Archive for March, 2016

Penile Curvature: How To Dissolve Peyronie’s Scar

March 26, 2016

Andrew Siegel MD  3/26/16

FullSizeRender-2

Peyronies Disease is an inflammatory condition of the penis that causes penile curvature and an uncomfortable or painful erection.  Scarring of a region of the sheath surrounding the erectile chambers of the penis (tunica albuginea) occurs, sabotaging the ability to obtain a straight and rigid erection with the potential for dramatically interfering with one’s sexual and psychological health. The scarring causes the presence of a hard lump(s), penile shortening, narrowing, curvature, a visual indentation of the penis described as an “hourglass” deformity, and painful, less rigid erections.

Penile pain, curvature, and poor expansion of the erectile chambers contribute to difficulty in having a functionally and anatomically correct rigid erection suitable for intercourse. The curvature can range from a very minor, barely perceptible deviation to a deformity that requires “acrobatics” to achieve vaginal penetration to an erection that is so angulated that intercourse is impossible. The angulation can occur in any direction and sometimes involves more than one angle, depending on the number, location and extent of the scar tissue.

Although it can occur at any age, Peyronies most commonly occurs in 50-60 year-olds. The underlying cause is suspected to be chronic penile trauma, associated with bending and buckling following years of sexual intercourse. This type of injury activates an abnormal scarring process with an acute phase characterized by painful erections and an evolving scar, curvature and deformity and a chronic phase marked by resolution of pain and inflammation, stabilization of the curvature and deformity, and, not uncommonly, ED. The chronic phase typically occurs up to 18 months or so after the initial onset of symptoms.

Collagenase (Xiaflex) is an enzyme capable of dissolving scar tissue. It is derived from the clostridium bacteria and has been used for years for Dupuytren’s contracture, a similar situation to Peyronie’s that occurs on the hand, causing scarring of the tissue beneath the skin of the palm and fingers, making it challenging to straighten one’s fingers. Collagenase functions as a “chemical knife” capable of dissolving collagen, the main constituent of scar tissue. It is used for men with Peyronie’s disease and a penile angulation of 30 degrees or greater. The goal of treatment is disrupting the scar tissue and decreasing the curvature of the erect penis.

The injections are performed in an office setting by a urologist with Peyronie’s expertise. One course of treatment may involve as many as four treatment cycles, with each cycle consisting of two injections of collagenase directly into the scar tissue, each spaced 1-3 days apart. A few days after the second injection, the penis is manipulated, massaged and molded in order to “model” it into a straighter version of itself. Thereafter, the patient performs self-stretching of the flaccid penis three times daily for 6 weeks or so. Gentle self-straightening is also performed on a daily basis if spontaneous erections allow one to do so. The endpoint is achieving as straight a penis as possible with an angulation of less than 15 degrees. One treatment cycle may be repeated as many as four times.

Injection of Xiaflex can be highly effective, but is not without side effects including the expected results of an injection into tissue including bruising, swelling and mild-moderate pain. On rare occasions, a rupture of the erectile chamber of the penis (penile fracture) can occur. It is advisable to wait two weeks after the second injection of each treatment cycle before resuming sexual activity, provided the pain and swelling have subsided.

Auxilium/Endo, the pharmacological company that provides Xiaflex, has an excellent patient counseling tool that is available at the following site:

http://xiaflexrems.com/downloads/RMX-00014-XIAFLEX-REMS-Patient-Guide-(Patient-Counseling-Tool)-for-PD-(5).pdf

Bottom Line: Peyronie’s Disease, like Dupuytren’s contracture, is the presence of scar tissue in a very “operative” area of the body that can interfere with function and reduce one’s quality of life. Collagenase (Xiaflex) is a scar-dissolving chemical derived from bacteria that can reduce this scar tissue and vastly improve function and quality of life.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Arnold Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  

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

Concussions: Big Head/Little Head

March 19, 2016

Andrew Siegel MD 3/19/16

Earlier this week, Jeff Miller (N.F.L. senior VP for health and safety policy) officially acknowledged the link between football and chronic traumatic encephalopathy, the degenerative brain disease found in many former players.  In this entry, the important topic of chronic traumatic brain injuries is reviewed with a segue into chronic traumatic penis injuries.

Who Knew? The athletic “cup” provides protection to the male genitals for those participating in sports including baseball, hockey, soccer and boxing. The cup was devised years before the first protective helmet for heads was developed. This gives you some insight into men’s priorities!

