Archive for May, 2018

Testosterone Treatment and Tiny Testicles: There is a Better Option

May 25, 2018

Andrew Siegel MD  5/25/18

“If a man is prescribed Food and Drug Administration approved testosterone for androgen deficiency, his overall health improves but his sperm production declines and his testes shrink. If he is prescribed off-label clomiphene citrate, his health improves and his sperm production is preserved, as does the size of his testicles.  This selective receptor estrogen modulator for male reproductive endocrine therapy must be a great new discovery, right? Wrong. It has been around for 50 years.”

Dr. Craig Niederberger, Department Head of Urology, University of Illinois School of Medicine

The Magic of Testosterone (T)

For the symptomatic man who has low levels of T, boosting levels of this male  “rocket fuel” hormone can result in a remarkable improvement of energy, sexuality (sex drive, erections, ejaculation), masculinity, mood, body composition (muscle and bone mass), mental focus and other parameters. However, men considering T treatment must understand that T is not a cure-all and must only be used under the circumstances of symptoms of low T and laboratory testing that shows low T.  Most certainly, T has been over-marketed, over-prescribed and certain side effects have been understated. It is vital to understand the side effects of T before committing to treatment.

T Science

Most T is made by the testicles. Its secretion is governed by the release of luteinizing hormone (LH) from the pituitary, the master gland in the brain. Some of T is converted to the female hormone estradiol (E). E is the primary hormone involved in the regulation of the pituitary gland. Under the circumstance of adequate levels of T, E feeds back to the pituitary to turn off LH production. This feedback loop is similar to the way a thermostat regulates the temperature of a room in order to maintain a relatively constant temperature, shutting the heat off when a certain temperature is achieved, and turning it on when the temperature drops.

The Effect of Long-Term T Replacement

So, what happens when you have been on long-term T? This externally sourced T, whether it is in the form of gels, patches, injections, pellets, etc., shuts off the pituitary LH by the feedback system described above so that the testes stop manufacturing natural T. Additionally, the testes production of sperm is stifled, problematic for men wishing to remain fertile. In other words, external T is a contraceptive! Nearly all men will have suppression of sperm production while on T replacement, less so with the gels vs. the injections or implantable pellets.

Thus, using T results in the testes shutting down production of sperm and natural T and after long-term T use, the testes can actually shrivel, becoming ghosts of their former functional selves. “Use it or lose it” is relevant to every organ in the body and external T essential puts the testes into hibernation and dormancy.

If you stop the T after long-term use, natural function does not resume anytime quickly. Although recovery usually occurs within 6 months or so, it may take several years and permanent detrimental effects are possible.

The bottom line is that at the time you are receiving the benefits of T, your natural T is shut off and you can end up infertile, with smaller testicles (testicular atrophy, in urology parlance)!

Is there an alternative for the symptomatic male with low T?  Can you boost levels of T without shutting down your testes and developing shrunken, poorly functional gonads? 

The answer is an affirmative YES, and one that Big Pharma does not want you to know. There has been such a medication around for 50 years. It has been FDA approved for infertility issues in both sexes and is available on a generic basis. In urology we have used it for many years for men with low sperm counts. Here is a little secret: this medication also raises T levels nicely, and does so by stimulating the testes to secrete natural T rather than shutting them down.  No marble-sized testes that have their function turned to the “off” mode, but respectable family jewels.  The other really good news is that treatment does not necessarily need to be indefinite. The testes can be “kicked” back into normal function, and at some point a trial off the medication is warranted.

