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 >

Recognizing World Vasectomy Day

29 Apr 2019 Blog

A vasectomy is considered a permanent method of birth control by preventing the release of sperm when a man ejaculates. During a vasectomy, the vas deferens from each testicle is clamped, cut or otherwise sealed, which is the mechanism to prevent the flow of sperm. Vasectomy is easily performed in a doctor’s office under local anesthesia and requires less than 15 minutes by an experienced urologist.

According to the American Urological Association (AUA), vasectomy is the most common non-diagnostic operation performed by urologists in the United States. Estimates of the number of vasectomies performed annually in the U.S. vary depending on survey type. Data from the National Study of Family Growth in which only married couples were polled indicate a range from 175,000 to 354,000 annually.

World Vasectomy Day

Filmmaker and media activist Jonathan Stack has teamed up with urologist Dr. Doug Stein to create World Vasectomy Day. This commemoration is to encourage men to take responsibility for family planning and to transform this positive choice into a global movement. The event first took place in 2013 when Stack and Stein set out to inspire 100 doctors in 25 countries to do 1,000 vasectomies. They achieved the goal within 24 hours. The following year, over 400 physicians in 30 countries, including the U.S, Australia, India, Kenya, China and Colombia, performed almost 3,000 vasectomies, making it the largest male-focused family planning event in history.

According to Stack, “Sadly, while men waffle on the sidelines, more than 300 million women have had tubal ligations. That’s six times the number of men having vasectomies, even though tubal ligations are more invasive, costly and risky. While both procedures are almost equally effective, tubal failures can result in ectopic pregnancies, a leading cause of maternal mortality.”

States the AUA, “Given that vasectomy and tubal ligation have equivalent contraceptive effectiveness and that vasectomy enjoys advantages compared to tubal sterilization of lower cost, less pain, greater safety and faster recovery, vasectomy should be considered for permanent contraception much more frequently than is the current practice in the United States and most nations of the world.”

Vasectomy Myths

Performing a vasectomy is not only a quick procedure; it’s a safe one. Yet many men and women worry about the surgery for a variety of unfounded reasons. Let’s clear the air:

There are actually two ways to perform a vasectomy, including a no-scalpel vasectomy. That said, both vasectomy procedures can be performed safely and effectively, carrying very little risk.

The healing process generally requires one to two days to recover from the procedure. The most common symptoms after a vasectomy include swelling and soreness, but it’s rare for either to last. Usually over-the-counter medications, like ibuprofen and cold compresses, take away most pain or discomfort.

When a man has a vasectomy, it’s a common misconception to think that he stops producing sperm. However, after a vasectomy, it’s the sperm’s ability to be released that’s blocked off, not the ability to produce sperm.

A common myth about vasectomy is that it causes impotence, the inability to get an erection and keep an erection in order to engage in sexual activity. However, a vasectomy does not cause impotence. Some erroneously believe impotence occurs by preventing sperm from being released during ejaculation. Actually, sperm make up such a small portion of ejaculate and that the difference is not even visible. The sperm that’s still produced, even after a vasectomy, is usually successfully absorbed into the body, causing no difference or repercussions.

Aside from sexually transmitted infections (STIs) that you should always be aware of and protect against, there’s no increased risk of disease from having a vasectomy. And this procedure does not put you at risk of developing cancer, specifically prostate and testicular cancer, as some believe.

On November 16, 2018, World Vasectomy Day held a live-streamed event in New York City, including informative interviews with experts and participants. More information can be found here.

To quote the event organizers, “A great man doesn’t run from risk; he shares responsibility with his partner.”

