How to Naturally Boost Your Testosterone Levels

15 Jul 2019 Blog

Testosterone has become a very in-vogue term. Many patients come into the office specifically asking for their testosterone levels to be checked.  The pharma industry has aggressively pursued direct-to-consumer advertising of testosterone replacement products, which has promoted a grass-roots awareness of testosterone issues, a topic that was previously the domain of urologists and endocrinologists.

So what is testosterone?

Testosterone (or T) is that all-important male hormone that goes way beyond male sexuality and is now regarded as a key factor in men’s health. Aside from contributing to libido, masculinity and sexual function, T is responsible for the physical changes that begin at puberty, including pubic, underarm and facial hair, deepening voice, prominent Adam’s apple and increased bone and muscle mass. Additionally, T contributes to your mood, bone and muscle strength, red blood cell count, energy, and general mojo.

What are the symptoms of low testosterone?

Most testosterone is manufactured in the testicles, although a small percentage is made by the adrenal glands.  There is a gradual decline in T that occurs with the aging process—approximately a 1% decline each year after age 30. This will occur in most men, but will not always be symptomatic. 40% of American men aged 45 or older have low or low range T.

Low T is associated with diabetes, bone mineral loss, and altered sexual function. Specifically, symptoms of low T may include one or more of the following:

  • fatigue
  • irritability
  • depression
  • decreased libido
  • erectile dysfunction
  • impaired orgasmic function
  • decreased energy and sense of well being
  • loss of muscle and bone mass
  • increased body fat
  • abnormal lipid profiles.

How obesity and lifestyle choices can affect testosterone levels

Obesity plays a pivotal role in the process leading to low T. Fat is not just fat—it is a metabolically active endocrine organ that does way more than just protrude from your abdomen. Fat has an abundance of the hormone aromatase, which functions to convert testosterone to the female sex hormone estrogen. The consequence of too much conversion of testosterone to estrogen is the potential for gynecomastia, (a.k.a. man boobs). Too much estrogen slows testosterone production, and with less testosterone, more abdominal obesity occurs and even more estrogen is made, a vicious cycle of emasculation.

The good news is that by losing abdominal fat, the unfortunate consequences of low T can often be reversed.

How to naturally boost your testosterone levels

  • A healthy lifestyle, including good eating habits, maintaining a healthy weight, engaging in exercise, obtaining adequate sleep, moderation with respect to alcohol intake, avoiding tobacco, and stress reduction are the initial approaches to treating low T. Insufficient sleep can lower T, and excessive alcohol increases the conversion of testosterone to estrogen. Maintaining an active sex life can help maintain T.
  • Lose the abdominal fat, with the caveat that a sufficient caloric intake of quality food and nutrients is necessary to prevent the body going into “starvation mode,” which can substantially decrease T production.
  • In terms of exercise, a healthy balance of aerobic, resistance, and core training is best. In particular, vigorous resistance exercise is crucial. This will help the flabby abdomen disappear and build lean muscle mass, which in turn will increase your metabolic rate.

Other treatment options for low testosterone

If lifestyle modifications fail to improve the symptoms of low T and levels remain measurably low via a simple blood test, a trial of T replacement under the supervision of your doctor can provide a meaningful improvement of your quality of life.

Written by Dr. Andrew Siegel

Kidney Disease: Symptoms, Treatment and Prevention

8 Jul 2019 Blog

Kidney disease is a very common cause of serious illness, affecting more than 25 million Americans. Each year approximately 110,000 new patients start dialysis treatments in the US, and kidney disease is responsible for nearly 100,000 American deaths annually.

How do the kidneys work under normal circumstances?

Our kidneys are a pair of bean-shaped, fist-sized organs that work diligently and silently behind the scenes constantly, filtering our blood free of toxins and waste products so that we can maintain a healthy existence. When they are working well, they are often taken for granted. The renal arteries bring blood to the kidneys, the kidneys do their magic, and the cleansed and purified blood is returned into the renal veins, with the liquid waste—urine—excreted into the ureters that drain into the urinary bladder.

If the kidneys stop working properly, excessive fluid and toxic waste builds up rapidly, resulting in death within a matter of days to weeks. Death by kidney failure is described as “euphoric” because of the very abnormal blood chemistries and electrolyte disturbances that occur…not that death is something to be “giddy” about, but kidney failure just happens to be an easier, more peaceful way to exit the planet than many others.

Because of their critical importance to our healthy existence, we should take great care of these prized possessions which nature gave us in duplicate. This “spare tire” is capable of sustaining life in the event of trauma, cancer requiring surgical removal, donating a kidney or other issues resulting in loss of one kidney.

The kidneys are multifunctional, not only filtering our blood to remove waste products, but also responsible for regulating fluid, electrolyte, acid-base balance and blood pressure. They are in charge of maintaining the proper fluid volume within our blood stream. They regulate the levels of our electrolytes including sodium, potassium, chloride, etc. They keep our blood pH (indicator of acidity) at a precise level to maintain optimal function. They are key players in the regulation of blood pressure. Furthermore—and unbeknownst to many—they are responsible for the production of several important hormones: calcitrol (calcium regulation), erythropoietin (red blood cell production), and renin (blood pressure regulation).

