How High Is Your V.I.Q. (Vaginal Intelligence Quotient)?

June 17, 2017

Andrew Siegel MD  6/17/2017

You may know your I.Q., but do you know your V.I.Q.?  Let’s begin with a test of your knowledge of lady parts and determine your “Vaginal Intelligence Quotient” or V.I.Q.  See how many of 8 female genital structures you can properly identify. Answers are at end of this blog entry.  Note that there is one anatomical part that virtually no one gets right.  (Thank you Michael Ferig, Wikipedia Commons).

vulva_hymen_miguelferig

 

The Female Nether Parts

The female nether parts are a mystery zone to a surprising number of women, who often have limited knowledge of the inner workings of their own genital anatomy. Many falsely believe that the “pee hole” and “vagina hole” are one and the same. The truth is that the terrain between a female’s thighs is more complicated than one would think…. three openings, two sets of lips, mounds, swellings, glands, erectile tissues and very specialized muscles. While female anatomy may be mysterious to many women, many men are downright clueless and would be well served to learn some basic anatomy. Learn lady parts…knowledge is power!

“The vagina is a place of procreative darkness, a sinister place from which blood periodically seeps as if from a wound.”

“Even when made safe, men feared the vagina, already attributed mysterious sexual power – did it not conjure up a man’s organ, absorb it, milk it, spit it out limp?”

–Tom Hickman from “God’s Doodle”

The names of several lady parts begin with the letter “V”—vulva, vagina and vestibule. What could be a better choice since the area (the vulva) is V-shaped?

pixabay-v

Thank you Pixabay for image above

The Vulva 

The vulva is the outside part of the female genitals. It consists of the mons pubis, labia majora, labia minora, vestibule, vaginal opening, urethral opening and clitoris.

The mons is the triangular mound that covers the pubic bone, consisting of hair-bearing skin and underlying fatty tissue. It extends down on each side to form the labia majora, folds of hair-bearing skin and underlying fatty tissue that surround the entrance to the vagina. Within the labia majora are two soft, hairless skin folds known as labia minora, which safeguard the entrance to the vagina. The upper part of each labia minora unites to form the clitoral hood (prepuce or foreskin) at the upper part of the clitoris and the frenulum (a small band of tissue that secures the clitoral head to the hood) at the underside of the clitoris.

Figure_28_02_02

(Anatomy of the vulva and the clitoris by OpenStax College – Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148635, no changes made to original)

The Vestibule

The vestibule is the “entryway,” an area located between the inner lips that contains the entrances to the vagina and the urethra. Urine exits from the urethral opening on the vestibule and not from the vaginal opening. There is a small amount of vestibule tissue that separates the urethral opening from the vaginal opening.

 The Vagina

The word “vagina” intelligently derives from the Latin word for “sheath,” a cover for the blade of a knife or sword. Most women (and men) falsely think of the vagina as the external female genitals. The external lady parts are the VULVA as opposed to the VAGINA, which is internal.

 The Clitoris

The word clitoris derives from the Greek “kleitoris,” meaning “little hill.” The clitoris is uniquely an erectile organ that has as its express purpose sexual function, as opposed to the penis, which is a “multi-tasking” sexual, urinary and reproductive organ. The clitoris is the center of female sensual focus and is the most sensitive erogenous zone of the body, playing a vital role in sensation and orgasm. If an orgasm can be thought of as an “earthquake,” the clitoris can be thought of as the “epicenter.” The head of the clitoris, typically only the size of a pea, is a dense bundle of sensory nerve fibers thought to have greater nerve density than any other body part.

Like the penis, the clitoris is composed of an external visible part and an internal, deeper, invisible part. The inner part is known as the crura (legs), which are shaped like a wishbone with each side attached to the pubic arch as it descends and diverges. The visible part is located above the opening of the urethra, near the junction point of the inner lips. Similar to the penis, the clitoris has a glans (head), a shaft (body) and is covered by a hood of tissue that is the female equivalent of the prepuce (foreskin).  The glans is extremely sensitive to direct stimulation.

The shaft and crura contain erectile tissue, consisting of spongy sinuses that become engorged with blood at the time of sexual stimulation, resulting in clitoral engorgement and erection. The clitoral bulbs are additional erectile tissues that are sac-shaped and are situated between the crura. With sexual stimulation, they become full, plumping and tightening the vaginal opening. The crura and bulbs can be thought of as the roots of a tree, hidden from view and extending deeply below the surface, yet fundamental to the support and function of the clitoral shaft and clitoral glans above, which can be thought of as the trunk of a tree.

When the clitoris is stimulated, the shaft expands with accompanying swelling of the glans. With increasing stimulation, clitoral retraction occurs, in which the clitoral shaft and glans withdraw from their overhanging position, pulling inwards against the pubic bone.

The clitoris is a subtle and mysterious organ, a curiosity to many women and men alike. It is similar to the penis in that it becomes engorged when stimulated and because of its concentration of nerve fibers, is the site where most orgasms are triggered. Clitorises, like penises, come in all different sizes and shapes. In fact, a large clitoris does not appear much different from a small penis. The average length of the clitoral shaft including the glans is 0.8 inches (range of 0.2-1.4 inches). The average width of the clitoral glans is 0.2 inches (range of 0.1-0.4 inches).

The clitoris becomes engorged and erect during sexual stimulation. Two of the pelvic floor muscles—the bulbocavernosus (BC) and ischiocavernosus (IC)—engage and contract and compress the deep internal portions of the clitoris, maintaining blood pressures within the clitoral erection chambers to levels that are significantly higher than systemic blood pressures.

The bulbocavernosus reflex is a contraction of the BC and IC muscles (and other pelvic floor muscles including the anal sphincter) that occurs when the clitoris is stimulated. This reflex is important for maintaining clitoral rigidity, since with each contraction of the BC and IC muscles there is a surge of blood flow to the clitoris, perpetuating clitoral engorgement and erection.

 

vulva_hymen_miguelferig

Thank you Michael Ferig, Wikipedia Commons, for illustration above

Answers to Anatomy Quiz:

LM: labia majora (outer lips); VV: vaginal vestibule; Lm: labia minora (inner lips);  C: clitoris; U: urethra (urinary channel); V: vagina; H: hymenal ring (remnant of membrane that partially covered vaginal opening); A: anus (butthole)

Your V.I.Q.:

0 correct:  Vaginally feeble

1-2 correct: Vaginally deficient

3-4 correct: Vaginally average

5-6 correct: Vaginally superior

7 correct: Vaginally gifted

8 correct: Vaginal Genius…as sharp as a seasoned gynecologist!

