 78.2% knew their Hb phenotype, of which, 79% were HbAA. A history of jaundice (P = 0.0001), hand and foot syndrome (P = 0.0001), frontal bossing (P = 0.0001), and low packed cell volume at surgery (P = 0.001) were found significant in predicting hemoglobinopathies. There was no mortality. CONCLUSION: Risk factors for hemoglobinopathies from this study included a positive history of jaundice, hand and foot syndrome, frontal bossing, and anemia. Proposed guidelines for HBE screening include the presence of hemoglobinopathy in one parent if one parent has sickle cell trait, and the other parent's genotype is unknown or if any of the risk factors is present.

Preoperative localization of undescended testes in children: comparison of clinical examination and ultrasonography.

BACKGROUND: Preoperative localization of the testis aids effective management of undescended testes. Various diagnostic techniques have been applied in the localization of undescended testes with varying results. The aim of this study was to compare clinical assessment and ultrasound evaluation in the preoperative localization of undescended testes in children. METHODS: A prospective evaluation of all boys undergoing operation for undescended testes at the Lagos University Teaching Hospital, Idi Araba, from July 2010 to June 2011 was carried out. The findings on preoperative clinical and ultrasound examinations were compared with intraoperative findings. RESULTS: Forty boys with 52 undescended testes were studied. The median age of the boys at the time of surgery was 4 years (range 1-11 years). Forty-five testes (86.5%) were accurately localized preoperatively by ultrasound while 25 testes (48.1%) were accurately localized on clinical examination. Ultrasound evaluation had an accuracy of 86.5% in preoperative localization of undescended testes. Clinical examination had an accuracy of 48.1% in preoperative localization of undescended testes. Ultrasound was more accurate than physical examination (p < 0.001). CONCLUSIONS: Ultrasonography is more accurate than clinical examination in the preoperative localization of undescended testes in children and could play a role in preoperative evaluation of patients with undescended testes.

H-type tracheo-oesophageal fistula: a diagnostic challenge in a resource-poor country. A case report.

H-type fistula is a rare form of congenital tracheo-oesophageal fistula accounting for 4% of all cases of Tracheo-oesophageal fistula. The typical picture is that of recurrent chest infection due to both missed and delayed diagnosis as well as cyanosis and choking during feeds. In resource poor countries this problem is further exaggerated by ignorance, poverty and lack of access to basic investigative modalities. This is the case of [abstract incomplete].

A prospective study of two methods of closing surgical scalp wounds.

BACKGROUND AND OBJECTIVE: Scalp wounds are commonly closed in two layers, although single layer closure is feasible. This study prospectively compared the two methods of closing scalp wounds. METHODOLOGY: Patients with non-traumatic scalp wounds were allocated to either the single layer closure group or the multilayer closure group. We obtained relevant data from the patients. The primary outcome measures were wound edge related complications, rate of suturing and cost of sutures used for suturing. RESULTS: Thirty-one wounds were in the single layer closure group and 30 were in the multilayer closure group. Age range was 1-80 years. The most common indication for making a scalp incision was subdural hematoma, representing 27.8% of all the indications. The most common surgery was burr hole drainage of subdural hematoma. Polyglactin acid suture was used for the inner layer and polyamide -00- for the final layer in the multilayer closure group. Only the latter suture was used for the single layer closure method. Total cost of suturing per wound in the single layer closure group was N= 100 (0.70USD) and N= 800 (5.30USD) in the multilayer group. The mean rate of closure was 0.39 ± 1.89 mm/sec for single layer closure and 0.23 ± 0.89 mm/sec in multilayer closure. The difference was statistically significant. Wound edge related complication rate was 19.35% in the single layer closure group and 16.67% in the multilayer closure method group. The difference was not statistically significant (z: 0.00, p value: 1.000; Pearson chi-squared (DF = 1)= 0.0075, p = 0.0785). CONCLUSION: The study shows that closing the scalp in one layer is much faster and more cost effective compared to the multilayer closure method. We did not observe significant difference in the complication rates in the two methods of closure. Long-term outcome, especially cosmetic outcome, remains to be determined in this preliminary study.

Swenson's pull-through in older children and adults: peculiar peri-operative challenges of surgery.

INTRODUCTION: The definitive treatment of Hirschsprung's disease is removal of the aganglionic bowel by a pull-through surgery. In most cases this surgery is performed in infancy or the neonatal period as presentation in older children and adulthood is rare. Nevertheless, pull-through in this age group may be necessary and present peculiar challenges. MATERIALS/METHODS: A prospective study of patients above 5 years with Hirschsprung's disease who presented at LUTH, Lagos between January 2007 and July 2010. RESULTS: There were fourteen patients (10 males and 4 females). The median age was 9 years (range 5-31 years). All the patients presented with constipation and abdominal distension. Seven patients presented with intestinal obstruction necessitating colostomy. Thirteen patients had short segment Hirschsprung's disease limited to the rectosigmoid. The only exception had long segment disease with the transition zone located at the transverse colon. Ten patients (71.4%) had colostomy before definitive pull-through while four patients (28.6%) had primary pull-through procedure without a colostomy. The definitive pull-through procedure done in all the patients was Swenson's abdomino-perineal pull-through and all the patients had a 2-layered colo-anal anastomoses. Due to the rigid pelvis in these patients, as well as possible scarring, simple blunt dissection was difficult in these cases. The median length of follow up was 11 months (range 6-28 months). There was one case (7.1%) of mortality. CONCLUSION: Older patients with Hirschsprung's disease present with intestinal obstruction and poor nutritional status that may necessitate preoperative colostomy. Swenson's pull-through in them poses peculiar challenges of mobilization of bowel and achieving a reliable colo-anal anastomosis, however, outcome is comparable with surgery in younger children if these challenges are overcome.

