Archive for December, 2016

10 Ways To Maintain Sexual Fitness

December 31, 2016

Andrew Siegel MD  12/31/16


(Thank you, Pixabay, for image above)

It is fundamental to understand that your genitals are not separate and independent entities, but part and parcel of your body as a whole. If your health is compromised by illness or poor lifestyle, you should not expect your penis or vagina to function any better than rest of your body, but in parallel with your general health. If you are overweight, “malnourished” on the basis of a poor diet, do not challenge your body with regular exercise, use tobacco, consume too much alcohol, are over-stressed, sleep deprived, etc., your sexual function will likely suffer in concordance with your general health. The bottom line is that general health drives genital health and that healthy sexual functioning is an excellent marker of general health.


Sex is a healthy and natural part of life.  A healthy sexual relationship is an important part of an overall healthy relationship, “cementing” the bond between those in the relationship.

Whether male or female, the concept of “sexual fitness” has recently come into vogue. The idea is that sexual health is related to overall health and that optimal functioning in the bedroom can only be achieved with an  healthy state of mind and body and that the root cause of declining sexual performance is  when general health is compromised.

Blood flow is our lifeline and defines our existence. The key to life is the unimpeded flow and delivery of oxygen and nutrients to every cell and tissue in the body to maintain proper function.  Cardiovascular health is thus imperative for general and sexual health and when blood flow is jeopardized, both general health and sexual function will suffer.

Cardiovascular fitness is based upon maintaining a healthy weight, consuming a nutrient-rich diet (lean proteins, abundant fruit, vegetables, legumes and avoidance of nutrient-poor processed foods, excessive sugar and refined foods, etc.), daily activity and exercise (including aerobic, resistance, core and pelvic floor), avoiding excessive stress, getting sufficient sleep and avoidance of toxins including tobacco and excessive alcohol. Negative behaviors pursued on a chronic basis can sap one’s health and vitality that is critical to sexuality.

Our human ability to perform physically—in any domain—declines as we age, explaining why most professional athletes are in their twenties or thirties. Sexual function is no exception, with sexual response generally declining gradually over time, most often predicated upon impaired blood flow and altered function of the cells and tissues that comprise the genitals.

One option is to wait for your sex life to go south and then be “reactive,” incorporating healthy lifestyle measures in an effort to reverse the damage. A better approach is to be “proactive” with attention to the following ten recommendations.

10 Ways To Maintain Sexual Fitness

  1. Maintain a Healthy Weight  This will help prevent fatty deposits that clog up your blood vessels, including the arterial supply to the penis and vulva/vagina.
  1. Eat Healthy  The bottom line is that you want your body running on premium fuel. Nutritionally wholesome, natural foods will help prevent the build-up of harmful fatty deposits that compromise genital blood flow. Poor dietary choices with calorie-laden, nutritionally-empty selections (e.g., fast, processed, or refined foods) puts you on the fast tract to clogged arteries that can make your sexual function as small as your belly is big.
  1. Minimize Stress  Stress causes the release of the hormones adrenaline and cortisol. Adrenaline narrows blood vessels, which has a negative effect on sexual response. Excessive cortisol secretion drives appetite and causes the accumulation of the bad belly fat (as opposed to fat under the skin).
  1. Eliminate Tobacco Tobacco contains nicotine and a cocktail of toxins that impairs blood flow and decreases the supply of oxygen, as well as promotes inflammation, compromising every organ in your body, including those vital for sexual function.
  1. Alcohol in Moderation  In small amounts, alcohol can alleviate anxiety and act as a vasodilator (increasing blood flow), but in large amounts it can be a major risk factor for sexual dysfunction. Everything in moderation!
  1. Sleep Tight  Sleeping has a critical restorative function. During this important downtime there is an increased rate of tissue growth and a decreased rate of tissue breakdown, vital for maintaining the integrity of our cells and tissues. Sleep deprivation causes a disruption in endocrine, metabolic, and immune function, resulting in increased appetite, increased cortisol, and higher amounts of sugar in the bloodstream. If you are exhausted, your genitals will be equally weary.
  1. Exercise   Exercise has a robust effect on sexual function through stress busting, mood improvement, fatigue reduction, increase of energy and better quality sleep. It reduces risk of diabetes, heart disease, stroke, high blood pressure, some cancers, osteoporosis, chronic medical problems, and physical disability. It improves muscular strength and tone, reduces body fat and helps weight control. It makes your heart a better and stronger pump, your blood vessels more elastic, and your muscles better able to use oxygen. Exercises that work out the muscles involved in sex—the core muscles, the external rotators of the hip, and the all-important pelvic floor muscles—will improve bedroom performance. 
  1. Pelvic Floor Muscle Exercises The pelvic floor muscles play a vital role with respect to all aspects of sexual function, from arousal to climax. Numerous scientific studies have documented the benefits of pelvic exercises (Kegels) in improving sexual function.
  1. Stay Sexually Active   Keep your genitals fit by using them on a regular basis for the purpose they were designed for. In other words, stay sexually active as nature intended! Sexual activity is vital for maintaining the ability to have ongoing satisfactory sexual intercourse. Regular sexual activity increases pelvic and genital blood flow and optimizes tissue health and elasticity, while orgasms tone and strengthen the pelvic floor muscles“Disuse atrophy” is a condition when the genitals adapt to not being used, with tissue wasting, genital shrinkage and weakness of the pelvic floor muscles. Use it or lose it!
  2. Maintain a Healthy Relationship.  It takes two to tango, so relationship harmony plays strongly into healthy sexual functioning just as discord and interpersonal issues profoundly contribute to sexual dysfunction.