What is kidney disease?

Under normal circumstances, the kidneys filter the blood, removing waste products and excessive fluid, returning into circulation the body’s important chemicals and constituents. When the filtration system is not working properly, one’s system is not cleared of the bad (waste products), resulting in electrolyte disturbances and proteinuria, a condition in which what is good for the body (protein) ends up being filtered out into the urine.

When the kidneys fail (end stage renal disease), the options are peritoneal dialysis, hemodialysis, kidney transplantation, or death. Peritoneal dialysis uses the peritoneal membrane that lines the abdomen as a filter to clear wastes and extra fluid from the body. Hemodialysis involves being hooked up to a machine that mimics the function of the kidneys; it requires three sessions weekly that take about 3-4 hours per session.

What are the symptoms of kidney disease?

The unfortunate thing about kidney disease is that it typically causes few symptoms until it is advanced; however, simple tests are capable of detecting it. Symptoms of kidney disease are non-specific and may include the following:

  • fatigue
  • decreased energy
  • poor appetite
  • difficulty concentrating
  • insomnia
  • swollen ankles and feet
  • nighttime muscle cramping
  • puffiness around one’s eyes
  • dry and itchy skin
  • frequent urination, particularly at night

How is kidney disease diagnosed?

A definitive sign of kidney disease is the presence of protein in the urine, which is easily detectable on a urinalysis. Additionally, uncontrolled high blood pressure is highly suggestive of kidney disease, as is an elevated serum creatinine, detectable by a simple blood test. Early detection is critical as it can help prevent kidney disease from progressing to kidney failure. The bottom line is that three simple tests can detect kidney disease: blood pressure; serum creatinine; urine albumin (protein).

What are the risk factors for kidney disease?

Risk factors for kidney disease include:

  • African-American race
  • diabetes
  • high blood pressure
  • family history of kidney disease

The two leading causes of chronic kidney disease are hypertension and diabetes, responsible for about two thirds of cases.

How is kidney disease treated?

Urologists are the specialists who deal with surgical kidney issues whereas nephrologists are the specialists who deal with medical kidney tissues including hypertension and impaired kidney function. If kidney disease is diagnosed, one will typically be referred to a nephrologist for further evaluation and management. Nephrologists will typically measure the serum creatinine, and do blood and urine tests to assess the glomerular filtration rate, a quantitative test of kidney function. Often a renal ultrasound is performed and in some cases it is necessary to do a renal biopsy to find the root cause of the kidney dysfunction.

Treatment for progressive kidney disease includes interventions such as blood pressure control, often with the use of ACE inhibitors and angiotensin receptor blockers, and control of diabetes.

Nutritional interventions include dietary protein restriction that may slow the progression of chronic kidney disease. High-protein intake can worsen the proteinuria and result in the accumulation of various protein breakdown products as a result of decreasing kidney function, which can cause toxic effects.

How to prevent kidney disease

So how do we care for our kidneys? The prescription for healthy kidneys is to maintain a healthy lifestyle and, if you have been neglectful in this department, to do a lifestyle remake through the following: good eating habits; maintaining a healthy weight; engaging in exercise; obtaining adequate sleep; consuming alcohol in moderation; avoiding tobacco; and stress reduction.

Additionally, being proactive by seeing a physician on a regular basis for “scheduled maintenance” is very important in order to detect kidney disease—or any other disease—as early as possible.

Written by Dr. Andrew Siegel

9 Ways to Overcome Premature Ejaculation

24 Jun 2019 Blog

What is Premature Ejaculation?

Premature ejaculation (PE) is a condition in which sexual climax occurs before, upon, or shortly after vaginal penetration, prior to one’s desire to do so, with minimal voluntary control. It is the most common form of male sexual dysfunction. “Rapid” ejaculation may be a kinder term than “premature” ejaculation.

The key features are:

  • Brief time to ejaculation (often less than one minute)
  • Lack of control over ejaculation
  • Sexual dissatisfaction, distress and frustration of partner

How Long Should it Take to Climax?

In a study of more than 1,500 men, The Journal of Sexual Medicine reported that the average time between penetration and ejaculation for a premature ejaculator was 1.8 minutes, compared to 7.3 minutes for non-premature ejaculators.

Another study of 500 couples across five countries reported results ranging from 33 seconds to 44 minutes with the median being 5.4 minutes.

What Causes Premature Ejaculation?

PE can be psychological and/or biological and can occur because of over-sensitive genital skin, hyperactive reflexes, extreme arousal or infrequent sexual activity. Other factors are genetics, guilt, fear, performance anxiety, inflammation and/or infection of the prostate or urethra and also can be related to the use of alcohol or other substances.

PE occurs in up to 30% of men, involving all ages, ethnicities, and socio-economic groups. PE can cause embarrassment, frustration and loss of self-confidence and can be devastating to a relationship. It is very typical among men during their earliest sexual experiences.