Medical education impact assessment: knowledge of final year medical students of Obafemi Awolowo University about male urethral catheterization.

BACKGROUND: Urethral catheterization is one of the commonest procedures performed by doctors either for prophylactic, diagnostic or therapeutic purposes. The medical education impact of this procedure on graduating medical students was assessed using a structured questionnaire. METHOD: This is a questionnaire--based study and the respondents were final year medical students who have completed their final examinations. RESULTS: There were 86 respondents with M:F ratio of 1. About a third of the respondents have not done urethral catheterization during their training while only 7% have done the procedure more than 5 times. All the students know that urethral catheterization is a sterile procedure and 96% knew that sterile gloves should be donned during the procedure. 92.4% of the respondents knew that skin preparation was necessary during the procedure with 75% of them responding that cetriomide and chlorhexidine solution was appropriate. 54% of the students used xylocaine as lubricant while 46% used KY Jelly. On the quantity of the lubricant for catheterization, only 2.7% of the respondents felt that 11-15 mls should be injected into the urethra. On the maximum amount of fluid to retain the balloon, only 36% of the students responded that it should be according to the specified capacity of the balloon. Majority of the students (88%) know that the catheter should get to the Y-junction before it is inflated. CONCLUSION: Most of the students in this study were taught appropriately the procedure of urethral catheterization; however about a third had not performed the procedure as a medical student.

Penile injuries from proximal migration of the Plastibell circumcision ring.

BACKGROUND: Although circumcision is the commonest surgical procedure performed on male neonates, complications still arise from all methods used by operators. PATIENTS AND METHOD: This was a prospective study of penile injuries resulting from proximal migration of the Plastibell device in neonate boys referred to the Lagos University Teaching Hospital, Lagos, Nigeria. The parameters measured were patients' biodata, presentation, management and treatment outcome. RESULTS: Twenty-three injuries resulting from circumcision with the Plastibell device all occurred from prolonged retention of the ring. In each case, the ring was retained and had migrated proximally. There was extensive skin loss in 17 (74%) babies. Urethrocutaneous fistulae were the result in nine (39%) of these cases, while partial necrosis of the glans penis occurred in four (17%). These complications resulted from the use of wrong-sized Plastibell kits, lack of follow-up by the medical staff, and inadequate maternal knowledge of ring fall-out time. CONCLUSION: Proximal migration of the Plastibell ring can result from employment of an inappropriate size, causing grievous penile injury. Adequate information should be provided to mothers of circumcised babies about possible complications of the Plastibell kit when employed. There is a need to redesign the Plastibell kit to eliminate its migration up the penile shaft.

Day case surgery in Nigerian children: influence of social circumstances of patients.

BACKGROUND: In order to achieve good results in day surgery and avoid pitfalls, selection of appropriate procedures and patients is required with attention given to the social circumstances among other considerations. The aim of this prospective study therefore was to evaluate the influence of the social circumstances of the patients on the performance of day surgery practice in our environment. METHOD: This was a prospective study carried out between April, 2004 and December, 2004, during which time 88 children aged 15 years and below with uncomplicated inguinal hernias were treated at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). The parents of the patients were interviewed about their social circumstances to determine the possibility of compliance with postoperative instructions. The data generated were then analyzed. RESULTS: More than half (54.6%) of the patients were from Ile-Ife. A few came from towns varying in distances from 65 to 80 km and spent an average time of 75 to 90 minutes to reach the hospital. Majority of the patients used public vehicles as a means of transport to and from the hospital in escort of their mothers. Despite the long distances and difficult traveling conditions, the parents still preferred day case surgery and were willing to obey postoperative instructions. CONCLUSION: From the findings in this study, day case surgery in children in our environment is feasible, despite the poor social circumstances of most of them. There is, however a compelling need to raise the standard of living of the people to enable them benefit maximally from day case surgery.

Outcome of primary closure of abdominal wounds following typhoid perforation in children in Ile-Ife, Nigeria.

