Prostate Cancer Update 2017: A More Nuanced Approach

December 3, 2016

Andrew Siegel MD  12/3/2016

prostate_cancerAttribution of above image: Blaus (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)%5D, via Wikimedia Commons

It was not so long ago that all prostate cancers were lumped together, the thought being that a cancer is a cancer and best served by surgical removal. Consequently, with the best of intentions, some unnecessary surgical procedures were performed that at times resulted in impaired sexual function, poor urinary control, and unhappy patients.

Fortunately, urologists have become wiser, recognizing that individual prostate cancers are unique and that a nuanced approach is the key to proper management. Some prostate cancers are so unaggressive that no cure is necessary, whereas others are so aggressive that no treatment is curative. One thing is for certain—we have vastly improved our ability to predict which prostate cancers need to be actively treated and which can be watched.

The Challenge Of Diagnosing Prostate Cancer

The vast majority of patients who have undiagnosed prostate cancer have NO symptoms—no pain, no bleeding, no urinary issues, no anything. The possible diagnosis of prostate cancer is usually entertained under three circumstances: when there is an elevated PSA (Prostate Specific Antigen) blood test; when there is an accelerated PSA (when the change in PSA compared to the previous year is considered to be too high); and when there is an abnormal prostate DRE (digital rectal exam)—a bump, lump, hardness, asymmetry, etc. The bottom line is that if you don’t actively seek prostate cancer, you’re not going to find it. When prostate cancer does cause symptoms, it is generally a sign of locally advanced or advanced prostate cancer. Therein lies the importance of screening.

The Dilemma Of Screening For Prostate Cancer

The downside of screening is over-detection of low risk prostate cancer that may never prove to be problematic, but may result in unnecessary treatment with adverse consequences. The downside of not screening is the under-detection of aggressive prostate cancer, with adverse consequences from necessary treatment not being given.

How Is The Diagnosis of Prostate Cancer Made?

When the PSA is elevated or accelerated and/or if there is an abnormal prostate DRE in a reasonably healthy man with good longevity prospects, an ultrasound-guided prostate biopsy is in order. Obtaining tissue for an exam by a pathologist is the definitive and conclusive test. The biopsy will reveal if cancer is present and its location, volume and grade (aggressiveness).

If prostate cancer is present, it is useful to determine the risk potential of the prostate cancer (“risk stratify”) by classifying it into categories based upon the following:

T (Tumor) category

T1c: cancer found because of PSA elevation or acceleration with a normal DRE

T2a: palpable (that which can be felt on DRE) cancer of half or less of one side

T2b: palpable cancer of more than half of one side

T2c: palpable cancer of both sides

T3a: cancer outside prostate, but sparing the seminal vesicles (reproductive structures that store semen)

T3b: cancer involving seminal vesicles

T4: regional spread of cancer to sphincter, rectum, bladder or pelvic sidewall

Gleason Score

Dr. Gleason devised a system that grades prostate cancer by observing the cellular architecture of prostate cancer cells under the microscope. He recognized that prostate cancer grade is the most reliable indicator of the potential for cancer growth and spread. His legacy, the grading system that bears his name, provides one of the best guides to prognosis and treatment. The pathologist assigns a separate numerical grade ranging from 3 – 5 to each of the two most predominant patterns of cancer cells. The sum of the two grades is the Gleason score. The Gleason score can predict the aggressiveness and behavior of the cancer, with higher scores having a worse prognosis than lower scores.

Grade Group 1 (Gleason score 3+3=6)

Grade Group 2 (Gleason score 3+4=7)

Grade Group 3 (Gleason score 4+3=7)

Grade Group 4 (Gleason score 4+4=8)

Grade Group 5 (Gleason score 4/5+4/5=9 or 10)

The significance of the Gleason Grade Group can be understood by examining the PSA five years after surgical removal of the prostate, correlating survival with the Grade Group. Ideally, after surgical removal of the prostate gland the PSA should be undetectable. A detectable and rising PSA after surgical removal is a sign of recurrent prostate cancer. The five-year rate of PSA remaining undetectable (biochemical recurrence-free progression) for surgical removal of the prostate in Grade Groups 1-5 is the following: 96%, 88%, 63%, 48%, and 26% respectively, indicating the importance of the grading system with respect to prognosis.

Number cores with cancer

Generally 12 – 14 biopsies are obtained, occasionally more. In general, the more cores that have cancer, the greater the volume of cancer and the greater the risk.

Percent of tumor involvement (PTI)

The percentage of any given biopsy core that has cancer present. In general, the greater the PTI, the greater the risk.

PSA

PSA is an excellent “tumor marker” for men with prostate cancer. In general, the higher the PSA, the greater the risk category.

PSA density

The relationship of PSA level to size of the prostate, determined by dividing the PSA by the volume of the prostate. The volume of the prostate is easily determined by ultrasound or by MRI (magnetic resonance imaging). A PSA density > 0.15 is greater risk.

 

Risk Stratification For Prostate Cancer

Based upon the aforementioned parameters, an individual case of prostate cancer can be assigned to one of five risk categories ranging from very low risk to very high risk. This risk assignment is helpful in predicting the future behavior of the prostate cancer and in the decision-making process regarding treatment.

Very Low Risk: T1c; Gleason score ≤ 6; fewer than 3 cores with cancer; less than 50% of cancer in each core; PSA density < 0.15

Low Risk: T1-T2a; Gleason score ≤ 6; PSA < 10

Intermediate Risk: T2b-T2c or Gleason score 7 or PSA 10-20

High Risk: T3a or Gleason score 8-10 or PSA > 20

Very High Risk: T3b-T4 or Gleason grade 5 as the predominant grade (the first of the two Gleason grades in the Gleason score) or > 4 cores Gleason score 8-10

 

Prostate Cancer Treatment

Prostate cancer treatment is based upon risk category and life expectancy and includes the following:

RALP (robotic-assisted laparoscopic prostatectomy): surgical removal of the prostate gland using robotic assistance

RT (radiation therapy): this can be used as definitive treatment or alternatively for recurrent disease after RALP or immediately following healing from RALP under the circumstance of adverse pathology report

ADT (androgen deprivation therapy): a means of decreasing testosterone level, since the male sex hormone testosterone stimulates prostate growth

AS (active surveillance): actively monitoring the disease with the expectation to intervene with curative therapy if the cancer progresses. This will involve periodic DRE, PSA, MRI, and repeat biopsy.

Observation: monitoring with the expectation of giving palliative therapy (relieving pain and alleviating other problems that may surface without dealing with the underlying cause)  if symptoms develop or a change in exam or PSA suggests that symptoms are imminent.

 

Prostate Cancer Treatment Based Upon Risk Stratification

Very Low Risk

< 10 year life expectancy: observation

10-20 years life expectancy: AS

> 20 years life expectancy: AS or RALP or RT

Low Risk

<10 years life expectancy: observation

>10 years life expectancy: AS or RALP or RT

Intermediate Risk

<10 years life expectancy: observation or RT + ADT 4-6 months

>10 years life expectancy: RALP or RT + ADT 4-6 months

High Risk

RALP or RT + ADT 2-3 years

Very High Risk:

T3b-T4: RT + ADT 2-3 years or RALP (in select patients) or ADT

Lymph node spread: ADT or RT + ADT 2-3 years

Metastatic disease: ADT

Bottom Line: Excluding skin cancer, prostate cancer is the most common cancer type in men, accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk. The median age of prostate cancer at diagnosis is the mid 60s and in 2015 there were 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are currently about 2.5 million prostate cancer survivors in the USA.  It is important to diagnose prostate cancer as early as possible in order to decide on the most appropriate form of management—whether it is surgery, radiation, or observation/monitoring. Risk stratification can help the decision-making process.

“Appropriate treatment implies that therapy be applied neither to those patients for whom it is unnecessary nor to those for whom it will prove ineffective. Furthermore, the therapy should be that which will most assuredly permit the individual a qualitatively and quantitatively normal life. It need not necessarily involve an effort at cancer cure. Human nature in physicians, be they surgeons, radiotherapists, or medical oncologists, is apt to attribute good results following treatment to such treatment and bad results to the cancer, ignoring what is sometimes the equally plausible possibility that the good results are as much a consequence of the natural history of the tumor as are the bad results.”

Willet Whitmore, M.D.

(Dr. Whitmore served as chief of urology for 33 years at what is now Memorial Sloan-Kettering Cancer Center. He died of prostate cancer at age 78 in 1995.)

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

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

 

 

 

 

When Stress Causes A “Headache” In The Pelvis

November 26, 2016

Andrew Siegel MD 11/26/2016

stress

Image above attributed to Dr. David Potter, licensed under the Creative Commons Attribution-Share Alike 4.0 International license.

