Pelvic Floor Disorder: Causes, Symptoms and Treatment

11 Nov 2019 Blog

According to the National Institutes of Health, roughly a quarter of U.S. women are affected by a pelvic floor disorder. Pelvic floor disorders are a result of weakened or injured muscles and connective tissue in the pelvic cavity that may cause a variety of uncomfortable symptoms making physical activity difficult and sexual intercourse painful.

What is the pelvic floor? What does it do?

The pelvic floor—which men and women both have—is a hammock-shaped group of muscles, connective tissues, and nerves that support the organs and help them function. Both men and women have a:

  • Bladder
  • Bowel
  • Rectum

Men also possess a prostate, whereas women possess a uterus and a vagina. These organs are also a part of the pelvic floor, which extends between the tailbone, pubic bone and hip bone.

What is a pelvic floor disorder?

A pelvic floor disorder refers to a dysfunction of any part of the pelvic floor, resulting in conditions such as:

  • Constipation, difficulties with emptying the bowels
  • Fecal incontinence, an inability to control bowel movements
  • Pain during intercourse or vaginal penetration
  • Pelvic organ prolapse, a weakness in the muscles that causes the organs to shift into the vaginal canal space
  • Urinary incontinence, a loss of control in managing the flow of urine

These conditions occur when the muscles become weakened or the connective tissue tears, typically due to trauma to the pelvic area, childbirth or natural deterioration with age. Genetics, excess weight (which places extra pressure on the pelvic floor) and lifestyle are also thought to play a role, as well as a variety of health issues such as:

  • Diabetes, which may impact how well the pelvic floor muscles function
  • Parkinson’s disease, a degenerative disease of the nervous system that affects nerves and muscle movement
  • Stroke, which can damage the part of the brain that controls bladder/bowel movement or include a medication regimen that causes incontinence as a side effect
  • Spinal stenosis, a narrowing of the spinal canal—typically in the neck or low back—that places pressure on the spinal cord or related nerves, potentially resulting in loss of bladder or bowel control

Symptoms can vary depending on which part of the pelvic floor is affected, but can include:

  • A feeling of needing to constantly have a bowel movement or a feeling of not completely emptying after a bowel movement
  • Any consistent pain in the pelvis, rectum or genital area, especially during intercourse
  • Painful or frequent urination
  • Pressure sensation in the vagina, such as the feeling that you are sitting on something or is protruding from the vagina
  • Straining or having to shift position in order to complete a bowel movement or while trying to empty the bladder

Although pelvic floor disorders may sound scary, they’re a fairly common issue, especially in women. In fact, according to one study, one-quarter of adult women in the U.S. report having at least one of these disorders.

What kind of doctor should I see for a pelvic floor disorder?

You can certainly speak to your OB/GYN or primary care provider (PCP) about the issues you are experiencing, but your best bet is to be seen by a urogynecologist or a urologist who specializes in pelvic floor disorders.

What is a urogynecologist?

A urogynecologist is a urologist or OB/GYN who opts to undergo highly-specific subspecialty training for conditions that impact the pelvic floor. This includes completing a fellowship—additional training after completing a residency program—that focuses on surgical and nonsurgical care of non-cancerous gynecologic issues.

When should I seek medical help for my pelvic floor disorder symptoms?

We understand that these issues can be uncomfortable to talk about, but they are common problems that can be medically managed with the right care. There is no reason to compromise your quality of life when there are plenty of treatment options available. Reach out to your PCP or OB/GYN for a urogynecologist recommendation.

At New Jersey Urology, we’re proud to have urogynecologists on staff to help patients living with these issues. Together, they offer years of combined experience in providing patients relief from pelvic floor disorders utilizing the latest techniques the industry has to offer, both surgical and nonsurgical, in a comfortable environment. This can include everything from specialized exercises (pelvic floor therapy) to a minimally invasive surgical repair of the pelvic floor.

Discover the difference in care for your pelvic floor disorder symptoms. For more information or to schedule an appointment with one of our urogynecologists, contact us today.

What Happens to Ejaculation As Men Age?

4 Nov 2019 Blog

There is little written on ejaculatory issues aside from timing problems (premature and delayed ejaculation) and hematospermia (blood in the semen). However, not a day goes by in my urology practice where I do not see at least several patients who complain about declining ejaculation function.

What does the word ejaculation mean?

Ejaculation derives from ex, meaning out + jaculari, meaning to throw, shoot, hurl, cast.

Trivia: You do not need an erection to ejaculate and achieve an orgasm. A limp penis cannot penetrate, but is very capable of ejaculation and orgasm. 

What happens to ejaculations as we age?

Ejaculation and orgasm often become less intense, with diminished force, trajectory and volume. What was once an intense climax with a substantial volume of semen that could be forcefully ejaculated gives way to a lackluster experience with a small volume of semen weakly dribbled out the penis. 

So what’s the big deal?

Men don’t like meager, lackadaisical-quality ejaculations and orgasms. Sex is important to many of us and getting a good quality rigid erection is foremost, but the culmination—ejaculation and orgasm—is equally vital. We may be 40 or 50 years old, but we still want to point and shoot like we did when we were 20. As the word origin indicates, we want to be able to shoot out, hurl or cast like an Olympian and we want that intensely pleasurable feeling of yesteryear.