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

FDA Decision on Pelvic Prolapse Repair Mesh Sets Back Women’s Health

22 Apr 2019 Blog

Written by Dr. Andrew Siegel

Recently the U.S. Food and Drug Administration (FDA) ordered the manufacturers of all remaining surgical mesh products for trans-vaginal repair of pelvic organ prolapse (Boston Scientific and Coloplast) to stop selling and distributing their products in the USA immediately. According to the FDA, the manufacturers in their premarket applications failed to provide reasonable assurance that the benefits of the products outweighed their risks, compared with trans-vaginal surgical tissue repair without mesh. The inaccessibility of these products will severely hamper treatment options for many women with pelvic organ prolapse and is a genuine disservice to the female population and a blow to women’s health, which has otherwise made major strides forward in the last few decades.

Clearly, the issue is NOT the mesh, which is a synthetic material—polypropylene—that has been used safely and effectively for years as a suture material and for virtually all hernia repairs. Rather, the issues are threefold—inappropriate manufacturing company marketing, inexperienced surgeon implanters, and our “ambulance-chasing” financially-motivated legal culture.

For years, the manufacturers of these mesh products—many of which ultimately removed themselves from the mesh business—assertively marketed these mesh products in “weekend” courses to surgeons (who were not surgically trained to perform these procedures). These inexperienced physicians then became avid mesh implanters and often engendered complications in the patients whom they implanted, setting the scene for law firms to aggressively advertise and seek clients for litigation.

Sadly, there is excellent scientific data to support the safety and efficacy of vaginal mesh when done in properly selected patients by skilled pelvic surgeons. Millions of such vaginal mesh surgeries have been performed successfully with minimal complications by pelvic surgeons with training in a subspecialty of urology and gynecology—female pelvic medicine and reconstructive surgery. This requires several years of specialty fellowship training after completion of urology or gynecology residency and a second board examination in addition to board certification in urology or gynecology, thus most in this subspecialty are dual board certified.

Why mesh in the first place?

Why use a synthetic material when native tissues can be used? The answer lies in the nature of pelvic organ prolapse. Analogous to a hernia, pelvic organ prolapse is a weakness in connective tissue support allowing a pelvic organ (often the bladder) to pooch down into the vagina and at times outside the vagina, causing an annoying bulge, pressure and often difficulties with urination. The mesh principle is using a structurally sound material instead of a patient’s defective connective tissues (that has already failed) to rebuild support. If a brick wall collapses because of structural issues, would one use the same bricks to rebuild the wall? Clearly the answer is no. This is why polypropylene mesh is used in the vast majority of hernia repairs: hardy structural support is needed to compensate for the native connective tissue defect.

The mesh principle: For anatomic defects, using weakened/defective native tissues for a structural repair often causes failures.

In the properly selected patient operated on with the appropriate surgical technique by the experienced surgeon, the results of vaginal mesh repairs have been extraordinarily gratifying and nothing short of a paradigm shift from the native tissue repair era. This procedure passes muster and the “MDSW” test—meaning I would readily encourage my mother, daughter, sister or wife to undergo the procedure if the situation called for it.

When performed by a skilled pelvic surgeon, the likelihood of cure or vast improvement is very high. Meshes are strong, supple and durable and the procedure itself is relatively simple, minimally-invasive and amenable to doing on an outpatient basis. When patients are seen several years after a mesh repair, their pelvic exams typically reveal restored anatomy with remarkable preservation of vaginal length, axis, caliber and depth.

Meshes act as a scaffold for tissue in-growth and ultimately should become fully incorporated by the body. I think of the meshes in a similar way to backyard chain-link fences that have in-growth of ivy. Meshes examined microscopically years after implantation demonstrate a dense growth of blood vessels and collagen in and around the mesh.

When mesh is used for bladder repair, there is rarely any need for trimming of the vaginal wall, which maintains vaginal dimensions as opposed to the native tissue repairs, which often demand some trimming of vaginal wall with alteration of vaginal anatomy. Another advantage of the mesh repair is that if there is some uterine prolapse accompanying the dropped bladder, the base of the mesh can be anchored to the cervix and thus provide support to the uterus as well as the bladder, potentially avoiding a hysterectomy.