It is virtually impossible to avoid stress in our lives. A small and manageable amount of stress—“eustress”—triggers adrenaline release, which increases pulse, respiratory rate and blood pressure, dilates the pupils and makes one hyper-alert, focused and motivated. All things considered, this can improve performance—think “caffeine on steroids.” However, excessive stress—”distress”—is clearly a bad situation, causing anxiety that can decrease performance, un-motivate and make life rather unpleasant.

The immediate manifestations of stress-mediated adrenaline release are due to the primitive “flight-or-fight” response that causes us to brace, tighten, clench and compress our bodies. Stress triggers rapid, shallow and less efficient chest breathing as opposed to proper breathing from the diaphragm, which is slow, steady deep and efficient. Slouching and poor posture from clenching and muscle tensioning further exacerbates the breathing issues.

Chronic stress—internalized—can have many physical manifestations, often tension headaches involving taut muscles in the head, neck and back. Other signs of stress-turned inwards are insomnia, fatigue, altered immune system function, depression and loss of sex drive. It can also be responsible for high blood pressure, angina, heart attacks and strokes as well as give rise to gastritis, peptic ulcer disease and irritable bowel syndrome. Urinary frequency is a not uncommon urological manifestation of chronic stress.

When stress is internalized within the pelvic floor muscles it can cause pelvic floor tension myalgia, which causes pelvic pain often accompanied by sexual, urinary and bowel symptoms. It can cause knots within the pelvic muscles—discrete sights of hyper-tensioned muscle. This tension myalgia is a very difficult and frustrating situation that often requires a number of different treatment approaches.

Because the pelvis is the site of important functions– urinary, sexual and bowel–it is a particularly bad location for holding tension. Pelvic “hypertension” can cause urinary, genital and rectal pain as well as adversely affect the proper performance of these systems. It can cause difficulty starting one’s urinary stream, a weak stream, incomplete emptying of the bladder and symptoms of overactive bladder (urgency, frequency, etc.). It can be responsible for pain with sexual stimulation and intercourse, sometimes to the extent that sexual intercourse is not possible. It can also cause constipation, hemorrhoids, fissures and other bowel symptoms.

When anxiety expresses itself through tension in the pelvic floor muscles, the physical tension and pain further contribute to emotional anxiety and stress reaction, which creates a vicious cycle. Poor posture, muscle overuse and abnormalities with the nerve pathway that regulates muscle tone are other factors that contribute to the pelvic tension.

Characteristically, the pain waxes and wanes in intensity, may “wander” to different locations and can be perceived to be superficial, intermediate or deep in the pelvic tissues. It can involve the lower abdomen, groin, pubic area, genitals, perineum, anus, rectum, hips and lower back. The pain is often described as “stabbing,” although it can be cramping, burning or itching in quality. Urination, bowel movements and sexual activity can aggravate the pain.

Because the symptoms of pelvic floor tension myalgia can be vague and variable, those afflicted often have difficulty precisely expressing their symptoms, although they usually have many complaints and have typically seen numerous physicians and have had multiple prior interventions. Many patients thought to have interstitial cystitis/chronic pelvic pain syndrome, irritable bowel syndrome, chronic prostatitis, vulvodynia and fibromyalgia in actuality have pelvic tension myalgia. In fact, this pelvic floor issue is probably one of the most common problems that urologists and gynecologists see and is likely one of the most misunderstood, misdiagnosed and mistreated conditions. Many suffering with it are miserable and deeply frustrated after having endured years of episodic agony without relief.

How Is Pelvic Floor Tension Myalgia Diagnosed?

Most important are a rectal exam in men and a pelvic exam in women to evaluate the pelvic floor muscles. Typical findings are tight, tender and weak pelvic muscles, spasticity, and difficulty in relaxing the muscles following contraction. Localized, knot-like bands can often be felt, similar to tension knots that can develop in back muscles. The pain can often be localized by a vaginal or rectal exam that identifies these trigger points, the sites of origin of the myalgia that when manipulated cause tremendous pain, often replicating the symptoms.

How Is Pelvic Floor Tension Myalgia Managed?

The key to treatment is to foster relaxation and “down-training” of the spastic pelvic muscles in order to untie the “knot(s).” By making the proper diagnosis and providing pain relief, the vicious cycle of anxiety/pain can be broken. Managing it often requires multiple approaches including stress management, anti-inflammatory and anti-spasmodic medications, and physical interventions.

Pelvic muscle training can be a useful piece of this multimodal management approach by its focus on developing proficiency in relaxing the pelvic muscles. The emphasis here is not on contracting these already over-contracted and over-tensioned muscles, which could aggravate the problem. This demands a different spin on the usual concept of pelvic training, which in this instance is not to increase tone and strength—rather it is to instill pelvic muscle awareness and enable the capacity for maximal pelvic relaxation, which is considered to be a “meditative” state between pelvic muscle contractions. Those suffering with this problem need to learn to unclench and release the pelvic floor muscles.

Focused therapies include the application of heat and pelvic massage. Pelvic floor physical therapists can be of great benefit to those suffering with pelvic tension myalgia. They use a number of physical interventions that provide pelvic muscle stretching and lengthening to increase muscle flexibility including trigger point therapy, which compresses and massages the knotted and spastic muscles. Those afflicted that are so motivated can pursue self-treatment regimens using internal, manually guided trigger point release wands that aim to relieve or eliminate the knots by self-directed manipulation and massage. These devices may be obtained without a prescription and are available online. Pelvic muscle tension myalgia sometimes requires injections of medication—including anesthetics, steroids or Botox—into the offending trigger points.

Bottom Line: In people afflicted with pelvic pain, the diagnosis of pelvic floor muscle tension myalgia should be a primary consideration. Physical interventions can be extremely helpful in alleviating the pain and untying the “knots” within the over-tensioned pelvic muscles. By making the proper diagnosis and providing pain relief and fostering muscle relaxation, the vicious cycle of anxiety/pain can be broken.

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

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com

Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: www.PrivateGym.com or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

The Ins And Outs Of The Vagina

November 19, 2016

Andrew Siegel MD 11/19/16

Chances are that you may be clueless about female genital anatomy and for good reason, as you had no formal instruction…no “vagina-ology” class exists. Education often involves knowledge imparted from friends and schoolmates and perhaps a talk from a parent on the “birds and the bees,” generally less than adequate means. “Sex Ed” classes in junior high school (a.k.a. middle school) were cursory and insufficient. Your dad’s Playboy, your mom’s Cosmo and other magazines may have provided some insight, but were certainly not the gospel. Pornography offers a totally skewed perspective. As a consequence, most people have been educated through practical experience with their own vagina or with those of sexual partners. Although there is no substitute for “hands on” experience, a bit of vaginal academics is certainly a good addition to practical experience.

For many men—and women for that matter—the vagina is a dark and mysterious place, a “black hole” of human anatomy, hidden in the deep recesses of the body. This landscape is complex terrain and unfortunately does not come with a topographical map explaining its intricate subterranean geography.

The following are quotes about the vagina from Tom Hickman’s book: “God’s Doodle: The Life and Times of the Penis”:

“A place of procreative darkness, a sinister place from which blood periodically seeped 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?”

The objective of this entry is to explore and demystify the vagina to help you comprehend and navigate its complexities. Knowledge is power and whether female or male, a greater understanding and appreciation of the anatomy, function and nuances of this curious and special female body part will most certainly prove useful.

Female Genital Anatomy 101

The hidden female nether parts and their inner workings are a mystery zone to a surprising number of women. Many falsely believe that the “pee hole” and the “vagina hole” are one and the same…not surprising given that lady parts are much more unexposed, subtle and complex than the more obviously exposed man parts. However, what lies between the thighs is more complicated and intricate than one might think…. three openings, two sets of lips, swellings, glands, erectile tissue, muscles and more.

Let’s first set the record straight on the difference between the vagina and vulva, geography that is often confused. When referring to external visible “girly” anatomy, most people incorrectly speak of the “vagina”—this is actually the “vulva,” divided in half by a midline slit known in medical jargon as the pudendal cleft or cleft of Venus or in slang terms, “camel toe.” The “vagina,” on the other hand, is the internal, flexible, cylindrical, muscular passageway that extends from vulva to cervix (neck of the uterus). The vaginal opening on the vulva is known in medical terms as the vaginal introitus. Further down south is the landscape between the vulva and the anus known in medical jargon as the perineum or in slang terms, “taint.”

vulva

(Anatomy of the vulva 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)

Bottom Line: The vulva is external, the vagina internal. Good to remember.