The science of ejaculation

Sexual climax consists of three phases—emission, ejaculation, and orgasm. When the intensity and duration of sexual stimulation surpasses a threshold, emission occurs, in which secretions from the prostate gland, seminal vesicles, epididymis, and vas deferens are deposited into the urethra within the prostate gland. During ejaculation the pelvic floor muscles contract rhythmically, sending wave-like contractions rippling down the urethra to forcibly propel the semen in a pulsating and explosive eruption. Orgasm is the intense emotional excitement that accompanies the physical act of ejaculation.  

Big head versus little head

Ejaculation is an event that takes place in the penis; orgasm occurs in the brain.

The process of emission and ejaculation is actually a very complex and highly coordinated neurological event involving several specific centers in the brain (amygdala, thalamus and other areas), spinal cord and peripheral nervous system.

What makes up the love juices?

Less than 5% of the volume of semen is actually sperm and the other 95+% is a cocktail of genital juices that provides nourishment, support and safekeeping for sperm. 70% of the volume comes from the seminal vesicles, which secrete a thick, viscous fluid and 25% from the prostate gland, which produces a milky-white fluid. A negligible amount is from the bulbo-urethral glands, which release a clear viscous fluid (pre-come) that has a lubrication function. 

What’s normal volume?

The average ejaculate volume is 2-5 cc (one teaspoon is the equivalent of 5 cc).  While a huge ejaculatory load sounds like a good thing, in reality it can cause infertility. The sperm can literally “drown” in the excessive seminal fluid. 

Why does the seminal tank dry with aging?

As men get older, there are changes in the reproductive organs, particularly the prostate gland, one of the few organs in the body that enlarges with age.

The aging prostate and seminal vesicles produce less fluid; additionally the ducts that drain the genital fluids can become clogged. In many ways, the changes in ejaculation parallel the changes in urination experienced by the aging male. Certain medications that are used to treat prostate enlargement profoundly affect ejaculatory volume. Additionally, the pelvic floor muscles—which play a vital role in ejaculation—weaken with aging. 

What about the pelvic floor muscles?

The pelvic floor muscles play a key role in ejaculation. The bulbocavernosus muscle (BC) is the motor of ejaculation, that which supplies the “horsepower.” The BC surrounds the inner, deepest portion of the urinary channel. It is a compressor muscle that during sex engorges the spongy erection chamber that surrounds the urethra and engorges the head of penis. At the time of climax, the BC expels semen by virtue of its strong rhythmic contractions, allowing ejaculation to occur and contributing to orgasm.

A weakened BC muscle may result in semen dribbling with diminished force or trajectory, whereas a strong BC can generate powerful contractions that can forcibly ejaculate semen at the time of climax.

How to get the juices flowing again?

Pelvic floor muscle training can be a useful tool to improve ejaculation. The stronger the BC, the higher the ejaculatory horsepower and the better the capacity for engorgement of the erection chamber that envelopes the urethra, resulting in optimized urethral pressurization and ejaculation. The intensified ejaculation resulting from a robust BC can enhance the orgasm that accompanies the physical act of ejaculation.

Written by Dr. Andrew Siegel

How To Use Your Pelvic Floor Muscles to Overcome Overactive Bladder

28 Oct 2019 Blog

What is overactive bladder?

Overactive Bladder (OAB) is defined as urinary urgency (the sudden and urgent desire to urinate) and frequency (urinating too often, which can be during both awake and sleep hours), with or without urgency incontinence (urinary leakage associated with the urgent desire to urinate). It’s often due to involuntary contractions of the urinary bladder in which the bladder squeezes without its owner’s permission. Although it can occur without provocation, it’s commonly triggered by positional changes such as going from sitting to standing, exposure to running water, approaching a bathroom, and when placing the key in the door to one’s home.

The American Urological Association guidelines for OAB recommend pelvic floor muscle (PFM) training as first-line therapy for OAB. Voluntary PFM contractions can effectively inhibit involuntary bladder contractions and squelch the urgency and urgency incontinence.

How does the bladder work?

In order to effectively tap into the powers of the pelvic floor, a basic understanding of bladder function is necessary. During urine storage, the bladder muscle is in a relaxed, non-contracting state, and the urinary sphincters – responsible for urinary control – are engaged (contracted). During urine emptying, the bladder muscle contracts and the sphincter muscles relax synchronously.

This “antagonistic” relationship between the bladder muscle and the PFMs can be used to the advantage of those suffering with OAB. Because people with OAB often have bladders that contract involuntarily causing the symptoms of urgency and frequency, a means of getting the bladder to relax is to intentionally engage the PFMs to benefit from the reflex relaxation of the bladder that occurs with voluntary contraction of the PFMs.

The PFM-Bladder Reflex

This is a very useful and practical reflex that you can easily access. This reflex is unique because it can be engaged voluntarily and because it results in the relaxation of a muscle as opposed to its contraction. Anyone who has ever experienced an urgent desire to urinate or move one’s bowels will find this reflex of great practical use. When the reflex is deployed, it will result in relaxation of both the urinary bladder and rectum and a quieting down of the urgency.