Note that sexual intercourse in and of itself is a great form of general exercise because of the kinetics involved and the demands on the cardiovascular system, core, pelvic floor and other skeletal muscles. Of the “10 ways to maintain sexual fitness,” staying sexually active covers 6 of them (maintaining a healthy relationship, staying sexually active, pelvic floor exercises, general exercise, sleeping tight and minimizing stress).

Bottom Line: The “Golden Rule”: Treat your genitals kindly (in terms of a healthy lifestyle) and the favor will be returned; treat your genitals poorly and they will rebel. The proactive approach will keep you functioning smoothly for many years. General health and fitness will foster sexual health and fitness, and staying sexually active is a vital means of maintaining general health and fitness.

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”:

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



Erection “Destiny”

December 24, 2016

Andrew Siegel MD  12/24/2016

Uninformed, uneducated and unprepared for the aging process, one has little choice but to passively observe and accept the gradual changes that unfold over time.  The purpose of this entry is to inform, educate and prepare you for the expectations of sexual function as you age.  Sadly, it is often not a pretty picture as aging can be unkind and Father Time does not spare sexual function.

Although erectile dysfunction (ED) is not inevitable, with each passing decade, more and more men join the ED club. All aspects of sexuality decline, although sexual interest suffers the least depreciation, leading to a swarm of men who are eager, but unable–a most frustrating combination. With aging there is typically less sexual activity, and with less sexual activity “disuse atrophy” in which the de-conditioned penis becomes smaller in stature and, in a vicious cycle, even less functional. The senior years also bear witness to the testicles dangling loosely like pendulous breasts of elderly women. Time and gravity are cruel conspirators.

shutterstock_side view manjpeg

A Few Definitions

Erection: The rigid state of the penis under circumstances of sexual stimulation.

Destiny: What the future has in store for you.

Erection Destiny: What the future has in store for your erection capabilities.

What Might Be In Store In The Future

The general trends that follow are structured by decade. Individuals may vary significantly from others in their age group, as “chronological” age is not the ultimate factor and may be trumped by “functional” age.  This guide was crafted after many years spent in the urology trenches, working the front line with thousands of patient interactions.

Age 18-30: Your sexual appetite is prodigious and sex often occupies the front burners of your mind. It requires very little stimulation to achieve an erection—even the wind blowing the right way might be enough to stimulate a rigid, gravity-defying erection, pointing proudly at the heavens. The sight of an attractive woman, the scent of her perfume, merely the thought of her can fully arouse you. You get erections even when you don’t want them…if there was only a way to bank these for later in life! You wake up in the middle of the night sporting a rigid erection. When you climax, the orgasm is intense, forceful and powerful. When you arise from sleep, it is not just you that has arisen, but also your penis.

It doesn’t get better than this…you are an invincible king… a professional athlete at the peak of his career! All right, maybe not invincible…you do have an Achilles heel—you may sometimes ejaculate prematurely because you are so hyper-excitable and at times in a new sexual situation you have performance anxiety, a mechanical failure brought on by your all-powerful mind dooming the capabilities of your exceptional plumbing.

Age 30-40: Changes occur ever so slowly, perhaps so gradually that they are barely noticeable. Your sex drive remains vigorous, but not as obsessive and all consuming as it once was. You can still get quality erections, but they may not occur as spontaneously, as frequently and with such little provocation as they did previously. You may require some touch to develop full rigidity. You still wake up in the middle of the night with an erection and experience “morning wood.” Ejaculations and orgasms are hardy, but you may notice some subtle differences, with your “rifle” being a little less powerful and of smaller caliber. The time it takes to achieve another erection after ejaculating increases. You are that athlete in the twilight of his career, seasoned and experienced, with the premature ejaculation of yonder years occurring much less frequently.

Age 40-50: After age 40, changes become more obvious. You are still interested in sex, but not nearly with the passion you had two decades earlier. You can usually get a pretty good-quality erection, but it now often requires touch and the rock-star rigidity of years gone by gives way to a firm penis, still suitable for penetration. The gravity-defying erections don’t have quite the upward angle they used to. At times you may lose the erection before the sexual act is completed. You notice that orgasms have lost some of their kick and ejaculation has become feebler than previously. Getting a second erection after climax is not only more difficult, but also may be something that you no longer have much interest in. All in all though, you still have some game left.

Age 50-60: Sex is still important to you and your desire is still there, but is typically diminished. Your erection can still be respectable and functional, but is not the majestic sight that it once was, and touch is often necessary for full arousal. Nighttime and morning erections become few and far between. The frequency of intercourse declines while the frequency of prematurely losing the erection before the sexual act is complete increases. A dribbling-quality ejaculation occurs with diminished volume and force, begging the question of why you are “drying up.” Orgasms are less intense and at times it feels like nothing much happened—more “firecracker” than “fireworks.” Getting a second erection is difficult, and you may find much more delight in sleeping rather than pursuing a sexual encore. Sex is no longer a sport, but a recreational activity…sometimes just reserved for the weekends.

Age 60-70: “Sexagenarian” is a misleading word…more apt a term for the 18-30 year-old group, because your sex life doesn’t compare to theirs—they are the athletes and you the spectators. Your testosterone level has plummeted over the decades, probably accounting for your diminished desire. Erections are still obtainable with some coaxing, but they are not five star erections, more like three stars, suitable for penetration, but not the rigid flagpole of yonder years. They are less reliable, and at times your penis suffers with “attention deficit disorder,” unable to focus and losing its mojo prematurely, unable to complete the task at hand. Spontaneous erections, nighttime, and early morning erections become rare occurrences. Climax is not so climactic and explosive ejaculations are a matter of history. At times, you think you climaxed, but are unsure because the sensation was un-sensational. Ejaculation is down to a mere dribble. Seconds?…no thank you…that is reserved for helpings on the dinner table! Sex is no longer a recreational activity, but an occasional amusement.

Age 70-80: When asked about his sexual function, my 70-something-year-old patient replied: “Retired…and I’m really upset that I’m not even upset.”

You may still have some lingering sexual desire left in you, but it’s a far cry from the fire in your groin that you had when you were young. With physical coaxing and coercion, your penis can at times be prodded to rise to the occasion, like a cobra responding to the beck and call of the flute of the snake charmer. The quality of erections has noticeably dropped, with penile fullness without the rigidity that used to make penetration such a breeze. At times, the best that you can do is to obtain a partial erection that cannot penetrate, despite pushing, shoving and manipulating. Spontaneous erections have gone the way of the 8-track player. Thank goodness for discovering that even a limp penis can be stimulated to climax, so it is still possible for you to experience sexual intimacy, although the cli-“max” is more like a cli-“min.”

Age 80-90: You are now a full-fledged member of a group that has an ever-increasing constituency—the ED club. Although you as an octogenarian may still be able to have sex, most of your brethren cannot; however, they remain appreciative that at least they still have their penises to use as spigots, allowing them to stand to urinate, a distinct competitive advantage over the womenfolk. Compounding the problem is that your spouse is no longer a spring chicken and because she has likely been post-menopausal for many years, she has a significantly reduced sex drive and vaginal dryness, making sex downright difficult, if not impossible. If you are able to have sex on your birthday and anniversary, you are doing much better than most. To quote one of my octogenarian patients in reference to his penis: “It’s like walking around with a dead fish.”

Age 90-100: To quote the comedian George Burns: “Sex at age 90 is like trying to shoot pool with a rope.” You are grateful to be alive and in the grand scheme of things, sex is low on the list of priorities. You can live vicariously through pleasant memories of your days of glory that are lodged deep in the recesses of your mind, as long as your memory holds out. When and if you do get an erection, you never want to waste it!

Sometimes A Cigar Is More Than A Cigar

Although changes in sexual function are virtually inevitable with the aging process, a decline is sexual function can also be a “canary in the trousers”—an indicator that a underlying medical problem exists that is of greater significance than the ED. In other words, erection quality can serve as a barometer of cardiovascular health– rigid and durable erections a gauge of good cardiovascular health and ED often a clue of poor cardiovascular health. Since the blood flow to the small penile arteries (diameter 1-2 millimeters) is often compromised in ED, the larger coronary arteries (4 millimeters) may be affected as well—if not now, then at some point in the not-to-distant future. For this reason, men with ED should have a medical evaluation seeking arterial disease elsewhere in 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”:

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

“Girl” At Birth, “Boy” At Puberty… and A Blockbuster Drug

December 17, 2016

Andrew Siegel MD 12/17/16

Last weeks’ entry discussed the similarities and common embryological origin of male and female genitals.  Today’s entry segues into a fascinating genetic defect that causes “ambiguous” genitalia and how Big Pharma capitalized on the positive aspects of this genetic defect and created a billion dollar industry with a type of medication in common usage and, in fact, one that yours truly takes on a daily basis.

Whether one develops a penis or a vagina is determined instantly the moment the father’s sperm penetrates the mother’s egg. The egg contains only an X chromosome and the sperm either an X or Y chromosome. The blueprint for female genital development is when the coupling results in an XX; the blueprint for male genital development when the coupling results in an XY.

Bottom Line: Genetic (chromosomal) sex determines genital sex. The father determines the sex of the child.

Skip ahead to a few weeks later, when the fertilized egg has turned into an embryo. At this time the external genitals are identical…somewhat surprising considering how very different the genitals are in appearance at birth and beyond.

Female genitals are the “default” model, which will remain female, absent the presence of the male hormone testosterone (T). When T is present it is converted into an activated form–dihydrotestosterone (DHT) –which causes conversion of what would be a vulva and vagina into a penis and scrotum. Biochemical magic!

In the young embryo there are three key genital structures: the “tubercle,” the “folds” and the “swellings.”

In the absence of T/DHT, the genital tubercle (a midline swelling) develops into a clitoris. The urogenital folds (two vertically-oriented folds of tissue below the genital tubercle) become  labia minora (inner lips). The labio-scrotal swellings (two vertically-oriented bulges outside the urogenital folds) fuse to become labia majora (outer lips).

In the presence of T/DHT the genital tubercle morphs into a penis, the urogenital folds become the urethra and part of the penile shaft and the labio-scrotal swellings fuse to become a scrotum.

Bottom Line: Female external genitals are the default model. The developing embryo will remain female unless T/DHT are available to masculinize the external genitals. 

“Ambiguous” genitalia

XY chromosomes determine male genital development and XX chromosomes determine female genital development and the vast majority of the time, the external genitals develop as per genetic blueprint with no ambiguity—a penis vs. a clitoris, scrotum vs. labia, etc.

However, the developmental process that causes genital tissue to become “male” or “female” can be disrupted and may lead to “ambiguous” genitals. These disruptions can cause the external genitals to not have a typical male or female appearance, making it difficult to identify an infant as male or female. Rarely, the appearance may be the complete opposite of the genetic sex (XX or XY).

The ambiguous genitals of a genetic female have the following characteristics: a clitoris that is substantially enlarged and can look like a small penis; the urethral opening in an abnormal location; and fused labia that appear like a scrotum. The situation can be so extreme that the infant is thought to be a newborn male with undescended testicles.

By far, the most common cause of XX appearing males is a condition of the adrenal gland that affects the production of hormones ultimately resulting in a genetic female having high levels of T.  These high levels “masculinize” the female default model.

The ambiguous genitals of a genetic male have the following characteristics: a small penis resembling an enlarged clitoris; an abnormal location for the urethral opening, sometimes opening on the perineum and not the penis; a small scrotum that may be separated in the midline appearing as labia; and undescended testicles.

XY appearing females can occur because of lack of production of T, lack of T receptors such that the body cannot respond to T, or the presence of T but lack of the enzyme that converts T to DHT (more on this below).