The medication is clomiphene citrate, a.k.a Clomid, and I will refer to it as CC. CC is an oral pill commonly used in females to stimulate ovulation and in males to stimulate sperm production. CC is a selective estrogen receptor modulator (SERM) and works by increasing the pituitary hormones that trigger the testes to produce sperm and testosterone. CC blocks E at the pituitary, so the pituitary sees less E and makes more LH and thus more T, whereas giving external T does the opposite, increasing E and thus the pituitary makes less LH and the testes stop making T.

clomiphene-citrate-tablets

Works Like A Charm

CC usually works like a charm in increasing T levels and maintaining sperm production, testes anatomy (size) and function. Its safety and effectiveness profile has been well established and minor side effects occur in proportion to dose and may include (in a small percentage of men): flushes, abdominal discomfort, nausea and vomiting, headache, and rarely visual symptoms.  In general, those with the highest LH levels have the poorest response to CC, probably because they already have maximal stimulation of the testes by the LH.

Not FDA Approved For Low T

One issue is that CC is not FDA approved for low T, only for infertility.  Many physicians are reluctant to use a medication that is not FDA approved for a specific purpose. It needs to be used “off label,” even though it is effective and less expensive than most of the other overpriced T products on the market.

Bottom Line: Treatment to boost T levels should only be done when one has genuine symptoms of low T and a low T level documented on laboratory testing. Using externally-sourced T to boost T successfully raises T and often resolves the symptoms of low T but shuts down the testes and nullifies whatever natural T was being produced as well as sperm production. Clomid is an oral, less expensive alternative that stimulates natural T production and the oral pill formulation is an easier and more discreet delivery system than sloppy gels, injections and pellets.

A study from Journal of Urology (Testosterone Supplementation Versus Clomiphene Citrate: An Age Matched Comparison of Satisfaction and Efficiency. R. Ramasamy, JM Scovell, JR Kovac, LI Lipshultz in J Urol 2014;192:875-9) compared T injections, T gels, CC and no treatment.  T increased from 247 to 504, 224 to 1104 and 230 to 412 ng/dL, respectively, for CC, T injections and gels. Men in all of the 3 treatment arms experienced similar satisfaction. The authors concluded that CC is equally effective as T gels with respect to T level and improvement in T deficiency-related clinical symptoms and because CC is much less expensive than T gels and does not harm testes size or sperm production, physicians should much more often consider CC, particularly in younger men with low T levels.

Wishing you the best of health and a wonderful Memorial Day weekend,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

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

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

Advertisements

60 Minutes Disses Boston Scientific Meshes: WTF?

May 18, 2018

Andrew Siegel MD  5/18/2018

60 Minutes Trashes Boston Scientific and Pelvic Meshes

Last Sunday, a piece aired on the CBS weekly 60 Minutes concerning Boston Scientific meshes that are used in the field of female urology. The segment was spun in such a way that many viewers were likely to get the wrong impression about Boston Scientific products that are used for two common pelvic floor issues–stress urinary incontinence and pelvic organ prolapse.  These meshes are composed of polypropylene, a synthetic material that is commonly used inside the human body for many purposes, including  hernia repairs as well as a suture material.   I cannot speak for the provenance of the raw materials used for Boston Scientific meshes, although the issue has apparently been addressed by Boston Scientific as well as the FDA, but I can certainly vouch for the safety and effectiveness of their slings and meshes.  After watching the 60 Minutes piece, one might wrongly conclude that Boston Scientific meshes specifically, and all polypropylene meshes generally, are downright dangerous and should never be used in humans.

Au contraire!  Boston Scientific is a reputable company dedicated to both female and male pelvic health and their mesh products (Obtryx mid-urethral sling for stress urinary incontinence and the Uphold Lite for anterior and apical pelvic organ prolapse) are well-designed and clinically effective. I have implanted these products successfully in hundreds of women with stress incontinence and pelvic organ prolapse over the course of many years and will continue to use them.  Furthermore, I have always found the Boston Scientific “reps” to be knowledgeable, available and helpful and the company always willing to provide ample educational opportunities for physicians.  With respect to meshes used for pelvic reconstructive surgery, polypropylene has been the “gold standard” for many years.  Many clinical publications support the safety and effectiveness of polypropylene pelvic floor meshes and numerous medical societies and regulatory bodies have endorsed the utility of polypropylene pelvic meshes for pelvic floor dysfunction.