How to Use the PFM-Bladder Reflex To Overcome OAB

When you feel the sudden and urgent desire to urinate, pulse the PFMs five times, briefly but intensely. When the PFM are so deployed, the bladder muscle reflexively relaxes and the feeling of intense urgency should disappear. Likewise, when the PFMs are so deployed, the rectum relaxes and the feeling of intense bowel urgency should diminish. This reflex is a keeper when you are stuck in traffic and have no access to a toilet!

PFM training helps stimulate the inhibitory reflex between the PFMs and the bladder muscle. A PFM training program will stimulate your awareness of the PFMs and enable you to isolate them and increase their strength, tone, and endurance. The inhibitory reflex will become more robust and you’ll develop an enhanced ability to counteract urgency, frequency and urgency incontinence. Urgency can often be diminished and the urgency incontinence can often be abolished.

Getting beyond inhibiting urgency after it occurs is preventing it from occurring in the first place.  In order to do so, it’s important to recognize the specific triggers that induce the urgency, frequency or incontinence: hand washing, key in the door, rising from sitting, running water, entering the shower, cold or rainy weather, etc.  Prior to exposure to a trigger, rapid flexes of the PFM can preempt the involuntary bladder contraction before it has a chance to occur.

Bottom Line: There are many treatments available for OAB, including decreasing your fluid and caffeine intake, bladder retraining, oral medications, Botox injections into the bladder and neurostimulation. As a first-line approach, tap into the powers of your PFM and harness the natural reflex in which involuntary bladder contractions can be inhibited or prevented by engaging your PFM.

Written by Dr. Andrew Siegel

Peyronie’s Disease: Causes and Treatment Options

21 Oct 2019 Blog

Peyronie’s Disease is an inflammatory condition of the penis that causes penile curvature and an uncomfortable or painful erection that can dramatically interfere with one’s sexual health. It’s not uncommon, with more than 120,000 cases per year in the USA (only a small fraction of cases are actually treated.) Although it can manifest at any age, it most commonly occurs in 50-60 year olds.

What causes Peyronie’s Disease?

Essentially, Peyronie’s Disease is caused by scar tissue in a bad location, which sabotages the ability to obtain a straight and rigid erection. It causes fibrous, inelastic “plaques” of the sheath surrounding the erectile chambers within the penis, resulting in deformities of the penis during erections. It can also cause a hard lump or lumps, shortening, curvature and bending, narrowing, and/or a visual indentation of the penis described as an hourglass deformity. These deformities lead result in painful, less rigid erections that can dramatically interfere with one’s sexual and psychological health.

The underlying cause of Peyronie’s is unclear, but is suspected to be penile trauma—perhaps associated with excessive bending and buckling from sexual intercourse—that activates an abnormal scarring process. The acute phase is characterized by painful erections and an evolving scar, curvature and deformity. The chronic phase typically occurs up to 18 months after initial onset and is characterized by resolution of pain and inflammation, stabilization of the curvature and deformity, and possible erectile dysfunction.

What are the side effects of Peyronie’s Disease?

Penile pain, curvature, and poor expansion of the erectile cylinders contribute to difficulty in having a functional and anatomically correct rigid erection suitable for intercourse. The curvature can range from a very minor, barely noticeable deviation to a deformity that requires “acrobatics” to achieve vaginal penetration, to an erection that is so angulated that intercourse is impossible. The angulation can occur in any direction and sometimes involves more than one angle, depending on the number, location and extent of the scarring. Although the scarring is physical, it often has psychological ramifications, causing anxiety and depression.

Peyronie’s regresses in about 15% of men, progresses in 40% of untreated men, and remains stable in 45% of men. Many men become very self-conscious about the appearance of their penis and the limitations it causes, and they may avoid sex entirely.

What are the treatment options for Peyronie’s Disease?

Treatment options include:

  • Oral medications
  • Topical agents
  • Injections into the scar tissue
  • Shock wave therapy
  • Surgery

Upon initial diagnosis, most men are started on oral Vitamin E, 400 IU daily, as this has the potential to soften the scar tissue causing the plaque. Many of the treatments listed above are not particularly effective because scar tissue is a challenging problem.

If there is an unsatisfactory response to conservative treatment options, a penile implant may be appropriate. This can manage the dual problems of erectile dysfunction and penile angulation. If erections are adequate, but angulation precludes intercourse, options include procedures that attempt to counteract the curvature by doing a nip and tuck opposite the plaque in an effort to make expansion more symmetrical. Although this technique is effective in improving the angulation, it does so at the cost of penile shortening. Other more complex procedures involve incising or removing the scar tissue and using grafting material to replace the tissue defect.

Written by Dr. Andrew Siegel 

Hydrocele: Symptoms, Diagnosis & Treatment

14 Oct 2019 Blog

What is a hydrocele?

A hydrocele is an accumulation of fluid within the sac that surrounds the testicle, resulting in ballooning and enlargement of the scrotum. It can vary in size from just slightly bigger than the actual testes to larger than a cantaloupe.

Each testicle is surrounded by a thin sac known as the tunica vaginalis. The tunica vaginalis has an inner layer and an outer layer. There is a small amount of fluid present between these two layers that serves as lubrication so the testes can rotate and move freely within the scrotum. The inner layer is responsible for manufacturing this fluid, and the outer layer is responsible for its reabsorption.