PE can be lifelong or acquired and sometimes occurs on a situational basis. Lifelong PE is thought to have a strong biological component. Acquired PE can be biological, based on inflammation/infection of the reproductive tract or psychological, based upon situational stressors. PE can sometimes be related to Erectile Dysfunction (ED), with the rapid ejaculation brought on by the desire to climax before losing the erection.

Emphasis on ejaculation as the focal point of sexual intercourse tends to increase the performance anxiety that can initiate the problem. Once PE has occurred and established itself, fear of and mental preoccupation with the issue can actually induce the unwanted rapid ejaculation, creating a vicious cycle.

How to Overcome Premature Ejaculation

  1. Diversionary Thoughts: Non-erotic mental diversionary tactics (concentrating on thoughts other than ejaculating) may prevent PE. Baseball, work, counting backwards, etc., are examples of such thoughts, but these are rarely effective and diminish the pleasure of sexual intimacy.
  2. Down Tempo: This requires one to develop a mindfulness of the sensation immediately before ejaculation. By slowing the pace of pelvic thrusting and varying the angle and depth of penetration before the “point of no return” has passed, the feeling of imminent ejaculation may dissipate.
  3. Pause-Start Method: If slowing the tempo is not sufficient to prevent the PE, one may need to stop thrusting completely while maintaining penetration in order for the ejaculatory “urgency” to go away. Once the sensation to ejaculate subsides, pelvic thrusting may be resumed.
  4. Squeeze Technique: Originated by Masters and Johnson, as imminent ejaculation approaches, the penis is withdrawn and the head of the penis is squeezed until the feeling of ejaculation passes, after which intercourse is resumed. Although effective, it requires sexual interruption, is cumbersome and demands a very cooperative partner.
  5. Pelvic Floor Muscle Training: Contracting one’s pelvic floor muscles is a less cumbersome alternative to the Master and Johnson technique. Instead of the clunky and obvious squeeze technique, a more subtle and discreet method is to slow the pace of intercourse, pause the pelvic thrusting and do a sustained pelvic muscle contraction. This is an internal “squeeze” without the external hand squeeze and can achieve the same goal, short-circuiting the premature ejaculation. With sufficient practice and the achievement of “muscle memory,” this process can become easier and the problem of PE improved, particularly with commitment to a pelvic floor muscle training program.
  6. Decreasing Sensitivity: One method of doing so is by using thick condoms. Alternatively, local anesthetics in the form of topical creams, gels, and sprays can desensitize the penis. These include Lidocaine cream or gel, Lidocaine and Prilocaine (EMLA cream) or Lidocaine spray (Promescent) that are applied before intercourse. Another desensitization technique is increasing the frequency of ejaculation since PE tends to be more pronounced after longer periods of sexual abstinence. By masturbating prior to engaging in sexual intercourse, the PE may be controlled.
  7. Erection Pills: Viagra, Levitra, Cialis and Stendra, which are commonly used for ED, can have a role in the treatment of men with acquired PE that is due to ED.
  8. SSRI Antidepressants: These selective serotonin reuptake inhibitors can substantially delay ejaculation. One is generally started on a low dose, with an increase in dosage as necessary. Once an effective dosage is achieved, the medication can be used on a situational basis, several hours prior to sexual intercourse.
  9. Counseling: Since PE can be on a psychological basis, it may be beneficial to seek the counsel of a sexual therapist. This can be done in conjunction with some of the aforementioned techniques to hasten the resolution of the PE.

Although not life-threatening, PE is a common and distressing quality of life problem that is sometimes relationship-threatening. The good news is that there are a number of effective treatment options available, so one need not suffer with the problem.

Written by Dr. Andrew Siegel 

penile fracture

Penile Fracture: How to Treat a Broken Penis

17 Jun 2019 Blog

Although there is no bone in the human penis, there is still a risk of penile fracture that requires medical intervention and surgical treatment. 

The penis is an organ with an impressive ability to multitask, having urinary, sexual and reproductive functions.  As a urinary organ, it allows directed urination that allows men to stand to urinate and have a directed urinary flow, a very handy benefit, especially useful with respect to certain public restrooms. As a sexual and reproductive organ, the erect penis permits vaginal penetration and sexual intercourse and functions as a conduit for the placement of semen into the vagina, and hence DNA transfer and perpetuation of the species. No other organ in the body demonstrates such a great versatility in terms of the physical changes between its “inactive” versus “active” states.

Penile rigidity (or hardness) relies on the basis of blood flow. The human penis has no bone, unlike the penis of many other mammals. The function of the “bony”, or os penis, in other mammals is to facilitate sexual intercourse by maintaining penile rigidity. The human penis obtains its bone-like firmness by blood filling and inflating the spongy tissue within the two erectile cylinders of the penis (corpora cavernosa), similar to air inflating the tire of a car.

Erections are necessary to make the penis firm enough to achieve vaginal penetration. The price paid for penile rigidity is the small chance of an injury occurring when erect—as opposed to being flaccid, which is a state that is protective against blunt injuries.

What is a penile fracture?