Proper Repair of a Dropped Bladder (Cystocele)

Not every cystocele is the same, differing in type, extent, symptoms, and degree of bother. The central type (top image below) is a central weakness of the support tissues of the bladder that can cause a pronounced degree of prolapse. The lateral type (bottom image below) is a detachment of the bladder support from the pelvic sidewalls, usually causing only a modest degree of prolapse. Most women have a combination of these two, a combined central-lateral type.

CD

lat defect

 

In my opinion, the classic “plication” repair (sewing together of native tissues)— a.k.a. colporrhaphy—is best suited to a central cystocele in which satisfactory native tissues are present.  However, this will not adequately address a lateral defect cystocele or a combined cystocele. Thus, it is important to determine the type of cystocele in terms of repairing it with native tissues. One of the advantages of a mesh repair is that it addresses all three types of cystocele. Additionally, instead of using native tissue that has already failed in terms of providing adequate structural support, mesh repairs use a strong and durable material to provide support.

Factors influencing me to do a mesh repair over a classic colporrhaphy are the following: poor tissues; risk factors for recurrence including chronic constipation, cough, obesity, and occupations that require manual labor; a relatively young patient who will need a durable repair; and those patients who have already failed a native tissue repair.

In the appropriately selected patient operated on with the proper surgical technique, the results of polypropylene mesh repairs have been extraordinarily gratifying. These procedures pass muster and the “MDSW” test—meaning I would readily encourage my mother, daughter, sister or wife to undergo the procedure if needed. When performed by a skilled pelvic surgeon, the likelihood for cure or vast improvement is great and the likelihood for complications is minimal. Meshes are strong, supple and durable and the procedure itself is relatively simple, minimally-invasive and amenable to outpatient surgery. When patients are seen years after a mesh repair, they are usually extremely satisfied and their pelvic exams typically reveal restored anatomy with remarkable preservation of vaginal length, axis, caliber and depth.

Meshes act as a scaffold for tissue in-growth and ultimately should become fully incorporated by the body. I think of a surgical mesh in a similar way to a backyard chain-link fence that has in-growth of ivy. Meshes examined microscopically years after implantation demonstrate a dense growth of blood vessels and collagen in and around the mesh.

As compared to the classic plication, when a mesh is used for bladder repair, there is rarely any need for trimming the vaginal wall, which makes for a more anatomical repair in terms of vaginal preservation. Another advantage of mesh repairs is that if the patient has a mild-moderate degree of uterine prolapse accompanying the cystocele, the base of the mesh can be anchored to the cervix and thus provide support to the uterus as well as the bladder, potentially avoiding a hysterectomy.

In my opinion, the keys to success are the following: estrogen cream preoperatively in the post-menopausal patient; intravenous and topical antibiotics; a small vaginal incision; good surgical exposure; careful technique making sure the mesh is anchored at the appropriate anatomical sites; trimming the mesh to use the least mesh load possible; avoiding mesh folding, redundancy and tension; and vaginal packing and oral antibiotics post-operatively.

The bottom line is that mesh repairs for pelvic organ prolapse have been revolutionary in terms of the quality and longevity of results—a true game changer. They represent a dramatic evolution in the field of female urology and urological gynecology, offering a vast improvement in comparison to the pre-mesh era. That said, they are not without complications, but the complication rates should be reasonably low under the circumstance of proper patient selection, a skilled and experienced surgeon performing the procedure, excellent surgical technique, utilization of the optimal mesh and patient preparation.

Mesh Integration

Three factors are integral to mesh integration, the process by which the mesh incorporates seamlessly into the body: mesh, patient, and surgeon factors. The goal is for the mesh to fully incorporate into the body so that it can serve its role in providing support to the urethra and/or bladder to cure/improve the stress incontinence and/or cystocele, respectively.

The “gold standard” mesh is large-pored, elastic, monofilament polypropylene. This has been the standard for sling surgery for stress urinary incontinence for over 20 years and for pelvic reconstructions for many years as well. This material is also the standard for mesh hernia repairs and also serves as a hardy suture used for closure of the abdominal wall.