A hydrocele is a disorder of the production and reabsorption. For example, when the outer layer of the tunica vaginalis is unable to reabsorb all of the fluid that is produced by the inner layer, the fluid will gradually accumulate. Hydroceles may also result from trauma, infections, tumors or operations such as a hernia and varicocele repairs. The fluid content of most hydroceles is straw-colored and odorless.

How is a hydrocele diagnosed?

They are evaluated by physical examination and are often further characterized by an ultrasound of the scrotum, allowing for a detailed examination of the underlying testicle that often cannot be provided by physical examination because the size of the hydrocele.

How is a hydrocele treated?

Most small and moderate-sized hydroceles that are minimally symptomatic can be managed by periodic checkups. If a hydrocele progresses to the point where it causes discomfort, pain, tightness, deformity, or embarrassment, an option is to pass a needle into the hydrocele sac and drain the fluid, but this is most often just a temporary fix, as the root cause is unchanged and the fluid generally will re-accumulate.

The most definitive means of management is a relatively simple outpatient surgical procedure called a “hydrocele repair” or “hydrocelectomy.” The incision is typically made through the midline “seam” of the scrotum. The involved testicle and surrounding hydrocele sac are delivered through the incision, the sac is opened, the fluid is drained, and generally the sac is excised and oversewn. Alternatively, the opened sac is turned back on itself and sewn to itself.  Either method results in exposing the testes to the scrotal wall (as opposed to the outer layer of the tunica), which functions to resorb the fluid produced by the inner layer of the tunica. This procedure is highly successful.

Written by Dr. Andrew Siegel

Bladder Cancer: Symptoms, Diagnosis and Treatment

7 Oct 2019 Blog

In the United States, the prevalence of bladder cancer has increased greatly over the last few decades, with more than 60,000 new cases diagnosed annually. It occurs more frequently in men than in women, and is usually diagnosed in adults over 60 years old. When bladder cancer is diagnosed and treated in the early stages, the chances of survival are excellent.

More than 90% of newly diagnosed bladder cancers are urothelial cell carcinomas (cancers originating from the unique lining of the urinary tract). Most patients have superficial cancer that involves the very inner layers of the bladder wall. Less than one fourth have invasive disease that involves the deeper layers of the bladder wall, and less than 5% present with metastatic disease, defined as spread beyond the confines of the bladder.

What causes bladder cancer?

Cancer-causing agents (carcinogens) are most often responsible for bladder cancer. Bladder cancer is highly associated with tobacco smoking. Even if one stopped smoking years ago, the risk is related to the quantity of tobacco smoked over the years. The carcinogens that are present in tobacco are absorbed through the lungs, into the bloodstream, and are filtered through the kidneys directly into the bladder, where their prolonged contact time with the lining of the bladder leads to cancerous changes.

Certain occupations put people at a greater risk for bladder cancer because of exposure to chemicals, including: hairdressers, painters, machinists, printers, and those who work with dyes, textiles, rubber, leather, and petrochemicals.

What are the symptoms of bladder cancer?

Bladder cancer most commonly manifests with blood in the urine, either visible or microscopic (seen only under microscopic magnification). It may also cause irritative lower urinary tract symptoms including urgency, frequency, discomfort with urinating, and urinary leakage.

How is bladder cancer diagnosed?

The evaluation for blood in the urine includes imaging, cytology, and cystoscopy.

  • Imaging tests are means of visualizing the anatomy of the urinary tract, typically through ultrasound, computerized tomography (CT), or magnetic resonance imaging (MRI).
  • Cytology is a microscopic inspection of a urine sample by a pathologist for the presence of abnormal or cancerous cells that slough off the lining of the bladder, similar to a Pap smear done to screen for cervical cancer.
  • Cystoscopy is a visual inspection of the entire lower urinary tract (bladder and urethra) using a tiny, flexible, lighted instrument attached to a camera and monitor.

When a bladder tumor is identified on cystoscopy, attention is directed to the number of tumors present, their size, location within the bladder, and physical appearance.

Once a bladder tumor is recognized, it needs to be removed and sent for pathological evaluation. This is performed under general or spinal anesthesia via cystoscopy, using an electric loop which is used to remove the area of concern as well as cauterize (use electricity to coagulate tissue) the underlying and adjacent tissue, both to stop bleeding and further destroy tumor cells.

The biopsied tissue is carefully examined by a pathologist, who will provide valuable information regarding malignancy vs. benignity, the type of tumor, depth of tumor, and grade of tumor.

Types of Bladder Cancer

The biopsy information will enable the staging of the bladder cancer, a means of classifying the cancer. Staging of bladder cancer is as follows:

  • Ta: Superficial cancer is found only in polyps (papillary) on the surface of the inner lining of the bladder.
  • Tis: Carcinoma-in-situ. Tumor is found only in flat lesions on the surface of the inner lining of the bladder.
  • T1: Tumor is found in the connective tissue below the lining of the bladder but has not spread to the bladder muscle.
  • T2: Tumor has spread to the muscle layer deep to the lining of the bladder.
  • T3a: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer as identified under microscopic examination.
  • T3b: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer and is capable of being identified without a microscope.
  • T4: Tumor has spread to the prostate in men and to the uterus or vagina in women, or to the pelvic or abdominal wall in either gender.