A penile fracture is a rare but dramatic occurrence in which the outer sheath surrounding the erectile cylinders of the penis ruptures under the force of a strong blow to the erect penis. It’s not unlike the tire of a car being driven forcibly into a curb, resulting in a gash in the tread. Even though there’s no bone in the human penis, the term fracture is an appropriate term for the injury, because the outer sheath literally ruptures, resulting in a break of the integrity of the erectile cylinders. A fracture of the penis is a medical emergency, and prompt surgical repair is necessary to obtain satisfactory cosmetic and functional results.

What causes a penile fracture?

Blunt traumatic injuries rarely occur to the non-erect penis because of its mobility and flaccidity. Blunt trauma to the penis is usually of concern only when the penis is in an erect state. When the penis is rigid, there is peak tension and stretch on the outer sheath. A penile fracture occurs when this outer tunic—already under internal stretch and tension by virtue of the expansion of the erectile cylinders—is further subjected to external blunt trauma. This usually occurs under the situation of vigorous sexual intercourse, most often when the penis slips out of the vagina and strikes the perineum (area between the vagina and anus), sustaining a buckling injury.

Fracture can also occur under the circumstance of rolling over or falling onto the erect penis as well as any other situation that could inflict damage to the erect penis, such as walking into a wall in a poorly illuminated room or very forcible masturbation.

A penile fracture typically causes a rather classic and dramatic clinical scenario. An audible popping sound occurs as the outer sheath ruptures, followed by acute pain, rapid loss of erection, and purplish discoloration and extreme swelling of the penis, as the blood within the erectile cylinders escapes through the rupture site, similar to a blow-out of a car tire.

How is a penile fracture treated?

MRI can be used to demonstrate the precise site, extent and anatomy of the fracture. Penile fractures need to be promptly addressed in the operating room, as surgical repair of the injury is important in order to maintain erectile function and minimize scarring of the erectile cylinders that could result in penile bending and angulation. Essentially, the skin of the penis is temporarily degloved (peeled back like a banana skin) and the fracture is identified and repaired with sutures, after which the skin is reattached.

If allowed to heal on its own without surgical intervention, scarring will occur at the site of the fracture and many patients will develop a penile curvature with erections. As a result of the scar tissue, when an erection occurs, there is asymmetrical expansion of the erectile cylinders, resulting in a penile bend or deviation that can be to the extent as to preclude or require extreme acrobatics to have sexual intercourse.

The long and the short of it is that penile fracture is a rare but serious occurrence; this emergency situation demands an expedient trip to the operating room to maintain satisfactory erectile function. 

Written by Dr. Andrew Siegel

How Diabetes Affects Urological Health

10 Jun 2019 Blog

Did you know a common symptom of undiagnosed diabetes is frequent urination? This is because of the urine-producing effect of glucose in the urine. People with urinary frequency will often consult a urologist in error, thinking that the problem is related to their kidneys, bladder or prostate, when it’s actually the sugar in the urine that’s causing the problem. Because of this urinary frequency, urologists often have the opportunity to make the initial diabetes diagnosis and refer the patient for appropriate care.
Diabetes has harmful effects on all body systems, including urological health. Many urological problems occur as a result of diabetes, including urinary infections, kidney and bladder conditions, foreskin issues and sexual problems. Additionally, diabetes increases the risk of kidney stones.

What is diabetes?

Diabetes is a disease in which blood glucose levels are elevated. Glucose is the body’s main fuel source, derived from the diet.  Insulin, a hormone secreted by the pancreas, is responsible for moving glucose from the blood into the body’s cells. In diabetes, either there is no insulin, or alternatively, plenty of insulin, but the body cannot use it properly. Without functioning insulin, the glucose stays in the blood and not the cells that need it, resulting in potential harm to many organs.

Two distinct types of diabetes exist. Type 1 is an autoimmune condition in which the body’s immune system destroys insulin-producing cells, severely limiting or completely stopping all insulin production. It is often inherited and is responsible for about 5% of diabetes. It is managed by insulin injections or an insulin pump.

Type 2 diabetes is caused by overeating and sedentary living and is responsible for 95% of diabetes. This form of diabetes is caused by insulin resistance, a condition in which the body cannot process insulin and is resistant to its actions. Type 2 diabetes is a classic example of an avoidable and “elective” chronic disease that occurs because of an unhealthy lifestyle.

Common symptoms of diabetes are frequent urination, thirst, extreme hunger, weight loss, fatigue and irritability, recurrent infections, blurry vision, cuts that are slow to heal, and tingling or numbness in the hands or feet.

How does diabetes affect the bladder?

Many diabetics have urological problems that affect the bladder. A common problem is impaired sensation in which the bladder becomes “numb” and the patient gets no signal to urinate. Another problem is impaired bladder contractility in which the bladder muscle does not function properly, causing an inability to empty the bladder completely. Other diabetics develop involuntary bladder contractions, or overactive bladder, causing urinary urgency, frequency and incontinence.

How does diabetes affect the kidneys?

Diabetes is the most common cause of kidney failure, accounting for almost half of all new cases. Even with diabetic control, the disease can lead to chronic kidney disease, kidney failure and the need for dialysis or kidney transplantation.

How does diabetes affect the urinary tract and genitals?