Patient considerations are equally vital.  Risk factors for integration problems include: compromised or poor-quality vaginal tissues; radiated tissues; diabetes; patients on steroids; immune-compromised patients; and patients who use tobacco.

Foremost, a well-trained, experienced pelvic surgeon should be the person doing the mesh implantation. The surgeons most skilled and adept fake newsat this type of surgery are those who have undertaken fellowship training in female pelvic medicine and reconstructive surgery after completion of their urology or gynecology training. It is sensible to check if your surgeon is specialized, and if not, at least has significant clinical experience doing mesh implantation procedures. It is particularly important that the surgeon performing the mesh implant is capable of taking care of any complications that may arise.

The “Mesh-up”

Historically, many of the problems that occurred resulting from mesh implantations were not intrinsic to the mesh itself but were potentially avoidable issues that had to do with surgical technique and/or patient selection. Complications with integration such as mesh exposure—a situation where the mesh is “exposed” in the vagina and is not positioned in the correct surgical plane—can and do occur in a small percentage of patients (even when properly selected and when done by a well-trained pelvic surgeon).  When this situation occurs, it is generally quite manageable, although it will often involve revision surgery if it does not respond to conservative measures.

The crux of the “mesh-up” problem was that a few years ago several of the companies that sold mesh products–in an effort to amplify sales and profits–inappropriately and aggressively promoted their products to physicians who were not trained pelvic surgeons.  They offered “weekend training courses” to general gynecologists, many of whom started implanting pelvic meshes into patients after only a brief training period, often with disastrous results, with many patients sustaining incorporation issues.  This ultimately led to lawsuits and litigation and thereafter several of the mesh companies including Johnson and Johnson Gynecare and American Medical Systems pulled their mesh products off the market.  Fortunately for pelvic surgeons and patients alike, Boston Scientific remained in business, and it is their sling and mesh products that I most commonly implant for female pelvic surgical procedures.

This is not to say that there have not been bad mesh products on the market.  Historically, both the Mentor ObTape and the Tyco IVS sling were poorly designed mesh slings that did not have favorable incorporation features, had horrific results and were ultimately withdrawn from the market.

All of the slings and meshes that remain on the market that are used for pelvic floor surgery in the USA—including the Boston Scientific products–have favorable incorporation features and have been time-tested and have demonstrated their utility. Boston Scientific did not deserve a reaming on 60 Minutes, but I suppose it is irresponsible “spin” that makes for a story and commands advertising dollars.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

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

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

Artificial Urinary Sphincter (AUS): What You Need To Know

May 12, 2018

Andrew Siegel MD   5/12/2018

Severe involuntary leakage of urine following prostate surgery is a rare event, occurring in less than 5% of men following prostatectomy for prostate cancer, and in an even smaller percentage of men who have undergone prostate surgery for a benign process.  Following prostatectomy, it most often results from scarring of the bladder neck sphincter.  Severe incontinence can be devastating to one’s quality of life, affecting psychological, emotional, and sexual well-being and often causing loss of self-esteem, depression, and avoiding a healthy, productive, and active lifestyle.

Fortunately, for the small percentage of men rendered severely incontinent after prostatectomy, the AUS offers a great opportunity for cure and in significantly improving quality of life. It functions as a mechanical compression device of the urethra that is under the patient’s control, providing simple and discreet control over bladder storage and emptying.  Implanted entirely within the body, the device mimics the function of a healthy sphincter muscle by keeping the urethra closed until the patient desires to urinate.

The AUS prosthesis is a saline fluid-filled device composed of solid silicone elastomer consisting of three interconnected components: a cuff implanted around the urethra, a pressure-regulating balloon reservoir implanted behind the pubic bone, adjacent to the bladder, and a control pump implanted in the scrotum.  The cuff gently squeezes the urethra closed, preventing urine from passing.  When one wants to urinate, he simply squeezes and releases the control pump that is situated in the scrotum, temporarily transferring fluid from the cuff to the pressure regulating balloon.  The cuff opens, allowing urine to flow through the urethra.  Within several minutes, the pressure regulating balloon automatically returns the fluid to the cuff to once again pinch the urethra closed.