Traumatic brain injuries

Concussions resulting from contact sports and their sequelae of traumatic brain injuries have emerged as a hot topic. Football, boxing, soccer, hockey, rugby, lacrosse, mixed martial arts, etc., clearly incur risks for head trauma. Years ago, it was the expectation of athletes “to grin and bear it” after violently striking their heads in pursuit of victory. (I remember well when my son played football as a youngster in the competitive state of Pennsylvania, where an ambulance waited on the sidelines ready to transport unconscious 8 to 10 year-old boys to the ER. That ambulance did not sit idle for long.)

Today, sports-induced concussions have been brought to the forefront with all of the hubbub about athletes collapsing after hitting their heads and news about former NFL players suing over brain injuries. The movie “Concussion” ushered this subject to the big screen. Fortunately, positive changes are being made, with “concussion medicine” becoming a specialty discipline and concussion protocols put into force for many organized sports at the high school and college levels.

The human brain weighs about 3 pounds, is gelatinous in consistency and contains about 100 billion neurons. Nature has given us a remarkably thick skull to protect the delicate structure within. The brain literally “floats” in fluid within the skull. When the skull accelerates or decelerates rapidly—as occurs in a direct strike—the skull movement is abruptly arrested, but the brain continues in motion, twisting and bouncing within the skull, which can result in brain micro-trauma.

538px-Concussion_mechanics.svg (Modified version of Image: Skull and brain normal human.svg by Patrick J. Lynch, medical illustrator, Creative Commons Attribution 2.5 License 2006)

A concussion is currently defined as a motion injury of the brain. When I was in medical school, a concussion was defined as a transient loss in consciousness, but the truth of the matter is that less than 10% of concussions involve loss of consciousness. 90% of concussions manifest with symptoms including headaches, light sensitivity, nausea, vomiting, incoordination, disorientation, and abnormally slow reflexes and thinking.

It is unusual for a single concussion to result in long-term issues, as concussions are recoverable injuries if identified and treated properly. However, multiple concussions repeated over a course of many years– commonplace occurrences among athletes participating in contact sports– leave participants susceptible to chronic traumatic brain injuries including chronic traumatic encephalopathyAlzheimer’sParkinson’s disease and other forms of dementias.

How does this relate to the penis?

Sexual intercourse–which by definition is the forceful collision of two bodies– is no less of a contact sport than any of the aforementioned athletic endeavors. In parallel with traumatic brain injuries (big head), the penis (little head) is another anatomical zone that can get banged up over time. By the time a man is in his 50’s, he has likely had sex thousands of times, and as pleasurable as sex is, in reality it can be quite a traumatic event. Between self-inflicted and partnered pounding, hammering, pummeling and other abuse through self-manipulation and penetrative intercourse, respectively, it’s a wonder that the appendage doesn’t fall off!

Acute trauma is rare, but on occasion superficial veins can rupture, resulting in penile bruising and swelling that gets patients into my office in a real hurry. Rarer and more dramatic is the fractured penis that occurs when he “zigs” and she “zags,” resulting in a forceable miss-stroke and a serious injury that requires emergency surgery (previously covered in another blog: https://healthdoc13.wordpress.com/2015/01/24/breaking-bad-what-you-need-to-know-about-penile-fracture/)

dsc014431

(The image to the side is a photo I snapped of a statue of a man with a broken penis in Alcazar Palace in Seville, Spain.)

As opposed to acute trauma, chronic trauma to the penis is a not uncommon occurrence that is most often asymptomatic for many years. Just the act of obtaining a rigid erection puts tremendous compression stress forces on the penis. The outer sheath enveloping the erectile chambers of the penis—the tunica albuginea (white tunic)—is second only to the lining of the brain—the dura mater—in terms of its being the toughest tissue in the body. It is subjected to tremendous forces when the penis is erect because of the hypertensive blood pressures within the erectile chambers, well in excess of 200 millimeters mercury at full rigidity.

The potential for micro-trauma to the white tunic increases exponentially when one inserts that erect penis into a vagina and two parties move, bump and grind, creating intense shearing stress forces on the penis.  Certain positions angulate the penis and create more potential liability for injury than others. Even gentle sex can be rough with a single act of intercourse resulting in hundreds of thrusts with significant rotational, axial and torqueing strains and stresses placed upon the erect penis with the potential for subtle buckling injuries. Repeat performance perhaps a few times a week for many decades and by the time a man is in his 50s, on a cumulative basis, traumatic penile injuries—often asymptomatic in their developmental stages—can cause scarring to the white tunic and “chronic traumatic penopathy.”

