Male Sexual Dysfunction: A Predictor of Heart Disease

Erectile Dysfunction (ED) serves as a good proxy for cardiac and general health. The presence of ED is as much of a predictor of heart disease as is a strong family history, tobacco smoking, or elevated cholesterol!

All fat is not created equal.

Having some fat on our bodies is not a bad thing. Fat serves a number of useful purposes, such as cushioning internal organs, providing insulation to conserve heat, and storing energy and fat-soluble vitamins. Fat is also part of the structure of the brain and cell membranes and is used in the manufacturing process of several hormones.

However, not all fat is the same. It’s important to distinguish between visceral fat and subcutaneous fat. Visceral fat– also referred to as a “beer belly” – is internal fat located deep within the abdominal cavity. Subcutaneous fat – also known as “love handles” – is superficial fat located between the skin and the abdominal wall.

In addition to the physical distribution of the fat being different, so is the nature of the fat. Although neither type is particularly attractive, visceral fat is much more hazardous to one’s health than subcutaneous fat. Visceral fat increases the risk of heart disease, diabetes and metabolic disturbances. Subcutaneous fat is inactive, relatively harmless, and generally does not contribute to health problems.

Visceral fat is essentially a metabolically active endocrine “organ” that does way more than just create an unsightly protrusion from our abdomens. It produces numerous hormones and other chemical mediators that have many detrimental effects on all systems of our body, including risk of diabetes, cardiovascular disease, low testosterone, erectile dysfunction (ED) and premature death.

So how can erectile dysfunction predict heart disease?

Visceral fat and metabolic syndrome are highly associated with low testosterone and poor erection and ejaculation function. The fatty tissue present in obese abdomens contains abundant amounts of the enzyme aromatase which converts testosterone to estrogen, literally emasculating obese men. So, visceral fat can steal away our masculinity, male athletic form and body composition, mojo, strength, and the ability to obtain and maintain a good quality erection.

This is why ED serves as a good proxy for cardiac and general health. The presence of ED is as much of a predictor of heart disease as is a strong family history, tobacco smoking, or elevated cholesterol.

FactoidThe penis can function as a “canary in the trousers.” Since the penile arteries are generally rather small (diameter of 1- 2 mm) and the coronary (heart) arteries larger (4 mm), it stands to reason that if vascular disease is affecting the tiny penile arteries and causing ED, it may affect the larger coronary arteries as well — if not now, then at some time in the future. In other words, the fatty plaque that compromises blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a genital “stress test.”

What does this all mean?

  • Visceral fat is a bad, metabolically-active form of fat that is highly correlated with metabolic syndrome, diabetes, heart disease and sexual dysfunction.
  • ED often occurs in the presence of “silent” heart disease (no symptoms) and serves as a marker for increased risk for heart disease (as well as stroke, peripheral artery disease and death). ED will often occur 3-5 years before heart disease manifests. Early detection of ED provides an opportunity to decrease the risk of heart disease and the other forms of blood vessel disease. ED has a similar or greater predictive value for heart disease as do traditional factors including family history, prior heart attack, tobacco use and elevated cholesterol. The greater the severity of the ED, the greater the risk and extent of heart disease and blood vessel disease.

What can I do?

Lifestyle intervention has the potential for reversing visceral obesity, metabolic syndrome and sexual dysfunction. This lifestyle intervention involves achieving a healthy weight, losing the belly fat, eating healthy, exercising regularly, quitting smoking, limiting alcohol intake, and managing stress.

Written by Dr. Andrew Siegel


6 Surprising Risk Factors for Erectile Dysfunction (ED)

Having problems with erections from time to time is common and shouldn’t be cause for concern. However, if these problems become progressively worse or happen routinely with sex, you may want to speak with your doctor about erectile dysfunction (ED). Erectile dysfunction, or impotence, is the inability to develop and maintain an erection firm enough for sexual intercourse. According to the Urology Care Foundation, ED affects as many as 30 million men.

Although increasing age is the biggest contributing factor, here are six other risk factors for erectile dysfunction that may surprise you:

  1. You have anxiety at work. Men who work in an environment that causes anxiety and/or depression are more likely to suffer from ED. Erections require the nervous system to trigger them, so if the system is depressed, it can be difficult to trigger and maintain an erection.
  2. You have diabetes. ED prevalence in men with diabetes ranges from 35-75% and occurs 10-15 years earlier than men without diabetes. Irregular blood sugar can damage the nerves and blood vessels that allow blood flow in the penis.
  3. You have bad oral hygiene. Research shows that men who suffer from chronic periodontitis are more likely to suffer from ED. Periodontitis is often associated with oral inflammation, which decreases nitric acid production and blood flow.
  4. You regularly add salt to food. High blood pressure and cholesterol are often associated with high-sodium intake, which restricts blood flow. Restricting blood flow to the penis may be a contributing cause of ED.
  5. You enjoy riding a bike. Bike riding can desensitize and damage the nerves in the pelvic floor, which can make it difficult for men to get an erection. Scale back on the number of miles you ride on your bike each week and focus on other kinds of exercise if ED is a problem for you.
  6. You’re trying to reverse hair loss. Certain medications for hair loss, such as Propecia and Avodart, can cause ED because they reduce the amount of dihydrotestosterone in the blood.

Talk to your doctor if you’re experiencing symptoms of erectile dysfunction. There are many treatment options available to improve your quality of life.


5 Common Vasectomy Myths Debunked by Urologists

According to the Urology Care Foundation, more than 500,000 men in the U.S. choose vasectomy for birth control each year. But is it right for you? Because it’s a permanent form of birth control, many men have questions or concerns before having a vasectomy. This is normal and to be expected. To help you make an informed decision, our urologists are debunking some common vasectomy myths:

Myth: Vasectomy is a risky surgery.

Truth: A vasectomy is a safe and effective minor surgery that is usually performed in your doctor’s office. However, all surgeries have risks. After a vasectomy procedure, mild discomfort, bruising, and swelling is normal. Most men recover within one to two weeks.

Myth: Vasectomy can always be reversed.

Truth: While many men are good candidates for a vasectomy reversal procedure, only about half of these procedures are successful. The tube that the sperm passes through, called the vas deferens, is reconnected during a vasectomy reversal. It is a more complicated surgery because there are different ways to reconnect the vas deferens. Because there is no guarantee that a vasectomy reversal will be successful, it is important to be sure that you want to get a vasectomy in the first place.

Myth: You’ll lose sexual function.

Truth: A vasectomy does not hinder your sex life as the production of testosterone is not affected. The procedure blocks sperm but does not reduce the amount of semen produced, so there is no noticeable difference when you ejaculate.

Myth: Vasectomy is 100% effective right away.

Truth: It can take two to three months following a vasectomy to ensure there is no live sperm. A backup form of birth control should be used during this time. Only 1 to 2 women out of 1,000 will get pregnant in the year following their partner’s vasectomy.

Have other questions about vasectomies and vasectomy reversals?

If you have questions about getting a vasectomy, contact your local NJU office to schedule a consultation with a urology specialist.


Ejaculation: What to Expect As You Age

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

What does the word ejaculation mean?

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

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

What happens to ejaculations as we age?

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

So what’s the big deal?

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

The science of ejaculation

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

Big head versus little head

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

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

What makes up the love juices?

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

What’s normal volume?

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

Why does the seminal tank dry with aging?

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

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

What about the pelvic floor muscles?

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

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

How to get the juices flowing again?

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

Written by Dr. Andrew Siegel


Peyronie’s Disease: Causes and Treatment Options

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

What causes Peyronie’s Disease?

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

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

What are the side effects of Peyronie’s Disease?

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

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

What are the treatment options for Peyronie’s Disease?

Treatment options include:

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

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

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

Written by Dr. Andrew Siegel 


What to Expect After Adult Circumcision

What is a circumcision?

Circumcision is the surgical removal of the foreskin. The procedure takes about thirty minutes and is performed under general anesthesia. The entire foreskin is removed using an incision just behind the head of the penis. This leaves the head of the penis completely exposed. Local anesthesia will be used to relieve discomfort after the operation.

Why is circumcision performed?

Circumcision is usually performed on newborns for medical, social, or cultural purposes. According to the CDC, more than 58% of newborns in the United States are circumcised. However, people with an uncircumcised penis may choose to become circumcised later in life for many reasons, including:

  • Phimosis (tight foreskin cannot be retracted to expose head of penis)
  • Paraphimosis (retracted foreskin cannot be brought back to cover head of penis)
  • Balanitis (inflammation of head of penis)
  • Posthitis (inflammation of the foreskin—pronounced pos-THI-tis)
  • Cosmetic or personal reasons
  • Tearing of the penile skin when sexually active

Although circumcision is a simple procedure, it’s a larger surgery for adults than it is for newborns.

What can I expect afterwards?

You will be sent home with a compression dressing that can be removed in 48 hours. If it falls off sooner than that it’s not a problem. Absorbable stitches are used that do not require removal. After the dressing is removed, petroleum jelly can be applied to the stitch line to prevent the penis from sticking to your underwear.

You will likely experience pain for a few days that can be managed with analgesics that will be prescribed. Anti-inflammatories such as Advil and Ibuprofen are preferred to the narcotics as they are equally effective and have less side effects. You should not drive a car or operate machinery if you are using a narcotic for pain relief.

Activities need to be restricted for a few days. Sexual activity cannot be pursued for at least six weeks to allow full healing. You may experience pain with spontaneous erections.

When do I need to follow-up in the office?

You will need to be checked back in the office a week or two after the circumcision, and at the six-week point.

Written by Dr. Andrew Siegel


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