Blausen_0059_ArtificialUrinarySphincter

The AUS, first developed in 1972, has been used successfully for over 45 years and has been implanted in more than 150,000 men. Over the years, biomedical engineering refinements have further improved the AUS.  About two thirds of men will be completely continent after an AUS implant, and the other one third will experience only minor incontinence, requiring one or two small pads per day. The overall patient satisfaction rate exceeds 90%.

In order to be an appropriate candidate for the AUS, incontinence needs to be on the basis of a weakened or damaged sphincter and not due to bladder over-activity.  Additionally,  bladder capacity needs to be adequate and urinary flow rate sufficient to empty the bladder. The incontinence should be present for a minimum of 6 months before considering the AUS, since spontaneous improvement occurs for some time after prostatectomy. One obviously need to be sufficiently motivated to receive an implant, and its use demands manual dexterity in order to operate the control pump.

Implantation of the Artificial Urinary Sphincter

Implantation of the AUS is a one hour or so outpatient surgical procedure done under anesthesia.  The conventional operation is performed with one’s legs in stirrups and requires one incision in the abdomen and the other in the perineum (area between scrotum and anus).  In 2003, Dr. Steve Wilson and I devised an innovative technique for AUS implantation via a single scrotal incision. The advantages of the scrotal technique are a single incision, the fact that it can be done supine (lying on one’s back versus legs up in stirrups), faster operative time, ease of doing the procedure and decreased patient discomfort.  In either case, the control pump is one-size fits all, but the cuff is precisely measured to your anatomy and the pressure-regulating balloon reservoir is usually chosen to be 61-70 cm water pressure.

It is important to know that the AUS will not be activated– and thus will not be functional– for about a 6-week period of time to allow for healing of tissues. Activation is a simple process that is done in the office, involving minimal discomfort.

It is advisable to order and wear a MedicAlert bracelet (www.medicalert.org) to inform health care personnel that you have an AUS implant in the event of a medical emergency. If you were rendered unconscious or unable to communicate, this bracelet will inform emergency medical staff that you have an AUS, because if there is ever a need for a urethral catheter, it is imperative that the AUS be deactivated prior to catheter placement in order to avoid damaging the urethra.

FAQ

Who manufactures the AUS?

American Medical Systems Men’s Health Division of Boston Scientific, Inc. http://www.BostonScientific.com

Will insurance cover the AUS?

Medicare has a coverage policy for incontinence control devices, which includes the AUS.  Most commercial health insurers also cover the AUS when deemed medically necessary for the patient.

How effective is the AUS?

More than 90% of patients with the AUS have greatly improved continence, many of whom achieve complete urinary control with no need for pads and the remainder of whom have occasional, minor stress incontinence with vigorous activities, typically requiring one or two small pads per day.  The 61-70 cm pressure regulating balloon provides 61-70 cm of pressure around the urethra, which is sufficient closure for most of the activities of daily living.

Does the AUS need to be measured to my body?

The control pump is “one size fits all”, but the cuff is sized to the circumference of your urethra to achieve a proper fit.  The reservoir comes in a variety of pressures.  The higher the pressure of the reservoir, the tighter the closure of the urethra. The tighter the closure of the urethra, the better is the continence, but also the greater the chance of urethral damage from the higher pressures. A balance must be achieved in order to achieve the necessary pressure to achieve continence while minimizing potential damage to the urethra. In practical terms, this translates into a 61-70 cm. pressure reservoir for most men.

Can I have an AUS if I underwent surgery followed by radiation therapy?

Yes, but radiation therapy increases the  potential risk for complications because of tissue damage, scarring, decreased blood flow and less optimal wound healing.