How is bladder cancer treated?

Bladder cancer often needs to be treated with a surgical procedure involving either partial or complete removal of the urinary bladder. If the entire bladder needs to be removed, the ureters (tubes that conduct the urine from the kidneys to the bladder) need to be diverted to a piece of intestine that is either attached to the skin to a collection bag or attached to the urethra (neo-bladder or “reconstructed” bladder). At times, in lieu of surgery, chemo-radiation can be utilized (a combination of radiation therapy provided by the radiation oncologist and chemotherapy provided by the medical oncologist).

Superficial cancers are usually managed with cystoscopy, with regular “surveillance” due to the high predilection for recurrence. It’s important to have frequent check-ups (every 3 months for the first year after initial diagnosis), consisting of periodic urinalysis, urine cytology, imaging, and cystoscopy. If surveillance does not demonstrate any recurrences, the interval between follow up can gradually be increased (to every 6 months in the 2nd year; if there are no recurrences, to an annual check-up). If a recurrence is found, treatment must be repeated and the surveillance frequency then starts anew with the every 3-month cycle.

To help prevent recurrence, under certain circumstances it is beneficial to use a medication that is instilled in the bladder on a weekly basis—this is especially useful when many tumors are present, in the presence of a high-grade tumor, or cancers that have recurred. It’s particularly useful for carcinoma-in-situ (CIS), a variant of bladder cancer that is very superficial, flat, yet of a high-grade pathological nature. The medication of choice is tuberculosis vaccine—BCG (bacillus Calmette Guerin), which is a live, attenuated (weakened) form of tuberculosis bacteria!

Written by Dr. Andrew Siegel

What Causes Chronic Testicular Pain?

30 Sep 2019 Blog

Orchialgia is the medical term for chronic testicular pain, defined as constant or intermittent pain in the testicles, lasting for three or more months and interfering with one’s quality of life. It’s not an uncommon problem for men of all ages, but it is seen more frequently in young adults. It certainly keeps us busy in the office…some morning sessions seem like “ball clinics”!

What do the testes do?

The testes are paired, oval-shaped organs that are housed in the scrotal sac. They have two functions, testosterone and sperm production. The tough, protective cover of the testes (tunica albuginea) encase tiny tubes called seminiferous tubules which make sperm cells. The testes also contain specialized cells called Leydig cells that produce testosterone. Sperm from the testes travels to the epididymis for storage and maturation. The epididymis empties into the vas deferens, which conducts sperm to the ejaculatory ducts.

Where are the testes located?

The testes are suspended in the scrotal sac via the spermatic cord, a “rope” of tissue containing connective tissue, the vas deferens, the testes arteries, veins, lymphatics, and nerves. The spermatic cord is enveloped by tissues that are extensions of the connective tissue coverings of three of the abdominal core musclesThe most important of these coverings surrounding the spermatic cord is the cremaster muscle, which elevates the testes in a northern direction when it contracts.

What does the scrotal sac do?

The scrotal sac has several functions. The scrotal sac houses the testes and aids in their function by regulating their temperature. For optimal sperm production, the testes need to be a few degrees cooler than core temperature. The dartos muscle within the scrotal wall relaxes or contracts depending on the ambient temperature, allowing the testes to elevate or descend to help maintain this optimal temperature. Under conditions of cold exposure, the dartos contracts, causing the scrotal skin to wrinkle and to bring the testicles closer to the body. When exposed to heat, dartos relaxation allows the testicles to descend and the scrotal skin to smoothen.

What causes chronic testicular pain?

Chronic testicular pain can be caused by numerous conditions, and it’s important to rule out the following possibilities:

  • Infection: An infection of the testes (orchitis), epididymis (epididymitis), both (epididymo-orchitis), or the spermatic cord (funiculitis). Infections can be bacterial, viral, and at times inflammatory without an actual infection.
  • Tumor: A benign or malignant mass of the testes or epididymis.
  • Groin hernia: A prolapse of intra-abdominal contents through a weakness in the connective tissue support of the groin.
  • Torsion: A twist of the testes or one of the testes or epididymal appendages.
  • Hydrocele: An excess fluid collection in the sac surrounding the testes.
  • Spermatocele: A cyst resulting from a blockage of one of the sperm ducts within the epididymis.
  • Varicocele: Varicose veins of the spermatic cord.
  • Trauma: Injury.
  • Prior operations: Groin hernias are most commonly associated with chronic testes pain; less commonly, vasectomies and any other type of groin or pelvic surgery.
  • Referred pain: Pain perceived in the testes, but originating elsewhere, e.g., a kidney stone that has dropped into the ureter, or a lower spine issue affecting the nerves to the testes.
  • Tendonitis: There are numerous muscles with tendons that insert into the pubic bone region that can be subject to injury and inflammation.
  • Pelvic floor muscle tension myalgia: Excessive muscle tension in these muscles can cause pelvic pain, including pain in the testes.
  • Idiopathic: This fancy medical term means that we are clueless about the origin of the pain. Unfortunately, many men have idiopathic orchialgia, a distressing and frustrating experience for both patient and urologist.