Diabetics have more frequent urinary tract infections because of factors including improper functioning of the infection-fighting white blood cells, glucose in the urine, and compromised blood flow. Diabetics have a greater risk of asymptomatic bacteriuria and pyuria (the presence of white cells and bacteria in the urine without infection), cystitis (bladder infections), and pyelonephritis (kidney infections).

Impaired bladder emptying further complicates the potential for infections. Diabetics have more serious complications of pyelonephritis, including kidney abscess, emphysematous pyelonephritis (infection with gas-forming bacteria), and urosepsis (a very serious systemic infection originating in the urinary tract requiring hospitalization and intravenous antibiotics).

Fournier’s gangrene (necrotizing fasciitis) is a soft tissue infection of the male genitals that often requires emergency surgery, can be disfiguring and has a very high mortality rate. More than 90% of patients with Fournier’s gangrene are diabetic. Diabetic patients also have an increased risk of infection with surgical procedures, particularly those involving prosthetic implants, including penile implants, artificial urinary sphincters, and mesh implants for pelvic organ prolapse.

How does diabetes affect the foreskin?

Balanoposthitis is medical speak for inflammation of the head of the penis and foreskin. As mentioned previously, a tight foreskin that cannot be pulled back to expose the head of the penis (phimosis) can be the first clinical sign of diabetes in uncircumcised men. At least 25% of men with this problem have underlying diabetes. It is common for these men to have fungal infections under the foreskin because of the risk factors of a warm, moist, dark environment in conjunction with the presence of glucose in the urine. The good news is that phimosis and fungal infections often respond well to diabetic control.

How does diabetes affect sexual function?

Sexual functioning is based upon good blood flow and an intact nerve supply to the genitals and pelvis. Diabetics often develop sexual problems (in fact, diabetes is the most common cause of erectile dysfunction) because of the combination of neuropathy and blood vessel disease. Men commonly have a reduced sex drive and have difficulty achieving and maintaining erections.

Diabetes increases the risk of erectile dysfunction threefold. Diabetes has clearly been linked with testosterone deficiency, which can negatively impact sex drive and sexual function. Because of the neuropathy, many diabetic males have retrograde ejaculation, a situation in which semen goes backwards into the bladder and not out the urethra. Female diabetics are not spared from sexual problems and commonly have reduced desire, decreased arousal and sexual response, vaginal lubrication issues and painful sexual intercourse.

How is diabetes managed?

With Type 2 diabetes, it’s vital to modify lifestyle, including dietary changes that avoid diabetic-promoting foods and replacement with healthier foods in order to have appropriate sugar control to help prevent diabetic complications. Diabetics should refrain from high glycemic index foods (those that are rapidly absorbed) including sugars and refined white carbohydrates. Instead, diabetics should consume high-fiber vegetables, fresh fruits, and whole-grain products. Regular exercise is equally as important as healthy eating, and the combination of healthy eating, physical activity, and weight loss can often adequately address Type 2 diabetes.

When lifestyle measures cannot be successfully implemented or do not achieve complete resolution, there are different classes of medications that can be used to manage the diabetes. However, lifestyle modification should always be the initial approach, since lifestyle (in large part) caused the problem and is capable of improving/reversing it. At times, when diet, exercise and drugs are unable to control the diabetes, bariatric (weight loss) surgery may be needed to control and even potentially eliminate the diabetes.

Written by Dr. Andrew Siegel

4 Treatment Paths for Erectile Dysfunction

3 Jun 2019 Blog

Erectile dysfunction (also known as impotence, or ED) is the inability to get and keep an erection firm enough for sex. A practical approach to treating ED —similar to the strategy for most medical issues — starts with a medical history, physical examination and basic lab tests. More extensive testing may be suggested depending on the individual.

If the evaluation indicates that the ED is psychological or emotional in origin, referral to a qualified psychologist, psychiatrist or sexual counselor will be the next step. If the lab results indicate low testosterone, additional hormone tests will be done to determine the precise cause of the low testosterone, then a treatment aimed at normalizing the levels will be suggested. If testing shows undiagnosed or poorly controlled diabetes or a risky lipid and cholesterol profile, a referral to another medical professional will be necessary.

Although ED treatment is tailored to the individual patient, there are four general paths of treatment for ED:

1. Lifestyle makeover. A healthy lifestyle can “reverse” ED naturally, as opposed to “managing” it. Since ED can often be considered a “chronic disease,” healthy lifestyle choices can reverse it, prevent it from getting worse, or even prevent it altogether.

Since sexual function is based on many body parts working together, this approach is to nurture every cell, tissue and organ in the body.The goal is to achieve a healthy weight, adopt a healthy diet, exercise regularly, get enough good quality sleep, stop using tobacco, consume alcohol in moderation, and reduce stress.

Aside from general cardio and strength exercises, specific pelvic floor muscle exercises (“man-Kegels”) are beneficial to improve the strength, power and endurance of the penile “rigidity” muscles.

If a healthy lifestyle can be adopted, sexual function will often improve dramatically, as well as overall health improvements. Since many medications have side effects that negatively impact sexual function, a bonus of lifestyle improvement is potentially needing lower dosages or perhaps eliminating medications (blood pressure, cholesterol, diabetes), which can result in further improving sexual function.