Fact: The word “vulva” derives from the Latin “cunnus” (hence the derivation of the slang C-word. The word “vagina” derives from the Latin word for “sheath,” a cover for the blade of a knife or sword, an apt term.

vagina-collage-public-domain

Above image (public domain) entitled “Vagina Collage”…note that it should be entitled  “Vulva Collage”

Many Functions Of The Vagina

The vagina is an amazingly versatile and multifunctional organ that is truly a “cave of wonders.” Beyond being a sexual organ, it is an inflow pathway and receptacle for semen, an exit pathway for menstrual blood, and a birth canal. It is not simply a passive channel, but an active and dynamic, highly responsive passageway that has the capacity for voluntary muscular contraction.

Anatomy Of The Vagina

The average depth of the vagina (without sexual stimulation) is 3-4 inches or so, but with sexual stimulation and arousal, the vagina is capable of considerable expansion and distension to a much greater potential. The elasticity of the vagina is truly impressive (perhaps the most elastic and stretchable organ in the body), with the ability to stretch to accommodate a full-term infant and then return to a relatively normal caliber. The width of the vagina varies throughout its length, narrowest at the vaginal opening and increasing in diameter throughout its depth. It is typically about 1 inch in diameter at the external opening.

Joke from Maxim.com:

  1. Just how deep is the average vagina?
  2. Deep enough for a man to lose his house, his car, his dog and half of all his savings and assets…

All vaginas are unique with a great variety in shape, size and even color, similar to variations in penile anatomy. The vagina is a banana-shaped structure and when a woman lies down on her back, the more external part of the vagina (closest to the vaginal opening) is straight, and the inner, deeper part angles/curves downwards towards the sacral bones (the lower part of the vertebral column that forms the back bony part of the pelvis). This vaginal “axis” often changes with aging and childbirth.

banana-25239_960_720

Banana representing vaginal axis, with inner portion curved towards sacrum and outer portion straight (Thank you Pixabay for image)

Fact: Although the vagina recovers remarkably well after childbirth, anatomy does generally change to some extent. Pelvic examination is usually easily able to distinguish between women who have and have not had children vaginally. Of note, elective C-section (no labor) preserves vaginal anatomy. Women who have an enlarged vaginal outlet due to childbirth may have difficulty in satisfactorily “accommodating” the penis, resulting in the vagina merely “surrounding” the penis rather than firmly “squeezing” it, with the end result being diminished sensation for both partners.

The vagina has pleats and corrugations called rugae that maximize the elasticity and stretchiness of the vagina. They are accordion-like ruffles and ridges that supply texture, which increase friction for the penis during sexual intercourse. In a young woman they are prominent, but with aging they tend to disappear.

Fact: Vaginal rugae are like tread on a tire…in young women they appear like deep grooves on a new snow tire, whereas in older women they appear like thinning tire tread, completely bald at their most extreme…aging can be cruel.

The vaginal wall has an inner lining of “skin” known as epithelium, which is surrounded by connective tissues and a muscular coat. The vaginal muscle is comprised of an inner layer that is circular in orientation and an outer layer that is oriented longitudinally. Contraction of the inner muscle tightens the vagina. Contraction of the outer muscle shortens and widens the vagina. The vagina is secured within a “bed” of powerful pelvic floor muscles.

To better understand  vaginal anatomy, it is useful to divide it arbitrarily into thirds: outer, inner and middle. The outer and inner thirds are where “all the action is,” the outer third being the hub of sexuality, the inner third the hub of reproduction and the middle third essentially a connection between the inner and outer thirds.

Outer third: The outer third of the vagina is rich in nerve fibers and is the most sensitive part of the vagina. The “orgasmic platform” is the Masters and Johnson term for the anatomical “base” that responds to sexual arousal and stimulation with pelvic blood congestion. It consists of the outer third of the vagina and the engorged inner lips.

Middle third: The middle third is a conduit connecting the outer and inner thirds.

Inner third: The cervix (opening to the uterus) sits in the inner third of the vagina. Its presence within the deep vagina defines the deepest recesses of the vagina, which are referred to as the fornices (singular fornix), derived from the Latin word for “arches.” The largest fornix is the one behind the cervix (posterior fornix) with the two smaller fornices above and to the sides of the cervix (anterior and lateral fornices).

Question: What do you think is the origin of the word “fornicate”?

sobo_1906_508

Image above:  Uterus, Cervix and Inner Third Vagina from Dr. Johannes SobottaSobotta’s Atlas and Text-book of Human Anatomy 1906, note the vaginal rugae and the relationship of the cervix with the inner vagina

Fact: In the man-on top sexual intercourse position, the penis reaches the anterior fornix, while in the rear-entry position it reaches the posterior fornix.

The Pelvic Floor Muscles And The Vagina

The pelvic floor muscles play a pivotal role with respect to vaginal and sexual function, their contractions facilitating and enhancing sexual response. They contribute to arousal, sensation during intercourse and the ability to clench the vagina and firmly “grip” the penis. The strength and durability of their contractions are directly related to orgasmic potential since the pelvic muscles are the “motor” that drives sexual climax and can be thought of as the powerhouse of the vagina. During orgasm, the pelvic floor muscles “shudder.”

There is great variety in the bulk, strength, power and voluntary control of the pelvic floor muscles that support the vagina. Some women are capable of powerfully “snapping” their vaginas, whereas others cannot generate even a weak flicker.

3-superficial-and-deep-pfm

Image above: Female pelvic floor muscles, illustration by Ashley Halsey from The Kegel Fix

Fact: “Pompoir” is a sexual technique in which a woman contracts her pelvic floor and vaginal muscles rhythmically to stimulate the penis without the need for pelvic motion or thrusting. Women who diligently practice Kegel exercises can develop powerful pelvic floor muscles and become particularly adept at this technique resulting in extreme vaginal “dexterity” and the ability to refine pulling, pushing, locking, gripping, pulsing, squeezing and twisting motions, which can provide enough stimulation to bring a male to climax.  

Fact: “Penis Captivus” is a rare condition in which a male’s erect penis becomes stuck within a female’s vagina. It is thought to be on the basis of intense contractions of the pelvic floor muscles, causing the vaginal walls to clamp down and entrap the penis. It usually is a brief event and after female orgasm and/or male ejaculation, withdrawal becomes possible. However, it sometimes requires medical attention with a couple showing up in the emergency room tightly connected, like Siamese twins. Not a good call to 911!

Sexual Function And The Vagina

Under normal circumstances, the vagina is not “primed” for sex and is little more prepared for intercourse than is a flaccid penis. The un-stimulated vagina is essentially a closed “potential space” in which the vaginal roof and floor are in contact. With sexual stimulation, the vagina expands with lengthening and widening of its inner two-thirds and flattening of the rugae. The cervix and uterus pull up and back. Pelvic blood flow increases and the vaginal walls undergo a “sweating-like” reaction as a result of pelvic blood congestion, creating a slippery and glistening film. Most of the lubrication is based upon seepage from this increased blood flow, but some comes from Bartholin’s and Skene’s glands. Bartholin’s glands are paired, pea-size glands that drain just below and to each side of the vagina. During sexual arousal they secrete small drops of fluid, resulting in moistening of the opening of the vagina. Skene’s glands are paired glands that drain just above and to each side of the urethral opening. They are the female equivalent of the male prostate gland and secrete fluid with arousal.

With sexual excitement and stimulation, in addition to vaginal lubrication from increased pelvic blood flow, there is congestion and engorgement of the vulva, vagina and clitoris.

Fact: The profound vaginal changes that occur during sexual arousal and stimulation are entirely analogous to the changes that occur during male arousal: expansion of penis length and girth, retraction of the testicles towards the groin, and the release of pre-ejaculate fluid.

With increasing stimulation and arousal, physical tension within the genitals gradually builds and once sufficient intensity and duration of sexual stimulation surpass a threshold, involuntary rhythmic muscular contractions occur of the vagina, uterus, anus and pelvic floor muscles, followed by the release of accumulated erotic tension (a.k.a. orgasm) and a euphoric state. Thereafter, the genital engorgement and congestion subside, muscle relaxation occurs and a peaceful state of physical and emotional bliss and afterglow become apparent.

Fact: Anatomy can affect potential for experiencing sexual climax.

Sexual intercourse results in indirect clitoral stimulation. The clitoral shaft moves rhythmically with penile thrusting by virtue of penile traction on the inner 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 lips, there will be limited clitoral stimulation and less satisfaction in the bedroom. Furthermore, studies have suggested that a larger clitoris that is closer to the vaginal opening is more likely to be stimulated during penetrative sexual intercourse.

At the time of sexual climax, some women are capable of “ejaculating” fluid. The nature of this fluid has been controversial, thought by some to be hyper-lubrication and others to be Bartholin’s and/or Skene’s gland secretions. There are certain women who “ejaculate” very large volumes of fluid at climax and studies have shown this to be urine released because of an involuntary bladder contraction that can accompany orgasm.

