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.

Majority of these patients have "No" evidence of urinary infection. This symptom appears to be related to

1. Hot climate with excessive sweating.
2. Concentrated urine often with less water intake.
3. Possibly, type of food and Chillies consumed
4. Their 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.

Finally in my opinion, like the oesophagus, urethra in "Arabs" is very sensitive and a slightly concentrated or acidic urine leads to "burning" sensation.

The next most common cause of this symptom is what I label as "cystourethritis syndrome of males".

Initially 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.

My 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.

Though a 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.

What is 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 Yemen—it 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.

Frequently 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"). Dribbling ("Katraa") 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.

Many of these symptoms are "kept going" by the extensive investigations ordered by the doctors. In fact most of the patients want "invasive" or "painful" investigations.

Thus 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").

On 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!

Urethralgia Fugax—Similar 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 .

The next common symptom is that of passing sticky substance ("Shaaham") in the urine. In some of these patients, phosphaturia is detected.

In others, presence of a few sperms is reported on urine examination. "Wastage" of sperms ("Dood") in 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!

Majority of 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 neurosis.

Yellow ("Asfar") urine—is 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.

Normal 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") disease—jaundice!

Symptom of "Oligospermia" ("Dood"—"Naagis"-"Mani") Since the Arab patients are fond of getting investigated, routine semen examination is often asked for. I have frequently had patients—more often Yemenis—who, 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.

The symptoms of sex weakness are discussed elsewhere.

Pain in 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.

Although 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.

Symptoms due to enlarged prostate—Enlarged 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.

My 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 "Tayeeb"! (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!!

Kidney stones—in 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 stones ("Kiliya"— "Hassa" or"Hajur").

Surprisingly 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.

This 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.

Second 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 one system.

Also I would look for evidence of

1. Urinary infection (proved by urine culture) and
2. Obstructive uropathy (seen on l.V.P.)

I often ask for the following investigations as well , namely :

• Blood uric acid
• Serum calcium
• Twenty four hours urine calcium and uric acid
• Acid load test to exclude renal tubular acidosis.

After 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.

Out of 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.