2. ED pills and mechanical devices. It’s my opinion that oral ED medications should be reserved for when lifestyle optimization fails to improve sexual issues. This may be at odds with some physicians who find it convenient to simply prescribe meds, and with some patients who want a quick and easy fix. However, as good as Viagra, Levitra, Cialis and Stendra may be, they are expensive, have side effects, are not effective for every patient and cannot be used by everyone, as there are medical situations and certain medications that may prevent their use.

In this category, I also include mechanical, non-pharmacological, non-surgical devices, including low-intensity penile shockwave therapy, vacuum suction devices, vibration devices and penile traction devices.

  • Low-intensity shockwave therapy is an exciting new treatment option that uses acoustic energy to cause mechanical stress and microtrauma to erectile tissues. This stimulates the growth of new blood vessels and nerve fibers and potentially enables penile tissue to regain the ability for spontaneous erection.
  • Vacuum suction devices are mechanical means of producing an erection in which the penis is placed within a plastic cylinder that is connected to a manual or battery-powered vacuum. Negative pressure engorges the penis with blood and a constriction band is temporarily placed around the base of the penis to maintain the erection. 80% of men can achieve good rigidity, but many do not continue using the device because of its cumbersome nature.
  • Venous constriction devices are used in conjunction with the vacuum suction devices to trap blood in the penis and help maintain the erection. They also can be used without the suction devices in certain circumstances. Men who find these beneficial are usually able to obtain a reasonable quality rigid erection but tend to lose it prematurely.
  • Vibration devices were traditionally employed to provoke ejaculation in men with spinal cord injuries who desired to father children. Subsequently, they have achieved broader utility and are now also used to facilitate erections in men with ED. Dual-armed vibratory stimulation of the penile shaft is capable of inducing an erection and ultimately ejaculation.
  • Penile traction devices use mechanical pulling forces to lengthen and/or straighten the penis to manage or prevent penile shortening and angulation.

3. Vasodilator urethral suppositories and penile injections. These are suppositories and injections that increase penile blood flow and induce erections.

  • M.U.S.E. (Medical urethral system for erection) is a small medicated vasodilator pellet available in a variety of different dosages that is placed within the urinary channel of the penis after urinating. Absorption occurs through the urethra into the adjacent erectile chambers, inducing increased penile blood flow and potentially an erection. About 40% of men can achieve rigidity, but it is often inconsistent.
  • Prostaglandin E1 is injected directly into one of the erectile chambers of the penis, resulting in increased blood flow and erectile rigidity. After being taught the technique of self-injection, vasodilator medications can be used on demand, resulting in rigid and durable erections. A combination of medications can be used for optimal results—one such popularly used combination consists of papaverine, phentolamine and alprostadil, known as “Trimix.”  90% or so of men achieve an excellent response, although many men are reluctant to put a needle into their penis.

4. Penile prostheses. Penile prostheses can be life changers for men who cannot achieve a sustainable erection. Surgically implanted under anesthesia on an outpatient basis, they provide the necessary penile rigidity to have intercourse whenever and for however long desirable.

  • The semi-rigid device is a simple one-piece flexible rod, one of which is implanted within each of the paired erectile chambers. The penis is bent up for sexual intercourse and down for concealment.
  • The inflatable device is a three-piece unit that is capable of inflation and deflation. Inflatable inner tubes are implanted within the erectile chambers, a fluid reservoir is implanted behind the pubic bone or abdominal muscles and a control pump in the scrotum, adjacent to the testes. When the patient desires an erection, he pumps the control pump several times, which transfers fluid from the reservoir to the inflatable inner tubes, creating a hydraulic erection that can be used for as long as desired. When the sexual act is completed, the device is deflated via the control pump, transferring fluid back to the reservoir and restoring a flaccid state.

Learn more about Men’s Health at New Jersey Urology >

Urethral Diverticulum in Women: Symptoms, Causes and Treatment

28 May 2019 Blog

A urethral diverticulum (UD) is a pocket or pouch that forms along the urethra. Many are small and not symptomatic. However, because of their location, they can become filled with urine and lead to infections. UDs only occur in approximately 5% of adult females, most commonly between the age 40-70.

Symptoms of UD include:

  • Dysuria (painful and burning urination)
  • Dribbling (urinary leakage after finishing urinating)
  • Dyspareunia (painful sexual intercourse)

Urethral diverticulum commonly causes a mass or lump in the top vaginal wall as well as dribbling urine, burning or pain when urinating, and pain with sexual intercourse. They can also cause urinary infections that don’t respond well to antibiotic treatment. On occasion, a urethral diverticulum may cause obstructive lower urinary tract symptoms (LUTS) and rarely, the inability to urinate.

The underlying cause of urethral diverticula is often an infection and/or obstruction in the para-urethral glands. These glands surround the urethra and when they become obstructed, the glands can become infected and lead to abscess formation which subsequently ruptures into the urethra. During the healing phase, the cells that line the urethra can then grow out into the cavity formed by the ruptured abscess, forming a urethral diverticulum.