BACKGROUND: Abdominal wounds following surgery for typhoid perforation are classified as dirty, with an infection rate of over 40%. To date, the optimal method for closure of these wounds remains controversial. Delayed primary closure which was conventionally recommended as standard practice, is now considered to be of no value in preventing surgical site infection (SSI). This study evaluates the outcome of primary closure of this class of wounds in children in Ile-Ife, Nigeria, and advocates a multidisciplinary wound management protocol. PATIENTS AND METHODS: This is a retrospective study of children aged < 1-15 years who had had surgery for typhoid perforation in a teaching hospital in south western Nigeria, over a period of ten years. RESULTS: Thirty-two patients, 18 males and 14 females, in the ratio of 1.3:1 were managed for typhoid perforation during the ten year period. All 32 patients had primary closure of their abdominal wounds. There was primary wound healing in six (18.8%) patients, while 19 (59.4%) patients had surgical site infections. Wound dehiscence, intraabdominal abscess, and faecal fistulas were the other complications documented in the study. CONCLUSION: Abdominal wounds of typhoid perforation, though classified as being dirty, can be closed primarily with good healing outcomes. A multidisciplinary approach to wound management will reduce the incidence of wound sepsis and its associated morbidity and costs.

Determinants of mortality in neonatal intestinal obstruction in Ile Ife, Nigeria.

BACKGROUND: Neonatal intestinal obstruction (NIO) is a common cause of mortality. This study determined the causes of mortality in patients with NIO at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile Ife. PATIENTS AND METHODS: Records of all cases of NIO managed at OAUTHC between January 1996 and December 2005 were retrospectively reviewed and the possible factors that may result in mortality were analysed. RESULTS: Sixty-three neonates with intestinal obstruction were managed, representing 24.3% of the neonatal admissions during the study period. Forty-two were males and 21 were females (M:F = 2:1). The majority (71.4%) of the patients presented within the first week of life. Anorectal malformation constituted 57.1% of the causes of NIO. Other causes included Hirschsprung's disease, duodenal atresia, intestinal malrotation with midgut volvulus and jejunal atresia. There were 18 deaths, with a mortality rate of 28.6%. Reoperation, postoperative bleeding and peroperative sepsis were significant determinants of mortality. CONCLUSION: NIO is associated with significant mortality in our centre. Repeat surgery, postoperative bleeding and sepsis were the significant factors that contributed to mortality in NIO.

Evaluation of cosmetic appearance of herniotomy wound scars in African children: Comparison of tissue glue and subcuticular suturing.

AIM: To evaluate the cosmetic appearance of herniotomy wound scars closed using either the tissue glue or subcuticular suturing technique. MATERIALS AND METHODS: Prospective randomised control study; randomisation into tissue glue and suturing groups. Ethical clearance obtained. Cosmetic outcome were based on visual analogue scale by parents and Hollander wound evaluation scale by a Plastic Surgeon blinded to the wound closure method. RESULTS: Fifty one wounds were evaluated, 26 in the tissue glue group and 25 in the suturing group. Parents' evaluation using Visual Analogue scale (VAS) showed that in the suturing group, 17 parents (68%) gave a VAS of 8cm while six parents (24%) gave a score of 7cm. Two parents (8%) gave a score of 9cm. In the tissue glue group, 22 parents (84.6%) scored the scar of their children as 8 or 9cm on the VAS while four parents (15.4%) gave a score of 7cm. The median VAS was 8cm for both groups with a range of 7 to 9cm. The Chi- square test showed that the parents preferred tissue glue compared with subcuticular suturing (X2 = 7.90, P < 0.05). The Hollander Wound Evaluation Scale (HWES) used by Plastic Surgeon showed 21 herniotomy wounds (84%) had a score of 6 in the suturing group while four wounds (16%) had a score of 5. In the tissue glue group, 19 wounds (73%) had a score of 6, six wounds (23.1%) had a score of 5 and a patient (3.8%) had a score of 4. The median score is 6 for both groups. There was no statistically significant difference between both groups (X(2) = 1.481, P = 0.393). CONCLUSION: This study has shown that the cosmetic outcome of wound closure using the tissue glue technique and subcuticular suturing technique are similar.

Digital rectal examination for prostate and rectal tumour: knowledge and experience of final year medical students.

BACKGROUND: It is most pertinent that medical students are taught the necessary skills for digital rectal examination (DRE) before they become doctors. OBJECTIVE: The study is to assess the knowledge and experience of final year medical students regarding DRE for prostate and rectal tumours. METHODS: Well-structured questionnaire were administered to each of the final year medical students of Ladoke Akintola University of Technology a week to their final examinations. RESULTS: Response was received from 127 (60%) of the students, 124 (97.6%) agreed that they have been taught DRE. Most of the students, 102 (80.3%), have done one to five DRE, three (2.4%) and have never performed DRE while none of the students have done more than ten DRE. Only in 49 (38.6%) of cases were the findings of the students on DRE always confirmed by a doctor. Nine students (7.1%) have never felt a clinical BPH and none had felt it more than five times. Sixty-six (52.0%) have never felt a malignant prostate and none of the students have felt it up to three times. Most of the students, 106 (83.5%), have never felt a rectal tumour on DRE Only five (3.9%) felt very confident of their ability to give an opinion based on their findings on DRE while 105 (82.7%) felt reasonably confident CONCLUSIONS: The students have been taught DRE and a good number of them have performed it. Few of the DRE done by the students were cross-checked by a doctor. Most of the students have problems differentiating BPH from cancer of the prostate and many of them were not very confident of their findings on DRE.