10 Common Penile “Flaws” You May Have That Are Actually Quite Normal

October 14, 2017

 Andrew Siegel MD   10/14/17

A penis is a special organ—a man’s joy, if not pride—and certainly one of his most prized, appreciated and cherished possessions, to which he has a significant attachment. As multifunctional as a Swiss Army knife, it allows him to stand to urinate (an undervalued capability), rises and firms to the occasion to allow for sexual penetration, and ejaculates genetic material–the means to perpetuate the species. A marvel of hydraulic engineering, within nanoseconds of sexual stimulation it is uniquely capable of increasing its blood flow 50 times over baseline, transforming its shape and size. Penis magic!

Each and every penis is unique.  As variable as snowflakes, they come in every size, shape and color. Beyond “size matters”—often a source of male preoccupation—men are often obsessed, if not preoccupied, with the appearance of their genitals.  In my interactions with patients, concerns are often voiced about symmetry, color, pigmentation, angulation, spots, blemishes, vein patterns, shrinkage and other oddities. Unless you are in the habit of closely inspecting other men’s genitals (as urologists are), you are unlikely to realize how common and completely normal most of these genital variations are.

 10 Common Penile “Flaws” You May Have That Are Actually Quite Normal

  1. Penis leans to one side

left or right

No human is perfectly symmetrical and the flaccid penis rarely hangs perfectly centered. Wherever your penis naturally lies when you are clothed—whether left or right—is not indicative of your political leaning or left vs. right-sided brain predominance and is of absolutely no significance or consequence whatsoever!

Interesting trivia: “Throckmorton’s sign” is a term used jokingly by medical students, residents and attending physicians. A positive Throckmorton sign is when the penis points to the side of the body where the pathology is, e.g., if a man is getting surgery for a right groin hernia and the penis points to the right side. The Throckmorton sign indicates the proper side of the pathology at least 50% of the time!  Operating room humor! 

  1. Slight penile curvature when erect

pixabay banana

Thank you Pixabay, for image above

Again, although perfect symmetry may be desirable, the norm for the erect penis is not to be perfectly straight. There is often a subtle bend to the left, right, up or down.  Some men have a penis that has a banana-like curvature. Slight bends—considered totally normal—are to be distinguished from Peyronie’s disease, a condition in which there is significant angulation due to scarring of the sheaths of the erectile chambers. It is a potentially serious condition that can cause painful erections and erectile dysfunction.

  1. One testicle hangs lower

pixabay plumsThank you Pixabay, for image above

If you ever wondered why one of your testes is slightly bigger or heavier and hangs lower than the testes on the other side, you are in good company. Paralleling women with breast asymmetry, the vast majority of men have testes asymmetry, so your mismatched gonads are perfectly normal.

  1. Dark genital skin

Hyperpigmentation (darkening) of the median raphe (the line running from anus to perineum to scrotum to undersurface of penis) and other areas of the penis is extremely common.  In fact, it is normal for the penile skin color to be darker than other areas of the body, because of the effect of sex hormones on the cells that produce pigment (melanocytes).  The circumcision line, as well, is often deeply pigmented.

  1. Freckles, moles and skin tags

pixabay spottedThank you Pixabay, for image above

The penis is covered by skin–just like the rest of the body–and is therefore subject to common benign skin growths, including moles, freckles and skin tags. These are generally harmless and usually do not require any treatment unless desired for cosmetic reasons. However, if you have a growth that changes in size, color or texture, you should have it checked out because penile cancers do occur on occasion.  Skin tags are small fleshy protuberances and can be confused with genital warts, so if you have any doubt, get checked.

  1. Other penis and scrotal bumps and lumps

Pearly penile papules are raised “pearly” bumps that appear around the corona (the base of the head of the penis). They consist of one or more rows of small, fleshy, yellow-pink or transparent, smooth bumps surrounding the penile head. They are benign and do not cause harm, but sometimes are treated for cosmetic reasons, usually with freezing or lasering.

Pearly_Penile_Papules_Front

Pearly penile papules, By AndyRich48 (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)%5D, via Wikimedia Commons

Sebaceous glands produce oil that nourishes the hair follicles of the genitals. These glands appear as numerous small yellowish bumps on the scrotum and penile base.  In some men, they are prominent and referred to as sebaceous gland hyperplasia.  At times, they can exist without a hair follicle even being present.  Regardless, they are a normal occurrence.  See public domain image below–a.k.a. Fordyce spots.

Fordyces_spot_closeup.public domain. jpg

  1. Scattered scrotal spots

Angiokeratomas are benign purplish skin growths with a scaly surface that are not uncommonly present on the scrotum. They consist of dilated thin-walled blood vessels with overlying skin thickening. These skin lesions can occasionally bleed and also cause fear and anxiety since they can resemble more serious problems such as melanoma. If in any doubt, get it checked out.

Angiokeratoma_of_the_Scrotum_5

Scrotal angiokeratomas, By Jlcarter2 (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or   CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)%5D, via Wikimedia Commons

  1. Veiny vanity

Every man has a unique penile venous pattern, the anatomy as unpredictable as the distinctive venous anatomy of the hand and wrist. In some men, the veins are twisted and prominent and in other men they are barely noticeable.  No matter what the pattern, venous anatomy is highly variable and individualized and is normal.

  1. Loose skin

Unlike most other skin on the body that is more tightly attached, penile skin is loosely attached to underlying tissues, allowing for expansion with erections. Since the physical state of the penis can vary from totally flaccid to totally rigid, when the penis is fully deflated, the skin may appear to be somewhat floppy and redundant, which is absolutely normal.  Scrotal skin often becomes increasing lax with the aging process, such that the testicles typically hang quite low in the elderly male, paralleling the common situation of pendulous breasts of the elderly female.

10. Shrinkage

Penile size in an individual is quite variable, based upon penile blood flow. The more blood flow, the more tumescence (swelling); the less blood flow, the less tumescence. “Shrinkage” can be 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 temporary reduced blood circulation.  Don’t worry, that sorry and spent looking penis can magically be revived with some TLC!

Bottom line: If you have an imperfect penis…welcome to the club!  No penis or scrotum is perfect.  Far from being an object of beauty, genital imperfections are the norm, so there is no need for feeling self-conscious. Just be happy that your little “fella” can function properly and enjoy his own happiness from time to time! Function over form!

Wishing you the best of health,

2014-04-23 20:16:29

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

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

 

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Kegels: One Size Does Not Fit All!

October 7, 2017

Andrew Siegel MD   10/7/17

shutterstock_femalebluepelvic

Athletes use a variety of fitness and strength-training programs to maximize their strength and endurance. A one-size-fits-all approach—the same exercise regimen applied to all—is clearly not advantageous because of the varying functional requirements for different sports.  Specific, targeted and individualized exercise programs are used to enhance and optimize performance, depending upon the particular sport and individual athlete. The ultimate goal of training is “functional fitness,” the achievement of strength, power, stamina and the skill set to improve performance and prevent specific functional impairments (injuries).

Pelvic floor dysfunction is a broad term applied to the scenario when the pelvic muscles and connective tissues are no longer functioning optimally.  This gives rise to pelvic issues including pelvic organ prolapse, urinary and bowel incontinence, sexual dysfunction and pelvic pain syndromes.  A one-size-fits-all Kegel pelvic floor muscle exercise approach has traditionally been used to manage all forms of pelvic floor dysfunctions. For many years, patients who were thought to be able to benefit from Kegels were handed a brochure with instructions to do 10 repetitions of a 10-second Kegel contraction followed by 10 rapid contractions, three times daily.