Fact: “Persistent genital arousal disorder” is a rare sexual problem characterized by unwanted, unremitting and intrusive arousal, genital engorgement and multiple orgasms without sexual interest or stimulation. It causes great distress to those suffering with it and there are no known effective treatments. It typically does not resolve after orgasm.

The G-Spot—named after German gynecologist Ernst Grafenberg—was first described in 1950 and was believed to be an erogenous zone located on the upper wall of the vagina, anatomically situated between the vagina and the urethra (urinary channel). Stimulation of this spot was thought to promote arousal and vaginal orgasm.

Fact: There is little scientific support for the existence of the G-spot as a discrete anatomical entity; however, many women feel that they possess an area on the roof of the vagina that is a particularly sensitive pleasure zone. Although its existence remains controversial, the G-spot is certainly a powerful social phenomenon.

Regular sexual activity is vital for maintaining the ability to have ongoing satisfactory sexual intercourse with the vagina staying fit and healthy if one remains sexually active, as nature intended. Vaginal penetration increases pelvic and vaginal blood flow, optimizing lubrication and elasticity, while orgasms tone and strengthen the pelvic floor muscles that support vaginal function. “Disuse atrophy” is a condition when the vagina adapts to not being used, with thinning and fragility of the vaginal walls and weakness of the pelvic floor muscles. Use it or lose it!

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.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. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. 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 and 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.

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

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.

Prostate Steaming For Better Urinary Streaming

November 12, 2016

Andrew Siegel MD 11/12/2016

A new, minimally invasive procedure for treating symptomatic prostate enlargement has been tested in clinical trials and has been shown to be safe and effective. I was informed about it at a recent urology meeting in Prague and was intrigued because of its simplicity. The prostate steaming procedure–called “Rezum”–takes less than 15 minutes and uses convective heat energy in the form of steam to open up the obstructed prostate gland. 

Convection Versus Conduction

Convection is the transfer of thermal energy by heating up a liquid, resulting in currents of thermal energy traveling away from the heating source.  This type of energy is used for the Rezum prostate steaming procedure.

This is as opposed to conduction, which is heat transfer via molecular agitation. Thermal energy that is directly applied to tissues heats up molecules and is transferred through tissues as higher-speed molecules collide with slower speed molecules. Conduction energy is commonly used in surgery to cut or coagulate tissues.

Benign Prostate Enlargement (BPH)

BPH is a common condition in men above the age of 50. Based upon aging, genetics and testosterone, the prostate gland enlarges to a variable extent. As it does so, it often compresses the urinary channel (like a hand around a garden hose), causing urinary obstructive and irritative symptoms that can be quite annoying.  Obstructive symptoms include: a weak, prolonged stream that is slow to start and tends to stop and start (to quote my patient: “peeing in chapters”) and incomplete emptying. Irritative symptoms include: strong urges to urinate, frequent urinating, nighttime urinating and possibly urinary leakage before arrival at the bathroom.

pre-treatment_v2

BPH (note the tissue compressing the urinary channel)

Medications or surgical procedures are often used to alleviate the symptoms of BPH.  One class of medication relaxes the muscle tone of the prostate (Flomax, Uroxatral, Rapaflo, etc.); another class shrinks the prostate (Proscar, Avodart). The erectile dysfunction medication Cialis has also been used (daily dosing) to help manage symptomatic BPH. Commonly performed procedures to improve the symptoms of BPH include Greenlight laser photovaporization of the prostate, Urolift procedure and TURP (transurethral resection of the prostate). The Rezum prostate steam procedure is a new addition to the BPH armamentarium.

Rezum Prostate Steaming

The prostate is a compartmentalized organ with discrete anatomical zones (compartments). The transition zone is the area responsible for benign enlargement. In the Rezum procedure, radio-frequency energy is used to convert a small volume of water to steam, which is injected within the  transition zone of the prostate via a retractable needle under direct visual guidance (cystoscopy). The steam adheres to the anatomy of the prostate zones, its spread limited by the zonal anatomy. Each steam (convective water vapor thermal energy) injection takes less than 10 seconds and utilizes no more than a few drops of water. The number of injections necessary is based upon the size of the prostate gland, but it generally requires only a few.

watervaportreatment

Steam being injected into prostate tissue via a retractable needle

Convection uniformly disperses the steam, causing targeted cell death of prostate cells. This slowly and gradually will un-obstruct the prostate and alleviate the symptoms of BPH.

It is unusual for the actual procedure to take much longer than a few minutes, although the patient will need preparation time before and recovery time after the procedure. After the Rezum is completed, a catheter is placed for a few days. Common temporary side effects include inability to urinate (the reason for the catheter), discomfort with urination, urinary urgency, frequency, and blood in the urine or semen. Symptomatic improvement may be noted as early as two weeks after the procedure, but it may take up to 3 months before maximal benefits are derived.

tissue_resorption_v2

Prostate anatomy 3-months following Rezum procedure

A multi-center, randomized, controlled study was recently reported in the Journal of Urology. 200 men were randomized to active treatment with Rezum versus control. The study concluded that convective water vapor energy provides durable improvements in the symptoms of BPH, preserving erectile and ejaculatory function.

Bottom Line: This quick outpatient procedure for BPH  is safe and effective, can be performed in an office setting using sedation and can treat certain anatomical variations (e.g. middle lobe prostate enlargement) that cannot be treated by some of the alternative methods. Erectile and ejaculatory functions are preserved in most patients, which is often not the case with the BPH medications, Greenlight laser and TURP. A disadvantage is that the Rezum is not immediately effective, requiring a catheter for several days and a period of several weeks before symptomatic improvement is evident. Our urology practice is now offering this procedure to patients.

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

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

 

 

The Little Muscles That Could: The Mysterious Muscles You Should Be Exercising

November 5, 2016

Andrew Siegel MD 11/5/2016

This entry was a feature article in the Fall 2016 edition of BC The Magazine: Health, Beauty & Fitness.

(A new blog is posted weekly. To receive the blogs via email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com)

3-superficial-and-deep-pfm

Image above: female pelvic floor muscles, illustration by Ashley Halsey from The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health

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Image above: male pelvic floor muscles, illustration by Christine Vecchione from Male Pelvic Fitness: Optimizing Sexual and Urinary Health

There are over 600 muscles in the human body and they all are there for good reasons. However, some are more critical to health and survival than others. In the class rank it is a no-brainer that the heart muscle is valedictorian, followed by the diaphragm. What may surprise you is that the pelvic floor muscles (a.k.a. Kegel muscles) rank in the top ten of the hierarchy.

The pelvic floor muscles are a muscular hammock that make up the floor of the “core” muscles. They are located in the nether regions and form the bottom of the pelvis. They are among the most versatile muscles in the body, equally essential in both women and men for the support of the pelvic organs, bladder and bowel control and sexual function. Because they are out of sight they are frequently out of mind and often not considered when it comes to exercise and fitness. However, without functional pelvic muscles, our pelvic organs would dangle and we would be diapered and asexual.

Our bodies are comprised of a variety of muscle types: There are the glamour, for show, mirror-appeal, overt, seen and be witnessed muscles that offer no secrets—“what you see is what you get”—the biceps, triceps, pectorals, latissimus, quadriceps, etc. Then there are muscles including the pelvic floor muscles that are shrouded in secrecy, hidden from view, concealed and covert, unseen and behind the scenes, unrecognized and misunderstood, favoring function over form, “go” rather than “show.” Most of us can probably point out our “bi’s” (biceps), “tri’s” (triceps), “quads” (quadriceps), “pecs” (pectorals), etc., but who really knows where their “pelvs” (pelvic floor muscles) are located? For that matter, who even knows what they are and how they contribute to pelvic health?

Strong puritanical cultural roots influence our thoughts and feelings about our nether regions. Consequently, this “saddle” region of our bodies (the part in contact with a bicycle seat)—often fails to attain the respect and attention that other zones of our bodies command. Cloaking increases mystique, and so it is for these pelvic muscles, not only obscured by clothing, but also residing in that most curious of regions–an area concealed from view even when we are unclothed. Furthermore, the mystique is contributed to by the mysterious powers of the pelvic floor muscles, which straddle the gamut of being critical for what may be considered the most pleasurable and refined of human pursuits—sex—but equally integral to what may be considered the basest of human activities—bowel and bladder function.

The deep pelvic floor muscles span from the pubic bone in front to the tailbone in the back, and from pelvic sidewall to pelvic sidewall, between the “sit” bones. The superficial pelvic floor muscles are situated under the surface of the external genitals and anus. The pelvic floor muscles are stabilizers and compressors rather than movers (joint movement and locomotion), the more typical role that skeletal muscles such as these play. Stabilizers support the pelvic organs, keeping them in proper position. Compressors act as sphincters—enveloping the urinary, gynecological and intestinal tracts, opening and closing to provide valve-like control. The superficial pelvic floor muscles act to compress the deep roots of the genitals, trapping blood within these structures and preparing the male and female sexual organs for sexual intercourse; additionally, they contract rhythmically at the time of sexual climax. Although the pelvic floor muscles are not muscles of glamour, they are certainly muscles of “amour”!