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com (much of the content from today’s entry was excerpted from The Kegel Fix)

The Fickle Phallus

June 10, 2017

Andrew Siegel MD  6/10/17

3 screw icon square

 

The penis is a fickle and temperamental friend who can be volatile, unpredictable and even hot-headed at times.  He has many states of existence, ranging from as shrunken and soft as a marshmallow to a “proud soldier”– rock-hard with exquisite posture. Between deflated and inflated, there are an infinite number of intermediate states, dependent on the dynamic balance between the closing and opening mechanisms of the blood flow to the penile erectile chambers.  It is important to understand that the same physiology applies to female genitals and clitoral function. 

The Autonomic Nervous System: The Network Ultimately Responsible for this

The autonomic nervous system controls “unconscious” body functions, including heart rate, breathing, digestion and contributes in a large way to regulate sexual function.

Heart rate and contraction are dynamic, changing moment-to-moment, even beat-to-beat, since they are “governed” by two competing halves of the autonomic nervous system.  The two systems—sympathetic and parasympathetic—are in a constant tug-of-war based upon external stimuli and one’s interpretation of them.

The sympathetic nerves respond to threats, fears and anxieties —an agitated state of mind and blood vessel tone—with the classic flight-or-fight response, which accelerates heart rate, heart contractility, respiratory rate, blood pressure and constricts arteries throughout the body.  The sympathetic system boots up when one is presented with a sudden anxiety-provoking event, such as being in a near-miss car accident.

On the other hand, the other half of the autonomic nervous system is the parasympathetic nervous system—the calmer and more relaxed state of mind and blood vessel tone—which slows down heart rate and respiratory rate, reduces heart contractility and lowers blood pressure by dilating arteries. The parasympathetic system is the system that predominates when we are not in situations that provoke fear and anxiety, governing many day-to-day bodily functions.

The_Autonomic_Nervous_System

Above image from Wikipedia, in public domain

 

Erectile function is complex and based upon many factors, both physical and psychological, but the ultimate determinant is chemistry that drives penile blood flow or lack thereof.  The state of the penis (flaccid vs. rigid vs. any intermediate state) at any given moment is based upon the balance between sympathetic (contractile) and parasympathetic (relaxant) factors. As the cardio-vascular system function is predicated upon the predominance of sympathetic versus parasympathetic stimulation, so the function of the peno-vascular system is predicated upon the predominance of sympathetic versus parasympathetic function. After all, the penis can be considered to be an extension of the vascular system that can be referred to as the “dangling aorta.”

Penile erection occurs with activation of parasympathetic (nitric oxide-cyclic guanosine phosphate pathway) nerves, which foster the relaxation of the penile arterial smooth muscle and the smooth muscle of the erectile tissue and inhibition of contractile mechanisms, all of which cause blood to rush into and inflate the penile erectile chambers.

Alternatively, penile flaccidity occurs with activation of sympathetic (norepinephrine pathway) nerves, which foster the contraction of the penile arterial smooth muscle and the smooth muscle of the erectile tissue and inhibition of relaxing mechanisms, all of which causes blood to exit and deflate the penile erectile chambers.

Sympathetic nervous system activity causing increased smooth muscle tone in erectile tissue is likely involved in the occurrence of psychological as well as in cardiovascular erectile dysfunction.

The bottom line is that the state of penile inflation at any given moment is highly influenced by the balance between sympathetic and parasympathetic function. High sympathetic activity causes a shriveled and decompressed penis, while high parasympathetic activity an erect and rigid penis. This is the very reason why one needs to have a relaxed temperament in order to perform sexually and also explains why anxiety can doom erectile function. A perfectly healthy 21-year-old with absolutely normal “plumbing” can be doomed to sexual failure if performance anxiety creates such a high sympathetic tone state. Similarly, a 50-year-old man who uses Viagra to increase penile blood flow and help obtain a rigid erection can have the beneficial effect of the medicine neutralized by a highly anxious state of mind.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

So Your Vagina Is Loose: Now What?

June 3, 2017

Andrew Siegel MD  6/3/17

After your newborn  has used your vagina as a giant elastic waterslide (and perhaps repeated a few times), you may find that your lady parts are not quite the same.  Obstetrical “trauma” to the nether muscles (genital and pelvic muscles) and stretching of the vaginal opening can lead to permanent changes. Multiple childbirths, large babies, use of forceps for delivery, and age-related changes of the pelvic muscles and connective tissues further compound the issue.  This condition, a.k.a. vaginal laxity, is characterized by the vaginal opening being wider and looser than it should be.

recto copy

Image above of vaginal laxity in patient immediately before vaginal reconstructive surgery: rectocele (blue arrow: rectum pushing up into back wall of vagina), perineal scarring (white arrow: scarring between vagina and anus) and catheter in urethra (red arrow: channel that conducts urine)

Trivia: Leonardo Da Vinci had an interesting take on male and female perspectives: “Woman’s desire is the opposite of that of man.  She wishes the size of the man’s member to be as large as possible, while the man desires the opposite for the woman’s genital parts.”

Vaginal Laxity

Vaginal looseness–sometimes to the point of gaping– is one of the most common physical changes found on pelvic exam following delivery.  This often overlooked, under-reported, under-appreciated, under-treated condition commonly occurs following pregnancy and vaginal delivery.  Not only is it bothersome to the woman dealing with the problem, but it can also lead to body image issues, decreased sexual sensation, less sexual satisfaction (for partner as well) and disturbances in self-esteem.

It is important to distinguish vaginal laxity from pelvic organ prolapse (an internal laxity in which one or more of the pelvic organs –bladder, uterus, rectum–bulge into the vagina and at times beyond the vaginal opening).  The photo above illustrates a woman with both issues.

The vagina of a woman with laxity often cannot properly “accommodate” her partner’s penis, resulting in the vagina “surrounding” the penis rather than firmly “squeezing” it, with the end result being diminished sensation for both partners.  Under normal circumstances, sexual intercourse results in indirect clitoral stimulation with the clitoral shaft moving rhythmically with penile thrusting by virtue of penile traction on the inner vaginal lips, which join together to form the hood of the clitoris.  When the vaginal opening is too wide to permit the penis to put enough traction on the inner vaginal lips, clitoral stimulation is also limited, another factor resulting in less satisfaction in the bedroom.