Scarring to the white tunic can be problematic, resulting in deformities of the penis during erections, including the presence of a hard lump, shortening, curvature, narrowing, a visual indentation of the penis described as an hour-glass deformity and pain with erections as well as less rigid erections.  Penile pain, curvature, and poor expansion of the erectile chambers contribute to difficulty in having a functional and anatomically correct rigid erection suitable for intercourse.  This is known as Peyronie’s Disease, which fortunately only occurs in about 5% of men and is a treatable condition.  This topic has previously been covered:  https://healthdoc13.wordpress.com/2015/05/23/peyronies-disease-not-the-kind-of-curve-you-want/.

Bottom Line: The following relationship analogy sums it up: Chronic traumatic encephalopathy is to athletes who participate in contact sports is to concussions as is chronic traumatic penopathy is to sexually active males is to buckling trauma during intercourse.  Experts in the field of  “concussion medicine” want to spread the following advice: “Protect your brain – you only get one of them.” To this I add: “Protect your penis—you only get one of them. No matter what your game, be careful and proceed with caution!

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Arnold Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  

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

 

 

 

 

 

 

Ejaculation: His and Hers

March 12, 2016

Andrew Siegel, MD   3/12/2016

One of the advantages of the specialty of urology is that it encompasses patients of both genders, unlike gynecology, which strictly involves females. Since I am board certified in Urology as well as in Female Pelvic Medicine, my practice allows me to have an equal balance of male and female patients. This gives me the opportunity to appreciate comparative male and female pelvic anatomy and function, which in reality are remarkably similar–a fact that may surprise you.

 A Few Brief Words on the Embryology of the Genitals.

Who Knew? Female and male external genitals are remarkably similar. In fact, in the first few weeks of existence as an embryo, the external genitals are identical.

The female external genitals are the “default” model, which will remain female in the absence of the male hormone testosterone. In this circumstance, the genital tubercle (a midline swelling) becomes the clitoris; the urogenital folds (two vertically-oriented folds of tissue below the genital tubercle) become the labia minora (inner lips); and the labio-scrotal swellings (two vertically-oriented bulges outside the urogenital folds) fuse to become the labia majora (outer lips).

Gray1119

(Comparison of genital anatomy,  1918 Gray’s Anatomy, Dr. Henry Gray, public domain)

In the presence of testosterone, the genital tubercle morphs into the penis; the urogenital folds fuse and become the urethra and part of the shaft of the penis; and the labio-scrotal swellings fuse to become the scrotal sac.  So, the clitoris and the penis are essentially the same structure, as are the outer labia and the scrotum.                                                                                              

Ejaculation

Ejaculation is the expulsion of fluids at the time of sexual climax. The word “ejaculation” derives from ex, meaning out and jaculari, meaning to throw, shoot, hurl, cast. We are all familiar with male ejaculation, an event that is obvious and well understood and well studied. However, female ejaculation is a mysterious phenomenon and a curiosity to many and remains poorly understood and studied.

Male Ejaculation

Men often “dribble” before they “shoot.” The bulbo-urethral glands, a.k.a. Cowper’s glands, are paired, pea-sized structures whose ducts drain into the urethra (urinary channel). During sexual arousal, these glands produce a sticky, clear fluid that provides lubrication to the urethra. (These glands are the male versions of Bartholin’s glands in the female, discussed below).

Once a threshold of sexual stimulation is surpassed, men reach the “point of no return,” in which ejaculation becomes inevitable. Secretions from the prostate gland, seminal vesicles, epididymis, and vas deferens are deposited into 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 (the bulbocavernosus and ischiocavernosus) spasm rhythmically, sending wave-like contractions rippling down the urethra to forcibly propel the semen out in a pulsatile and explosive eruption. Ejaculation is the physical act of expulsion of the semen, whereas orgasm is the intense emotional excitement and climax, the blissful emotions that accompany ejaculation.

Male_anatomy

(Male Internal Sexual Anatomy, permission CC BY-SA 3.0, created 18 April 2009)

What’s in the Ejaculate?

Less than 5% of the volume is sperm and the other 95+% is a cocktail of genital secretions that provides nourishment, support and chemical safekeeping for sperm. About 70% of the volume comes from the seminal vesicles, which secrete a thick, viscous fluid and 25% from the prostate gland, which produces a milky-white fluid. A negligible amount is from the bulbo-urethral glands, which release a clear viscous fluid that has a lubrication function. The average ejaculate volume is 2-5 milliliters (one teaspoon is the equivalent of 5 milliliters).

Who Knew?  While a huge ejaculatory load sounds desirable, in reality it is correlated with having fertility issues. The sperm can literally “drown” in the excess seminal fluid.

Female Ejaculation

This is a much less familiar subject than male ejaculation and a curiosity to many. Only a small percentage of women are capable of expelling fluid at the time of sexual climax.

The nature of this fluid is controversial, thought by some to be excessive vaginal lubrication and others to be glandular secretions. Although the volume of ejaculated fluid is typically small, there are certain women who ejaculate very large volumes of fluid at climax. Expulsion of fluid at climax may come from four possible sources: vaginal secretions; Bartholin’s glands; Skene’s glands; and the urinary bladder.

Skenes_gland

(Skene’s and Bartholin’s Glands, created 22 January 2007, original uploader Nicholasolan  en.wikipedia, Permission: CC-BY-SA-2.5, 2.0, 1.0; GFDL-WITH-DISCLAIMERS; CC-BY-S)

During female arousal and sexual stimulation, the vaginal walls lubricate with a “sweating-like” reaction as a result of the increased blood flow to the genitals and pelvic blood congestion, creating a slippery and glistening film. The amount of this lubrication is highly variable. Some women with female ejaculation can release some of this fluid at the time of climax by virtue of powerful contractions of the vaginal and pelvic floor muscles.

Bartholin’s glands are paired, pea-size glands that drain just below and to each side of the vaginal opening. They are the female versions of the male bulbo-urethral glands and during sexual arousal they secrete small drops of fluid, resulting in moistening of the opening of the vagina.

Skene’s glands (para-urethral glands) are paired glands that drain just above and to each side of the urethral opening. They are the female homologue of the male prostate gland and secrete fluid with arousal.

Scientific studies have shown that those women who are capable of ejaculating very large volumes are actually having urinary incontinence due to an involuntary contraction of the urinary bladder that accompanies orgasm. This is often referred to as “squirting.”

Bottom Line: In the animal kingdom (including human beings), sex is a clever “bait and switch” scheme. In the seeming pursuit of a feel-good activity, in reality—determined by nature’s evolutionary sleight of hand—participants are hoodwinked into reproducing. The ultimate goal of the reproductive process is the fusion of genetic material from two individuals to perpetuate the species.

The penis functions as a “pistol” to place DNA deeply into the female’s reproductive tract with ejaculation a necessity for the process. Similarly, the female genitals need to be sufficiently lubricated to optimize this process and the combination of vaginal lubrication from enhanced blood flow contributed to by Skene’s and Bartholin’s secretions will optimize nature’s ultimate goal.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym and PelvicRx, comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Arnold Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  

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

 

 

 

 

Penile Injection Therapy: A Small Prick For A Bigger One

March 5, 2016

Andrew Siegel MD 3/5/2016

In 1983, at the American Urological Association meeting in Las Vegas, an event occurred that forevermore changed the field of male sexual dysfunction. Giles Brindley, a British physiologist, appeared from behind the podium and dropped his trousers, revealing to the audience his erection that had been induced by the injection of a medication directly into his penis. Commented one authority: “Farther down the Strip, Seigfried and Roy were making a white Bengal tiger disappear, and two circus aerialists—one sitting on the other’s shoulders—were traversing a tightrope without a net. But even in Vegas they’d never seen a show like this.” Few medical breakthroughs have had the dramatic effect that Brindley’s demonstration had, solidifying the principle that an erection is caused by smooth muscle relaxation in the erectile sinus tissues of the penis.

 

When first-line (healthy lifestyle) and second-line measures (ED meds, vibrational stimulation, penile pump)  are not sufficient in restoring erectile rigidity, penile injection therapy can be an effective and safe third-line option.

Penile injections of vasodilator drugs (medications that promote penile blood inflow) are beneficial for a wide range of medical conditions associated with ED. Vasodilator drugs injected directly into the penile erectile chambers bypass psychological, neurological, and hormonal factors and act locally on the erectile sinus tissues, causing blood to pour into the erectile chambers, inducing a rigid erection on demand. Injection therapy can be useful in ED due to psychological, neurological and hormonal causes as well as in men with some degree of blood vessel disease due to fatty plaque blocking arterial inflow. These injectable medications are the only such drugs that are capable of initiating an erection—in other words, achieving an erection without sexual stimulation.

A tiny needle is used to inject the medication into the side of the penis, directly into one of the paired penile erectile chambers. An erection usually occurs within 5-30 minutes and lasts for a variable amount of time, depending on the dosage of the medication. Injection-induced erections do not interfere with one’s ability to ejaculate or experience an orgasm.

Alprostadil (Caverject, Edex) is a commonly used vasodilator that increases penile blood flow and relaxes arterial and erectile sinus smooth muscle in the erectile chambers, resulting in a rigid erection. A combination of medications is often used to obtain optimal results. This combination is known as Trimix and consists of three drugs: Alprostadil, Papaverine and Phentolamine.

Who Knew? In 1982, French vascular surgeon Dr. Ronald Virag discovered the effect of Papaverine on erections when he mistakenly infused it into the penis, thinking he was administering saline. The patient immediately developed an erection and Dr. Virag realized that a new treatment for ED was possible.

Patients interested in using penile injection therapy are taught how to do the procedure during a urological office visit, at which time a test dose is administered. It is not a difficult technique to learn, although it requires some degree of dexterity. After learning the technique, the medication can be self-administered on demand. It often requires some trial and error to get the dosage just right so that the erection lasts an appropriate amount of time, in accordance with individual needs. With practice, one rapidly becomes skilled in the technique—not unlike learning to use contact lenses.

Side effects can be pain, bruising, scarring and prolonged erections. The most common side effect is a dull ache that is usually mild and tolerable. This typically happens with Alprostadil more commonly than with Trimix. A bruise may occur at the injection site and is best prevented by applying compression on the injection site for several minutes following the injection. Occasionally, a small lump can develop at the site of repeated injections and rarely penile scarring may be a consequence.

On occasion, a prolonged erection (priapism) may occur. It is undesirable to have an erection that lasts for more than four hours. If this occurs, it may require the injection of a medication to reverse the effects of the vasodilator drug and decrease penile blood flow in order to bring the erection down. This is safest done in an ER setting where cardiac monitoring can be performed.

Who Knew? Many male stars in the adult film industry use Trimix in order to achieve the erectile rigidity and durability necessary for their performances.

Sadly, there are some unscrupulous medical groups who prey on unsuspecting and vulnerable ED patients, often offering injection therapy without discussion of alternative treatments and charging patients exorbitant fees for medications such as Trimix.. See the following LA Times article concerning this:

http://articles.latimes.com/2011/apr/07/local/la-me-boston-medical-20110404

The reality is that medications such as Trimix can be obtained via prescription from your urologist at reputable compounding pharmacies for very reasonable fees. It should not cost an arm and a leg to obtain a rigid penis!

Technique of Penile Injection

Preliminary tips:

  • Shave the base of the penis to make the process easier.
  • If possible, immediately before injecting, manipulate the penis to obtain some penile blood flow and filling.  The procedure will be easier with a plumper penis.
  • Avoid injecting into superficial veins.
  • The injection only needs to be done on one side even though there are two injection chambers, since they communicate.
  • Vary the injection site to avoid scarring.
  • Do not inject more than three times weekly.

 

Triple-P_Injection

(Author: Post Prostate, Source: Own work; 16 March 2013)

  1. If you are right-handed, use your left thumb to protect the 12 o’clock position (penile nerves) and your left index finger to protect the 6 o’clock position (urethral channel). If you are left-handed, use your right thumb to protect the 12 o’clock position (penile nerves) and your right index finger to protect the 6 o’clock position (urethral channel).
  2. Use an alcohol swab to cleanse the base of the penis in order to prevent infections and then set aside the swab and save.
  3. Holding the prefilled syringe like a pen, in dart-like fashion penetrate the skin of the penis at a right angle, passing the needle as far as it will go. The site should be between the 1 o’clock and 3 o’clock position for a righty and 9 o’clock and 11 o’clock position for a lefty. The base of the shaft is the easiest location for the injection; however, because the erectile chambers run all the way to the head of the penis, any shaft location is acceptable for the injection site.
  4. Inject the full contents of the syringe by applying pressure to the plunger.
  5. Remove the syringe and use the alcohol swab to apply pressure to the injection site for several minutes.
  6. Observe your penis becoming increasingly rigid and the rest is up to you!

Bottom Line:  Penile injection therapy can be an effective and safe option for restoring erectile function when first and second-line measures are not sufficient.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com.  In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Arnold Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  

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