A pelvic exam typically reveals a tender, firm, cystic swelling of the top vaginal wall. When the swelling is manipulated, urine or possibly pus may be expressed through the urethra. MRI is the imaging test of choice to further evaluate the details, location and complexity of urethral diverticula. Another important test is urethroscopy, a visual inspection of the urethra using a small, lighted instrument to establish the location of the connection site between the diverticulum and the urethra.

Not all urethral diverticula require treatment, particularly if they are small and not symptomatic. Conservative measures that may relieve symptoms include compressing the diverticulum after urinating to preclude the post-void dribbling, antibiotics and using a needle and syringe to aspirate the contents.

Surgical management of symptomatic urethral diverticula involves excision of the diverticulum (urethral diverticulectomy) with repair of the urethra (urethroplasty). The surgery is performed via vaginal incision and requires the complete removal of the diverticular sac(s) down to the connection with the urethra. In the event of an infected diverticulum, it is important to treat with antibiotics prior to the surgery to eradicate the infection as best as possible. The surgical procedure is generally done on an outpatient basis and requires a urinary catheter (typically for 7–14 days), antibiotics, pain medication, and a bladder relaxant.

Urethral diverticulectomy has a high success rate with respect to relieving the presenting symptoms and resumption of normal urinary function post-surgery. As with any surgical procedure, there is always a small risk of complication. In general, the closer a urethral diverticulum is located to the bladder neck (where the urethra and bladder meet), the greater the risk for complications. Risks include bladder or ureteral injury, urinary incontinence, urethral stricture (scarring resulting in narrowing of the channel), urethral-vaginal or vesico-vaginal fistulas (abnormal connection between the vagina and the urethra or the vagina and bladder) and recurrence of the urethral diverticulum.

Written by Dr. Andrew Siegel

PSA Screening 101: What You Should Know

20 May 2019 Blog

Prostate-specific antigen, or PSA, is a chemical produced by the prostate gland. PSA functions to liquefy semen following ejaculation, aiding the transit of sperm to the egg. A small amount of PSA filters 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 PSA. As a man ages, his PSA rises based upon the typical enlarging prostate that occurs with growing older.

How is PSA used to screen for prostate cancer?

Using PSA testing, about 90% of men have a normal PSA. Of the 10% of men with an elevated PSA, about 30% 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 greater than 1.5 had a 0.5% risk of developing prostate cancer, those between 1.5-4.0 had about an 8% risk, and those greater than 4.0 had more than a 10% risk.

Although it is an imperfect screening test, PSA remains the best tool currently available for detecting prostate cancer. It should not 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. The most informative use of PSA screening is when it is obtained serially, with comparison on a year-to-year basis providing much more meaningful information than a single, out-of-context PSA.

Is there any truth that the PSA test is worthless?

A major backlash against screening occurred a few years ago with the United States Preventive Services Task Force (USPSTF) grade “D” recommendation against PSA screening and their call for total abandonment of the test. This organization counseled against the use of PSA testing in healthy men, postulating that the test does not save lives and leads to more tests and treatments that needlessly cause pain, incontinence and erectile dysfunction. Please note, there was not a single urologist on the committee. The same organization had previously advised that women in their 40s not undergo routine mammography, setting off another blaze of controversy. Uncertainty in the lay press prompted both patients and physicians to question PSA testing and recommendations for prostate biopsy.

Is there really any harm in screening? Although there are potential side effects from prostate biopsy (although they are few and far between) and there certainly are potential side effects with treatment, there are no side effects from drawing a small amount of blood. The bottom line is that when interpreted appropriately, the PSA test provides valuable information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. Dismissing this important test does a great disservice to patients who may benefit from early prostate cancer detection.

Why should I get screened for prostate cancer?

Excluding skin cancer, prostate cancer is the most common cancer in men (1 in 9 lifetime risk), accounting for 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 stage. Early and timely intervention for those 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 cancers 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.

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.

Does an elevated PSA always mean one has prostate cancer?

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 an imperfect 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.

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 is little sense in screening. Another important factor is individual preference since the decision to screen should be a collaborative decision between a patient and their physician.

PSA screening detects 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 metastases and prostate cancer death and it is recommended that it be obtained annually starting at age 40 in men who have a greater than a 10-year life expectancy. PSA testing in men who have been diagnosed with prostate cancer provides valuable information about pretreatment staging, risk assessment and monitoring after treatment. Although PSA has many shortcomings, when used intelligently and appropriately, it will continue to save lives.

Written by Dr. Andrew Siegel

Tunica Cysts: What You Should Know

14 May 2019 Blog

Written by Dr. Andrew Siegel

The tunica albuginea is a dense fibrous sheath that surrounds, covers and protects the delicate contents of each testicle. The tunica albuginea is surrounded by a second layer, the tunica vaginalis. Tunica cysts, which are benign cystic masses, may arise from either tunic.

What is a tunica cyst?