Pelvic floor muscle “dysfunction” is a common condition referring to when the pelvic floor muscles are not functioning properly. It affects both women and men and can seriously impact the quality of one’s life. The condition can range from “low tone” to “high tone.” Low tone occurs when the pelvic muscles lack in strength and endurance and is often associated with stress urinary incontinence (urinary leakage with coughing, sneezing, laughing, exercising and other physical activities); pelvic organ prolapse (when one or more of the female pelvic organs falls into the space of the vagina and at times outside the vagina); and altered sexual function, e.g., erectile dysfunction or vaginal looseness.  High tone occurs when the pelvic floor muscles are over-tensioned and unable to relax, giving rise to a pain syndrome known as pelvic floor tension myalgia.

A first-line means of dealing with pelvic floor dysfunction is getting these muscles in tip-top shape. Tapping into and harnessing their energy can help optimize pelvic, sexual and urinary health in both genders. Like other skeletal muscles, the pelvic muscles are capable of making adaptive changes when targeted exercise is applied to them. Pelvic floor training involves gaining facility with both the contracting and the relaxing phases of pelvic muscle function. Their structure and function can be enhanced, resulting in broader, thicker and firmer muscles and the ability to generate a powerful contraction at will—necessary for pelvic wellbeing.

Pelvic floor muscle training can be effective in stabilizing, improving and even preventing issues with pelvic support, sexual function, and urinary and bowel control. Pursuing pelvic floor muscle training before pregnancy will make carrying the pregnancy easier and will facilitate labor and delivery; it will also allow for the effortless resumption of the exercises in the post-partum period in order to re-tone the vagina, as the exercises were learned under ideal circumstances, prior to childbirth. Similarly, engaging in pelvic training before prostate cancer surgery will facilitate the resumption of urinary control and sexual function after surgery. Based upon solid exercise science, pelvic floor muscle training can help maintain pelvic integrity and optimal function well into old age.

Bottom Line: Although concealed from view, the pelvic floor muscles are extremely important muscles that deserve serious respect. These muscles are responsible for powerful and vital functions that can be significantly improved/enhanced when intensified by training. It is never too late to begin pelvic floor muscle training exercises—so start now to optimize your pelvic, sexual, urinary, and bowel health.

Wishing you the best of health,

2014-04-23 20:16:29

www.AndrewSiegelMD.com

Andrew Siegel MD practices in Maywood, NJ. He is dual board-certified in urology and female pelvic medicine/reconstructive surgery and is Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and attending urologist at Hackensack University Medical Center. He is a Castle Connolly Top Doctor New York Metro area and Top Doctor New Jersey. He is the author ofTHE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health (www.TheKegelFix.com) and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health (www.MalePelvicFitness.com). He is co-creator of PelvicRx, an interactive, FDA-registered pelvic floor muscle-training program that empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance, this program helps improve sexual function and urinary function. In the works is the female PelvicRx pelvic floor muscle training for women. Visit: http://www.UrologyHealthStore.com to obtain PelvicRx. Use promo code “UROLOGY10” at checkout for 10% discount.

Even More About Pelvic Prolapse: Diagnosis & Treatment

October 29, 2016

Andrew Siegel MD 10/29/2016

Note: This is the final entry in a 3-part series about pelvic organ prolapse.

 How is POP diagnosed and evaluated?

The diagnosis of POP can usually be made by listening to the patient’s narrative: The typical complaint is “Doc, I’ve got a bulge coming out of my vagina when I stand up or strain and at times I need to push it back in.”

After listening to the patient’s history of the problem, the next step is a pelvic examination in stirrups.  However, the problem with an exam in this position is that this is NOT the position in which POP typically manifests itself, since POP is a problem that is provoked by standing and exertion. For this reason, the exam must be performed with the patient straining forcefully enough to demonstrate the POP at its fullest extent.

A pelvic examination involves observation, a speculum exam, passage of a small catheter into the bladder and a digital exam. Each region of potential prolapse through the vagina—roof, apex, and floor—must be examined independently.

box

A useful analogy is to think of the vagina as an open box (see above), with the vaginal lips represented by the open flaps of the box.  A cystocele (bladder prolapse) occurs when there is weakness of the roof of the box, a rectocele (rectal prolapse) when there is weakness of the floor of the box, and uterine prolapse or enterocele (intestinal prolapse) when there is weakness of the deep inner wall of the box.

Inspection will determine tissue health and the presence of a vaginal bulge with straining. After menopause, typical changes include thinning of the vaginal skin, redness, irritation, etc. The ridges and folds within the vagina that are typical in younger women tend to disappear after menopause.

Useful analogy: The normal vulva is shut like a closed clam. POP often causes the vaginal lips to gape like an open clam.

Since the vagina has top and bottom walls and since the bulge-like appearance of POP of the bladder or rectum look virtually identical—like a red rubber ball—it is imperative to use a speculum to sort out which organ is prolapsing and determine its extent. A one-bladed speculum is used to pull down the bottom wall of the vagina to observe the top wall for the presence of urethral hypermobility and cystocele, and likewise, to pull up the top wall to inspect for the presence of rectocele and perineal laxity. To examine for uterine prolapse and enterocele, both top and bottom walls must be pulled up and down, respectively, using two single-blade specula. Once the speculum is placed, the patient is asked to strain vigorously and comparisons are made between the extent of POP resting and straining, since prolapse is dynamic and will change with position and activity.

 

exam-relaxed

Image above shows vaginal exam at rest (mild prolapse)

exam-minor-strain

Image above shows vaginal exam with straining (moderate prolapse)

exam-full-streain

Image above shows vaginal exam with more straining (more severe prolapse)

After the patient has emptied her bladder, a small catheter (a narrow hollow tube) is passed into the bladder to determine how much urine remains in the bladder, to submit a urine culture in the event that urinalysis suggests a urinary infection and to determine urethral angulation. With the catheter in place, the angle that the urethra makes with the horizontal is measured. The catheter is typically parallel with the horizontal at rest. The patient is asked to strain and the angulation is again measured, recording the change in urethral angulation that occurs between resting and straining. Urethral angulation with straining (hypermobility) is a sign of loss of urethral support, which often causes stress urinary incontinence (leakage with cough, strain and exercise).

Finally, a digital examination is performed to assess vaginal tone and pelvic muscle strength. A bimanual exam (combined internal and external exam in which the pelvic organs are felt between vaginal and external examining fingers) is done to check for the presence of pelvic masses. On pelvic exam it is usually fairly obvious whether or not a woman has had vaginal deliveries. With exception, the pelvic support and tone of the vagina in a woman who has not delivered vaginally can usually be described as “high and tight,” whereas support in a woman who has had multiple vaginal deliveries is generally “lower and looser.”

Depending upon circumstances, tests to further evaluate POP may be used, including an endoscopic inspection of the lining of the bladder and urethra (cystoscopy), sophisticated functional tests of bladder storage and emptying (urodynamics) and, on occasion, imaging tests (bladder fluoroscopy or pelvic MRI).

cystogram-normal

Image above is x-ray of bladder showing oval-shaped well-supported normal bladder.

cd-cystocele

                    Image above is x-ray of bladder showing tennis-racquet shaped bladder,                          which is high-grade cystocele.

How is POP treated?

First off, it is important to know that POP is a common condition and does not always need to be treated, particularly when it is minor and not causing symptoms that affect one’s quality of life.

There are three general options of managing POP: conservative; pessary and surgery (pelvic reconstruction).

Conservative treatment options for POP include pelvic floor muscle training Kegel); 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.

A pessary is a mechanical device available in a variety of sizes and shapes that is inserted into the vagina where it acts as “strut” to help provide pelvic support.

512px-pessaries

Image above is an assortment of pessaries (Thank you Wikipedia, public domain)

The side effects of a pessary are vaginal infection and discharge, the inability to retain the pessary in proper position and stress urinary incontinence caused by the “unmasking” of the incontinence that occurs when the prolapsed bladder is splinted back into position by the pessary. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.

Studies comparing the use of pessaries with pelvic floor training in managing women with advanced POP have shown that both can significantly improve symptoms; however, pelvic floor muscle training has been shown to be more effective, specifically for bladder POP.