Are their shortcomings with this one-size-fits-all approach?  Clearly, the answer is yes. A one-size-fits-all approach lacks the nuance necessary to properly tackle the different types of pelvic floor dysfunction. Aligning the pelvic floor dysfunction with the appropriately tailored training program that focuses on improving the area of weakness is vitally important, since each pelvic floor dysfunction is associated with unique and specific deficits in pelvic muscle strength, power and/or endurance. One size does not fit all!

After decades of “stagnancy” following the 1940s transformative work of Dr. Arnold Kegel—the physician who was singularly responsible for popularizing pelvic floor exercises in women after childbirth–there has been a resurgence of interest in pelvic floor training. I am humbled and honored to have contributed to this “pelvic renaissance” with the publication of the short paperback book The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health, which introduces home-based, progressive, tailored exercises consisting of strength, power and endurance pelvic training regimens customized for each specific pelvic floor problem.

The initial goal of pelvic floor muscle training is muscle adaptation, the process by which pelvic muscle growth occurs in response to the demands placed it, with adaptive changes occurring in proportion to the effort put into the exercises. More challenging exercises are needed over time in order to continue the growth process that occurs as “new normal” levels of pelvic fitness are established. This translates into slowly and gradually increasing contraction intensity, duration of contractions, number of repetitions and number of sets.  The “plasticity” of the pelvic muscles require continued training, at minimum a “maintenance” program after completion of a course of pelvic training.

Although the short-term goal of pelvic floor muscle training is adaptation, the long-term goal is the achievement of functional pelvic fitness.  The vast majority of women who are taught Kegel exercises are not instructed how to put them into practical use. Go figure!  This concept of functional pelvic fitness is the actionable means of applying pelvic conditioning to daily tasks and real-life common activities. This is the essence of Kegel pelvic floor training—not simply to condition the pelvic floor muscles, but to apply this conditioning and proficiency in such a way and at the appropriate times so as to improve quality of one’s life.   These Kegels-on-demand—as I refer to them—can be lifesavers and quite a different take on Kegels, as opposed to static, isolated, out of context exercises.

Important Nuances and Details of Pelvic Training

Contraction intensity: This is the extent that the pelvic muscles are squeezed, ranging from a weak flicker of the muscles to a robust and vigorous contraction. High intensity contractions build muscle strength, whereas less intensive, but more sustained contractions, build endurance.

Contraction Type: Pelvic contractions vary in duration. It is relatively easy to intensively contract the pelvic muscles for a brief period, but difficult to maintain that intensity for a longer duration contraction. Snaps are rapid, high intensity pulses that take less than one second per cycle of contracting and relaxing. Shorts are slower, less intense squeezes that can last anywhere from two to five seconds. Sustained are less intense squeezes that last ten seconds or longer.

Relaxation duration: The amount of time the pelvic muscles are unclenched between contractions.

Repetitions: The number of contractions performed in a single set.

Set: A unit of exercise.

Strength: The maximum amount of force that a pelvic muscle can exert.

Power: The ability to rapidly achieve a full intensity contraction, which is a measure of contraction strength and speed–in other words, how quickly strength can be expressed.  Power is fostered by rapidly and explosively contracting the pelvic muscles.

Endurance (stamina): This is the ability to sustain a pelvic contraction for a prolonged time and the ability to perform multiple contractions before fatigue sets in.

Range of motion: The cycle of full pelvic contraction (muscle shortening) to complete relaxation (muscle lengthening).  This is vital in pelvic muscle training because the goal is not only to increase strength, power and endurance, but also flexibility, which is accomplished by bringing the muscle through the full range of motion.

Bottom Line:  A one-size-fits-all Kegel pelvic floor exercise program does not suit all women with pelvic floor dysfunction. To obtain optimal results, pelvic training must be tailored to the specific dysfunction. The achievement of functional pelvic fitness is one of the key goals (“key-goals”… get it?) of Kegel exercises and of the Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.  Finally, it is important to know that pelvic exercises are appropriate not only for women suffering with the aforementioned pelvic floor dysfunctions, but also for those who wish to maintain healthy pelvic functioning and prevent future problems.

Wishing you the best of health,

2014-04-23 20:16:29

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

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

For informative information on pelvic floor muscle training, please consult the following books by the author:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

Cover

The Kegel Fix is written for educated and discerning women who care about health, well-being, fitness, nutrition and enjoy feeling confident, sexy and strong.  The book has separate chapters on each of the pelvic floor dysfunctions and provides a specific, targeted pelvic floor training regimen for each.

 

Game Plan for Men’s Healthy Sexual Functioning

September 30, 2017

Andrew Siegel MD 9/30/17

man-and-woman-1464255_1920

Thank you, Pixabay, for image above.

Functioning well in the bedroom–like health in general–should never be taken for granted. During early adulthood it rarely, if ever, crosses our minds that at sometime in the future many body functions decline, including sexual function.  However, the truth of the matter is that paralleling general health and fitness, maintaining our sexual health and fitness takes some effort to avoid the almost inevitable deterioration in function.  Today’s entry reviews a “game plan” for maintaining healthy sexual functioning into our golden years.

  • Know the Fundamentals

For better or worse, penile erections are not on the basis of a bone in the penis, as they are in many mammals.  Erections occur when pressurized blood inflates the erectile chambers of the penis. The erect penis has blood pressure in excess of 200 mm (extreme hypertension), giving rise to bone-like rigidity and hence the slang term, boner.

The penis is a marvel of hydraulic engineering, uniquely capable of increasing its blood flow 50 times over baseline within nanoseconds of sexual stimulation, transforming its shape and size. This is accomplished by smooth muscle relaxation within the penile arteries and within the sinuses of the erectile chambers.

Once blood inflates the erectile chambers, closure of penile veins and contractions of the pelvic floor muscles effectively trap the pressurized blood in the penis and maintain the penile hypertension necessary for a sustained erection.

  • Know the Stats

The Massachusetts Male Aging Study showed that after age 40 there is a decline in all aspects of sexuality.  Erectile dysfunction (ED) is present in about 40% of men by age 40 with an increase in prevalence of about 10% for each decade thereafter. Although there are many causes of ED, the common denominator is insufficient blood flow to fill the erectile chambers of the penis, or alternatively, sufficient inflow but poor venous trapping, both often caused by a decline in smooth muscle relaxation with aging.

  • Know the Score

Performance ability with every physical activity declines as we get older and this explains why most professional athletes are in their twenties or thirties. Although everything eventually goes to ground, hopefully it will happen slowly. Young men can achieve a rock-hard erection simply by seeing an attractive woman or thinking a vague sexual thought. As we get older, it is not uncommon for erotic thoughts or sights to no longer be enough to provoke an erection, with the need for direct touch. Some of the common male sexual changes that occur with aging are: diminished sex drive; decreased rigidity and durability of erections; decrease in volume, force, and arc of ejaculation; decreased orgasm intensity; and an increased recovery time before being able to get a second erection.  

  • Know the Opponents: Gluttony and Sloth

A healthy weight and healthy eating habits, exercise, adequate quality and quantity of sleep, tobacco avoidance, use of alcohol in moderation, stress avoidance, and a balanced lifestyle will optimize sexual potential.  Abide by the golden rule of the penis: “Treat your penis nicely and it will be nice to you in return; treat your penis poorly and it will rebel.

  • Fuel for Performance

A healthy diet will reduce the risk of sexual dysfunction. Eat a variety of wholesome natural foods including fresh vegetables and fruit, plenty of fiber, lean protein sources, legumes and healthy fats including nuts, avocados and olive oil. Avoid eating processed foods and minimize sugar, refined carbohydrates and highly saturated animal fats.

  • Stay in Peak Form

Try to achieve “fighting weight” to maximize your performance in the sexual arena.

  • Train for Performance

Exercising—including cardio, core, and strength training—is vital for health in general and sexual health in particular. When it comes to sexual health, it is vital to focus on the all-important pelvic floor muscles (PFM). PFMT (pelvic floor muscle training) will help optimize erectile function and prevent/treat ED.

To understand why PFMT can help your performance in the bedroom, it is necessary to have some understanding of what the PFM do. When you have an erection, the bulbocavernosus muscle and ischiocavernosus muscles engage. Contractions of these muscles not only help prevent the exit of blood from the penis, enhancing rigidity, but also increase blood flow to the penis—with each contraction of these muscles, a surge of blood flows into the penis. Additionally, they act as powerful struts to support the roots of the penis (like the roots of a tree), the foundational support that, when robust, will allow a more “skyward” angling erection (like the trunk of a tree).  The bulbocavernosus muscle also is the “motor” of ejaculation, contracting rhythmically at the time of sexual climax and forcing semen out of the urethra.

Increasing the strength, tone and condition of these muscles through PFMT will allow them to function in an enhanced manner—namely more powerful contractions with more penile rigidity and stamina as well as improved ejaculatory issues, including premature ejaculation.

  • Talk to your Coach

Visit the PelvicRx website where you can purchase a male pelvic floor training DVD and have a private chat session with a pelvic floor trainer.

Wishing you the best of health,

2014-04-23 20:16:29

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

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

Author of:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Co-creator of the male pelvic floor training DVD: PelvicRx

 

 

 

Menopause: Impact on Nether Regions

September 23, 2017

Andrew Siegel MD  9/23/17

Symptoms_of_menopause_(raster)

Image above by Mikael Häggström (Own work) [CC0], via Wikimedia Commons

Menopause is the cessation of estrogen production by the ovaries.  It typically occurs at about age 51-years-old, so most women can expect to live another thirty or more years following this event. Many bodily changes occur with menopause, with the urinary and genital systems undergoing sudden and, at times, dramatic changes due to the absence of estrogen stimulation.

The constellation of symptoms related to menopause used to be referred to as “atrophic vaginitis” or “vulvo-vaginal atrophy.” However, these terms were considered disparaging, hurtful and cruel, especially the words “atrophic” and “atrophy,” which imply wasting away through lack of nourishment. Also, the “-itis” designation incorrectly implied inflammation or infection. A more politically correct, medically accurate, less embarrassing and more acceptable term was proposed by the International Society for the Study of Women’s Sexual Health and the North American Menopause Society: “Genitourinary Syndrome of Menopause (GSM).”

“Genitourinary Syndrome of Menopause”–  I don’t particularly care for this term because of its length, the fact that it sounds way too clinical, and implication that menopause causes a medical “syndrome” or “disease” as opposed to a natural, physiological, age-appropriate, virtually universal situation.  Why not label the constellation of symptoms related to menopause as “menopausal symptoms and signs”?

The female hormone (estrogen)-stimulated vagina of a young adult female has a very different appearance from that of a female after menopause. The vestibule, vagina, urethra and base of the urinary bladder have abundant estrogen receptors that are no longer stimulated after menopause, resulting in diminished tissue elasticity and integrity.  Age-related changes of the vulva and vagina can lead to dry, thinned and brittle tissues with loss of vaginal length and width, lubrication potential and expansive ability. Considering that nature’s ultimate purpose of sex is for reproduction, perhaps it is not surprising that when the body is no longer capable of producing offspring, changes occur that affect the anatomy and function of the genital organs.

Symptoms and Signs of Menopause

General

  • Hot flashes
  • Night sweats
  • Sleep disturbances
  • Mood changes and fluctuations

Vulva

  • Thinning/loss of elasticity of labia and underlying fatty tissues
  • Diminished tissue sensitivity
  • Paler, thinner and more fragile vulvar skin
  • Increase in vulvar skin issues and vulvar pain, burning, itching and irritation

 Vagina

  • Thinning of the vaginal wall
  • Loss of vaginal ruffles and ridges
  • Shortened vaginal dimensions
  • Looseness of  the vaginal opening
  • Increased vaginal pH (less acid environment)
  • Increased vaginal colonization by colon bacteria and more frequent vaginal infections

 Sexual

  • Diminished sex drive
  • Vaginal dryness
  • Diminished arousal
  • Diminished lubrication
  • Diminished ability to achieve orgasm
  • Tendency for painful sexual intercourse

 Urinary 

  • Thinning of the urethral wall and tissues adjacent to the urethra
  • Urinary infections: Before menopause, healthy bacteria reside in the vagina; after menopause, the vaginal bacterial ecosystem changes to colon bacteria, which can predispose to infections.
  • Overactive bladder symptoms: urinary urgency, frequency, urgency incontinence
  • Stress urinary incontinence (urinary leakage with sneezing, coughing, exercise and exertion)
  • Urethral caruncles (benign fleshy outgrowths at the urethral opening)

What to do?

If the symptoms and signs of menopause are not bothersome, nothing need be done. In fact, many women relish not having menstrual periods and tolerate menopause uneventfully.  However, if one’s quality of life is adversely affected, consideration can be made for hormone replacement therapy, particularly if the menopausal symptoms are disruptive and debilitating.

Hormone Replacement

Systemic hormone therapy is available in the form of pills, skin patches, sprays, creams and gels. It can be effective in managing bothersome menopausal symptoms when used for the short-term. Estrogen alone is used in women who have had a hysterectomy, whereas estrogen and progesterone in those who have a uterus. The potential side effects of systemic therapy include an increased risk for heart disease, breast cancer and stroke.

Vaginal hormone therapy is available in creams, rings and tablets. The advantage of  locally-applied estrogen is that it can help manage menopausal pelvic floor issues with minimal absorption into the body and minimal potential systemic effects, as would be expected from oral hormone replacement therapy. It can be helpful for painful intercourse, overactive bladder, stress urinary incontinence, pelvic organ prolapse and recurrent urinary tract infections. Additionally, because estrogen restores suppleness to the vaginal tissues, it can be very useful both before and after vaginal surgical procedures (most commonly for stress urinary incontinence and pelvic organ prolapse).

Note: I commonly prescribe topical estrogen therapy, typically a small dab applied vaginally prior to sleep three times weekly.  It has proven helpful and effective in a variety of circumstances.

Kegel Exercises

Clinical studies have demonstrated that Kegel exercises can effectively improve certain domains of sexual function, particularly arousal, orgasm and satisfaction. This is not surprising given that the pelvic floor muscles are essential to arousal and orgasm, with weakness in these muscles resulting in reduced pelvic and vaginal blood flow and lack of adequate lubrication, painful intercourse and difficulty achieving climax.  Furthermore, Kegel exercises can be effective in the management of overactive bladder, stress urinary incontinence, and pelvic organ prolapse.

Stay Sexually Active: Use it or Lose it

Sexual intercourse can be painful after menopause because of anatomical and functional changes that result in difficulty in accommodating a penis.  This is particularly the case if one has not been sexually active on a regular basis.  Sexual activity is vital for maintaining the ability to have ongoing satisfactory sexual intercourse. Vaginal penetration increases pelvic and vaginal blood flow, optimizing lubrication and elasticity, while orgasms tone and strengthen the pelvic floor muscles that support vaginal functionLubricants can be used for women experiencing vaginal dryness and painful intercourse.

Lifestyle Modification

Pursuing a healthy lifestyle can provide some degree of relief from menopausal symptoms. These measures include a maintaining a healthy weight, a diet emphasizing plant-based proteins, fruits and vegetables, moderate exercise, sufficient quantity and quality of sleep, caffeine reduction, tobacco cessation and alcohol in moderation.

Bottom Line: Menopause is an inevitable part of the aging process with the absence of menstrual periods a welcome change for many women.  However, the cessation of estrogen production can cause a host of symptoms and consequences, particularly affecting the urinary and genital organs.  If symptoms are bothersome, there are numerous means by which to improve them. 

Wishing you the best of health,

2014-04-23 20:16:29

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

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

 

Practical Approach To Erectile Dysfunction

September 16, 2017

Andrew Siegel MD  9/16/17

shutterstock_side view manjpeg

ED is a highly prevalent condition and a common reason for a urology consultation.  A pragmatic approach to its diagnosis and treatment–the topic of today’s entry–has always worked well for my patients.  A practical approach starts with simple and sensible measures, and only in the event that these are not successful, proceeding with more complex and involved strategies, dividing management options into four tiers of complexity. 

 Principles to managing male sexual issues are the following:

  • If it ‘ain’t broke,’ don’t fix it: “First do no harm.”
  • Educate to enable informed decisions: “The best prescription is knowledge.”
  • Try simple, conservative options before complex and aggressive ones: “Simple is good.”
  • Healthy lifestyle is vital: “Genes load the gun, but lifestyle pulls the trigger.”

Questions that need to be asked in order to evaluate ED include the following:

AS and DM

  • How long has your problem been present?
  • Was the onset sudden or gradual?
  • How is your sexual desire?
  • How is your erection quality on a scale of 0-5 (0 = flaccid; 5 = rigid)?
  • Can you achieve an erection capable of penetration?
  • Is your problem obtaining an erection, maintaining an erection, or both?
  • Is your problem situational? Consistent? Variable?
  • Are nocturnal, early morning and spontaneous erections present?
  • Do you have a bend or deformity to the erect penis?
  • How confident are you about your ability to complete the sexual act?
  • Are there ejaculation issues (rapid, delayed, painful, inability)?
  • Do you have symptoms of low testosterone?
  • What treatments have been tried?

Of equal relevance are medical, nutritional, exercise and surgical history, medications, and use of tobacco, alcohol and recreational drugs.  A tailored physical includes blood pressure, pulses and an exam of the penis, testes and prostate.  Basic lab tests including urinalysis, serum glucose, HbA1c, lipid profile and testosterone.

Information derived from the evaluation as described above will provide a working diagnosis and the ability to formulate a treatment approach.  Although a nuanced and individualized approach is always best, four lines of treatment for ED are defined—from simple to complex—in a similar way that four lines of treatment can be considered for arthritis.  For arthritis of the knee, for example, first-line therapy is weight loss to lessen the mechanical stress on the joint, in conjunction with physical therapy and muscle strengthening exercises. Second-line therapy is anti-inflammatory and other oral medications that can help alleviate the pain and inflammation. Third-line therapy is injections of steroids and other formulations.  Fourth-line therapy is surgery.

If the initial evaluation indicates a high likelihood that the ED is largely psychological/emotional in origin, referral to a qualified psychologist/counselor is often in order.  If the lab evaluation is indicative of low testosterone, additional hormone blood tests to determine the precise cause of the low testosterone are done prior to consideration for treatment aimed at getting the testosterone in normal range.  If the lab evaluation demonstrates unrecognized or poorly controlled diabetes or a risky lipid and cholesterol profile, appropriate medical referral is important.

Practical treatment of ED


elephant penis
 Credit for photo above goes to one of my patients; note the 7 prodigious appendages!

First-line: Lifestyle makeover

 A healthy lifestyle can “reverse” ED naturally, as opposed to “managing” it. ED can be considered a “chronic disease,” and as such, changes in diet and lifestyle can reverse it, prevent its progression and even prevent its onset.

My initial approach is to think “big picture” (and not just one particular aspect of the body working poorly).  Since sexual functioning is based upon many body components working harmoniously (central and peripheral nerve system, hormone system, blood vessel system, smooth and skeletal muscles), the first-line approach is to do what nurtures every cell, tissue and organ in the body. This translates to getting down to “fighting” weight, adopting a heart-healthy and penis-healthy diet (whole foods, nutrient-dense, calorie-light, avoiding processed and refined junk foods), exercising moderately, losing the tobacco habit, consuming alcohol in moderation, managing stress (yoga, meditation, massage, hot baths, whatever it takes, etc.), and getting adequate quantity and quality of sleep. Aside from general exercises (cardio, core, strength and flexibility training), specific pelvic floor muscle exercises (“man-Kegels”) are beneficial to improve the strength, power and endurance of the penile “rigidity” muscles.

If a healthy lifestyle can be adopted, sexual function will often improve dramatically, in parallel to overall health improvements. Many medications have side effects that negatively impact sexual function. A bonus of improved lifestyle is potentially allowing lower dosages or elimination of medications (blood pressure, cholesterol, diabetic meds, etc.), which can further improve sexual function.

“The food you eat is so profoundly instrumental to your health that breakfast, lunch and dinner are in fact exercises in medical decision making.”  Thomas Campbell MD

 

healthy meal

Above: A nice, healthy meal consisting of salmon, salad, veggies and quinoa

 

fat belly

Above: Not the kind of belly you want–visceral obesity is a virtual guarantee of pre-diabetes–if not diabetes–and greatly increases one’s risk of cardiovascular disease, including ED

Bottom line: Drop pounds, eat better, move more, stress less, sleep soundly = love better!

Second-line: ED pills and mechanical devices

In my opinion, the oral ED medications should be reserved for when lifestyle optimization fails to improve the sexual issues. This may be at odds with other physicians who find it convenient to simply prescribe meds, and with patients who want the quick and easy fix.  However, as good as Viagra, Levitra, Cialis and Stendra may be, they are expensive, have side effects, are not effective for every patient and cannot be used in everyone, as there are medical situations and medications that you might be on that preclude their use. In the second-line category, I also include the mechanical, non-pharmacological, non-surgical devices, including the Viberect and the vacuum suction devices.

Viagra (Sildenefil). Available in three doses—25, 50, and 100 mg—it is taken on demand and once swallowed, it will increase penile blood flow and produce an erection in most men within 30-60 minutes if they are sexually stimulated, and will remain active for up to 8 hours.

 Levitra (Vardenefil). Similar to Viagra, it is available in 5, 10, and 20 mg doses. Its effectiveness and side effect profile is similar to Viagra.

Cialis (Tadalafil).  Available in 2.5, 5 mg, 10mg, and 20 mg doses, its effectiveness and side effect profile is similar to Viagra. Its duration of action is approximately 36 hours, which has earned it the nickname of “the weekender.” Daily lower doses of Cialis are also FDA-approved for the management of urinary symptoms due to benign prostate enlargement.

Stendra (Avanafil). Similar to Viagra, it is available in 50, 100 and 200 mg doses. Its advantage is rapid onset.

Vacuum suction device                                                                                                                          This is a mechanical means of producing an erection in which the penis is placed within a plastic cylinder connected to a manual or battery-powered vacuum. The negative pressure engorges the penis with blood and a constriction band is temporarily placed around the base of the penis to maintain the erection.

Viberect device                                                                                                                               Initially employed as a means of triggering ejaculation in men with spinal cord injuries using vibrational energy, it has achieved wider use in provoking erections in men with ED. The device has dual arms that are placed in direct contact with the penile shaft. The vibratory stimulation will cause an erection and ultimately induce ejaculation.

Third-line: Vasodilating (increase blood flow) urethral suppositories and penile injections

These drugs are not pills, but other formulations (suppositories and injections) that increase penile blood flow and induce an erection.

M.U.S.E. (Medical urethral system for erection).  This is a vasodilator pellet—available in 125, 250, 500, and 1000 microgram dosages—that is placed into the urinary channel after urinating.  Absorption occurs through the urethra into the adjacent erectile chambers, inducing increased penile blood flow and potentially an erection.

Caverject and Edex (Prostaglandin E1) are vasodilators that when injected directly into the erectile chambers result in increased blood flow and erectile rigidity. After one is taught the technique of self-injection, the medication can be used on demand, resulting in rigid and durable erections.  A combination of medications can be used for optimal results– this combination is known as Trimix and consists of Papaverine, Phentolamine, and Alprostadil.

Fourth-line: Penile implants

There are two types of these devices that are surgically implanted into the erectile chambers under anesthesia, most often on an outpatient basis. Penile implants are totally internal, with no visible external parts, and aim to provide sufficient penile rigidity to permit vaginal penetration.

The semi-rigid device is a simple one-piece flexible unit consisting of paired rods that are implanted into the erectile chambers. The penis with implanted flexible rods is bent up for sexual intercourse and bent down for concealment. The inflatable device is a three-piece unit that is capable of inflation and deflation. Inflatable inner tubes are implanted within the erectile chambers, a fluid reservoir is implanted behind the pubic bone and a control pump in the scrotum, adjacent to the testes. When the patient desires an erection, he pumps the control pump several times, which transfers fluid from the reservoir to the inflatable inner tubes, creating a hydraulic erection which can be used for as long as desired. When the sexual act is completed, he deflates the mechanism via the control pump, transferring fluid back to the reservoir.

Penile implants can be a life changer for a man who cannot achieve a sustainable erection. They provide the necessary penile rigidity to have intercourse whenever and for however long that is desirable.

 

Wishing you the best of health,

2014-04-23 20:16:29

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

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

How Strong Are Your Pelvic Floor Muscles?

September 9, 2017

Andrew Siegel MD  9/9/17

Note: Although the image below is that of a woman who has likely has a strong pelvic floor, this entry is equally relevant for both women and men. 

Mr-yoga-leg-extended-bridge-pose

Attribution of above image: By Mr. Yoga (http://mryoga.com/) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)%5D, via Wikimedia Commons

 

The Pelvic Floor Muscles in Men and Women (really not so different)

1116_Muscle_of_the_Perineum

Attribution of above image: By OpenStax [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)%5D, via Wikimedia Commons

A Few Questions & Answers About the PFM

Q. Why should you give a hoot about your PFM?                               

A. PFM integrity, strength and endurance are vital for optimal sexual, urinary, and bowel function in both females and males. If you don’t think bladder/intestinal control, pelvic organ support or sex is important, don’t bother to read on!

Q. Why do your PFM weaken?                                                                                  

A. The PFM lose strength with aging, obesity and not using them (disuse atrophy).  Their integrity is deeply impacted by pregnancy, labor and delivery in females and pelvic surgery (radical prostatectomy, colon/rectum operations, etc.) in males.

Q.  How can your PFM be strengthened?                                                                        

A. Like any skeletal muscles, the PFM can be strengthened through targeted exercise.

Q. What are important parameters of PFM function?

A. Strength at rest and with actively contracting the PFM; ability to voluntarily relax the PFM; endurance (ability to sustain a PFM contraction before fatigue sets in); and repeatability (the number of times a PFM contraction can be performed before fatigue sets in).

Q.  How is PFM strength tested?  

A. There are many ways to assess PFM strength.  Some clues as to female PFM strength are a snug and firm vagina with no urinary control issues, dropped pelvic organs or sexual problems. Some clues as to male PFM strength are good quality erections and ejaculation and no dribbling of urine after completing urinating. The ability to briskly lift up the erect penis (while in the standing position) when contracting the PFM is a sign of PFM strength. 

Other means of assessing PFM strength are the following:

1. Visual Inspection: Observe the perineum (area between anus and scrotum/vagina) prior to and during the PFM contraction.  The perineum should lift upwards and inwards and the anus should contract (anal wink). 

2. Vaginal (or Anal) Palpation: Place a finger in the vagina or anus, contract the PFM and subjective judge PFM strength using the Oxford scale (0-5). 0: no contraction; 1: flicker; 2: weak; 3: moderate;  4: good; 5: strong 

3. Perineometry: A pressure-measuring probe is placed in the vagina or rectum.  The device registers the squeeze pressure on the probe during a PFM contraction.

4. Electromyography: Patch electrodes (that resemble EKG electrodes) are placed on the  perineum. A recording of electrical activity generated by PFM contractions is made.

5. Dynamometry: A cylindrical steel tube that measures compressive strength is placed in the vagina or rectum. The device registers the squeeze pressure on the load cell built into the steel tube.

6. Ultrasound: Sound wave technology images the perineum and PFM during an active contraction.

Bottom Line:  Unlike the external, mirror-appealing muscles, the PFM are humble muscles that are shrouded in secrecy,  unseen and behind the scenes and often unrecognized and misunderstood. Their mysterious powers straddle the gamut of being vital for what may be considered the most pleasurable and sublime of human pursuits—sex—but equally integral to what may be considered the least refined of human activities—bowel and bladder function. Because they are out of sight and out of mind, they are often neglected. However, there is great merit in exercising important hidden muscles, including the heart, diaphragm and PFM. Although they are not the muscles of “glamour,” the PFM are the muscles of “amour” and merit the respect that is accorded the external glamour muscles of the body. 

Wishing you the best of health,

2014-04-23 20:16:29

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

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

For more information on the pelvic floor muscles and how to properly condition them, please consult the following books by the author:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

Bloody Semen: Frightening, But Usually Not To Worry

September 2, 2017

Andrew Siegel MD  9/2/17

Hematospermia is medical speak for a bloody ejaculation. It is a not uncommon occurrence, usually resulting from inflammation of one of the male reproductive parts, typically the prostate or seminal vesicles.  As scary as it is, it is rarely indicative of a serious underlying disorder.  Like a nosebleed, it can be due simply to a ruptured blood vessel. It is almost always benign and self-limited,  typically resolving within several weeks. On occasion it may become recurrent or chronic, causing concern and anxiety, but again, rarely due to a serious problem.

Factoid: The most common cause of a bloody ejaculation is following a prostate biopsy.

 

Illu_repdt_male

Thank you, Wikipedia, for image above, public domain

What is semen?

Semen is a nutrient vehicle for sperm that is a concoction of secretions from the testes, epididymis, urethral glands, prostate gland, and seminal vesicles.  The clear secretions from the urethral glands account for a tiny component, the milky white prostate gland secretions for a small amount of the fluid, and the viscous secretions from the seminal vesicles for the bulk of the semen. Sperm makes up only a minimal contribution.

Factoid:  After vasectomy the semen appears no different since sperm make up a negligible portion of the total seminal volume.

What exactly occurs during ejaculation?

After a sufficient level of sexual stimulation is achieved (the “ejaculatory threshold”), secretions from the prostate gland, seminal vesicles, epididymis, and vas deferens are deposited into the part of the urethra within the prostate gland.  Shortly thereafter, the bladder neck pinches closed while the prostate and seminal vesicles contract and the pelvic floor muscles spasm rhythmically, sending wave-like contractions rippling down the urethra to propel the semen out.

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

Factoid: It is the pelvic floor muscles that are the muscle power behind ejaculation.  Remember this: strong pelvic muscles = strong ejaculation.

Since the prostate and seminal vesicles contribute most of the volume of the semen, bleeding, inflammation or other pathology of these organs is usually responsible for bloody ejaculations. The bleeding may cause blood in the initial, middle, or terminal portions of the ejaculate.  Typically, blood arising from the prostate occurs in the initial portion, whereas blood arising from the seminal vesicles occurs later. The color of the semen can vary from bright red, indicative of recent or active bleeding, to a rust or brown color, indicative of old bleeding.

What are some of the causes of blood in the semen?

  • Infection or inflammation (urethritis, epididymitis, orchitis, prostatitis, seminal vesiculitis, etc.)
  • Ruptured blood vessel, often from intense sexual activity
  • Reproductive organ cysts or stones
  • Following prostate biopsy (from numerous needle punctures); following vasectomy
  • Pelvic trauma
  • Rarely malignancy, most commonly prostate cancer and less commonly, urethral cancer
  • Coagulation issues or use of blood thinners

 How is hematospermia evaluated and treated?

A brief history reveals how long the problem has been ongoing, the number of episodes, the appearance of the semen and the presence of any inciting factors and associated urinary or sexual symptoms. Physical examination involves examination of the genitals and a digital rectal examination to check the size and consistency of the prostate. Laboratory evaluation is a urinalysis to check for urinary infection and blood in the urine, and a PSA (prostate specific antigen) blood test.  At times a urine culture and/or semen culture needs to be done.

Hematospermia is typically managed with a course of oral antibiotics because of the infection/inflammation that is often the underlying cause.  In most cases, the situation resolves rapidly.

If the bloody ejaculations continue, further workup is required.  This may involve imaging with either trans-rectal ultrasonography (TRUS) or magnetic resonance imaging (MRI) and at times, cystoscopy. TRUS is an office procedure in which the prostate and seminal vesicles are imaged by placing an ultrasound probe in the rectum. MRI imaging is performed at an imaging center under the supervision of a radiologist. The MRI provides a more thorough diagnostic evaluation, but is more expensive and time consuming.  Both TRUS and MRI can show dilated seminal vesicles, cysts of the ejaculatory ducts, prostate or other reproductive organs, and ejaculatory or seminal vesicle stones.  MRI can also show sites suspicious for prostate cancer. Cystoscopy is a visual inspection of the inner lining of the urethra, prostate and bladder with a small-caliber, flexible instrument. Treatment is based on the findings of the imaging and diagnostic studies, but again, it is important to emphasize the typical benign and self-limited nature of hematospermia.

Bottom Line: Blood in the ejaculation is not uncommon and is frightening, but is usually benign and self-limited and easily treated. In the rare situation where it persists, it can be thoroughly evaluated to assess the underlying cause.  If you experience hematospermia, visit your friendly urologist to have it checked out.

Wishing you the best of health,

2014-04-23 20:16:29

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

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

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

The aforementioned books will teach men and women, respectively, how to strengthen their pelvic floor muscles.

Urologic Injuries Among U.S. Soldiers Deployed To The Middle East

August 26, 2017

Andrew Siegel MD   8/26/17

Urological trauma (Urotrauma) is not uncommon among members of the USA military deployed in the Middle East. From October 2001-August 2013, approximately 1500 male soldiers suffered genital and/or urinary injuries.  Most were external, involving the penis, scrotum, testicles and urethra. At least one-third of these external injuries were severe, with 150 men losing either one or both testicles. The increased survival following complex traumatic injuries, which in prior conflicts would have likely resulted in death, now often result in survival of men with severe injuries, including those of the urological system. These injuries significantly affected sexual, urinary and reproductive health.

Defense.gov_News_Photo_110109-A-6521C-047_-_U.S._Army_soldiers_Staff_Sgt._Chad_Kair_Sgt._1st_Class_Travis_Leonhardt_and_Sgt._1st_Class_Charles_Houston_coordinate_security_during_a_meeting_to.jpg

Attribution of image above: By English: Sgt. Sean P. Casey, U.S. Army (www.defense.gov) [Public domain], via Wikimedia Commons

Improvements in battlefield medicine have significantly increased survival rates among injured soldiers.  However, these improvements have resulted in unprecedented numbers of soldiers—who previously would have died—surviving with injuries.  When traumatic injuries to the urinary and genital tract occur, they often result in urinary and sexual dysfunction, fertility issues and severe psychological trauma.

During the 12-year period under review, there were 30,000 injuries to deployed soldiers. 5% of soldiers sustained one or more urological injuries.  The majority of the injured were junior enlisted and members of the US Army or US Marine Corps, under 30 years old.  Most urological injuries occurred during battle and were predominately caused by explosive devices causing penetrating injuries. The scrotum was most commonly injured, followed by the testicles, penis, and urethra.  Loss of the entire penis and/or one or both testicles occurred in about 150 men. The consequence of severe genital injury is often a shortened, disfigured, nonfunctional penis, even despite conventional reconstructive surgery. Commonly accompanying urological trauma are brain trauma, pelvic fracture, colon and rectal injury and lower extremity injuries resulting in amputation.

The current pattern of urological injury represents a shift from internal urological structures—including the kidney, ureter, and bladder—to external urological structures.  This is attributed to the use of body armor that protects the chest and abdomen, but not the external genitals.  Furthermore, the rugged terrain in Afghanistan exposes soldiers patrolling on foot to genital blast trauma from ground-based explosive devices. Traditionally, the protective clothing to minimize genital trauma from ground-based explosive high-energy projectiles devices is a lightweight boxer brief undergarment and a thicker brief-type outer garment that is worn over combat trousers.  The US Army has introduced a new “pelvic protector” designed to shield the soldier’s genital and perineal areas from debris generated by improvise explosive devices.

Bottom Line:  Male external genitals were the predominant structures injured in recent warfare. Severe testicular and/or penile injury occurred in a substantial portion of the soldiers, with urological injuries often accompanying general body trauma. Sadly, most injuries—many of which are disfiguring genital injuries—occur at the time of peak sexual and reproductive potential, negatively affecting relationships and paternity.  Fortunately, advances in injury prevention, organ reconstruction/replacement, penile transplantation, regenerative medicine and advanced sperm salvage have the potential of making a significant difference in the health and well-being of soldiers with significant genital/urinary trauma.

Resource for this entry: “Epidemiology Of Genitourinary Injuries Among Male United States Service Members Deployed To Iraq And Afghanistan: Early Findings From The Trauma Outcomes And Your General Health Project” J Janak, J Orman, D Soderdahl and S Hudak, Journal of Urology: Volume 197, pages 414 – 419, February 2017

Wishing you the best of health,

2014-04-23 20:16:29

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

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

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Healt

 

Men’s Health: Holistic Urology Approach

August 19, 2017

Andrew Siegel MD   8/19/17

pixabay

Thank you, Pixabay, for image above

Men Don’t Ask For Directions, Etc…

With respect to their health, women are usually adept at preventive care and commonly see an internist or gynecologist regularly.  On the other hand, men—who could certainly take a lesson from the fairer sex—are generally not good at seeing doctors for routine checkups. Not only has our culture indoctrinated in men the philosophy of “playing through pain,” but also the lack of necessity of seeking medical care when not having a specific problem or pain (and even when men do develop dangerous health warning signs, many choose to ignore them.). Consequently, many men have missed out on some vital opportunities: To be screened for risks that can lead to future medical issues; be diagnosed with problems that cause no symptoms (such as high blood pressure, glaucoma and prostate cancer); and counseled regarding means of modifying risk factors and optimizing health.

Many Men Don’t Have A Doc

Urologists evaluate and treat a large roster of male patients, a surprising number of whom have not sought healthcare elsewhere and do not have a primary physician. Urological visits offer an opportunity to not only focus on the specific urological complaint that drives the visit (usually urinary or sexual problems), but also to take a more encompassing holistic health approach, emphasizing modifications in diet, physical activity, and other lifestyle factors that can prevent many untoward consequences and maximize health. By getting men engaged in the healthcare system on a timely basis, they can be helped to minimize those risk factors that typically cause the illnesses that afflict men as they age.

Identifying and modifying risk factors can mitigate, if not prevent, a number of common maladies.  Modifiable risk factors for the primary killer of men—cardiovascular disease—include poor diet, obesity, physical inactivity, excessive alcohol, tobacco consumption, stress, high blood pressure, high blood glucose and diabetes, high cholesterol, obstructive sleep apnea, low testosterone and depression. The bottom line is that every patient contact provides an opportunity for so much more than merely treating the sexual or urinary complaint that brought the patient into the office. Furthermore, many systemic disease processes—including diabetes, obstructive sleep apnea, cardiovascular diseases, etc.—have urological manifestations and symptoms that can be identified by the urologist who in turn can make a referral to the appropriate health care provider.

Erections are an Indicator of Health

Many men may not cherish seeing doctors on a routine basis, but a tipping point occurs when it comes to their penises not functioning!  Erectile dysfunction (ED) is a common reason for men to “bite the bullet” and call their friendly urologist for a consultation. The holistic approach by the consultant urologist is to not only manage the ED, but to diagnose the underlying risk factors that can be a sign of broader health issues than simply poor quality erections. Importantly, ED can be a warning sign of an underlying medical problem, since the quality of erections serves as a barometer of cardiovascular health.

    “A man with ED and no known cardiovascular disease                                                                      is a cardiac patient until proven otherwise.”

Graham Jackson, M.D., cardiologist from the U.K.

Since the penile arteries are small in diameter and the coronary (heart) arteries larger, it stands to reason that if vascular disease—generally a systemic process that is diffuse and not localized—is affecting the tiny penile arteries, it may affect the larger coronary arteries as well, if not now, then at some time in the future. In other words, the fatty deposits that compromise blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a “stress test.” In fact, the presence of ED is as much of a predictor of cardiovascular disease as is a strong family history of cardiac problems, tobacco smoking, or elevated cholesterol.

Dr. Jackson cleverly expanded the initials ED to mean: Endothelial dysfunction (endothelial cells line the insides of arteries); early detection (of heart disease); and early death (if missed). For this reason, men with ED should undergo a medical evaluation seeking arterial disease elsewhere in the body (heart, brain, aorta, and peripheral blood vessels).

Urologists have a broad network of colleagues (including internists, cardiologists, pulmonologists, gastroenterologists, medical oncologists, radiologists, radiation oncologists, general surgeons, etc.) that can be collaborated with and to whom patients can be referred to if and when their expertise is needed.

Urine is Golden

Of all the bodily secretions that humans produce, urine uniquely provides one of the best “tells” regarding health.  A simple and inexpensive urinary dipstick can diagnose diabetes, kidney disease, urinary tract infection, the presence of blood and hydration status, in a matter of moments.

What a dipstick can reveal:

specific gravity… hydration status

pH…acidity of urine

leukocytes…urinary infection

blood…many urological disorders including kidney and bladder cancer

nitrite…urinary infection

bilirubin…a yellow pigment found in bile, a substance made by the liver; its presence may be indicative of jaundice

protein…kidney disease

glucose…diabetes

Case report of a recent patient

54-year-old male with six-month history of frequent daytime urination as well as awakening 3-4 times during sleep hours to urinate. Additionally, he has difficulty maintaining erections and premature ejaculation. Physical examination of the abdomen, genitalia and prostate was unremarkable. Urinalysis showed large glucose. Lab studies showed glucose 204 (normally < 100); HbA1c 10.6% (normally < 5.6); testosterone 202 (normally > 300) and PSA 4.2 (elevated for his age). 

He was referred to an internist for management of diabetes that manifested with urinary frequency, elevated urine and blood glucose and elevated HbA1c (a measure of blood glucose levels over the past 6 weeks).  With appropriate management of the diabetes, the urinary frequency resolved. Because of the PSA elevation he is scheduled for an MRI of the prostate, and because of the low testosterone, he is undergoing additional endocrine testing to see if the problem is testicular or pituitary in origin and certainly will be a candidate for medical therapy if improved lifestyle measures fail to sufficiently elevate the testosterone.

Bottom Line: Preventive and proactive care—as many pursue regularly for their prized automobiles (e.g., lubrication and oil changes, replacing worn belts before they snap while on the road, etc.)—provides numerous advantages.  The same strategy should be applied to the human machine!  Since contact with a urologist may be a man’s only connection with the healthcare system, a vital opportunity exists for the urologist to offer holistic care in addition to specialty genital and urinary care.  The goal is to empower men by getting them invested in their own health in order to minimize disease risk and optimize vitality. 

Wishing you the best of health,

2014-04-23 20:16:29

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

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

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

 

Diabetes And Urological Health

August 12, 2017

Andrew Siegel MD  8/12/17

Your taste buds may crave sugar (glucose), but the rest of your body sure doesn’t!

A common presenting symptom of undiagnosed diabetes is frequent urination because of the urine-producing effect of glucose in the urine. People with such urinary frequency will often consult a urologist (urinary tract specialist) erroneously, thinking that the problem is kidney, bladder or prostate in origin, when in actuality it is the sugar in the urine that is the source of the problem.

Because of this urinary frequency presentation of diabetes, urologists often have the opportunity to make the initial diagnosis and refer the patient for appropriate care. Similarly, many uncircumcised men who have foreskin problems–particularly when the foreskin becomes stuck down over the head of the penis and will not retract (phimosis)–have undiagnosed diabetes. A simple dipstick of urine in conjunction with the typical presenting symptoms of frequent daytime and nighttime urination and/or foreskin issues directs the proper diagnosis.

Diabetes has detrimental effects on all body systems, with the urinary and genital systems no exception. Today’s entry reviews the impact of diabetes on urological health. Many urological problems occur as a result of diabetes, including urinary infections, kidney and bladder conditions, foreskin issues and sexual problems.  Additionally, diabetes increases the risk of kidney stones. Although many of the same urinary issues that are present in diabetics commonly also occur with the aging process (in the absence of diabetes), the presence of diabetes hastens their onset and severity.  Diabetes can have catastrophic consequences including the following: heart disease, stroke, blindness, kidney failure requiring dialysis and vascular disease resulting in amputations.

Wickipedia public domain copy

Thank you, Wikipedia, for the above public domain image

Diabetes 101

Diabetes is a disease in which blood glucose levels are elevated. Glucose is the body’s main fuel source, derived from the diet.  Insulin, a hormone secreted by the pancreas, is responsible for moving glucose from the blood into the body’s cells so that life processes can be fueled. In diabetes, either there is no insulin, or alternatively, plenty of insulin, but the body cannot use it properly. Without functioning insulin, the glucose stays in the blood and not the cells that need it, resulting in potential harm to many organs.

Two distinct types of diabetes exist. Type 1 is an autoimmune condition in which the body’s immune system destroys insulin-producing cells, severely limiting or completely stopping all insulin production.  It is often inherited and is responsible for about 5% of diabetes. It is managed by insulin injections or an insulin pump.

Type 2 diabetes is caused by overeating and sedentary living and is responsible for 95% of diabetes. This form of diabetes is caused by insulin resistance, a condition in which the body cannot process insulin and is resistant to its actions. Anybody with excessive abdominal fat is on the pathway from insulin resistance towards diabetes.  Type 2 diabetes is a classic example of an avoidable and “elective” chronic disease that occurs because of an unhealthy lifestyle.

Sad, but true: Chances are that if you have a big abdomen (“visceral” obesity marked by internal fat) you are pre-diabetic. This leaves you with two pathways: the active pathway – cleaning up your diet, losing weight and getting serious about exercise, in which this potential problem can be nipped in the bud. However, if you take the passive pathway, you’ll likely end up with full-blown diabetes.

Common presenting symptoms of diabetes are frequent urination, thirst, extreme hunger, weight loss, fatigue and irritability, recurrent infections, blurry vision, cuts that are slow to heal, and tingling or numbness in the hands or feet.

Complications of diabetes occur because of chronic elevated blood glucose and consequent damage to blood vessels and nerves.  Diabetes accelerates atherosclerosis, a condition in which fatty deposits occur within the walls of arteries, compromising blood flow and the delivery of oxygen and nutrients to tissues. Diabetic “small blood vessel” disease can lead to retinopathy (visual problems leading to blindness), nephropathy (kidney damage leading to dialysis), and neuropathy (nerve damage causing loss of sensation).  Diabetic “large vessel disease” can cause coronary artery disease, stroke, and peripheral vascular disease.  Diabetes increases the risk of infections because of poor blood flow and impaired function of infection-fighting white blood cells.

Diabetes and the bladder

Many diabetics have urological problems on the basis of the neuropathy that affects the bladder.  These issues include impaired sensation in which the bladder becomes “numb” and the patient gets no signal to urinate as well as impaired bladder contractility in which the bladder muscle does not function properly, causing inability to empty the bladder completely.  Other diabetics develop involuntary bladder contractions (overactive bladder), causing urinary urgency, frequency and incontinence.

Diabetes and the kidneys

Diabetes is the most common cause of kidney failure, accounting for almost half of all new cases. Even with diabetic control, the disease can lead to chronic kidney disease, kidney failure and the need for dialysis or kidney transplantation.

Diabetes and urinary/genital Infections

Diabetics have more frequent urinary tract infections than the general population because of factors including improper functioning of the infection-fighting white blood cells, glucose in the urine (a delightful treat for bacteria) and compromised blood flow. Diabetics have a greater risk of asymptomatic bacteriuria and pyuria (the presence of white cells and bacteria in the urine without infection), cystitis (bladder infections), and pyelonephritis (kidney infections).  Impaired bladder emptying further complicates the potential for infections.  Diabetics have more serious complications of pyelonephritis including kidney abscess, emphysematous pyelonephritis (infection with gas-forming bacteria), and urosepsis (a very serious systemic infection originating in the urinary tract requiring hospitalization and intravenous antibiotics).  Fournier’s gangrene (necrotizing fasciitis) is a soft tissue infection of the male genitals that often requires emergency surgery (that can be disfiguring) and has a very high mortality rate.  Over 90% of patients with Fournier’s gangrene are diabetic. Diabetic patients also have an increased prevalence of infections with surgical procedures, particularly those involving prosthetic implants, including penile implants, artificial urinary sphincters, and mesh implants for pelvic organ prolapse.

Diabetes and the foreskin

Balanoposthitis is medical speak for inflammation of the head of the penis and foreskin. As mentioned previously, a tight foreskin that cannot be pulled back to expose the head of the penis (phimosis) can be the first clinical sign of diabetes in uncircumcised men. At least 25% of men with this problem have underlying diabetes.  It is common for these men to have fungal infections under the foreskin because of the risk factors of a warm, moist, dark environment in conjunction with the presence of glucose in the urine. The good news is that phimosis and fungal infections often respond nicely to diabetic control.

Who Knew? I learned from a patient of mine that this issue is referred to in slang as “sugar dick.”

Diabetes and sexual function

Sexual functioning is based upon good blood flow and an intact nerve supply to the genitals and pelvis.  Diabetics often develop sexual problems (in fact, diabetes is the most common cause of erectile dysfunction) because of the combination of neuropathy and blood vessel disease.  Men commonly have a reduced sex drive and have difficulty achieving and maintaining erections.  Diabetes increases the risk of erectile dysfunction threefold.  Diabetes has clearly been linked with testosterone deficiency, which can negatively impact sex drive and sexual function.  Because of the neuropathy, many diabetic males have retrograde ejaculation, a situation in which semen goes backwards into the bladder and not out the urethra.  Female diabetics are not spared from sexual problems and commonly have reduced desire, decreased arousal and sexual response, vaginal lubrication issues and painful sexual intercourse.

Diabetic management

With Type 2 diabetes it is vital to modify lifestyle, including dietary changes that avoid diabetic-promoting foods and replacement with healthier foods in order to have appropriate sugar control to help prevent diabetic complications. Diabetics should refrain from high glycemic index foods (those that are rapidly absorbed) including sugars and refined white carbohydrates and instead should consume high-fiber vegetables, fresh fruits, and whole-grain products.  Regular exercise is equally as important as healthy eating, and the combination of healthy eating, physical activity, and weight loss can often adequately address Type 2 diabetes.

When lifestyle measures cannot be successfully implemented or do not achieve complete resolution, there are different classes of medications that can be used to manage the diabetes. However, lifestyle modification should always be the initial approach, since lifestyle (in large part) caused the problem and is capable of improving/reversing it.  At times, when diet, exercise and drugs are unable to control the diabetes, bariatric (weight loss) surgery may be needed to control and even potentially eliminate the diabetes.

Bottom Line:  Diabetes is a serious chronic illness with potentially devastating complications. Type 1 diabetes is relatively rare and unavoidable, but is manageable with insulin replacement. Type 2 diabetes is epidemic and its prevalence has increased dramatically coincident with the expanding American waistline. It can be improved/reversed through integration of healthy eating habits, weight management, and exercise. Lifestyle modifications can be amazingly restorative to general, urological and sexual health and overall wellbeing. After all, our greatest wealth is health.

Wishing you the best of health,

2014-04-23 20:16:29

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

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

Amazon page for Dr. Siegel’s books