The bottom line is that mesh repairs for pelvic organ prolapse have been revolutionary in terms of the quality and longevity of results—a true game-changer. They represent a dramatic evolution in the field of female urology and urological gynecology, offering a vast improvement in comparison to the pre-mesh era.

That said, they are not without complications, but the complication rates should be reasonably low under the circumstances of proper patient selection, a skilled and experienced surgeon performing the procedure, proper surgical technique, and proper patient preparation. Three factors are integral to proper mesh integration: mesh factors, patient factors and surgeon factors.

The gold standard mesh is a piece of large-pored, elastic, monofilament polypropylene—any other synthetic can result in integration issues. This is the standard for sling surgery as well, and time has proved this to be the best synthetic mesh.

Patient considerations are very important as risk factors for integration problems include the following: compromised or poor-quality vaginal tissues, diabetes, patients on steroids, immune-compromised patients, radiated tissues, and tobacco users.

Foremost, a well-trained, experienced surgeon should be the one doing the mesh implantation. It is sensible to check if your surgeon is specialized, and if not, at least has significant clinical experience doing mesh procedures. It is particularly important that the surgeon performing the mesh implant is capable of taking care of any of the small percentage of complications that may arise and are most often quite manageable.

Again, many of the problems that have occurred are not intrinsic to the mesh itself, but are potentially avoidable issues that have to do with either the surgical technique used to implant the mesh or to patient selection. Rather than addressing these issues, the FDA has chosen to throw out the proverbial “baby with the bath water,” leaving in the wake of this short-sighted decision many female patients who will needlessly suffer.

Learn more about women’s health services at New Jersey Urology >

12 Steps to Overcoming Overactive Bladder (OAB)

15 Apr 2019 Blog

Written by Dr. Andrew Siegel

Overactive Bladder (OAB) is a common condition often due to one’s bladder contracting (squeezing) at any time without warning. This involuntary bladder contraction can give rise to the symptoms of urgency, frequency (daytime and nighttime) and urgency incontinence. The key symptom of OAB is urinary urgency (a.k.a. “gotta go”), the sudden and compelling desire to urinate that is difficult to postpone. This problem can occur in both women and men, although it is more common in females.

Although OAB symptoms can occur without specific provocation, they may be triggered by exposure to running water, cold or rainy weather, hand-washing, entering the shower, positional changes such as arising from sitting, and getting nearer and nearer to a bathroom, particularly at the time of placing the key in the door to one’s home.

12 Steps To Overcoming OAB

The goal of these 12 steps is to re-establish control of the urinary bladder. Providing that the recommendations are diligently adhered to, there can be significant improvement, if not resolution, of OAB symptoms.