The Guevedoces

In the early 1970s, a Cornell endocrinologist (hormone specialist) conducted an expedition to the Dominican Republic to investigate reports of children who were thought to be “girls” at birth who turned into “boys” at puberty.  These biological males with normal male chromosomal make-up (XY) are born with female-appearing genitals and shockingly develop male genital anatomy at the time of puberty. These children were called guevedoces (“penis at 12 years”).

In this isolated village, 2% of births in the 1970s were guevedoces.  These children who appeared to be girls at birth developed a penis, testicles and typical male physical characteristics at the time of puberty. Most guevedoces were found to be descendants of a single common ancestor. The problem was shown to be deficiency of an enzyme known as 5-alpha reductase (5AR), responsible for converting T into  DHT, the more potent activated form of T. During embryonic development, DHT is essential for the development of normal male external genitals.  In the absence of DHT, the external genitals develop as female.

Internally the guevedoces have male gonadal tissue (testes and not ovaries). The external genitals are feminized, with a short “vagina,” undescended testicles and an absent uterus. With the testosterone surge at puberty, the tiny penis–- that was thought to be a clitoris–-develops into a normal-size, functional penis; at the same time, the testicles, previously not within the scrotal sac, descend into the scrotum, and other typical male characteristics develop including sex drive, body musculature, voice change, etc.  For the duration of their lives, the guevedoces resemble other Dominican men in all respects except that they have scanty beard growth and never develop acne, prostate gland enlargement or baldness.


A male with 5AR deficiency at age 12, 19 and 42

The discovery of this congenital 5-alpha reductase (5AR) deficiency in this small enclave of the Dominican Republic enabled an effective drug treatment for prostate enlargement. In the 1970s a drug was developed that replicated the effects that the 5AR deficiency had on the adult guevedoces population. Scientists reasoned that if 5AR could be inhibited after the external genitalia were fully formed and mature, then a medication to shrink the prostate, relieve urinary symptoms and treat baldness and acne might be developed.

The legacy of the guevedoces became a class of drugs known as 5AR inhibitors (5ARIs), the “prostate pills.”  Finasteride (Proscar for the prostate; Propecia for male pattern baldness), the original 5ARI, was approved in 1992. Dutasteride (Avodart) followed, and the treatment approach to prostatic obstruction was forevermore changed. Aside from prostate shrinkage and symptomatic relief of urinary symptoms, this class of drugs is an effective treatment for male pattern baldness.

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”:

Andrew Siegel MD practices in Maywood, NJ.  He is board-certified in both urology and female pelvic medicine/reconstructive surgery and is Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and attending urologist at Hackensack University Medical Center. He is a Castle Connolly Top Doctor New York Metro area and Top Doctor New Jersey.

Dr. Siegel is the author ofTHE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health ( and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health ( 


Men Are From Mars, Women From Venus, But There’s Not Much Difference Between A Vagina And A Penis

December 10, 2016

Andrew Siegel MD 12/10/2016

What is it that most distinguishes a male from a female? The obvious answer is the genitals, with the penis/scrotum having a vastly different appearance from a vagina/vulva.  Despite the male and female genitals being the feature that most characterizes the difference between a male and female, there are striking similarities. The genitals of both sexes are biologically homologous– similar in structure and having a common embryological origin–with development into male versus female based simply on the hormonal environment at the time of development.  Today’s entry discusses the similarities (as opposed to the differences) between the genitals and the “homologues,” the specific anatomical structures that are of common embryological origin and are more alike than are commonly recognized. 

Whether one develops a penis or a vagina is determined at the moment the sperm penetrates the egg. The egg contains an X chromosome and the sperm either an X or Y chromosome. When the coupling results in an XX, the blueprint for female development is established; when the coupling results in an XY, the blueprint for male development is established. The bottom line is that the father determines the sex of the child.

Several weeks later, when the fertilized egg has turned into an embryo, the external genitals are identical. Female genitals are the “default” model, which will remain female, absent the presence of the male hormone testosterone (T). T is activated to dihydrotestosterone (DHT) that causes conversion of what would be a vulva and vagina into a penis and scrotum. Biochemical magic! The bottom line is that the developing embryo will remain female unless T/DHT are available to masculinize the external genitals.

In the young embryo there are three key genital structures: the “tubercle,” the “folds” and the “swellings.” In the absence of T/DHT, the genital tubercle (a midline swelling) develops into a clitoris. The urogenital folds (two vertically-oriented folds of tissue below the genital tubercle) become labia minora (inner lips). The labio-scrotal swellings (two vertically-oriented bulges outside the urogenital folds) fuse to become labia majora (outer lips). In the presence of T/DHT the genital tubercle morphs into a penis, the urogenital folds become the urethra and part of the penile shaft and the labio-scrotal swellings fuse to become a scrotum.

Genital Homologues

The penis is the homologue of the clitoris. Both structures are highly sensitive organs with a tremendous concentration of nerve fibers and contain erectile tissue (corpora) that enables them to expand in size and rigidity with stimulation. Both the penis and clitoris have a head (glans) and shaft and deep internal roots. Both are covered with a layer of skin that can be pulled back to expose the underlying anatomy. In the male this is referred to as the foreskin, which is the homologue of the female clitoral hood.


Comparison of penis (left) and clitoris (right)–note similar shape and internal structure, Attribution: Esseh, Wikipedia Commons

The male scrotal sac is the homologue of the female labia majora. The raphe (the seam that runs vertically up the perineum, scrotum and penis) is the homologue of the pudendal cleft (the slit between the labia) in the female.



Comparison of vulva (left) and scrotum (right); note similarity of outer labia to scrotum and female pudendal cleft to male raphe,  by Richiex (Own work) [CC BY-SA 3.0 ( or GFDL (, via Wikimedia Commons

The male prostate gland is the homologue of the female Skene’s glands. Both produce fluid that is released at the time of sexual climax. The male Cowper’s glands are the homologue of the female Bartholin’s glands, both of which secrete fluid at the time of sexual stimulation, pre-ejaculate fluid in the male and vaginal lubrication fluid in the female.



Male anatomy, note prostate gland and Cowper’s glands, by Male_anatomy.png: FAQ derivative work: Tsaitgaist (Male_anatomy.png) [GFDL ( or CC-BY-SA-3.0 (, via Wikimedia Commons


Note Skene’s gland and Bartholin’s glands openings below and to side of urethra and vagina respectively, by Nicholasolan (Skenes gland.jpg) [GFDL (, CC-BY-SA-3.0 ( or CC BY-SA 2.5-2.0-1.0 (, via Wikimedia Commons

Bottom Line: As different as female and male anatomy are, so they are similar.  The study of comparative genital anatomy and embryological origin is fascinating.  Next week’s entry addresses when this process of differentiation into male versus female goes awry, leading to “ambiguous” genitalia, and how the study of one such particular genetic defect led to the creation of a billion dollar blockbuster drug in common use for purposes of shrinking enlarged prostates and growing hair in men with male pattern baldness.   

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”:

Andrew Siegel MD practices in Maywood, NJ.  He is board-certified in both urology and female pelvic medicine/reconstructive surgery and is Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and attending urologist at Hackensack University Medical Center. He is a Castle Connolly Top Doctor New York Metro area and Top Doctor New Jersey.

Dr. Siegel is the author ofTHE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health ( and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health ( 

Prostate Cancer Update 2017: A More Nuanced Approach

December 3, 2016

Andrew Siegel MD  12/3/2016

prostate_cancerAttribution of above image: Blaus (Own work) [CC BY-SA 4.0 (, via Wikimedia Commons

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

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

The Challenge Of Diagnosing Prostate Cancer

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

The Dilemma Of Screening For Prostate Cancer

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

How Is The Diagnosis of Prostate Cancer Made?

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

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

T (Tumor) category

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

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

T2b: palpable cancer of more than half of one side

T2c: palpable cancer of both sides

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

T3b: cancer involving seminal vesicles

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

Gleason Score

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

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

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

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

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

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

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

Number cores with cancer

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

Percent of tumor involvement (PTI)

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


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

PSA density

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


Risk Stratification For Prostate Cancer

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

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

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

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

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

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


Prostate Cancer Treatment

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

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

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

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

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

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


Prostate Cancer Treatment Based Upon Risk Stratification

Very Low Risk

< 10 year life expectancy: observation

10-20 years life expectancy: AS

> 20 years life expectancy: AS or RALP or RT

Low Risk

<10 years life expectancy: observation

>10 years life expectancy: AS or RALP or RT

Intermediate Risk

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

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

High Risk

RALP or RT + ADT 2-3 years

Very High Risk:

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

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

Metastatic disease: ADT

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

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

Willet Whitmore, M.D.

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

Wishing you the best of health,

2014-04-23 20:16:29

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Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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