7 Ways to Know if You Have a Loose Vagina

  1. You cannot keep a tampon in.
  2. During sexual intercourse, your partner’s penis often falls out.
  3. Your vagina fills with water while bathing.
  4. You have vaginal flatulence, passage of air trapped in the vagina.
  5. When examining yourself in the mirror you see the vaginal lips parted and internal tissues exposed (it should be shut like a clam shell).
  6. Sexual intercourse is less satisfying for you and your partner and noticeably different than before childbirth.
  7. You have difficulty experiencing orgasm.

Means of quantitating vaginal laxity and the strength of the pelvic and vaginal muscles that are used by physicians include:

  1. Visual inspection of the vulva, which shows vaginal gaping, exposure of internal tissues and decreased distance from vagina to anus
  2. Pelvic exam while having the patient contract down upon the examiner’s fingers, using the modified Oxford scale of 0-5 (0–very weak pelvic contraction; 5–very strong pelvic contraction)
  3. Manometry, a measurement of resting pressure and pressure rise following a pelvic floor muscle contraction
  4. Dynamometry, a measurement of pelvic muscle resting and contractile forces using strain gauges
  5. Electromyography, recording the electrical potential generated by the depolarization of pelvic floor muscle fibers

On a practical basis, means #1 and #2 are usually more than sufficient to make a diagnosis of vaginal laxity

 Vaginal Laxity:  What to do?

  • Over-the-Counter Herbal Vaginal Tightening Creams: Don’t even bother. These non-regulated products can be harmful and there is no scientific evidence to support their safe and effective use.
  • Kegel Exercises, a.k.a. Pelvic Floor Muscle Training: Worth the bother!  This non-invasive, first-line, self-help form of treatment should be exploited before considering more aggressive means. Increasing the strength, power and endurance of the pelvic floor muscles has the potential for improving vaginal laxity as well as sexual function, urinary and bowel control and pelvic prolapse.
  • Use it or lose it: Stay sexually active to help keep the pelvic and vaginal muscles toned.  Although you might think that sexual intercourse might worsen the problem by further stretching the vagina, in actuality it will help improve the problem and increase vaginal tone.
  • Energy-Based Devices: There are a host of new technologies that are being used for “vaginal rejuvenation” in an office setting. These are typically lasers or units that use targeted radio-frequency energy that are applied to the vaginal tissues. One such device uses mono-polar radio-frequency therapy with surface cooling.  It works by activating fibroblasts (the type of cells that makes fibers involved in our structural framework) to produce new collagen stimulating remodeling of vaginal tissue. The vaginal surface is cooled while heat is delivered to deeper tissues.                                                                                                                                                               Note: The jury is still not out on the effectiveness of these procedures. What is for certain is that they are costly and not covered by medical insurance.  Anecdotally, I have a few patients who claim that they have had significant improvement in vaginal dryness and other symptoms of menopause after undergoing laser treatment.      
  • Vaginoplasty/Levatorplasty/Perineorrhaphy/Perineoplasty: This is medical speak for the surgical reconstructive procedures that are performed to tighten and narrow the vaginal opening and vaginal “barrel.”  The goal is for improved aesthetic appearance, sexual friction, sexual function and self-esteem. These procedures are often performed along with pelvic reconstructive procedures for pelvic organ prolapse, particularly for a rectocele, a condition in which the rectum prolapses into the bottom vaginal wall.

 The term vaginoplasty derives vagina and plasty meaning “repair.”  The term levatorplasty derives from levator (another name for deep pelvic floor muscles) and plasty meaning “repair.” Perineorrhaphy derives from perineum (the tissues between vagina and anus) and –rrhaphy, meaning “suture,” while the term perineoplasty derives from perineum (the tissues between vagina and anus) and plasty meaning “repair.”

Within the perineum are the superficial pelvic floor muscles (bulbocavernosus, ischiocavernosus and transverse perineal muscles) and deeper pelvic floor muscles (levator ani).  Perineal muscle laxity is a condition in which the superficial pelvic floor muscles become flabby. Weakness in these muscles cause a widened and loosened vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal axis such that the vagina assumes a more upwards orientation as opposed to its normal downwards angulation towards the sacral bones.

3. superficial and deep PFM

Illustration of pelvic floor muscles by artist Ashley Halsey from “The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health

The surgical reconstructive procedures referred to above narrow the relaxed vaginal opening and vaginal barrel and address cosmetic concerns. The aforementioned muscles are buttressed to rebuild the perineum, resulting in a tighter vaginal opening and vaginal barrel, increased distance from vaginal opening to anus, restoration of the proper vaginal angle and an improvement in cosmetic appearance.

public domain

Illustration above from public domain.  On left is lax vagina with incision made from point A to point B where vagina and perineum meet. On right the superficial pelvic muscles are accessed and ultimately buttressed in the midline, converting the initial horizontal incision to one that is closed vertically.

Marietta S pre-PP

Image above of lax vagina before surgical repair; (c) Michael P Goodman, MD. Used with permission

.Mariette S 6 wk p.o. PP

Image above of lax vagina after surgical repair; (c) Michael P Goodman, MD. Used with permission.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

No Erections Without A Solid Base

May 27, 2017

Andrew Siegel MD  5/27/2017  Happy Memorial Day Weekend!

A flagpole needs a solid base of support in order to stand tall and not be felled by the elements.  One that is poorly mounted will falter as soon as the wind picks up or other adverse circumstances surface.  This is analogous to a tree and its root system with no tree able to stand tall and bear the elements without a deep and powerful root system.  In both cases, the hidden, behind-the-scenes support system is equally important to the exposed product.

at20op_-03__topflight-telescoping-20ft-flagpole_1_1.jpg

Flagpole base

Exposed_mango_tree_roots

Exposed roots of a mango tree, by Aaron Escobar [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)%5D, via Wikimedia Commons

…And so it is with the penis. Like the flagpole and the tree that require a solid base of support, the penis also necessitates a sturdy foundation in order to be able to morph into a “proud soldier,” tall and erect in posture.  This foundation also enables the ability to maintain this rigid stability despite exposure to the “elements”– the substantial torquing and buckling forces the penis is subjected to at the time of sexual activity.

* Thank you to Paul Nelson–friend, colleague and president of the Erectile Dysfunction Foundation and launcher of FrankTalk.org–who came up with the clever  flagpole analogy.

What You See is Not What You Get

Half the penis is exposed and half is hidden.  The visible portion of the penis (pendulous penis) is the external half.  The internal half (infrapubic penis) lies under the surface and is known as the penile roots or in medical speak, the crura. Like the roots of a tree or the base of a flagpole responsible for foundational support, the roots of the penis stabilize and support the erect penis so that it stays rigid and skyward-angling with excellent “posture.”  Without functioning penile roots, the penis would remain limp, would dangle in accordance with gravity and have slouching posture at best.

4extintpenis

Illustration above by Christine Vecchione from “Male Pelvic Fitness: Optimizing Sexual & Urinary Health”

The penile roots are enveloped by two pelvic floor muscles, the BC (bulbocavernosus) and the IC (ischiocavernosus).  These rigidity muscles compress the roots of the penis, causing backflow of pressurized blood into the penis.  In a sexual situation, these muscles engage and contract, forcing blood within the roots of the penis into the external penis.  Not only is pressurized blood pushed into the external penis promoting rigidity, but also the contractions of these muscles causes the clamping of venous outflow—a tourniquet-like effect—that results in penile high blood pressure and full-fledged rigidity.  These muscles are also responsible for ejaculation—rhythmically compressing the urethra (urinary channel that runs through the penis) at the time of climax to cause the expulsion of semen.

Factoid: It is the BC and IC muscles that are responsible for the ability to lift one’s erect penis up and down (wag the penis) as they are contracted and relaxed.

00001Illustration above by Christine Vecchione from “Male Pelvic Fitness: Optimizing Sexual & Urinary Health”

The BC and the IC muscles together with the transverse perineal muscles and the levator muscles are collectively known as the pelvic floor muscles, a muscular hammock located between scrotum and anus  (“inner taint”). Although unseen and behind-the-scenes, hidden from view, these often unrecognized and misunderstood muscles have vital functions in addition to erection and ejaculation, including urinary and bowel control. As part of the core group of muscles, they affect posture, the lower back and the hips.

Take home message: The pelvic floor muscles are the rigidity muscles, necessary for transforming the stimulated penis that becomes plump into a rock-hard penis. When these muscles are not functioning optimally, one loses the potential for full rigidity.

Factoid: An erection—defined in hydraulic terms—is when the penile blood inflow is maximized while outflow is minimized, resulting in an inflated and rigid penis. The pressure in the penis at the time of an erection is sky-high (greater than 200 millimeters), the only organ in the body where high blood pressure is both acceptable and necessary for healthy functioning. This explains why blood pressure pills are the most common medications associated with erectile dysfunction.

Bottom Line: Neither flagpole, tree nor penis can be firmly supported without a solid foundation.  The penile roots and the pelvic floor muscles that surround them are the foundation.  Not only do these muscles support the deep roots of the penis, but they are also responsible for the high penile blood pressures responsible for erectile rigidity and are the motor power underlying ejaculation.  The IC muscle should be known as the “erector muscle” and the BC muscle the “ejaculator muscle.” Although not muscles of glamour, they are certainly muscles of “amour.”

Straddling the gamut of being vital for what may be considered the most pleasurable and refined of human pursuits—sex—they are equally integral to what may be considered the basest of human activities—bowel and bladder function.  These hidden muscles deserve serious respect and are capable of being intensified by training in order to improve and often prevent sexual, urinary and bowel issues. Why not consider exercising your erector and ejaculator muscles, as you do for so many other muscle groups in the body?

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

Co-creator of the PelvicRx male pelvic floor exercise program: http://www.PelvicRx.com

 

 

 

 

 

Rectoceles And Perineal Laxity: What You Need To Know

May 20, 2017

Andrew Siegel MD  5/20/17

recto copy

Image above: protrusion of the rectum into the floor of the vagina, a.k.a. rectocele (blue arrow); also note catheter in urethra (red arrow) and gaping vagina with scarring of tissues between vagina and anus, a.k.a. perineum (white arrow)

A rectocele is a specific type of pelvic organ prolapse in which the pelvic floor muscles and connective supporting tissue between the lower vaginal wall and rectum weaken, allowing protrusion of the rectum into the floor of the vagina and at times outside the vaginal opening. This not uncommonly follows vaginal childbirth, which places tremendous stresses on the tissues that provide to support of the pelvic organs. Other risk factors for the occurrence of a rectocele are chronic straining, menopause and weight gain.

Rectoceles are also known by the terms “dropped rectum,” “prolapsed rectum,” and “rectal hernia.” The most common symptom is an annoying vaginal bulge that worsens with assuming the upright position and being active and tends to improve with sitting, lying down and being sedentary. It is often quite noticeable when straining to move one’s bowels. It can give rise to bowel difficulties—most notably what is referred to as “obstructed defecation”—including constipation, incomplete bowel emptying, diarrhea and fecal incontinence. The prolapsed rectum often needs to be manipulated back into position in order to be able to effectively move one’s bowels. Rectoceles can also cause vaginal pressure, vaginal pain and painful sexual intercourse.

Relevant trivia: The word “rectum” derives from the Latin word meaning “straight,” because under normal circumstances the rectum is a straight chute, facilitating bowel movements. The presence of a rectocele causes kinking of the rectum to occur, destroying this anatomical arrangement and making bowel movements difficult without “splinting” the rectum (straightening it out) using one or more fingers placed in the vagina.

Often accompanying a rectocele is laxity of the perineal muscles, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. This causes a widened vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal angle. Women who are sexually active may complain of a loose or gaping vagina. This may lead to difficulty keeping a tampon in position without it falling out, the vagina filling with water while bathing, vaginal flatulence (the embarrassing passage of air) and sexual issues including difficulty retaining the penis with vaginal intercourse and difficulty achieving orgasm. Perineal laxity may result in the vagina “surrounding” the penis rather than firmly “squeezing” it during sexual intercourse, with the end result diminished pleasurable sensation for both partners. The perception of having a loose vagina and altered anatomy can lead to self-esteem and other psychological issues.

Relevant trivia: Under normal circumstances, sexual intercourse results in indirect clitoral stimulation. The clitoral shaft moves rhythmically with penile thrusting by virtue of penile traction on the inner vaginal lips, which join together to form the hood of the clitoris. However, if the vaginal opening is too wide to permit the penis to put enough traction on the inner vaginal lips, there will be limited clitoral stimulation and less satisfaction in the bedroom.

Management of Rectoceles

Rectoceles can be managed conservatively with pelvic floor exercises, behavioral modifications and consideration for using a pessary. Alternatively, surgical treatment, a.k.a. pelvic reconstruction, is often necessary for more extensive rectoceles or for those that do not respond to conservative measures.

Pelvic floor muscle training (PFMT) is useful under the circumstances of mild-moderate rectocele, for those who cannot or do not want to have surgery and for those whose minimal symptoms do not warrant more aggressive options. The goal of PFMT is to increase the strength, tone and endurance of the muscles that play a key role in the support of the rectum and perineum. Weak pelvic muscles can undoubtedly be strengthened; however, if there is connective tissue damage, pelvic training will not remedy the injury, but does serve to strengthen the muscles that can help compensate for the connective tissue impairment. If not completely cured with PFMT, the rectocele and perineal laxity can still be improved, and that might be sufficient.  Chapter 5 in The Kegel Fix book  (www.TheKegelFix.com) is devoted to a specific PFMT regimen for rectoceles and other forms of pelvic organ prolapse.  Note that if the pelvic floor muscles are torn or widely separated, PFMT will not be productive until surgical repair is performed.

Another component of conservative management is modification of activities that promote the rectocele (heavy lifting and high impact exercises), management of constipation and other circumstances that increase abdominal pressure, weight loss, smoking cessation and consideration for estrogen hormone replacement, since estrogen replacement can increase tissue integrity and suppleness.

A pessary is a mechanical device that is available in a variety of sizes and shapes and is inserted into the vagina where it acts as a “strut” to help provide pelvic support and keep the rectum in proper position. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.

Surgery is often necessary in the case of a symptomatic moderate-severe rectocele, particularly when quality of life has been significantly impacted. This type of surgery is most often done vaginally, typically on an outpatient basis. Both the rectocele and the perineal laxity are addressed.  The goal of surgery is restoration of normal anatomy with preservation of vaginal dimensions and improvement in symptoms with optimization of bowel and sexual function.  With improvement of anatomy, function often significantly improves, since function often follows form. Difficulties with evacuation, constipation, straining, incomplete emptying and fecal incontinence should improve, if not resolve. There should no longer be a need to splint the rectum and sexual function (for both patient and partner) should dramatically improve with the rebuilding of the perineum.

Marietta S pre-PP

Pre-operative photo–note gaping vulva, exposed vagina, rectocele and perineal laxity; (c) Michael P Goodman, MD. Used with permission

 

Mariette S 6 wk p.o. PP

Post-operative photo–note closed vulva, unexposed vagina and restored perineum after levatorplasty, vaginoplasty, perineorrhaphy and aesthetic perineoplasty; (c) Michael P Goodman, MD. Used with permission

 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com  

Much of the content of this entry was excerpted from Dr. Siegel’s The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health (Chapter 5. Pelvic Organ Prolapse)

6 Ways To Reduce Your Risk Of Prostate Cancer

May 13, 2017

Andrew Siegel MD  5/13/17

Prostate cancer is incredibly common– one man in seven will be diagnosed with it in his lifetime–with average age at diagnosis mid 60s. In 2015, an estimated 221,000 American men were diagnosed and 28,000 men died of the disease.  Although many with low-risk prostate cancer can be managed with careful observation and monitoring, those with moderate-risk and high-risk disease need to be managed more aggressively. With proper evaluation and treatment, only 3% of men will die of the disease. There are over 2.5 million prostate cancer survivors who are alive today.

Factoid: The #1 cause of death in men with prostate cancer is heart disease, as it is in the rest of the population. 

finger 2

This is the index finger of yours truly; observe the narrow digit, a most desirable feature for a urologist who examines many prostates in any given day.  The digital rectal exam of the prostate is a 15-second exam that is at most a bit uncomfortable, but vital in the screening process and certainly nothing to fear.

Wouldn’t it be wonderful if prostate cancer could be prevented? Unfortunately, we are not there yet—but we do have an understanding of measures that can be pursued to help minimize your chances of developing prostate cancer.

Factoid: When Asian men–who have one of the lowest rates of prostate cancer– migrate to western countries, their risk of prostate cancer increases over time. Clearly, a coronary-clogging western diet high in animal fat and highly processed foods and low in fruits and vegetables is associated with a higher incidence of many preventable problems, including prostate cancer.

The presence of prostate cancer pre-cancerous lesions commonly seen on prostate biopsy—including high-grade prostate intraepithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP)—many years before the onset of prostate cancer, coupled with the fact the prostate cancer increases in prevalence with aging, suggest that the process of developing prostate cancer takes place over a protracted period of time. It is estimated that it takes many years—often more than a decade—from the initial prostate cell mutation to the time when prostate cancer manifests with either a PSA elevation, an acceleration in PSA, or an abnormal digital rectal examination. In theory, this provides the opportunity for intervention before the establishment of a cancer.

Measures to Reduce Your Risk of Prostate Cancer

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

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

  1. Certain medications reduce the risk of prostate cancer by 25% or so and may be used for those at high risk, including men with a strong family history of prostate cancer or those with pre-cancerous biopsies. These medications include Finasteride and Dutasteride, which are commonly used to treat benign prostate enlargement as well as male pattern hair loss. These medications lower the PSA by 50%, so any man taking this class of medication will need to double their PSA in order to approximate the actual PSA. If the PSA does not drop, or if it goes up while on this class of medication, it is suspicious for undiagnosed prostate cancer. By shrinking benign prostate growth, these medications also increase the ability of the digital rectal exam to detect an abnormality.

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

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

 

12 STEPS TO OVERCOMING “OVER-ACTIVE” BLADDER (OAB)

May 6, 2017

Andrew Siegel MD  5/6/17 (my daughter’s 18th birthday!)

For most people, the urinary bladder is a cooperative and obedient organ, behaving and adhering to its master’s will, squeezing only when appropriate. However, some people have bladders that are unruly and disobedient, acting rashly and irrationally, squeezing at inappropriate times without their master’s permission. This condition is referred to as “overactive bladder” or OAB for short. This problem can occur in both women and men, although it is more common in females.

Picture1

“Gotta go,” the urinary urgency that is the hallmark of OAB

8. UUI

Image above (artist Ashley Halsey from “The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health”) illustrates a bladder contracting involuntarily, leading to urinary leakage

OAB (http://www.njurology.com/overactive-bladder/) 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.

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.

An evaluation includes a urinalysis (dipstick exam of the urine), a urine culture (test for urinary infection) if indicated, and determination of the post-void residual volume (amount of urine left in bladder immediately after emptying). A 24-hour voiding diary (record of urination documenting time and volume) is an extremely helpful tool.  Urodynamics (test of storage and emptying bladder functions), cystoscopy (visual inspection of inside of bladder), and renal and bladder ultrasound (imaging tests using sound waves) may also prove helpful.