The evaluation of the patient with chronic testicular pain includes a detailed medical history and a careful examination of the scrotal contents, groin, and prostate, if necessary. A urinalysis and urine culture will also be taken. It’s also helpful to obtain an ultrasound of the scrotum, a study which utilizes sound waves to image the testicle and epididymis. On occasion, it’s warranted to obtain imaging studies of the upper urinary tract and pelvis, as well as a CT or MRI of the spine if there is back or hip pain.

Can chronic testicular pain be treated?

The management of chronic testicular pain is directed at the underlying cause, although unfortunately this cannot always be precisely determined. Often, a course of antibiotics may prove helpful even if the physical findings are indeterminate. Anti-inflammatory medications such as Advil and ibuprofen are often useful in the short-term management. Supportive, elastic jockey shorts as well as local application of a heating pad can be helpful. At times, amitriptyline or Neurontin can be helpful for neurologically-derived pain. If the source of the pain is felt to be tension myalgia, referral to a pelvic floor physical therapist can be beneficial. A referral to a pain specialist, typically an anesthesiologist who focuses on this discipline, can be advantageous.

An injection of a local anesthetic into the spermatic cord (spermatic cord block) can be a useful diagnostic test and a means of alleviating the pain. If spermatic cord block proves successful in relieving the pain, it may be necessary to surgically denervate the spermatic cord, a procedure in which the nerve fibers in the spermatic cord are divided. Under extremely rare circumstances, removal of the epididymis or the testicle is necessary. Often chronic testis pain remains elusive with the source undetermined and is thought to be similar to other chronic inflammatory conditions.

Written by Dr. Andrew Siegel

What Is PSA And Why Should It Concern Me?

23 Sep 2019 Blog

What is PSA?

PSA (prostate specific antigen) is a chemical produced by the prostate gland. It functions to liquefy semen following ejaculation, aiding the transit of sperm to the egg. A small amount of PSA filtrates from the prostate into the blood circulation and can be measured by a simple blood test. In general, the larger the prostate size, the higher the PSA level since larger prostates produce more. As a man ages, his PSA rises based upon the typical enlarging prostate that occurs with growing older.

Why screen for prostate cancer?

Excluding skin cancer, prostate cancer is the most common cancer in men (1 in 7 lifetime risk), accounting for about one-quarter of newly diagnosed cancers in males. Prostate cancer causes absolutely no symptoms in its earliest stages and the diagnosis is made by prostate biopsy done on the basis of abnormalities in PSA levels and/or digital rectal examination. An elevated or accelerated PSA that leads to prostate biopsy and a cancer diagnosis most often detects prostate cancer in its earliest and most curable state. Early and timely intervention for men with aggressive cancer results in high cure rates and avoids the potential for cancer progression and consequences that include painful cancer spread and death.

The upside of screening is the detection of potentially aggressive prostate cancer that can be treated and cured. The downside is the over-detection of unaggressive prostate cancers that may never prove to be problematic, but may result in unnecessary treatment with adverse consequences. The downside of not screening is the under-detection of aggressive prostate cancers, with adverse consequences from necessary treatment not being given.

How is PSA used to screen for prostate cancer?
Although it’s an imperfect screening test, PSA remains the best tool currently available for detecting prostate cancer. It shouldn’t be thought of as a stand-alone test, but rather as part of a comprehensive approach to early prostate cancer detection. Baseline PSA testing for men in their 40s is useful for predicting the future potential for prostate cancer.

Upon PSA testing, about 90% of men are found to have a normal PSA. Of the 10% of men with an elevated PSA, 30% or so will have prostate cancer. In a recent study of 350,000 men with an average age of 55, median PSA was 1.0. Those with a PSA < 1.5 had a 0.5% risk of developing prostate cancer, those between 1.5-4.0 had about an 8% risk, and those > 4.0 had greater than a 10% risk.

Why is PSA elevated in the presence of prostate cancer?

Prostate cancer cells do not make more PSA than normal prostate cells. The elevated PSA occurs because of a disruption of the cellular structure of the prostate cells. The loss of this structural barrier allows accelerated seepage of PSA from the prostate into the blood circulation.

There is no letter C (for cancer) in PSA

Not all PSA elevations imply the presence of prostate cancer. PSA is prostate organ-specific but not prostate cancer-specific. Other processes aside from cancer can cause enhanced seepage of PSA from disrupted prostate cells. These include prostatitis (inflammation of the prostate), benign prostatic hyperplasia (BPH, an enlargement of the prostate gland), prostate manipulation (e.g., a vigorous prostate examination, prostate biopsy, prolonged bike ride, ejaculation, etc.).

Why is PSA not a perfect screening test?

PSA screening is imperfect because of false negatives (presence of prostate cancer in men with low PSA) and false positives (absence of prostate cancer in men with high PSA). Despite its limitations, PSA testing has substantially reduced both the incidence of metastatic disease and the death rate from prostate cancer.

How is PSA used in men diagnosed and treated for prostate cancer?

PSA is unquestionably the best marker to gauge prostate cancer status in the follow-up of men who have been treated for prostate cancer by any means. After surgical removal of the prostate gland for cancer, the PSA should be undetectable and after radiation therapy the PSA should decline substantially to a reading of usually less than 1.0. Rising PSA levels after treatment may be the first sign of cancer recurrence. Such a “biochemical” relapse typically precedes a “clinical” relapse by months or years.