What are alternatives to the AUS, assuming that behavioral techniques and pelvic floor muscle exercises have failed?

  1. Absorbent pads and garments
  2. Penile compression clamps
  3. External collecting devices
  4. Urethral bulking agents
  5. The male sling

The first three are external, bulky, mechanical means of coping with–not treating–the problem.  Urethral bulking agents have fared poorly and the male sling is a possibility, although it is indicated for lesser degrees of incontinence and achieves results far inferior to those possible with the AUS.

Who should not have an AUS prosthesis?

The AUS is not appropriate for a man with an obstructed lower urinary tract. It also should not be used for those with bladder-related incontinence (overactive bladder or a small-capacity, scarred bladder) as it is indicated only for those with sphincter-related incontinence. It cannot be effectively used in those with compromised dexterity or mental acuity.

What are the potential risks and complications associated with AUS implantation?

Infection   As with any surgery, an infection can develop after an AUS implant.  Every step is taken to reduce the likelihood of an infection, including intravenous antibiotics, an antiseptic scrub of the surgical site on the operating table followed by the application of an chlorhexidine and alcohol skin antiseptic immediately prior to the operation, double-gloving, meticulous surgical technique with the procedure done as quickly as possible, topical antibiotics to flush the surgical site, and minimizing operating room traffic. Antibiotic ointment is placed on the surgical incision prior to placing the surgical dressing. Patients are sent home with oral antibiotics.

Two of the three components of the AUS–the cuff and pump–are coated with an antibiotic combination called InhibiZone, which consists of rifampin and minocycline.  If an infection occurs and does not respond to antibiotics, it may be necessary to remove the AUS, an extremely rare occurrence.

MH AMS 800 urinary sphincter product

Image above: AUS with inhibiZone coating of control pump and cuff

 

Erosion   This is a breakdown of the urethral tissues that lie beneath the cuff.   It is generally treated with cuff removal to allow for urethral healing prior to consideration for cuff replacement at a later date.  Erosion can occur when a catheter is placed into the urinary bladder by health care personnel uninformed that the AUS device is in place. The delicate urethra, pinched closed by the inflated cuff surrounding it, is traumatized and damaged by catheter placement.  This situation can be avoided by deactivating the AUS prior to catheterization.  This is one of the reasons that a MedicAlert card and bracelet are useful considerations. Erosion of the other AUS components can also occur on a rare basis. The control pump can potentially erode through the scrotal skin and the pressure-regulating balloon reservoir into the urinary bladder.

Mechanical Malfunction   The AUS is effective and reliable, but it is a mechanical device that can ultimately malfunction. It is not possible to predict how long an AUS will function in an individual patient.  As with any biomedical prosthesis, this device is subject to wear, component disconnection, component leakage, and other mechanical problems that may lead to the device not functioning as intended and may ultimately require additional surgery to replace the device. The median durability of the device is about 7.5 years, although I have patients who still have a functional AUS 20 years after implantation.

Urethral Tissue Atrophy   This can result from the long-term pressure effect of the cuff on the urethra.  Essentially, the urethra shrinks down from being squeezed by the cuff, resulting in worsening of urinary control.  When this happens, it generally requires repositioning of the cuff to a new urethral location or the use of a smaller cuff or, on rare occasion, placement of a second cuff (tandem cuff).

Pain    Discomfort in the groin, penis, and scrotum is expected immediately after surgery and during the period when the device is first used. It is very rare to experience chronic pain from an implantation of an AUS.

Migration and Extrusion  Migration is the movement or displacement of components within the body space in which they were originally implanted.  Extrusion occurs when a component moves to an abnormal location outside of the body.  These are both extremely rare occurrences

Bottom Line: The artificial urinary sphincter (AUS) is an effective, safe and reliable implantable medical prosthesis to restore urinary control in men with severe, refractory stress urinary incontinence.  Although there is no means of totally replacing our natural sphincter system, the AUS is the only device that simulates normal sphincter function by opening and closing the urethra at the will of the patient. It provides consistent results in the treatment of incontinence following prostatectomy and is considered to be the “gold standard” in the management of this problem. Many patients report that the AUS is nothing short of “life changing,” converting men who are bladder “cripples” back to normal function and restoring their quality of life. 

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

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

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

Urethral Lozenge To Treat E.D.: What You Need to Know

May 5, 2018

Andrew Siegel MD   5/5/18

In Greek and Roman mythology, the muses were the goddess daughters of Zeus and Mnemosyne who presided over the arts and sciences. The term is now used to refer to a source of inspiration for a creative artist.  Today’s entry discusses a different kind of muse, technically M.U.S.E., an acronym for “medical urethra system/suppository for erection.” For men suffering with E.D., M.U.S.E. can be a source of inspiration for better quality erections.

In a practical approach to ED, vasodilating drugs (those that expand blood vessels and increase blood flow) can be considered to be third-line treatments for ED. MUSE is formulated as a urethral lozenge (suppository) that when absorbed functions to increase penile blood flow and induce an erection.

MUSE (Medical urethral system for erection) consists of alprostadil (prostaglandin E1) vasodilator pellets—available in 125, 250, 500, and 1000 microgram dosages—that are placed into the urinary channel after urinating.  Absorption occurs through the urethra into the adjacent erectile chambers, inducing increased penile blood flow and potentially an erection.

IMG_8823

Image above is the MUSE applicator with the MUSE pellet contained within

One of the problems with MUSE is that it is placed in the urethra, which has little to no role in erectile function, although it is surrounded by one of the erectile chambers (corpus spongiosum) that gets plump, although not rigid at the time of an erection. The neighboring paired erectile chambers (corpora cavernosa) are the two bodies that become rigid at the time of an erection. MUSE relies on the medication being locally absorbed from the urethra, into the corpus spongiosum and then into the corpora cavernosa.

Why did Willie Sutton rob banks?  Because that’s where the money is.  When it comes to erections, the money is in the corpora cavernosa.  Using MUSE is like robbing the building next to the bank.  Because it relies on absorption to an adjacent structure, the dosage required is significantly higher than when the medication is injected directly into the corpus cavernosum (penile injection therapy).  You may need to use a 1000 microgram pellet in the urethra, whereas if injected you might only need 10 micrograms. MUSE is effective in about 30-40% of men, working in about 15 minutes or so and resulting in an erection lasting for about an hour.

How to use MUSE:

Note: An applicator delivers the medicated pellet into the tip of the penis. It should be inserted after urinating, which functions to lubricate the urethra and make the administration easier.  The pellet is formulated to dissolve in the small amount of urine remaining in the urethra after urination.

  1. After the applicator is removed from the foil pouch, remove the protective cover from the applicator stem. The medicated pellet is visible because the applicator is transparent.
  2. Put the penis on full stretch and gently compress the head of the penis to straighten and open the urethra.
  3. Gently insert the applicator in the urethra to the level of the collar of the applicator.
  4. Push down on the button on the top of the applicator and hold for a few seconds to deploy the pellet.
  5. Gently rock the applicator from side to side to separate the pellet from the applicator tip and then remove the applicator and inspect to ensure release of the pellet.
  6. Holding the penis upright and stretched, kneed the penis between your hands for at least 10 seconds; if you feel a burning sensation, continue to kneed the penis until it subsides.
  7. Replace the cover on the applicator, place it in the opened foil pouch and discard.
  8. Stand up or walk around for 10 minutes or so while the erection is developing. Voila!

Side effects include urethral burning, aching in the penis, testicles, perineum and legs, redness of the penis and minor urethral bleeding or spotting.

Bottom Line: MUSE is another tool in the urologist’s erectile dysfunction toolbox.  Although it is not highly effective and its means of administration (via a urethral lozenge) may be distasteful to many, nonetheless it can be a means of improving ED for men who do not respond to lifestyle measures and the oral ED medications. 

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an 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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

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

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx