Archive for December, 2012

Peyronie’s Disease: What You Need To Know

December 28, 2012

Andrew Siegel. MD    Blog # 88

Peyronie’s Disease   is an inflammatory condition of the penis that causes scarring of the sheath surrounding the paired erectile cylinders within the penis.  As a result of this scarring, when an erection occurs, there is asymmetrical expansion of these erectile cylinders resulting in a penile curvature/angulation.  Peyronie’s causes a deformed and often uncomfortable erection that can dramatically interfere with a male’s sexual health.

Scar formation on the sheath of the erectile cylinders can cause pain with erections; penile curvature during erections; the presence of a penile scar or “plaque” that can be felt as a hard lump under the skin; a visual indentation of the penis described as an hour-glass deformity; and failure of the erectile bodies to properly fill with blood, causing erections of poor rigidity. Penile pain, curvature/angulation, and poor expansion of the erectile cylinders collectively can contribute to difficulty in having a functional and anatomically correct rigid erection suitable for satisfactory intercourse. The curvature can range from a very minor, barely noticeable deviation to a deformity that requires “acrobatics” to achieve vaginal penetration to an erection that is so angulated that intercourse is physically impossible.  The angulation can occur in any direction and sometimes involves more than one angle, depending on the number, location and extent of the scarring.

 

The angulation results from the scarring of the sheath of the erectile cylinders that, upon engorgement with blood, expand in an asymmetrical fashion. This situation is analogous to placing a piece of cellophane tape on a child’s balloon and then inflating it—where the tape (scar) is, the balloon cannot expand properly, resulting in an angulation at the point of the tape placement.

The prevalence of Peyronie’s is roughly 5% of the male population with a mean age of 57 years old. The underlying cause of Peyronie’s is unclear, but is suspected to be penile trauma, perhaps associated with vigorous sexual intercourse. The acute phase is characterized by painful erections and an evolving scar, curvature and deformity. The chronic phase that typically occurs a year or so after initial onset is characterized by absence of pain, stable deformity, and possible erectile dysfunction. Peyronie’s regresses spontaneously in about 15% of men, progresses in 40% of untreated men, and remains stable in 45% of men. Many men—understandably so—become very self-conscious about the appearance of their penis and the limitations it causes, and they avoid sex entirely.

Various treatment options include oral medications, topical agents, injections, shock wave therapy, and surgery.  Upon initial diagnosis, most men are started on oral Vitamin E, 400 IU daily, as this has the potential to soften the scar tissue causing the plaque. Unfortunately, however, none of the non-surgical options have proven to be very effective, because the essence of the issue is scar tissue in a very bad location.   This scarring sabotages the ability to obtain a straight and rigid erection. Erectile dysfunction can be managed with one of the oral E.D. medications including Viagra, Levitra, or Cialis.

If there is no response to conservative management of erectile dysfunction, a penile implant may be appropriate—this can manage the dual problems of erectile dysfunction and penile angulation. If erections are adequate, but angulation precludes intercourse, options include procedures that attempt to neutralize the angulation effect of the plaque by doing a nip and tuck opposite the plaque in an effort to make expansion more symmetrical.  Although this technique is effective in improving the angulation, it does so at the cost of some penile shortening, and I have yet to find a man who is pleased with losing penile length. Other more complex procedures involve incising or removing the scar tissue and using grafting material to replace the tissue defect.

Bottom Line: When scar tissue is only an anatomic consideration but not a functional consideration, it may be cosmetically unappealing, but is actually not such a bad situation.  However, when scar tissue occurs on an area of the body that moves, expands or acts as a conduit, it affects form as well as function, which is not a good thing. Thus a scarred elbow can impact mobility of the joint, scarred lungs can disturb breathing dynamics, a scarred bile duct can cause jaundice and scarred erectile cylinders can cause Peyronie’s disease. Unfortunately, it comes down to scar tissue in a bad place.

Resources:

www.peyroniesassociation.org

www.askaboutthecurve.com

www.menshealthPD.com

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

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Priapism: Too Much of A Good Thing

December 20, 2012

Andrew Siegel. MD    Blog # 87

 

Introduction

A rock-hard erection is a good thing—it is nature in action.  This remarkable change in physical state of our genitals enables us to have sexual intercourse and reproduce.  It is truly an ingenious design and feat of mechanical engineering.  However, when the system fails and an erection does not regress, it is not such a good thing—and in fact can negatively impact our sexual future.  This condition is known as priapism—an unwanted, persistent, painful erection that is not on the basis of sexual stimulation.  The word priapism is derived from the Greek and Roman mythological God of fertility named Priapus.  He is commonly portrayed in classical artwork as having disproportionally large genitals.

Although priapism is an uncommon medical disorder, it is important because of its major potential complications in terms of sexual destiny.  The potential risk when priapism occurs is mechanical damage to the penis. Although priapism is predominantly a male problem, it has been known to involve the female clitoris, the structure that is analogous to the male penis. However, clitoral priapism is an extraordinarily rare occurrence.

Erection mechanics

The penis consists of three cylinders: the solitary corpus spongiosum which contains the urethra (the channel that conducts urine out from the bladder), and the paired erectile cylinders called the corpora cavernosa (erectile bodies), which are anchored internally to the pubic bone and extend to the head of the penis. These erectile cylinders communicate with each other and are enclosed in a fibrous sheath.  The erectile cylinders contain spongy tissue that is endowed with a very rich blood supply. Under the circumstances of erotic or tactile stimulation, the sinuses of the corpora become engorged with blood, resulting in an erection. This seemingly simple process is actually a highly complex event requiring integrated functioning of the brain, nerves, blood vessels, and hormones.

Priapism

Priapism can occur at any age, ranging from the pediatric to the geriatric population.  When it occurs in children, it is most commonly on the basis of sickle cell disease.  Although many cases of priapism in both adults and children have no clear-cut underlying cause, possibilities include leukemia; use of certain medications; dialysis; neurological infections; herniated discs; spinal cord stenosis; anesthesia; genitourinary cancer; and penile or perineal trauma.   Certain medications—particularly the vasoactive agents injected into the penis as a treatment for erectile dysfunction that has not responded to the commonly used oral medications including Viagra, Levitra and Cialis—are commonly implicated in causing priapism.

Broadly speaking, priapism can be divided into two types, ischemic priapism and non-ischemic priapism.  Ischemia refers to compromised blood flow.  Ischemic priapism is also called veno-occlusive or low-flow priapism and is marked by minimal fresh blood flow within the erectile cylinders the penis—the blood content is old, clotted blood.  It is similar to other compartment syndromes in the body in which there is high-pressure in a closed space with metabolic changes and tissue damage. Ischemic priapism is painful because of the lack of oxygenated (fresh) blood flow to the genital tissues as well as the increased pressure within the erectile cylinders from the erection. Ischemic priapism can ultimately cause tissue necrosis (cellular death of the erectile tissue) and fibrosis (scarring), damaging the erectile tissue such that erectile dysfunction will result.   Generally, if an episode of ischemic priapism persists for more than 4 hours, functional damage to the erectile tissue of the penis will occur.

Non-ischemic priapism is usually on the basis of trauma to the penis or the perineum, the anatomical section of the body located between the scrotum and the anal area. A typical scenario for non-ischemic priapism is a straddle injury resulting from the perineum striking a blunt object such as the top tube of a bicycle or a fence. Non-ischemic priapism is generally not painful.  As a result of the trauma to the blood vessels, an abnormal connection occurs between the artery to the erectile cylinders and the spongy tissue within the erectile cylinders.  This abnormal connection promotes increased blood flow and unregulated blood filling of the erectile cylinders. Non-ischemic priapism is also called arterial or high-flow priapism.

One important diagnostic study is putting a needle into the erectile cylinder of the penis and aspirating (drawing out) blood and submitting it for blood gas testing. In ischemic priapism, the blood is usually dark and sludgy and very low in oxygen content as opposed to patients with non-ischemic priapism who have bright red blood that is well oxygenated. Color duplex ultrasound is another diagnostic method for distinguishing between ischemic and non-ischemic priapism.

Ischemic priapism is treated by decompressing the erectile cylinders to counteract the ischemia and manage the pain.  Initial treatment is evacuating blood from the erectile cylinders and irrigating them to try to release the clotted blood, along with injection of a vasoconstrictor agent (medication that constricts blood vessels), while monitoring blood pressure and cardiac rhythm, since these vasoconstrictors can elevate blood pressure and pulse.  If the ischemic priapism has occurred over an extended duration, it is unlikely to resolve with such local treatment and surgical shunting will likely be necessary.  A surgical shunt is a means of trying to facilitate blood drainage from the erectile cylinders to another anatomical structure.

Management of non-ischemic priapism initially is simply observation. If it fails to resolve, the next step is selective arterial embolization (blocking the abnormal connection by injecting a clotting substance into the injured blood vessel), a procedure done in interventional radiology.

Bottom Line:  As the television commercials state, if you have an erection that lasts more than four hours, call your doctor.  An erection that is prolonged to this duration is truly a medical emergency and could be your last if you do not get help… pronto!

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every Saturday morning.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts by email. Please avail yourself of these educational materials and share them with your friends and family.

Fracture Of The Penis

December 15, 2012

Andrew Siegel, M.D.   Blog #86

The images below were taken on my recent trip to Seville, Spain at Alcazar Palace.  The statue of the young man with the broken penis gave me the idea to do a posting on the subject of penile fracture.

DSC01444 DSC01447

The penis is an organ with an impressive ability to multi-task, having urinary, sexual and reproductive functions.   As a urinary organ, it allows directed urination that allows men to stand to urinate and have a directed urinary flow, a very handy benefit, especially useful with respect to certain public restrooms. As a sexual and reproductive organ, the erect penis permits vaginal penetration and sexual intercourse and functions as a conduit for the placement of semen into the vagina, and hence DNA transfer and perpetuation of the species.  No other organ in the body demonstrates such a great versatility in terms of the physical changes between its “inactive” versus “active” states.

Penile rigidity is on the basis of blood flow. The human penis has no bone, unlike the penis of many other mammals.  The function of the “bony” or os penis in those mammals that have it is to facilitate sexual intercourse by maintaining penile rigidity.  The female equivalent is the os clitoris, a bone in the clitoris that maintains rigidity, also not found in humans.  The human penis obtains its bone-like rigidity (hence the slang term boner) by virtue of blood filling and inflating the spongy tissue within the two erectile cylinders of the penis (corpora cavernosa), similar to air inflating the tire of a car.  Clitoral rigidity occurs in identical fashion, although on a much smaller scale.

Erections are necessary to make the penis rigid enough to achieve vaginal penetration.  The price paid for penile rigidity is the small chance of an injury occurring when erect—as opposed to being flaccid, which is state that is protective against blunt injuries. A penile fracture is a rare but dramatic occurrence in which the outer sheath surrounding the erectile cylinders of the penis ruptures under the force of a strong blow to the erect penis.  It is not unlike the tire of a car being driven forcibly into a curb, resulting in a gash in the tread. Even though there is no bone in the human penis, the term fracture is an appropriate term for the injury, because the outer sheath literally ruptures, resulting in a break of the integrity of the erectile cylinders. A fracture of the penis is a medical emergency, and prompt surgical repair is necessary to obtain satisfactory cosmetic and functional results.

DSC01443

Blunt traumatic injuries rarely occur to the non-erect penis by virtue of its mobility and flaccidity.  Blunt trauma to the penis is usually of concern only when the penis is in an erect state. When the penis is rigid, there is peak tension and stretch on the outer sheath. A penile fracture occurs when this outer tunic—already under internal stretch and tension by virtue of the expansion of the erectile cylinders—is further subjected to external blunt trauma. This usually occurs under the situation of vigorous sexual intercourse, most often when the penis slips out of the vagina and strikes the perineum (area between the vagina and anus, known in slang terms as the taint), sustaining a buckling injury.

In other words, she “zigs” and he “zags,” and a forcible miss-stroke occurs of sufficient magnitude as to rupture the outer sheath housing the erectile cylinders.  Fracture can also occur under the circumstance of rolling over or falling onto the erect penis as well as any other situation that could inflict damage to the erect penis, such as walking into a wall in a poorly illuminated room or very forcible masturbation.

A penile fracture typically causes a rather classic and dramatic clinical scenario. An audible popping sound occurs as the outer sheath ruptures, followed by acute pain, rapid loss of erection, and purplish discoloration and extreme swelling of the penis, as the blood within the erectile cylinders escapes through the rupture site, similar to a blow-out of a car tire.

 

MRI can be used to demonstrate the precise site, extent and anatomy of the fracture.  Penile fractures need to be promptly addressed in the operating room, as surgical repair of the injury is important in order to maintain erectile function and minimize scarring of the erectile cylinders that could result in penile bending and angulation. Essentially, the skin of the penis is temporarily de-gloved (peeled back like a banana skin) and the fracture is identified and repaired with sutures, after which the skin is reattached.

If allowed to heal on its own without surgical intervention, scarring will occur at the site of the fracture and many patients will develop a penile curvature with erections.  As a result of the scar tissue, when an erection occurs, there is asymmetrical expansion of the erectile cylinders, resulting in a penile bend or deviation that can be to the extent as to preclude or require extreme acrobatics to have sexual intercourse.

The long and the short of it is that penile fracture is a rare but serious occurrence; this emergency situation demands an expedient trip to the operating room to maintain satisfactory erectile function.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

You Tube channel: www.youtube.com/incontinencedoc

Blog subscription: A new blog is posted every Saturday morning.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts by email. Please avail yourself of these educational materials and share them with your friends and family.

Testes Exam

December 8, 2012

Testes Exam

 

Andrew Siegel, M.D.   Blog # 85

Question: For genital health issues, women have gynecologists, but who do men have for their genital health issues?

 Answer: Urologists

 

The next five blogs will be dedicated to men’s health issues.  Today’s blog will cover examination of the testicles and the next three will cover penile issues—fracture of the penis, priapism, and Peyronie’s disease—and the final will be on testicular torsion.

 

Examining one’s testicles is a simple task that can be lifesaving.  For most men, touching/manipulating/rearranging their nether parts is a natural and almost reflex activity that—supplemented with a little instruction, knowledge and direction—can be put to some very good clinical use.  What follows will also be appropriate for the partner of the man in question.  Several times in my career as a urologist, it has been the man’s partner that was astute enough to recognize a problem that prompted the patient visit in which a diagnosis of testicular cancer was made.

Although rare, testicular cancer is the most common solid malignancy in young men, with the greatest incidence being in the late 20’s, striking men at the peak of life.  Lance Armstrong, Scott Hamilton, Eric Shanteau, Tom Green, John Kruk, Brian Piccolo, Richard Belzer, and Bernard Goetz are all members of the testicular cancer club.

The great news is that it is a very treatable cancer, especially so when picked up in its earliest stages, when it is commonly curable.  One of the great advantages of having one’s gonads positioned in such an accessible locale (as opposed to the ovaries) is that examination and early cancer diagnosis is a cinch (once again, as opposed to the ovarian cancer, which most often presents at an advanced stage).

The goal of self or partner-exam is to pick up an abnormality in a very early—and treatable—stage, at a time when testes cancer is a localized issue that has not spread to the lymph nodes or lung, which are common sites of metastasis in advanced testicular cancer.

In its earliest phases, testes cancer will cause a lump, irregularity, asymmetry, enlargement or heaviness of the testicle.  It most often does not cause pain, so the absence of pain is not a feature that should dissuade you from getting an abnormality looked into.  If you feel something that was not present previously, please see a urologist—I promise that you will never be chided for being a “hypochondriac” for getting something checked out.  It is truly better to be safe and cautious.

The testicles can be examined anywhere, but a warm shower or bath is an ideal setting as the warm water tends to relax and thin the scrotal sac and allow the testes to descend to a position that is most accessible.  Soapy skin will eliminate friction and allow the examining fingers to easily roll over the testicles.

The exam is best performed with the thumb in front and the remaining fingers behind the testicles.  The four fingers immobilize and support the testicle and the thumb does the important work in examining the front, sides, top and bottom of the testicle; then the thumb immobilizes the front while the four fingers examine the back of the testes.  When examining the back surface of the testicle, the index and middle fingers will do most of the work. The motion is a gentle rolling one, feeling the size, shape, and contour and checking for the presence of lumps and bumps.

Compare the two testes in terms of size, shape and consistency.  Generally, the testicle feels firm, similar to the consistency of a hard-boiled egg, although it can vary between individuals and even in an individual.  Lumps can vary in size from a kernel of rice to a large mass many times the size of the normal testes.  It is important to know that not every testes abnormality is a cancer; in fact, most are benign.  The epididymis is a comet-shaped structure located above and behind the testes that is responsible for sperm storage and maturation.  It has a head, a body and tail, and it is worthwhile running your fingers over this structure as well.

 

This exam should be done regularly—perhaps every couple of weeks or so—such that you get to know your (or your partner’s) anatomy to the extent that you will be attuned to a subtle change.  Once you get in the habit of doing this on a regular basis, it will become second nature and virtually a subconscious activity that only takes a few moments.

And to every wife, girlfriend, partner…if your man is a stoic kind of guy who is not likely to examine himself here is what to do—at a passionate moment, pursue a subtle, not-too-clinical exam under the guise of intimacy—it may just end up saving his life.

Bottom line: Have the “cajones” to check your or your partner’s cajones.  Because sperm production requires that the testicles are kept cooler than core temperature, nature has conveniently designed man with his testicles gift wrapped in a satchel dangling from his mid-section. There is no organ in the body—save the breasts—that are more external and easily accessible.  Take advantage of that accessibility to do regular exams—it just might be lifesaving.

For more info:

http://www.seankimerling.org/

 

 Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every Saturday morning.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts by email. Please avail yourself of these educational materials and share them with your friends and family.