The management of OAB is challenging, yet rewarding, and necessitates a partnership between patient and physician. Successful treatment requires a willing, informed and engaged patient with a positive attitude. Management options for OAB range from non-invasive strategies to pills to surgery. It is sensible to start with the simplest and least invasive means of treatment and progress accordingly to more aggressive and invasive treatments if there is not a satisfactory response to conservative measures.  Behavioral treatments are first-line: fluid management, bladder training, bladder control strategies, pelvic floor muscle training and lifestyle measures.  Behavioral therapies may be combined with medication(s), which are considered second-line treatment. Third-line treatments include neuromodulation (stimulating specific nerves to improve OAB symptoms) and Botox injections into the urinary bladder.

References that will help the process include the following:

Book: THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health www.TheKegelFix.com

Book: MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health www.MalePelvicFitness.com

DVD: Easy-to-use, follow-along, FDA-registered pelvic training program that includes a detailed instruction guide, an interactive DVD and digital access to the guided training routines: www.PelvicRx.com

12 Steps To Overcoming OAB

The goal of the 12 steps that follow 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 7:00 PM 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 (see below) 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.

oab

Schematic diagram above illustrates the relationship of the contractile state of the bladder muscle to the contractile state of the PFM. Note that a voluntary PFM contraction can turn off an involuntary bladder contraction (+ symbol denotes contraction; – symbol denotes relaxation)

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, etc.–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 the 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.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Putting Some “Lead” In Your Pencil: A Fix For The “Innie” Penis

April 29, 2017

Andrew Siegel MD   4/28/2017

pencil pixbay

Thank you, Pixabay, for image above

As Multi-Functional as a Swiss Army Knife

The penis is an extraordinary organ with urinary, sexual and reproductive functions. The possession of a penis endows man with the ability to stand to urinate and direct his urinary stream, a distinct advantage over the clumsy apparatus of the fairer sex that generates a spraying, poor-directed stream that demands sitting down on a toilet seat. The advantage of being able to stand to urinate (and keep one’s body appropriately distanced from the horrors of many public toilets) is priceless. Although man does not often have to employ this, the capability (when necessary) of urinating outside is another benefit of our design.  Many find the outdoor voiding experience pleasing, observing the pleasant sounds and visuals of a forceful stream striking our target (often a tree) with finesse, creating rivulets and cascades to show for our efforts.

Getting beyond the urinary, the most dramatic penis magic is its ability to change its form in a matter of seconds, morphing into an erect “proud soldier” and enabling the wherewithal for vaginal penetration and with sufficient stimulation, for ejaculation.  All that fun, but really serving the purpose of the passage of genetic material and ultimately the perpetuation of our species…reproductive wizardry!

The water tap that could turn into a pillar of fire.”

Eric Gill

tap pixabay

pixabay pillar

Thank you, Pixabay, for images above

 

The Sometimes Cruel Process of Aging Does Not Spare the Penis

 “Getting older is an honor and a privilege, but getting old is a burden.”

Beverly Radow (my aunt, who will turn 90-years-old this year)

Long after our reproductive years are over and fatherhood is no longer a consideration, most men still wish to be able to achieve a decent-enough erection to have sexual intercourse.  As well, we still desire to be able to urinate standing upright with laser-like urinary stream precision.

However, the ravages of time (and poor lifestyle habits) can wreak havoc on penile anatomy and function.  Many middle-aged men typically gain a few pounds a year, ultimately developing a bit of a pubic fat pad–the male equivalent of the female mons pubis– and before you know it the penis appears shorter and becomes an “innie” as opposed to an “outie.”  In actuality, penile length is usually more-or-less preserved, with the penis merely hiding behind the fat pad, the “turtle effect.” Lose the fat and presto…the penis reappears. This is why having a plus-sized figure is not a good thing when it comes to size matters.

Useful Factoid: The Angry Inch…It is estimated that there is a one-inch loss in apparent penile length with every 35 lbs. of weight gain.

One of the problems with a shorter and more internal penis is that the forceful and precise urinary stream of yesteryear gives way to a spraying and dribbling-quality stream that can drip down one’s legs, spray over the floor and onto one’s feet (and even at times towards or on the gentleman next to you at the urinal!).

Almost Useless Factoid: Water Sports…Turkey vultures pee on themselves to deal with the heat of the summer on their dark feathers, since they lack sweat glands.  By excreting on their legs, the birds use urine evaporation to cool themselves down in the process of “urohidrosis.”  Unless you are a turkey vulture, peeing on yourself or others is rather undesirable!

The solution to having a recessed penis that is often hidden from sight and has lost its aiming capabilities is to sit on the toilet bowl to urinate, joining the leagues of our female companions who are “stream-challenged” because of their anatomy.

With aging (and poor lifestyle habits) also comes declining sexual function and activity as rigid erections going by the wayside.  However, like any other body part, the penis needs to be used on a regular basis—the way nature intended—in order to maintain its health. In the absence of regular sexual activity, disuse atrophy (wasting away with a decline in anatomy and function) of the penile erectile tissues can occur, resulting in a de-conditioned and smaller penis that does not function like it used to.

Factoid: Disuse Atrophy…If one goes too long without an erection, collagen, smooth muscle, elastin and other erectile tissues may become compromised, resulting in a loss of penile length and girth and limiting one’s ability to achieve an erection.  Conversely, sexual intercourse on a regular basis protects against ED issues and the risk of ED is inversely related to the frequency of intercourse.

The point I am trying to hammer home is that aging, weight gain and poor lifestyle habits often render men with penises that are:

  1. Shrunken and recessed
  2. Unreliable in terms of ability to pee straight, requiring sitting down on the toilet bowl like women
  3. Unreliable with respect to sexual function

Factoid: Point 1 + Point 2 + Point 3 = EMASCULATION (depriving man of his male role and identity)

What To Do?

The first step is to keep one’s body (and penis) as healthy as possible via intelligent lifestyle choices. These include the following: smart eating habits; maintaining a healthy weight; engaging in exercise (including pelvic floor muscle training); obtaining adequate sleep; consuming alcohol in moderation; avoiding tobacco; and stress reduction. The use of ED medications on a low-dose, daily basis can sometimes help all 3 issues.

In the event that the aforementioned means fail to correct the problem, a virtually sure-fire way of rectifying all three issues is by a simple surgical procedure.  Malleable penile implants (penile rods) are surgically placed into each erectile chamber of the penis (the two inner tubes of the penis that under normal circumstances fill with blood to create an erection). The implants act as skeletal framework for the penis (“bones” of the penis). Two USA companies, Coloplast and AMS (American Medical Systems) manufacture the rods that are in current use. They are very similar with subtle differences.

464x261_GenesisColoplast Genesis implant

AMS Spectra

American Medical Systems Spectra implant

The implant procedure of these two stiff-but-flexible rods into the erectile chambers of the penis is performed by a urologist on an outpatient basis.  Like shoes, the penile rods come in a variety of lengths and widths and fundamental to the success of the procedure is to properly measuring the dimensions of the erectile chambers in order to obtain an ideal fit. The small incision needed to implant the rods is closed with sutures that dissolve on their own. Healing typically takes about 6 weeks, after which sexual relations can be initiated.

An erection suitable for penetration and sexual intercourse is available 24-7-365, simply by bending the penis up. The penis is angled down for concealment purposes. It is flexible enough to be comfortably flexed up or down, while rigid enough for intercourse, the best of all worlds.

Print

Penile rods in action, bent down for concealment and up for urination and sex

Bottom Line:  It is not uncommon for aging, weight gain and unhealthy lifestyle factors to conspire to compromise penile anatomy and function with respect to apparent penile size, urinary stream precision and erectile rigidity.  This leaves one emasculated with a penis that is often concealed, shortened and habitually limp, impeding the ability to have sexual intercourse, as well as a spraying quality urinary stream necessitating sitting to urinate.  If lifestyle improvement measures do not correct the situation, literally and figuratively “putting some lead in your pencil” using a simple malleable penile implant can “kill three birds with one stone.” (I could not resist the very mixed metaphor.)  Confidence can be restored with the conversion of the “innie” penis to an “outie,” the ability to resume sexual intercourse and the reestablishment of a directed, non-spraying stream to permit standing to urinate.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

Bladder Cancer Treatment With TB Vaccine

April 22, 2017

Andrew Siegel MD  4/22/17

The use of tuberculosis vaccine (a.k.a. bacillus Calmette-Guerin or BCG) to treat bladder cancer is one of the great success stories in the history of using the immune system to combat cancer. For 40 years, BCG has been recognized as the standard of care for high-grade, superficial bladder cancer and carcinoma-in-situ (CIS), a flat but high-grade bladder cancer. The use of BCG is responsible for significantly reducing bladder cancer progression and recurrence.

IMG_2097

Image above: BCG in powdered form that needs to be reconstituted

bladder-ca

Image above: Typical appearance of a superficial bladder cancer

 

Bladder cancer has a strong tendency to recur, despite cystoscopy-guided complete removal of visible tumors (using a “telescope” placed within the bladder via the urethra). This approach can only treat obvious and visible tumors, with the real possibility that there are additional tumors present that are not yet visible (microscopic), since bladder cancer is a “field” disease—capable of occurring anywhere within the bladder lining. One of the rationales for using a medication like BCG is that it is a liquid formulation that is instilled in the bladder and will bathe all inner surfaces of the bladder. I often use the analogy of plucking out dandelions in your lawn individually as opposed to using a weed spray with respect to the difference between bladder tumor resection (cystoscopic surgical removal) and using a BCG-like medication.

A Brief History of BCG

BCG is a unique strain of “weakened” mycobacterium bovis (cow tuberculosis bacterium) developed by Albert Calmette and Camille Guerin at the Pasteur Institute in Lille, France in 1921 as a tuberculosis vaccine. At the time of its development, there was a growing recognition of the relationship between the immune system and cancer. In 1929, it was discovered that BCG might also have a role in the treatment of cancer when autopsy findings in TB patients were correlated with a reduced prevalence of cancers. Early investigators found that mice given BCG were protected against cancers that were implanted. In 1975, Dr. Jean deKernion at UCLA reported a melanoma that had spread to the bladder that was eliminated by direct injection of BCG into the melanoma. In 1976, Alvaro Morales successfully instilled BCG inside the bladder to treat bladder cancer and after clinical trials it was FDA approved for use within the bladder in 1990…The rest is history.

How It Works

BCG activates the immune system and triggers an inflammatory response that destroys bladder cancer cells. A good response to BCG immunotherapy requires a patient with an immune system capable of mounting a cellular immune response. It is accomplished by infusing a sufficient quantity of BCG so that it has direct contact with cancer cells.

How It Is Used

BCG is instilled directly within the urinary bladder.  One cycle is a once per week treatment for 6 weeks.  A full course is two cycles, followed by maintenance therapy. Typically the BCG treatment is initiated two weeks or so following the bladder tumor resection to allow the bladder time to heal. BCG is placed inside the urinary bladder using a narrow catheter. Retaining it for two hours is ideal and rotating body position is important so that all areas of the bladder are adequately bathed with the BCG.

Side Effects of BCG

Low-grade fever, urinary urgency, frequency, burning and blood in the urine are typical symptoms, often indicative of the immune response being mounted.   Occasionally, flu-like symptoms may occur, including fever, chills, cough, muscle and joint aches. When severe symptoms occur, BCG concentration can be reduced to 1/3, 1/10, 1/30, or even 1/100th of a dose to prevent escalating side effects.

 Tips For Patients Receiving BCG

  • Avoid drinking any fluids for at least 2 hours and avoid caffeine-containing products for at least 4 hours prior to bladder instillation in order to be able to retain the BCG for a full 2 hours after the instillation and to avoid diluting the concentration of the BCG.
  • Rotate your body in order to bathe all surface areas of the bladder with the BCG (supine, left, right, prone).
  • Care should be used when urinating after the BCG is instilled to avoid contaminating one’s hands or genitals with the BCG. Men should sit to urinate to reduce the likelihood of self-contamination. Hands and genitals should be thoroughly washed afterwards, and household bleach should be added to the toilet immediately after urination. The bleach should stand for 15 minutes before flushing to deactivate the BCG.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

YouTube site: http://www.YouTube.com/incontinencedoc

Vidscrip site (for short educational videos): http://www.Vidscrip.com/andrewsiegel

Pessaries To Treat Pelvic Organ Prolapse: What You Need To Know

April 15, 2017

Andrew Siegel MD    4 /15 /17

A pessary is a vaginal insert that is used to help provide pelvic support in women with vaginal prolapse of the urogenital organs, a.k.a. pelvic organ prolapse (POP). Pessaries are available in a variety of sizes and shapes and when positioned in place within the vagina, function as “struts” to help keep the prolapsing pelvic organ(s) in proper anatomical position. They are ideal for older patients who have medical issues that preclude surgical treatment and for women who opt for non-surgical management.  Pessaries need to be removed periodically in order to clean them.  Some are designed to permit sexual intercourse.

A Few Words on POP

POP is a common condition in which there is weakness of the pelvic muscles and connective tissues that provide pelvic support, allowing one or more of the pelvic organs to move from their normal positions into the potential space of the vaginal canal and, at its most severe degree, outside the vaginal opening. POP is an important issue in women’s health, with an increasing prevalence correlating with extended longevity. Two-thirds of women who have delivered children vaginally have anatomical evidence of POP (although many are not symptomatic) and 10-20% will need to undergo a corrective surgical procedure. The true prevalence of POP is not known because of the large number of women who do not seek medical care for the problem.

POP is not life threatening, but can be a distressing and disruptive problem that negatively impacts quality of life. Despite how common an issue it is, many women are reluctant to seek help because they are too embarrassed to discuss it with anyone or have the misconception that there are no treatment options available or fear that surgery will be the only solution.

POP may involve any pelvic organ including the urinary, intestinal and gynecological tracts. The bladder is the organ that is most commonly involved in POP. POP can vary from minimal descent—causing few, if any, symptoms—to major descent—in which one or more of the pelvic organs prolapse outside the vagina at all times, causing significant symptoms. The degree of descent varies with position and activity level, increasing with the upright position and/or exertion and decreasing with lying down and resting, as is the case for any hernia.

POP can give cause a variety of symptoms, depending on which organ is involved and the extent of the prolapse.  The most common complaints are the following: a vaginal bulge or lump, the perception that one’s insides are falling outside, and vaginal “pressure.”  Because POP often causes vaginal looseness in addition to one or more organs falling into the space of the vaginal canal, sexual complaints are common, including painful intercourse, altered sexual feeling and difficulty achieving orgasm as well as less partner satisfaction.

3 Options to Manage POP

  1. Conservative
  2. Pessaries
  3. Surgery (Pelvic Reconstruction) 

Conservative treatment options for POP include pelvic floor muscle training (for details on pelvic muscle training for POP see http://www.TheKegelFix.com), modification of activities that promote the POP (heavy lifting and high impact exercises), management of constipation and other circumstances that increase abdominal pressure, weight loss, smoking cessation and consideration for hormone replacement, since estrogen replacement can increase tissue integrity and suppleness.

Pessary Basics

A pessary is a non-surgical option for treating POP, used with the goal of improving quality of life, body image, and bladder, bowel and sexual function. Pessaries are made of soft and pliable hypoallergenic plastic or silicone and can successfully alleviate symptoms of POP in 85% of those who use them.  About 50% or so of women who trial pessaries continue to use them for the long term, with discontinuation typically occurring in those who cannot retain the pessary, those experiencing discomfort or pain, those who desire surgery, and those who are incapable of inserting and removing them.

It is important to know that pessaries are not successful in all women with POP.  They tend to fail in women with significantly enlarged vaginal openings, in which case the pessary can fall out with effort and exertion. Factors associated with a higher risk for failure are younger age, obesity, and weak pelvic floor muscles.

For Whom is a Pessary Appropriate?

  • Older women who are not candidates for surgery
  • Anyone who desires non-surgical management of their POP
  • For those who need to delay surgery, wish to defer surgery or simply desire to trial one prior to surgery

1-Pessary Image

Image Above: A Potpourri of Pessaries

What Types of Pessaries Are Available?

For Mild-Moderate POP

The ring pessary (7:00 position of image above) is the simplest and most commonly used pessary that has the least side effects.  It is widely employed because of its ease of insertion, good vaginal fit and allowance for sexual intercourse without removing it.  A variation of the ring pessary is one with central support. The oval pessary is a variation of the ring used in narrow vaginas.  The Shaatz pessary (4:00 position of image above) is another variation. The incontinence dish pessary (5:00 position of image above) is used for stress urinary incontinence and mild POP.  A variation of this comes with a central support.

For Moderate-Severe POP

The Gellhorn pessary (3:00 position of image above) is used for greater degrees of POP than the pessaries described in the paragraph above, which are typically used for mild-moderate POP.  It tends to produce the greatest degree of vaginal discharge because of its shape.   The Hodge pessary has wires that can be manually shaped to fit the nuances of one’s anatomy. The Gehrung pessary (10:00 position of image above) also has wires that allow it to be manually shaped.  The donut pessary (center position of image above) is soft allowing it to be compressed for insertion, even with its bulk.  The cube pessary (9:00 position of image above) comes with a tie to help with its removal.

What Are Side Effects Of Pessaries?

The most common side effects are vaginal discharge and vaginitis (vaginal irritation or infection).  Occasionally, vaginal ulcerations can occur because of abrasive contact of the pessary with the delicate lining of the vagina.

How Does One Get Fitted For A Pessary?

A pelvic exam is performed prior to the fitting in order to help determine the proper size and type.  A properly fitted pessary should be large enough to function optimally, but not so large that it causes pressure or discomfort. It should be possible to insert a finger between the pessary’s outer rim and the wall of the vagina.

Usually a ring pessary (size 2, 3, or 4) is initially trialled.  It comes in 9 sizes, ranging from 2.00-4.00 in 0.25 increments.  If unsuccessful, a Gellhorn (size 2, 2.25, 2.5, or 2.75), cube or other model is utilized, depending upon particular circumstances. The largest pessary that is comfortable is placed and the patient is asked to walk and strain to ensure that it remains in proper position.  Motivated patients can be taught how to remove, clean and reinsert it. Typically, removal is done once weekly prior to sleeping, with reinsertion the following morning.  For the less motivated patient, the gynecologist can remove, clean and replace the device every three months or so.

Bottom Line: Pessaries are a non-surgical alternative to help provide pelvic support in women with pelvic organ prolapse.  They are available in a variety of sizes and shapes and need to be fitted and sized to the particulars of one’s anatomy.  They fold and compress to facilitate insertion and removal.  They are ideal for older patients who have medical issues that preclude surgical treatment.  If pessaries fail to improve the POP or cannot be retained or are poorly tolerated, a surgical procedure–pelvic reconstruction–can be performed to remedy the problem.  

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com