  1. Fluid and caffeine moderation/medication assessment. Symptoms of OAB will often not occur until a “critical” urinary volume is reached, and by limiting fluid intake, it will take a longer time to achieve this volume. Try to sensibly restrict your fluid intake in order to decrease the volume of urinary output. Caffeine (present in tea, coffee, colas, some energy drinks and chocolate) and alcohol increase urinary output and are urinary irritants, so it is best to limit intake of these beverages/foods. Additionally, many foods—particularly fruits and vegetables—have hidden water content, so moderation applies here as well. It is important to try to consume most of your fluid intake before 7 p.m.  to improve nocturnal frequency. Diuretic medications (water pills) can contribute to OAB symptoms. It is worthwhile to check with your medical doctor to see if it is possible to change to an alternative, non-diuretic medication. This will not always be feasible, but if so, may substantially improve your symptoms.
  2. Urgency inhibition. Reacting to the first sense of urgency by running to the bathroom needs to be substituted with urgency inhibition techniques. Stop in your tracks, sit, relax and breathe deeply. Pulse your pelvic floor muscles rhythmically to deploy your own natural reflex to resist and suppress urgency.
  3. Timed voiding (for incontinence). Urinating by the “clock” and not by your own sense of urgency will keep your bladder as empty as possible. By emptying the bladder before the critical volume is reached (at which urgency incontinence occurs), the incontinence can be controlled. Voiding on a two-hour basis is usually effective, although the specific timetable has to be tailored to the individual in accordance with the voiding diary. Such “preemptive” or “defensive” voiding is a very useful technique since purposeful urinary frequency is more desirable than incontinence.
  4. Bladder retraining (for urgency/frequency). This is imposing a gradually increasing interval between voids to establish a more normal pattern of urination. Relying on your own sense of urgency often does not give you accurate information about the status of your bladder fullness. Urinating by the “clock” and not by your own sense of urgency will keep your voided volumes more appropriate. Voiding on a two-hour basis is usually effective as a starting point, although the specific timetable has to be tailored to the individual, based upon the voiding diary. A gradual and progressive increase in the interval between voiding can be achieved by consciously delaying urinating. A goal of an increase in the voiding interval by 15-30 minutes per week is desirable. Eventually, a return to more acceptable voiding intervals is possible. The urgency inhibiting techniques mentioned above are helpful with this process.
  5. Bowel regularity. Avoidance of constipation is an important means of helping control OAB symptoms. Because of the proximity of the rectum and bladder, a full rectum can put pressure on the bladder, resulting in worsening of urgency, frequency and incontinence.
  6. Pelvic floor muscle training (PFMT).  All patients need to understand the vital role of the pelvic floor muscles (PFM) in inhibiting urgency and frequency and preventing urge leakage. PFMT voluntarily employs the PFM to help stimulate inhibitory reflexes between the pelvic floor muscles and the bladder. Rhythmic pulsing of the PFM can inhibit an involuntary contraction once it starts and prevent an involuntary contraction before it even begins. Initially, one must develop an awareness of the presence, location, and nature of the PFM and then train these muscles to increase their strength and tone. These are not the muscles of the abdominal wall, thighs or buttocks. A simple means of recognizing the PFM for a female is to insert a finger inside her vagina and squeeze the PFM until the vagina tightens around her finger. A simple means of identifying the PFM for either gender is to start urinating and when about half completed, to abruptly stop the stream. It is the PFM that allows one to do so. It is important to recognize the specific triggers that induce urgency, frequency or incontinence and prior to exposure to a trigger or at the time of the perceived urgency, rhythmic pulsing of the PFM–“snapping” the PFM several times–can either preempt the abnormal bladder contraction before it occurs or diminish or abort the bladder contraction after it begins. Thus, by actively squeezing the PFM just before and during these trigger activities, the urgency can be diminished and the urgency incontinence can often be avoided.
  7. Lifestyle measures: healthy weight, exercise, tobacco cessation. The burden of excess pounds can worsen OAB issues by putting pressure on the urinary bladder. Even a modest weight loss may improve OAB symptoms. Pursuing physical activities can help maintain general fitness and improve urinary control. Lower impact exercises – yoga, pilates, cycling, swimming – can best help alleviate pressure on the urinary bladder by boosting core muscle strength and tone and improving posture and alignment. The chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, compromising the bladder, urethra and PFM. By eliminating tobacco, symptoms of OAB can be improved.
  8. Bladder relaxant medications. A variety of medications are useful to suppress OAB symptoms. It may take several trials of different medications or combinations of medications to achieve optimal results. The medications include the following: Tolterodine (Detrol LA), Oxybutynin (Ditropan XL), Transdermal Oxybutynin (Oxytrol patch), Oxybutynin gel (Gelnique), Trospium (Sanctura), Solifenacin (Vesicare), Darifenacin (Enablex) and Fesoterodine (Toviaz). The most common side effects are dry mouth and constipation. These medications cannot be used in the presence of urinary or gastric retention or uncontrolled narrow-angle glaucoma. The newest medication, Mirabegron (Myrbetriq), has a different mechanism of action and fewer side effects.
  9. Biofeedback. This is an adjunct to PFMT in which electronic instrumentation is used to relay feedback information about your PFM contractions. This can enhance awareness and strength of the PFM.
  10. Botox treatment. This is a simple office procedure in which Botox is injected directly into the bladder muscle, helping reduce OAB symptoms by relaxing those areas of the bladder into which it is injected. Botox injections generally will last for six to nine months and are covered by Medicare and most insurance companies.
  11. Percutaneous tibial nerve stimulation (PTNS). This is a minimally invasive form of neuromodulation in which a tiny acupuncture-style needle is inserted near the tibial nerve in the ankle and a hand-held stimulator generates electrical stimulation with the intent of improving OAB symptoms. This is done once weekly for 12 weeks.
  12. Interstim. This is a more invasive form of neuromodulation in which electrical impulses are used to stimulate and modulate sacral nerves in an effort to relieve OAB symptoms. A battery-powered neuro-stimulator (bladder “pacemaker”) provides the mild electrical impulses that are carried by a small lead wire to stimulate the selected sacral nerves that affect bladder function.

Learn more about Urinary Incontinence at New Jersey Urology >

7 Symptoms of Enlarged Prostate (BPH)

8 Apr 2019 Blog

Benign Prostatic Hyperplasia, or BPH, is the enlargement of the prostate gland. The prostate gland surrounds the urethra and assists in reproduction. As a man ages, the prostate gets larger and begins to put pressure on the bladder and urethra, causing uncomfortable symptoms.

About half of men over age 75 will experience symptoms of BPH. BPH is a very minor condition and is not related to prostate cancer. However, symptoms can cause discomfort and be inconvenient.

Many of the symptoms of BPH tend to relate to urination. Here are the 7 most common symptoms:

  1. Difficulty starting urination. The enlarged prostate alters the pressure of your bladder to pass urine. This can have damaging effects on your kidneys.
  2. Weak urine stream. As the urethra becomes constrained, urine passes at a much slower rate.
  3. Urgent need to urinate. You may go from not needing to urinate to suddenly needing to go because of how the bladder gets constrained.
  4. Issues with sleeping. Pressure from the enlarged prostate can mess with nerve signaling in the middle of the night. This leads to you thinking you have to urinate when you don’t.
  5. Feeling unable to completely empty your bladder. You may not be able to completely empty your bladder, which can lead to Urinary Tract Infections (UTI) and stone issues.
  6. Urinary tract infection. A UTI is caused by the urine that sits in your bladder which you can’t fully empty, creating an environment for bacteria to thrive.
  7. Bladder stones. The leftover urine in your bladder can also crystallize to create bladder stones.

BPH can cause these symptoms, but having these symptoms doesn’t necessarily mean you have BPH. There are many reasons why you may have urinary issues. Talk to your urologist about proper diagnosis.

Treating BPH

BPH treatment entirely depends on the individual case. Very minor cases may just need changes in lifestyle. In other cases there are medication and surgery options available. Keep in mind, there is no permanent cure for BPH, but treatment options are meant to lessen the symptoms caused by BPH to help improve your quality of life.

Learn more about men’s health services at New Jersey Urology >

Heart Healthy is Prostate Healthy

1 Apr 2019 Blog

Written by Dr. Eric Seaman:

Author Mark Moyad, MD, has coined the expression  “Heart healthy is prostate healthy.” At a recent speaking engagement for the physicians at New Jersey Urology, Dr. Moyad spoke of nutrition, overall health and its relationship to mortality from all causes – including prostate cancer. For example, statins (which lower cholesterol levels in the blood) may, for some patients, be both heart healthy and prostate healthy.

A group from the University of Wisconsin-Madison reports support for this statement. Reports found that men who were taking androgen deprivation therapy (also known as hormonal therapy) for prostate cancer not only had improved cancer-specific survival, but also overall survival. Dr. I. Anderson-Carter et al published an article titled “The Impact of Statins in Combination with Androgen Deprivation Therapy in Patients with Advanced Prostate Cancer: A Large Observational Study” in the February 2019 Journal of Urologic Oncology.

The study involved a retrospective review of records of more than 87,000 men on hormonal (or androgen deprivation) therapy for advanced prostate cancer. Out of those men, the patients who were also taking statins (more than 53,000) had a significantly longer average survival rate than those who did not. In fact, according to the report, not only was statin use associated with a 44% decreased risk of death from prostate cancer, but it was also associated with a 34% decreased risk of death from any cause.

These findings were true even after adjusting for possible confounding information related to age, race, PSA blood test results and Gleason score of the tumor (the appearance of the cells within the tumor which usually correlates with the aggressiveness of the tumor) as well as the Charlson Comorbidity Index (CCI). The CCI predicts one-year mortality for patients who may have other medical conditions such as heart disease or stroke.

The authors acknowledge the limitations of their report and conclude by stating that statins are “inexpensive, well-tolerated medications that offer a promising adjunct to ADT but require further prospective studies.”

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

Should I See a Doctor for Erectile Dysfunction?

18 Mar 2019 Blog

Some medical conditions are easy to ignore, especially when they seem as common as erectile dysfunction (ED). Although commercials may normalize the condition, it’s important to schedule an appointment with your urologist if you start experiencing signs and symptoms of ED.

Causes of Erectile Dysfunction

Causes of erectile dysfunction may include:

  • Increased nicotine usage
  • Increased alcohol consumption
  • Using new prescription medication
  • Fatigue

These causes can be temporary. However, ED can also be the result of a psychological or physical imbalance.

Psychological Causes of ED

Depression, anxiety, stress, and relationship problems can affect sexual performance. Your physician might suggest therapy to deal with anxiety caused by depression, or medication to lessen anxiety if it’s causing erectile dysfunction.

Physical (Organic) Causes of ED

Physical causes of ED are more common than psychological. Some medical conditions that cause ED include:

  • High blood pressure
  • High cholesterol
  • Heart and vascular disease
  • Diabetes
  • Kidney Failure
  • Liver Cirrhosis
  • Stroke
  • Epilepsy

Treating Erectile Dysfunction

The first step in treating erectile dysfunction is making an appointment with a urologist. Depending on the cause, one of our specialists will analyze your symptoms and come up with the proper treatment. Most physicians will also suggest that you get into a regular exercise routine and eat healthier. Living a healthy lifestyle can help reduce the frequency of ED.

Learn more about Men’s Health Services at NJU >

Can Varicocelectomy Improve In Vitro Fertilization (IVF) Outcomes? 

11 Mar 2019 Blog

Written by Dr. Eric Seaman:

Varicoceles are enlarged scrotal veins that lie next to the testicle or testicles. Varicoceles can be associated with loss of testicular size, testicular pain and infertility. Varicocele repair, also known as varcocelectomy, has been reported to improve results of semen analysis and its use in the treatment of male factor infertility has been well established.

In Vitro Fertilization (IVF) with Intracytoplasmic Sperm Injection (ICSI) has also been used very effectively in the treatment of male factor infertility. IVF with ICSI involves the injection of single sperm into individual eggs in order to produce embryos. These embryos are allowed to mature outside the body into blastocysts. A single blastocyst is then, typically, transferred back to the female partner.

Because so few sperm are required for IVF-ICSI, many have questioned whether varicocelectomy has any role in improving outcomes. Even in cases where sperm counts are too low to pursue the more primitive technique of Intrauterine Insemination (IUI), there are often a million sperm or more beyond what is necessary to pursue IVF with ICSI. So even if varicocele repair results in improved semen parameters, does it actually matter? Are IVF pregnancy results improved?

The surprising answer is that literature supports the fact that it does. A 2016 retrospective meta analysis by Kirby at al, (Fertil Steril. 2016;106(6):1338) examined the effect of varicocelectomy repair on pregnancy rates after IVF with ICSI. Although pregnancy rates did not show significant improvements, live birth rates actually did.