How is PSA best used to screen for prostate cancer?

The most informative use of PSA screening is when it’s obtained serially, with comparison on a year-to-year basis providing much more meaningful information than a single, out-of-context PSA. Because PSA values can fluctuate from lab to lab, it’s always a good idea to try to use the same laboratory for the testing.

Who should be screened for prostate cancer?

Men age 40 and older who have a life expectancy of 10 years or greater are excellent candidates for PSA screening. Most urologists do not believe in screening or treating men who have a life expectancy of less than 10 years. This is because prostate cancer rarely causes death in the first decade after diagnosis and other competing medical issues often will do so before the prostate cancer has a chance to. Prostate cancer is generally a slow-growing process and early detection and treatment is directed at extending life well beyond the decade following diagnosis.

The age at which to stop screening needs to be individualized, since “functional” age trumps “chronological” age and there are men 75 years old and older who are in phenomenal shape, have a greater than 10-year life expectancy and should be offered screening. This population of older men may certainly benefit from the early diagnosis of aggressive prostate cancer that has the potential to destroy quantity and quality of life. However, if a man is elderly and has medical issues and a life expectancy of less than 10 years, there’s little sense in screening. Another important factor is individual preference since the decision to screen should be a collaborative decision between patient and physician.

What are refinements in PSA testing?

PSA Velocity – Comparing the PSA values year to year is most informative. Generally, PSA will increase by only a small increment, reflecting benign prostate growth. If PSA accelerates at a greater rate than anticipated—a condition known as accelerated PSA velocity—further evaluation is indicated.

An isolated PSA (out of context) is not particularly helpful. What is meaningful is comparing PSA on a year-to-year basis and observing for any acceleration above and beyond the expected annual incremental change associated with aging and benign prostate growth. Many labs use a PSA of 4.0 as a cutoff for abnormal, so it is possible that one can be falsely lulled into the impression that their PSA is normal. For example, if the PSA is 1.0 and a year later it is 3.0, it is still considered a “normal” PSA (because it is less than 4.0) even though it has tripled (highly suspicious for a problem) and mandates further investigation.

PSA Density – PSA density (PSA divided by prostate volume) is the PSA level corrected to the size of the prostate. The prostate volume can be determined by imaging studies including ultrasound or MRI. PSA elevations are less worrisome under the circumstance of an enlarged prostate. A PSA density > 0.15 is concerning for prostate cancer.

Free PSA – PSA circulates in the blood in two forms: a “free” form in which the PSA is unbound, and a “complex” PSA in which the PSA is bound to a protein. The free PSA/total PSA ratio can offer a predictive value (similar to how HDL cholesterol/total cholesterol can be helpful in a person with an elevated cholesterol level). The higher the free to total PSA ratio, the greater the chance that benign enlargement of the prostate is the underlying source of the PSA elevation. In men with a PSA between 4 and 10, the probability of cancer is 9-16% if the free/total PSA ratio is greater than 25%; 18-30% if the ratio is 19-25%; 27-41% if the ratio is 11-18%, and the probability of cancer increases to 49-65% if the ratio is less than 10%.

4Kscore test – The 4Kscore Test is a refinement that measures the blood content of four different prostate-derived proteins: total PSA, free PSA, intact PSA and human kallikrein 2. Levels of these biomarkers are combined with a patient’s age, DRE status (abnormal DRE vs. normal DRE), and history of prior biopsy status (prior prostate biopsy vs. no prior prostate biopsy). These factors are processed using an algorithm to calculate the risk of finding a Gleason score 7 or higher (aggressive) prostate cancer if a prostate biopsy were to be performed. The test can increase the accuracy of prostate cancer diagnosis, particularly in its most aggressive forms. (It cannot be used if a patient has received a DRE in the previous 4 days, nor can it be used if one has been on Avodart or Proscar within the previous six months. Additionally, it cannot be used in patients that have within the previous six months undergone any procedure to treat symptomatic prostate enlargement or any invasive urologic procedure that may be associated with a PSA elevation.)

What is prostate MRI?

MRI is a high-resolution imaging test that does not require the use of radiation and is capable of showing the prostate and surrounding tissues in multiple planes of view, identifying suspicious areas. MRI uses a powerful Tesla magnet and sophisticated software that performs image-analysis, assisting radiologists in interpreting and scoring MRI results. A validated scoring system known as PI-RADS (Prostate Imaging Reporting and Data System) is used. This scoring system helps urologists make decisions about whether to biopsy the prostate and if so, how to optimize the biopsy.

PI-RADS Classification & Definition:
I – Most probably benign
II – Probably benign
III – Indeterminate
IV – Probable cancer
V – Most probably cancer

What is the definitive test for prostate cancer?

Prostate biopsy (ultrasound guided) is the definitive and conclusive test for prostate cancer. An elevated or accelerated PSA, abnormal digital rectal exam and suspicious MRI are all helpful, but “the buck stops here” with prostate biopsy, the conclusive test for prostate cancer.

Bottom Line: PSA testing provides valuable information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. PSA screening has resulted in detecting prostate cancer in its earliest and most curable stages, before it has a chance to spread and potentially become incurable.  PSA screening has unequivocally reduced metastatic prostate cancer and death from prostate cancer and it is recommended that the test be obtained annually starting at age 40 in men who have greater than a 10 year life expectancy.

