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 >

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 >

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