PFM Training (PFMT)

PFMT is useful under the circumstances of mild-moderate POP, 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 pelvic muscles that play a key role in the support of the pelvic organs. Weak pelvic muscles can be strengthened; however, if POP is due to connective tissue damage, PFMT will not remedy the injury, but will strengthen the pelvic muscles that can help compensate for the connective tissue impairment. PFMT is most effective in women with lesser degrees of POP and chances are that if your POP is moderate-severe, PFMT will be less effective. However, if not cured, the POP can still be improved, and that might be sufficient for you.

Numerous scientific studies have demonstrated the benefits of PFMT for POP, including improved pelvic muscle strength, pelvic support and a reduction in the severity and symptoms of POP. Improvements in pelvic support via PFMT are most notable with bladder POP as opposed to rectal or uterine POP. PFMT is also capable of preventing POP from developing when applied to a healthy female population without POP.

In symptomatic advanced POP, surgery is often necessary, particularly when quality of life has been significantly impacted. There are a number of considerations that go into the decision-making process regarding the specifics of the surgical procedure (pelvic reconstruction) to improve/cure the problem. These factors include which organ or organs are prolapsed; the extent and severity of the POP; the desire to have children in the future; the desire to be sexually active; age; and, if the POP involves a cystocele, the specific type of cystocele (since there are different approaches depending on the type). Surgery to repair POP can be performed vaginally or abdominally (open, laparoscopic or robotic), and can be done with or without mesh (synthetic netting or other biological materials used to reinforce the repair). The goal of surgery is restoration of normal anatomy with preservation of vaginal length, width and axis and improvement in symptoms with optimization of bladder, bowel and sexual function.

More than 300,000 surgical procedures for repair of POP are performed annually in the United States. An estimated 10-20% of women will undergo an operation for POP over the course of their lifetime.

Dr. Arnold Kegel—the gynecologist responsible for popularizing pelvic floor exercises—believed that surgical procedures for female incontinence and pelvic relaxation are facilitated by pre-operative and post-operative pelvic floor exercises. Like cardiac rehabilitation after cardiac surgery and physical rehabilitation after orthopedic procedures, PFMT after pelvic reconstruction surgery can help minimize recurrences. Pre-operative PFMT—as advocated by Kegel—can sometimes improve pelvic support to an extent such that surgery will not be necessary. At the very least, proficiency of the PFM learned pre-operatively (before surgical incisions are made and pelvic anatomy is altered) will make the process of post-operative rehabilitation that much easier.

Useful resource: Sherrie Palm is an advocate, champion and crusader for women’s pelvic health who has made great strides with respect to POP awareness, guidance and support. She is founder and director of the Association for Pelvic Organ Prolapse Support and author of “Pelvic Organ Prolapse: The Silent Epidemic.” Visit PelvicOrganProlapseSupport.org.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.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. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. 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 and 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.

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

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.

 

More About Pelvic Organ Prolapse (POP)

October 22, 2016

Andrew Siegel MD 10/22/2016

This is the second entry in a three-part series about pelvic organ prolapse.  It is important to understand that the issue in POP is NOT with the pelvic organ per se, but with the support of that organ. POP is not the problem, but the result of the problem. The prolapsed organ is merely an “innocent passenger” in the POP process.

How Much Of A Vaginal Bulge Can POP Cause?

The extent of prolapse can vary from minimal to severe and can vary over the course of a day, depending on position and activity level.  POP is more pronounced with with standing (vs. sitting or lying down) and with physical activities (vs. sedentary).

The simplest system for grading POP severity uses a scale of 1-4:

grade 1 (slight POP); grade 2 (POP to vaginal opening with straining); grade 3 (POP beyond vaginal opening with straining); grade 4 (POP beyond vaginal opening at all times).

Which Organs Does POP Affect?

POP can involve one or more of the pelvic organs including the following: urethra (urethral hypermobility); bladder (cystocele); rectum (rectocele); uterus (uterine prolapse); intestines (enterocele); the vagina itself (vaginal vault prolapse); and the perineum (perineal laxity).

Urethra

The healthy, well-supported urethra has a “backboard” or “hammock” of support tissue that lies beneath it. With a sudden increase in abdominal pressure, the urethra is pushed downwards, but because of the backboard’s presence, the urethra gets pinched closed between the abdominal pressure above and the hammock below, allowing urinary control.

When the support structures of the urethra are weakened, a sudden increase in abdominal pressure (from a cough, sneeze, jump or other physical exertion) will push the urethra down and out of its normal position, a condition known as urethral hypermobility. With no effective “backboard” of support tissue under the urethra, stress urinary incontinence will often occur.

sui

Urethral hyper-mobility causing stress urinary incontinence (the gush of urine) when this patient was asked to cough.

Bladder

Descent of the bladder through a weakness in its supporting tissues gives rise to a cystocele, a.k.a. “dropped bladder,” “prolapsed bladder,” or “bladder hernia.”

A cystocele typically causes one or more of the following symptoms: a bulge or lump protruding into or even outside the vagina; the need for pushing the cystocele back in in order to urinate; obstructive urinary symptoms (a slow, weak stream that stops and starts and incomplete bladder emptying) due to the prolapsed bladder causing urethral kinking; urinary symptoms (frequent and urgent urinating); and vaginal pain and/or painful intercourse.

untitled

Cystocele

Rectum

Descent of the rectum through a weakness in its supporting tissues gives rise to a rectocele, a.k.a. “dropped rectum,” “prolapsed rectum,” or “rectal hernia.” The rectum protrudes into the floor of the vagina. A rectocele typically causes one or more of the following symptoms: a bulge or lump protruding into the vagina, especially noticeable during bowel movements; a kink of the normally straight rectum causing difficulty with bowel movements and the need for vaginal “splinting” (straightening the kink with one’s fingers) to empty the bowels; incomplete emptying of the rectum; fecal incontinence; and vaginal pain and/or painful intercourse.

rectocele

Rectocele with perineal laxity

Perineum

Often accompanying a rectocele is perineal muscle laxity, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. Weakness in these muscles can cause the following anatomical changes: a widened and loose vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal orientation such that the vagina assumes a more upwards orientation as opposed to its normal downwards angulation towards the sacral bones.

Women with vaginal laxity who are sexually active may complain of a loose or gaping vagina, making intercourse less satisfying for themselves and their partners. This may lead to difficulty achieving orgasm, difficulty retaining tampons, difficulty accommodating and retaining the penis with vaginal intercourse, the vagina filling with water while bathing and vaginal flatulence (passing air through the vagina). The perception of having a loose vagina can often lead to low self-esteem.

Small Intestine

The peritoneum is a thin sac that contains the abdominal organs, including the small intestine. Descent of the peritoneal contents through a weakness in the supporting tissues at the innermost part of the vagina (the apex of the vagina) gives rise to an enterocele, a.k.a. “dropped small intestine,” “small intestine prolapse,” or “small intestine hernia.”

An enterocele typically causes one or more of the following symptoms: a bulge or lump protruding through the vagina, intestinal cramping due to small intestine trapped within the enterocele, and vaginal pressure/pain and/or painful intercourse.

enterocele

Enterocele

Uterus

Descent of the uterus and cervix because of weakness of their supporting structures results in uterine prolapse, a.k.a. “dropped uterus,” “prolapsed uterus,” or “uterine hernia.” Normally, the cervix is situated deeply in the vagina. As uterine prolapse progresses, the extent of descent into the vaginal canal will increase.

Uterine POP typically causes one or more of the following symptoms: a bulge or lump protruding from the vagina; difficulty urinating; the need to manually push back the uterus in order to urinate; urinary urgency and frequency; urinary incontinence; kidney obstruction because of the descent of the bladder and ureters (tubes that drain urine from the kidneys to the bladder) that are dragged down with the uterus, creating a kink of the ureters; vaginal pain with sitting and walking; painful intercourse; and spotting and/or bloody vaginal discharge from the externalized uterus, which becomes subject to trauma and abrasions from being out of position. The most extreme form of uterine POP is uterine “procidentia,” a situation in which the uterus is exteriorized at all times and, because of external exposure, has a tendency for ulceration and bleeding.

 

uterus

Uterine prolapse

ulcerated-procidentia

Severe uterine prolapse (procidentia) with ulcerative inflammation surrounding cervix

Vagina

The most advanced stage of POP occurs when the support structures of the vagina are weakened to such an extent that the vaginal canal itself turns inside out. Vault prolapse, a.k.a. “dropped vaginal vault,” “prolapsed vaginal vault,”or “vaginal vault hernia,” is rarely an isolated event, but often occurs coincident with other forms of POP and most often is a consequence of hysterectomy. If the vagina is likened to an internal “sock,” vaginal vault prolapse is a condition in which the sock is turned inside out. When I explain vaginal vault prolapse to patients, I demonstrate it by turning a front pocket of my pants inside out.

To be continued…

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.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. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. 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 and 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.

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

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.