Written by Dr. Andrew Siegel

6 Ways to Reduce Your Risk of Prostate Cancer

16 Sep 2019 Blog

Wouldn’t it be wonderful if prostate cancer could be prevented? Unfortunately, we’re not there yet—but we do have an understanding of what measures can be taken to help reduce your risk of developing prostate cancer.

Precancerous lesions are commonly seen on prostate biopsy many years before the onset of prostate cancer. We also know that there’s an increased prevalence of prostate cancer with aging. These facts suggest that the process of developing prostate cancer takes place over a long period of time—often more than a decade—from the initial prostate cell mutation to the time when prostate cancer manifests with either a PSA elevation, an acceleration in PSA, or an abnormal digital rectal examination. This means that there’s an opportunity for intervention before prostate cancer is established.

Here are six ways to reduce your risk of prostate cancer (and reduce risk of progression for men on active surveillance):

  1. Maintain a healthy weight, since obesity has been correlated with an increased prostate cancer incidence.
  2. “Eat food. Not too much. Mostly plants.” The smart advice from Michael Pollan. A healthy diet consists of abundant fruits and vegetables (full of antioxidants, vitamins, minerals and fiber) and real food, as opposed to processed and refined foods. Eat plenty of red vegetables and fruits including tomato products (rich in lycopene). Legumes (beans, nuts, peas, lentils, etc.) have an anti-inflammatory effect. Consume animal fats and dairy in moderation. Eat fatty fish containing omega-3 fatty acids such as salmon, tuna, sardines, trout and mackerel.
  3. Avoid tobacco and excessive alcohol intake.
  4. Staying active and exercising on a regular basis can reduce your risk for prostate cancer. If you do develop prostate cancer, you will be in tip-top physical shape and will heal that much better from any intervention necessary to treat the prostate cancer.
  5. Get checked out! Be proactive by seeing your doctor annually for a digital rectal exam of the prostate and a PSA blood test. Abnormal findings on these screening tests are what prompt prostate biopsies, the definitive means of diagnosing prostate cancer. The most common scenario that leads to a diagnosis of prostate cancer is a PSA acceleration, an elevation above the expected incremental annual PSA rise based upon the aging process.

It’s important to mention that an isolated PSA (out of context) is not particularly helpful. What is meaningful is comparing PSA on a year-to-year basis and observing for any acceleration above and beyond the expected annual incremental change associated with aging and benign prostate growth. Many labs use a PSA of 4.0 as a cutoff for abnormal, so it is possible that you can be falsely lulled into the impression that your PSA is normal.  For example, if your PSA is 1.0 and a year later it is 3.0, it is still considered a “normal” PSA even though it has tripled (highly suspicious for a problem) and mandates further investigation.

A healthy lifestyle, including a wholesome and nutritious diet, maintaining proper weight, exercising regularly and avoiding tobacco and excessive alcohol can lessen one’s risk of all chronic diseases, including prostate cancer. Be proactive by getting a 15-second digital exam of the prostate and PSA blood test annually. Prevention and early detection are key to maintaining both quantity and quality of life.

Written by Dr. Andrew Siegel

Prostate Cancer: Risk Factors and Treatment Options

9 Sep 2019 Blog

After a prostate cancer diagnosis, there can be a lot of information to take in. The path you and your doctor decide to take for treatment depends on certain factors including the stage of the cancer, your age, and your prostate-specific antigen (PSA) test results, among others.

Risk Factors for Prostate Cancer

You may have a higher risk of developing prostate cancer if you:

  • Are over 65 years old
  • Have a family history of prostate cancer
  • Are African American

Treatment Options for Prostate Cancer

There may be more than one treatment necessary and recommended by your doctor. Common prostate cancer treatments include:

  • Radiation therapy – Radiation therapy is often used after surgery when the cancer hasn’t spread outside of the prostate. This treatment requires radioactive seeds to be placed inside the prostate gland and is often done when the cancer is found early.
  • Hormonal therapy – These types of treatments block the effect or creation of testosterone. Because prostate tumors need testosterone to grow, hormonal therapy can prevent further growth of the cancer. This treatment does not cure the cancer.
  • Medication – Medication is given to help the body’s immune system fight cancer.
  • Prostatectomy – A surgical procedure to remove the prostate and surrounding tissue.

Types of Prostatectomy

There are four main types of prostatectomy:

  • Retropubic Surgery – requires an incision below the belly button to remove the prostate gland, causing as little damage to the nerves and blood vessels as possible.
  • Perineal Surgery – a cut is made between the anus and base of the scrotum. This is a smaller incision than the retropubic technique, but it is harder to spare nerves or remove lymph nodes.
  • Laparoscopic Surgery is when the surgeon makes several small cuts and uses long tools and a video camera to see inside during the procedure.
  • Robotic-assisted da Vinci® Surgery – the da Vinci® surgical system can be used to perform a prostatectomy. This technology allows your surgeon to make several small incisions as opposed to one larger incision, and the surgeon has a 3D view inside your body. The robotic-assisted surgical device can bend and rotate more than the human hand for better precision and control during the procedure.

Discuss your screening and treatment options with your urologist at New Jersey Urology.

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