Within that meta-analysis, one study cited, Esteves et al (J Urol. 2010; 184: 1442), revealed significantly higher pregnancy and live birth rates in a report comparing results of 80 men who underwent varicocelectomy prior to IVF vs162 men who did not.

Still, the decision of whether to perform varicocelectomy involves additional considerations. First, it is a minor surgical procedure for the male. Every procedure (including IVF with ICSI) involves risks and benefits. Second, improvements in semen parameters usually don’t occur for at least 3 months after the procedure is performed, adding more waiting time for the couple.

On the other hand, varicocelectomy sometimes offers a chance at avoiding IVF-ICSI altogether. I have personal recent experience in performing varicocelectomy on a patient who had a sperm count well below one million per ml (referred as severe oligospermia). The patient elected to have a microsurgical varicocelectomy. Four months after surgery, his sperm density increased to nine million per ml and a few months later, he and his wife conceived naturally. Certainly, that is not what always happens, but it is important to realize that sometimes it can.

Learn more about men’s health services at New Jersey Urology >

Kidney Stones 101: Symptoms, Treatment and Prevention

4 Mar 2019 Blog

Written by Dr. Andrew Siegel:

Kidney stones are a common problem that I treat daily. Kidney stones are often related to our dietary habits, the amount of fluids that we drink, and our weight.

If you have ever suffered with a kidney stone, you know what excruciating pain is. Many women who have experienced both passage of a kidney stone and natural childbirth without any anesthesia will report that the childbirth was the less painful of the two!

Stones are a common condition that have occurred in humans since ancient times — kidney stones have even been found in an Egyptian mummy dated 7000 years old. The good news is that most of them will pass spontaneously without the necessity for surgical intervention. If surgery is required, it is minimally invasive (open surgery for kidney stones has virtually gone by the wayside).

How do kidney stones form?

Kidney stones form when minerals that are normally dissolved in the urine precipitate out of their dissolved state to form solid crystals. This crystal formation often occurs after meals or during periods of dehydration. Most kidney stones manifest themselves during sleep, at a time of maximal dehydration.

Dehydration is also why kidney stones occur much more commonly during hot summer days than during the winter. Anything that promotes dehydration can help bring upon a stone, including exercise, saunas, hot yoga, diarrhea, vomiting, being on bowel prep for colonoscopy, etc.

In addition to dehydration, another factor that can contribute to kidney stone formation is excessive intake of certain vitamins. The biggest culprit is Vitamin C, also known as ascorbic acid. When metabolized by the body, vitamin C is converted into oxalate, one of the components of calcium oxalate stones, the most common type of stone. The problem is that vitamin C is a water-soluble vitamin, so any excessive intake is not stored in the body but appears in the urine in the form of oxalate.

Additionally, excessive dietary protein intake, fat intake, and sodium are all associated with an increased risk for kidney stones. Having inflammatory bowel disease or previous intestinal surgery can also increase the risk for stones. Urinary infections with certain bacteria can promote stone formation. Having a parathyroid issue and high circulating calcium levels is another cause of kidney stones. Obesity is also a risk factor for kidney stones. Some stones have a genetic basis, with a tendency to affect many family members.

A kidney stone starts out as a tiny sand particle that grows as the “grain” is bathed in urine that contains minerals. These minerals are deposited and coalesce around the grain. They can grow to a very variable extent so that when they start causing symptoms they may range from being only a few millimeters in diameter to filling the entire kidney.

What are the symptoms?

Some stones are “silent” because they cause no symptoms and are discovered when imaging studies are done for other reasons. However, most stones cause severe pain known as colic. Colicky pain is often intermittent, originating in the flank area and radiating down towards the groin.  It often causes an inability to get comfortable in any position, and is associated with sweating, nausea, and vomiting. Kidney stones can also cause blood in the urine, sometimes visible and, at other times, only on a microscopic basis.

When a stone moves into the ureter (the tube running from the kidney to the bladder), it can become impacted and block the flow of urine. Stones can sometimes cause lower urinary tract symptoms such as urgency and frequency, particularly when the stone approaches the very terminal part of the ureter that is actually tunneled through the wall of the bladder.

How are they diagnosed?

Kidney stones are usually easily diagnosed, based upon their rather classical presentation. However, on occasion, a stone causes no symptoms whatsoever and is picked up incidentally on an imaging study such as an ultrasound, a CAT scan, or an MRI. The imaging study of choice for evaluating a kidney stone is an unenhanced CAT scan (without contrast). A plain x-ray of the abdomen is very useful for stones that contain calcium, and thus are readily visible on an x-ray.

How are they treated?

Most stones will pass spontaneously without intervention given enough time. Conservative management involves hydration, analgesics and the use of a class of medications known as alpha-blockers that can help facilitate stone passage by relaxing the ureteral smooth muscle. As long as the pain is manageable and there is progressive movement of the stone seen on imaging studies, conservative management can continue to be an option.

Intervention is mandated under the following circumstances: intolerable pain; refractory nausea and vomiting with dehydration; larger stones that are not likely to pass; failure of a stone to pass after a reasonable amount of time; significant obstruction of the kidney; a high fever from a kidney infection that does not respond to antibiotics; a solitary kidney; and certain occupations that cannot risk impaired functions such as an airline pilot.

There are a number of minimally invasive means of treating kidney stones depending upon the size of the stone, its location, and the degree of obstruction of the urinary tract. Gone are the days when treating a kidney stone required a painful incision and a prolonged stay in the hospital. Shockwave lithotripsy is commonly used to treat stones in the kidney or upper ureter. Typically done under intravenous sedation, shockwave lithotripsy uses shock waves directed at the kidney stone via x-ray guidance to fragment the stones into pieces that are small enough so that they then can then pass down the ureter, into the bladder and out the urethra with the act of urinating.

Another means of managing stones, particularly amenable to stones in the lower ureter but also applicable to any stone, is ureteroscopy and laser lithotripsy. This procedure is done under general anesthesia. A narrow lighted instrument known as a ureteroscope is passed up the ureter to visualize the stone under direct vision.  A laser fiber is then utilized to break the stone into tiny particles. The largest fragments are removed using a special basket. A ureteral stent is often left in place after this procedure to allow the ureter to heal as well as to prevent obstruction of the kidney.

What are the risk factors?

You are at high risk for kidney stones if you:

  • Don’t drink enough fluids
  • Have an occupation that requires working in hot environments
  • Exercise strenuously without maintaining adequate hydration
  • Are a male, since the male to female ratio of kidney stone incidence is 3:1
  • Had a previous kidney stone, since about 50% of people who have a stone will experience a recurrence
  • Have a family history of kidney stones
  • Have a urinary tract obstruction
  • Have an excessive intake of oxalate, calcium, salt, protein and fat
  • Take excessive amounts of vitamin C, A, and D
  • Have an intestinal malabsorption
  • Have gout
  • Have parathyroid disease

Kidney Stone Prevention

The key to preventing kidney stones is to stay well hydrated, particularly when exposed to hot environments or when exercising for prolonged periods of time. It is also important to avoid overdoing it with certain vitamins—particularly vitamin C. The two biggest risk factors for kidney stones are, in fact, dehydration and excessive intake of vitamin C. Chances are that if you have a healthy diet, you have more than adequate intake of vitamin C and any extra is potentially dangerous. A good sign of adequate hydration is the color of your urine: the urine of a well-hydrated person will look light in color like lemonade, whereas the urine of a dehydrated person will look like apple juice.

So drink up, particularly on hot days…and squeeze some citrus fruit into your water instead of popping a vitamin C supplement…your kidneys will thank you!

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