 

What’s That Bulge Coming Out Of My Vagina?

October 15, 2016

Andrew Siegel MD   10/15/2016

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Photo above: typical appearance of  a vaginal bulge (in this case a dropped bladder)

“The thought was delivered just after my newborn’s placenta: A sneaking suspicion that things were not quite the same down there, and they might never be again…my daughter had finished using my vagina as a giant elastic waterslide.”

-Alissa Walker, Gizmodo.com, April 2, 2015

Between A Rock And A Hard Place

The bony pelvis provides the infrastructure to support the pelvic organs and to allow childbirth. Adequate “closure” is needed for pelvic organ support, yet sufficient “opening” is necessary to permit vaginal delivery. The female pelvis evolved as a compromise between these two important, but opposing functions.

The pelvic floor muscles (PFM) divide the abdominal and pelvic cavities above from the perineum below, forming an important structural support system that keeps the pelvic organs in place. Many physical activities result in significant increases in abdominal pressure, the force of which is largely exerted downwards towards the pelvic floor, especially when upright. This pelvic floor “loading” puts the PFM at particular risk for damage with the potential for pelvic organ prolapse, a.k.a. pelvic relaxation or pelvic organ hernia.

Pelvic Organ Prolapse (POP)

POP is a common condition in which there is weakness of the PFM and other connective tissues that provide pelvic support, allowing the pelvic organs to move from their normal positions into the space of the vaginal canal and, at its most severe degree, outside the vaginal opening. It is a situation in which the pelvic organs go wayward, literally “popping” out of place. POP often causes a bulge outside the vaginal opening, appearing like a man’s scrotum…little wonder why most women are disturbed by this condition.

Two-thirds of women who have delivered children have anatomical evidence of POP (although most are not symptomatic) and 10-20% will need to undergo a corrective surgical procedure. 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 of the pelvic organs including those of 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 exertion and decreasing with lying down and resting, as is the case for any hernia.

POP can give rise to 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.

When one’s bladder or rectum descends into the vaginal space, there can be an obstruction to the passage of urine or stool, respectively. This often requires placing one or more fingers in the vagina to manually push back the prolapsed organ. Doing so will straighten the “kink” in order to facilitate emptying one’s bladder or bowels. Pushing (and holding in place) a prolapsed organ back into position with one’s finger(s) is called “splinting.”

Why Do I Have A Bulge Coming Out Of My Vagina?

POP results from a combination of factors including multiple pregnancies and vaginal deliveries (especially deliveries of large babies), menopause, hysterectomy, aging and weight gain. Additionally, conditions that give rise to chronic increases in abdominal pressure contribute to POP. These include chronic constipation, asthma, bronchitis and emphysema (chronic wheezing and coughing), seasonal allergies (chronic sneezing), high-impact sports, and repetitive heavy lifting, whether work-associated or due to weight training. Other causes are genetic predispositions to POP and connective tissue disorders.

Childbirth is one of the most traumatic events that the female body experiences and vaginal delivery is the single most important factor in the development of POP. Passage of the large human head through the female pelvis causes intense mechanical pressure and tissue trauma (stretching, tearing, compression and crushing) to the PFM and PFM nerve supply. This results in separation or weakness of connective tissue attachments and alterations and damage to the integrity of the pelvis. POP that occurs because of a difficult vaginal delivery may not manifest until decades later. It is unusual for women who have not had children or who have delivered by elective caesarian section to develop significant POP.

To be continued…

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.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. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. 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 and 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.

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

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.

 

 

“Doc, My Penis Is Shrinking”

October 8, 2016

Andrew Siegel MD  10/8/16

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Image above: Roman copy of Apollo Delphinios by Demetrius Miletus at the end of the second century (Attribution: Joanbanjo (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)%5D, via Wikimedia Commons)

Not a day goes by in my urology practice when I fail to hear the following complaint from a patient: “Doc, my penis is shrinking.” The truth of the matter is that the penis can shrivel from a variety of circumstances, but most of the time it is a mere illusion—a sleight of penis, if you will. Weight gain and obesity cause a generous pubic fat pad, the male equivalent of the female mons pubis, which will make the penis appear shorter and retrusive. However, penile length is usually intact, with the penis merely hiding behind the fat pad, the “turtle effect.” Lose the fat and presto…the penis reappears. Having a plus-sized figure is not such a good thing when it comes to size matters, as well as many other matters.

Factoid: It is estimated that with every 35 lbs. of weight gain, there is one-inch loss in apparent penile length.

The 9-letter word every man despises: S-H-R-I-N-K-A-G-E, immortalized by Jason Alexander playing the character George in the Seinfeld series. Jerry’s girlfriend Rachel catches a glimpse of naked George after he has stepped out of a swimming pool. Suffice it to say that George’s penis was in a “non-optimized” state. George tries to explain: “Well I just got back from swimming in the pool and the water was cold.” Jerry makes the diagnosis: “Oh, you mean shrinkage” and George confirms: “Yes, significant shrinkage.”

Penis size has not escaped our “bigger is better” American mentality where large cars, homes, breasts,  buttocks and mega-logos on shirts are desirable and sought-after assets. The pervasive pornography industry–where many male stars are “hung like horses”– has given the average guy a bit of an inferiority complex.

Factoid: The reality of the situation is that the average male has an average-sized penis, but in our competitive society, although average is the norm, average curiously has gotten a bad rap.

Adages concerning penile size and function are common, e.g., “It’s not the size of the ship, but the motion of the ocean.” Or even better, as seen on a poster in a gateway while boarding an airplane: “Size should never outrank service.” The messages conveyed by these statements have significant merit, but nonetheless, to many men and women, size plays at least some role and many men have concerns about their size. Whereas men with tiny penises may be less capable of sexually pleasing a woman, men who have huge penises can end up intimidating women and provoking pain and discomfort.

Leonardo Da Vinci had an interesting take on 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.”

Penile Stats

As a urologist who examines many patients a day, I can attest to the fact that penises come in all shapes and sizes and that flaccid length does not necessarily predict erect length and can vary depending upon many factors. There are showers and there are growers. Showers have a large flaccid length without significant expansion upon achieving an erection, as opposed to growers who have a relatively compact flaccid penis that expands significantly with erection.

With all biological parameters—including penis size—there is a bell curve with a wide range of variance, with most clustered in the middle and outliers at either end. Some men are phallically-endowed, some phallically-challenged, with most somewhere in the middle of the road. In a study of 3500 penises published by Alfred Kinsey, average flaccid length was 8.8 centimeters (3.5 inches). Average erect length ranged between 12.9-15 centimeters (5-6 inches). Average circumference of the erect penis was 12.3 centimeters (4.75 inches). As with so many physical traits, penis size is largely determined by genetic and hereditary factors. Blame it on your father (and mother).

Factoid: Hung like a horse—forget about it! The blue whale has the mightiest genitals of any animal in the animal kingdom: penis length is 8-10 feet; penis girth is 12-14 inches; ejaculate volume is 4-5 gallons; and testicles are 100-150 pounds. Hung like a whale!

Factoid: “Supersize Me.” In order to make their genitals look larger, the Mambas of New Hebrides wrap their penises in many yards of cloth, making them appear massive in length. The Caramoja tribe of Northern Uganda tie weights on the end of their penises in efforts to elongate them.

“Acute” Shrinkage

Penile size in an individual can be quite variable, based upon penile blood flow. The more blood flow, the more tumescence (swelling); the less blood flow, the less tumescence. “Shrinkage” is a real phenomenon provoked by exposure to cold (weather or water), the state of being anxious or nervous, and participation in sports. The mechanism in all cases involves blood circulation.

Cold exposure causes vasoconstriction (narrowing of arterial flow) to the body’s peripheral anatomy to help maintain blood flow and temperature to the vital core. This principle is used when placing ice on an injury, as the vasoconstriction will reduce swelling and inflammation. Similarly, exposure to heat causes vasodilation (expansion of arterial flow), the reason why some penile fullness can occur in a warm shower.

Nervous states and anxiety cause the release of the stress hormone adrenaline, which functions as a vasoconstrictor, resulting in numerous effects, including a flaccid penis. In fact, when the rare patient presents to the emergency room with an erection that will not quit, urologists often must inject an adrenaline-like medication into the penis to bring the erection down.

Hitting it hard in the gym or with any athletic pursuit demands a tremendous increase in blood flow to the parts of the body involved with the effort. There is a “steal” of blood flow away from organs and tissues not involved with the athletics with “shunting” of that blood flow to the organs and tissues with the highest oxygen and nutritional demands, namely the muscles. The penis is one of those organs from which blood is “stolen”—essentially “stealing from Peter to pay Paul” (pun intended!)—rendering the penis into a sad, deflated state. Additionally, the adrenaline release that typically accompanies exercise further shrinks the penis.