Tunica cysts originate from the tunica albuginea and are the most common benign masses that originate external to the testicle. They are small, firm, irregular, plaque-like nubbins located on the surface of the testes ranging from 2 to 5 mm in size. They are often described as feeling like a grain of rice, and are most often found on the upper-front or upper-side aspect of the testicle. In most cases, they are not symptomatic and are discovered incidentally by the patient, who is typically around 40 years of age.

How are tunica cysts diagnosed?

Tunica cysts can cause a great deal of concern and worry because of the fear of testicular cancer, but they are distinguished from testicular cancer by being cystic (not solid) and on the outer surface of the testes as opposed to being within the testes. Ultrasonography is the imaging study of choice for evaluating testicular masses and can differentiate cystic, benign masses from solid, malignant masses.

On ultrasound, the tunica albuginea can be seen as a 2-layered echogenic (containing lots of echoes) structure surrounding the testicle and the cyst as a small, regular fluid-filled structure abutting the surface of the testicle. On occasion, a tunica cyst may calcify. Microscopically, they are seen to contain fluid and cellular debris.

How are tunica cysts treated?

Although tunica cysts can be surgically removed, it’s rarely necessary to do so because ultrasound can reliably confirm their benign diagnosis. Make an appointment with your urologist if you notice any testicular bumps or lumps during a self-exam.

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Bladder Infections in Women: 12 Ways to Keep Cystitis at Bay

6 May 2019 Blog

Written by Dr. Andrew Siegel:

Bladder infections (a.k.a., cystitis) are common among women. Acute cystitis is a bladder infection that typically causes the following symptoms:

  • Pain/burning
  • Frequent urination
  • Urinary urgency (“gotta go”)

Additional symptoms that may occur include: urinating small volumes, bleeding, and urinary incontinence (leakage).

Microscopic inspection of urine usually shows bacteria, white blood cells and red blood cells.  80-90% of cystitis is caused by Escherichia coli, 5-15% by Staphylococcus and the remainder by less common bacteria including KlebsiellaProteus, and Enterococcus.

The occasional occurrence of cystitis is a nuisance and often uncomfortable, but it is usually easily treated with a short course of oral antibiotics. When bladder infections recur time and again, it becomes important to fully investigate the source of the recurrence.

Bladder infections occur when bacteria gain access to the urinary bladder, which normally does not have bacteria present. The short female urethra and the proximity of the urethra to the vagina and anus are factors that predispose to cystitis.

For an infection to develop, the vagina and urethra usually have to be colonized with the type of bacteria that can cause an infection (not the normal healthy bacteria that reside in the vagina). These bacteria must ascend into the bladder and latch onto bladder cells.

Bladder Infections in Young Women

Women aged 18-24 years old have the greatest prevalence of bladder infections and sex is usually a key factor. The most common risk factors include:

  • A new sexual partner.
  • Recent sexual intercourse.
  • Frequent sexual intercourse.
  • Spermicides, diaphragms and spermicide-coated condoms (which can increase vaginal and urethral colonization with E. Coli).

Bladder Infections in Older Women

Cystitis is common after menopause, based upon the following factors:

  • Female hormone (estrogen) deficiency, which causes a change in the bacterial flora of the vagina such that EColi replaces Lactobacilli.
  • Age-related decline in immunity.
  • Incomplete bladder emptying.
  • Urinary and fecal leakage (incontinence), often managed with pads, which remain moist and contaminated and can promote movement of bacteria from the anal area towards the urethra.
  • Diabetes (particularly when poorly controlled, with high levels of glucose in the urine that can be thought of as “fertilizer” for bacteria).
  • Neurological diseases that impair emptying or cause incontinence.
  • Pelvic organ prolapse.
  • Obesity.
  • Poor hygiene.

12 Ways to Help Keep Cystitis at Bay:

  1. Stay well hydrated to keep the urine diluted.
  2. Wipe in a top-to-bottom motion after urination or bowel movementsAt minimum, urinate every four hours while awake to avoid an over-distended bladder.
  3. Maintain a healthy weight.
  4. Urinate after sex.
  5. If infections are clearly sexual-related, an antibiotic taken before or right after sex can usually preempt the cystitis.
  6. If you are diabetic, maintain the best glucose control possible.
  7. Seek urological consultation for recurrent infections to check for an underlying and correctable structural cause.
  8. Cranberry extract. Cranberries contain proanthocyanidins that inhibit bacteria from adhering to the bladder cells. There are formulations of cranberry extract available to avoid the high carbohydrate load of cranberry juice.
  9. Probiotics such as lactobacillus. These bacteria promote healthy colonization of the vagina, production of hydrogen peroxide that is toxic to bacteria, maintenance of acidic urine, induction of an anti-inflammatory response in bladder cells, and inhibition of attachment between bacteria and the bladder cells.
  10. D-MannoseThis sugar can inhibit bacteria from adhering to the bladder cells.
  11. Estrogen creamApplied vaginally, this can help restore the normal vaginal flora as well as uro-genital tissue integrity and suppleness.
  12. Vaccination. Currently in the research phase, the concept is an oral vaccine or vaginal suppository capable of providing immunity against the typical strains of bacteria that cause infections.

Learn more about Women’s Health at New Jersey Urology >

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