Cycling and other saddle sports—including motorcycle, moped, and horseback riding—put intense, prolonged pressure on the perineum (area between scrotum and anus), which is the anatomical location of the penile blood and nerve supply as well as pelvic floor muscles that help support erections and maintain rigidity.  Between the compromise to the penile blood flow and the nerve supply, the direct pressure effect on the pelvic floor muscles, and the steal, there is a perfect storm for a limp, shriveled and exhausted penis. More importantly is the potential erectile dysfunction that may occur from too much time in the saddle.

“Chronic” Shrinkage

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,” smaller and often temperamental penis.

Factoid: If you go for too long without an erection, smooth muscle, elastin and other tissues within the penis may be negatively affected, resulting in a loss of penile length and girth and negatively affecting ability to achieve an erection.

Factoid: Scientific studies have found that sexual intercourse on a regular basis protects against ED and that the risk of ED is inversely related to the frequency of intercourse. Men reporting intercourse less than once weekly had a two-fold higher incidence of ED as compared to men reporting intercourse once weekly.

Radical prostatectomy as a treatment for prostate cancer can cause penile shrinkage. This occurs because of the loss in urethral length necessitated by the surgical removal of the prostate, which is compounded by the disuse atrophy and scarring that can occur from the erectile dysfunction associated with the surgical procedure. For this reason, getting back in the saddle as soon as possible after surgery will help “rehabilitate” the penis by preventing disuse atrophy.

Peyronie’s Disease can cause penile shrinkage on the basis of scarring of the erectile tissues that prevents them from expanding properly.  For more on this, see my blog on the topic:

https://healthdoc13.wordpress.com/2015/05/23/peyronies-disease-not-the-kind-of-curve-you-want/

Medications that reduce testosterone levels are often used as a form of treatment for prostate cancer. The resultant low testosterone level can result in penile atrophy and shrinkage. Having a low testosterone level from other causes will also contribute to a reduction in penile size.

Are There Herbs, Vitamins or Pills That Can Increase Penile Size?

Do not waste your resources on the vast number of heavily advertised products that will supposedly increase penile size but have no merit whatsoever.  Realistically, the only medications capable of increasing penile size are the oral medications that are FDA approved for ED. Daily Cialis will increase penile blood flow and by so doing will increase flaccid penile dimensions over what they would normally be; the erect penis may be larger as well because of augmented blood flow.  Additionally, for many men this will restore the capability of being sexually active whereas previously they were unable to obtain a penetrable erection, thus allowing them to “use it instead of losing it” and maintain healthy penile anatomy and function.

Is Penile Enlargement Feasible Through Mechanical Means?

It is possible to increase penile size using tissue expansion techniques. The vacuum suction device uses either a manual or battery-powered source to create a vacuum in a cylinder into which the penis is placed. The negative pressure pulls blood into the penis, expanding penile length and girth. A constriction ring is placed around the base of the penis to maintain the erection. The vacuum is used to manage ED as well as a means of penile rehabilitation and is also used prior to penile implant surgery to increase the dimensions of the penis and allow a slightly larger device to be implanted than could be used otherwise. It can also be helpful under circumstances of penile shrinkage.

vsd

Vacuum Suction Device

The Penimaster Pro is a penile traction system that is approved in the European Union and Canada for urological conditions that lead to shortening and curvature of the penis. In the USA it is under investigation by the FDA. It is a means of using mechanical stress to cause penile tissue expansion and enlargement.

penimaster

Penimaster Pro

What’s The Deal With Penile Enlargement Surgery?

Some men who would like to have a larger penis may consider surgery. In my opinion, penile enlargement surgery, aka, “augmentation phalloplasty,” is highly risky and not ready for prime time. Certain procedures are “sleight of penis” procedures including cutting the suspensory ligaments, disconnecting and moving the attachment of the scrotum to the penile base, and liposuction of the pubic fat pad. These procedures unveil some of the “hidden” penis, but do nothing to enhance overall length. Other procedures attempt to “bulk” the penis by injections of fat, silicone, bulking agents, tissue grafts and other implantable materials. The untoward effects of enlargement surgery can include an unsightly, lumpy, discolored, painful and perhaps poorly functioning penis. Realistically, in the quest for a larger member, the best we can hope for is to accept our genetic endowment, remain physically fit, and keep our pelvic floor muscles well conditioned.

What’s Up With Penile Transplants?

The world’s first penis transplant was performed at Guangzhou General Hospital in China when microsurgery was used to transplant a donor penis to a recipient whose penis was damaged beyond repair in an accident. Subsequently, there have been several transplants done for penile trauma.  Hmmm, now here is a concept for penile enlargement!

What To Do To Avoid Shrinkage issues?

  • Accept that cold, stress and athletics will cause temporary shrinkage
  • Be aware that cycling and other saddle sports can cause shrinkage as well as erectile dysfunction: wear comfortable and protective shorts; get measured for a saddle with an appropriate fit; frequently rise up out of the saddle, taking the pressure off the perineum
  • Eat a healthy diet and stay physically active to maintain a lean physique
  • Use it or lose it: stay sexually active
  • Do pelvic floor exercises (a.k.a. Man Kegels): visit http://www.MalePelvicFitness.com
  • “Rehab” the penis to avoid disuse atrophy after radical prostatectomy: oral ED meds, pelvic floor muscle training, vibrational stimulation, vacuum suction device, penile injection therapy; consider “pre-hab” before the surgery
  • Seek urological care for Peyronie’s disease

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

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

E-book available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback available via websites. Author page on Amazon:

http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix

https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: www.PrivateGym.com or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx, Vacuum Suction Devices and many other quality products can be obtained at http://www.UrologyHealthStore.com. Use promo code “UROLOGY10” at checkout for 10% discount. 

It’s Not Just What’s In Your Genes That Counts: 10 Interesting Genetic Facts

October 1, 2016

Andrew Siegel MD 10/1/2016

This entry is a little diversion from my usual pelvic health blogs, but covers a fascinating topic that is at the forefront of medical research.

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(Thank you, Pixabay, for image above of DNA)

  1. Humans have 23 pairs of chromosomes, but apes have 24 pairs. We lost a chromosome during evolution, but gained a thumb…less is more! Noteworthy is that the genetic material of apes is 96% identical to that of humans.
  2. Our chromosomes contain 20,000 or so genes—only 2000 fewer than worms and less than corn, rice or wheat…in this instance, size doesn’t matter!
  3. Every cell in our body has identical chromosomes and genes, yet the expression of the genes varies greatly from cell to cell—skin cells are clearly very different than kidney cells, yet share the same genetic blueprint. The nuance, complexity and real mystery of our chromosomes is the orchestration of turning on and turning off certain genes in certain cells at certain times at certain places.
  4. Our genes can magically shuffle their sequence to make genetic variants to enable fighting off invading pathogens. This dynamic ability allows us to ward off pathogens that are constantly evolving.
  5. The basic function of genes is to encode for proteins. However, only 2% of the chromosome contains genes that do so. 98% of the genetic material of the chromosome does not encode for proteins and is either located between or within protein-encoding genes and is responsible either for regulating genes or has mysterious functions that are not understood.
  6. Many of our human genes are actually not human.  Embedded within our chromosomes are inactive portions derived from ancient viruses and other non-human sources.
  7. The ends of chromosomes have “telomeres” that protects the chromosomes from fraying, acting like the plastic pieces at the end of shoelaces.
  8. The simplicity of the genetic code is well understood: DNA builds RNA, RNA builds proteins, and a triplet of bases of DNA specifies one amino acid of the protein. However, we are clueless about the complexity of the genomic code, with no clear understanding of the coordination of gene expression to build, maintain and repair a human being.
  9. The Y chromosome determines maleness. It is the only unpaired chromosome, meaning no mate chromosome or duplicate copy, leaving each gene on the chromosome to fend for itself. If a mutation occurs, there is no repairing it by copying it from the intact gene on the sister chromosome. In other words, the Y chromosome has no backup (spare tire) and when a mutation occurs, it spells trouble, being the most vulnerable spot in the human genome. As a consequence, evolutionary forces have transferred important genetic material to less vulnerable chromosomes, whittling the Y chromosome down to being the smallest of all chromosomes. Like risk-taking men, the male chromosome lives dangerously!
  10. Mitochondria are the “powerhouses” of our cells, responsible for energy and metabolism. All human embryos inherit their mitochondria exclusively from their mothers, as sperm do not contribute mitochondria. If you feel depleted of energy, blame it on your mother!

 Much of the information for this entry was derived from an awesome book: The Gene: An Intimate History by Siddhartha Mukherjee, MD, one that I highly suggest that you put on your reading list.

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

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com

Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: www.PrivateGym.com or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount.