Archive for November, 2018

Big Ball Series: How To Examine Your Testes (And What You Need to Know About Testicular Cancer)

November 24, 2018

Andrew Siegel MD  11/24/2018

This is the concluding segment of the “Big Ball” series of entries, which provide information about maladies of the male gonads.

Image below: testes cancer occupying entire testicle (pathology: seminoma)

Seminoma_of_the_Testis_(with_ruler)_(267781611) Attribtion: Ed Uthman from Houston, TX, USA [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)%5D, via Wikimedia Commons

Most testes lumps, bumps and growths are benign and not problematic. Although cancer of the testicle is rare (< 9000 cases/ year in the USA), it is the most common solid cancer in young men age 15-40, with the greatest incidence in the late 20s, striking men at the peak of life.  Notable men who are members of the testes cancer club include the following: Tour de France Champion Lance Armstrong; baseball player Scott Shoenweis; skater Scott Hamilton; MTV Host Tom Green; comedian Richard Belzer; sportswriter Robert Lipsyte; and Olympian Eric Shanteau.  The great news is that it is a highly curable cancer, especially so when picked up in its earliest stages, and also potentially curable even at advanced stages.

Testes cancer has a predilection for occurring more commonly in Caucasian men as compared to African-American or Asian men and is seen more commonly in men with undescended testes and Klinefelter’s syndrome.

In its early phase, testes cancer causes a lump, irregularity, asymmetry, enlargement, heaviness or a dull ache of the testicle. It most often does not cause pain, so the absence of pain should not dissuade you from getting evaluated if you are concerned about something that does not feel right.

 Note well: If you feel that there is a lump or bump in or on your testes that was not present previously, please see a urologist. You will never be chided for being a “hypochondriac” for getting checked out; it is truly better to be safe and cautious.

Testes cancer can also present with a sudden fluid collection around the testes, breast enlargement and/or tenderness, back pain and rarely shortness of breath, coughing up of blood or a lump in the neck.

The testicles have two functions, the manufacture of sperm (via germ cells) and the manufacture of testosterone (via Leydig cells).  Most testes cancers (about 95%) are of germ cell origin.  Germ cell cancers consist either of seminomas or non-seminomas.  Non-seminomas include embryonal cell cancers, choriocarcinomas, yolk sac tumors and teratomas. Many testes cancers are mixed germ cell tumors consisting of several of the sub-types. 5% of testes cancers are of stromal cell origin, including Leydig or Sertoli cell tumors.

If a patient complains of an abnormality of the testes, the first step is a careful physical examination, usually followed by an ultrasound of the scrotum. The ultrasound will confirm if the mass is solid versus cystic (fluid-filled) and determine its precise location and size.  If the mass is suspicious for a malignancy, blood tests—known as tumor markers—consisting of alpha-feto protein (AFP), human chorionic gonadotropin (B-HCG) and lactate dehydrogenase (LDH) are routinely obtained.

An outpatient surgical procedure is necessary to remove the diseased testicle along with the spermatic cord that contains the blood and lymphatic supply of the testicle.  This is accomplished via a relatively small groin incision.  A pathologist examines the testes microscopically and determines the precise diagnosis.  At the time of surgery, some men will elect to have a testicular prosthesis implanted, whereas others are not concerned about an empty scrotal sac on one side.   Additional staging studies—repeat tumor markers after testes removal and computerized tomogram (CT) of the abdomen and pelvis as well as a chest x-ray—are often necessary to determine if there is any spread of the cancer to remote areas of the body.

Note: Stage I is confined to the testes; stage II to the regional lymph nodes (abdominal lymph nodes); stage III is distant spread.

Depending on the final pathology report and the staging studies, additional treatments may  be required.  At times chemotherapy is the treatment of choice, the go-to cocktail of medications often a combination of bleomycin, etoposide and cisplatinum (BEP).  At other times, sampling of the abdominal lymph nodes is necessary (retroperitoneal lymph node dissection) and depending on the specific pathology, at other times, radiation therapy is necessary.  In addition to the urologist, a medical oncologist and radiation oncologist often are involved with the treatment process.

The Sean Kimerling testicular cancer foundation is an awesome resource for learning more about this disease.

How to do a testes self-exam, a simple task that can be lifesaving

Since only 5% or so of men with testes cancer are diagnosed by a physician on routine physical exam and 95% are picked up in the followup of a testes abnormality noted by a man or his partner, it makes a lot of sense to learn how to do a good self exam. 

Note: For most men, touching/manipulating/rearranging their nether parts is a natural and almost reflex activity that—supplemented with a little instruction, knowledge and direction—can be put to some practical clinical use. What follows is appropriate for the partner of the man in question.  If your man is not willing to do self-exams, at a moment of intimacy do a “stealth” exam under the guise of affection—it just might be lifesaving.  Several times in my career as a urologist, it was the man’s partner that was astute enough to recognize a problem that prompted the patient visit that determined the diagnosis of testicular cancer. 

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

Because sperm production requires that testes are kept cooler than core temperature, nature has conveniently designed men with testicles dangling from their mid-sections. There are no organs in the body—save female breasts—that are more external and easily accessible to examination. One of the great advantages of having one’s gonads located in such an accessible locale—conveniently “gift wrapped” in the scrotal satchel—is that it makes them so easy to examine. This is as opposed to the ovaries, which are internal and not amenable to ready inspection. This explains why early testes cancer diagnosis is a cinch as opposed to ovarian cancer, which most often presents at a more advanced stage.

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

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

Compare the two testes in terms of size, shape and consistency.  Generally, the testicles feel firm, similar to the consistency of hard-boiled eggs, although this can vary between individuals and even in an individual.  Lumps can vary in size from a kernel of rice to a large mass many times the size of the normal testes.  The epididymis is a comet-shaped structure located above and behind the testes that is responsible for sperm storage and maturation.  It has a head, a body and tail, and it is worthwhile running your fingers over this structure as well.

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

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

New video on female pelvic floor exercises:  Learn about your pelvic floor

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Big Ball Series: What You Need to Know About Varicoceles

November 17, 2018

Andrew Siegel MD  11/17/2018

This is a continuation of the “Big Ball” series of entries, which provide information about common maladies that affect the contents of the scrotum.  The last few entries have covered hydrocele, spermatocele and epididymitis.  The final entry in the series will be next week, which will cover testes tumors–relatively rare occurrences, but one of the most common cancers involving young men. 

VaricoceleBy BruceBlaus [CC BY-SA 4.0  (https://creativecommons.org/licenses/by-sa/4.0)%5D, from Wikimedia Commons

A varicocele is a clump of varicose veins of the spermatic cord, the bundle of tissue containing the testicle’s blood supply. A varicocele causes an engorgement of blood that heats up the testicles, which is undesirable for optimal sperm production and fertility.  The reason testes are external to the core of the body is their necessity for temperatures lower than core temperatures; if testicular temperature is too high, sperm development can be negatively affected.

Varicoceles are not uncommon, found in about 20% of adult males.  Varicoceles are found commonly in infertile men, including 40% of men with primary infertility (unable to achieve pregnancy after at least 12 months of unprotected sexual intercourse) and 80% of men with secondary infertility (previously able to achieve pregnancy, but currently unable to do so).

Normally functioning veins have small valves that allow for only one direction of venous flow (backwards towards the heart).  A varicose vein has faulty valves that allow reverse direction of blood flow with gravitational maneuvers such as standing and straining. This causes a fullness in the cord of tissue in the scrotum immediately above the testes (spermatic cord).  Although many varicoceles do not cause symptoms, others give rise to fertility issues or a dull achy pain when the varicose veins are full.  90% of varicoceles are on the left side because of differences in venous drainage patterns of the left and right testicular veins.

Diagnosis

Although men who have large varicoceles often complain of a mass or bulkiness felt immediately above the testes, many are diagnosed on physical examination in men who have no symptoms. They classically feel like a “bag of worms,” are most common on the left side and often cause the testes to be lower and lie horizontally as opposed to its normal vertical axis. They become more pronounced with straining and heavy lifting. They can vary from small, asymptomatic, unnoticeable varicosities that are only detected by your physician, to very large, symptomatic varicosities that can cause shrinkage of the involved testes, testicular pain and fertility issues.

Grading of varicoceles

Grade I: felt only upon asking patient to strain

Grade II: felt when patient stands

Grade III: visible

Ultrasound is a simple and non-invasive means of imaging the varicocele and the testes and is capable of diagnosing a small varicocele that is not evident on physical exam.

Varicoceles and fertility

It is important to know that most men with varicoceles are not infertile, but varicoceles are found commonly in infertile men. Varicoceles are associated with impaired sperm production and sub-fertility and are the most common correctable cause of male infertility. Varicoceles can negatively affect sperm count, motility and appearance.  In general, the higher the grade of varicocele, the greater the negative effect on fertility.  Proposed mechanisms for the impaired fertility are downward reflux of kidney and adrenal gland toxins, decreased testicular oxygen levels, increased testicular temperature that can affect sperm development, abnormal testicular blood flow, hormone imbalances, increased sperm DNA fragmentation, and oxidative stress.

Varicoceles merit treatment if there is discomfort or pain associated with gravitational and strain maneuvers or in the face of infertility. In the adolescent population, pediatric urologists generally repair varicoceles when there is discrepancy in the size of the testicles and when the smaller testicle is noted on the side of the varicocele.  In this setting, the goal of surgery is to improve testicular volume and sperm concentration.

Treatment

An asymptomatic varicocele causing no pain or fertility issues needs no treatment. Treatment is recommended for men with infertility or chronic discomfort associated with the varicocele. The goal of treatment is to occlude all of the varicose veins draining the affected testes, to improve the fertility issue and/or the pain issue.  This can be achieved with surgery or embolization.  Surgery can be on an outpatient basis done laparoscopically or open, with the laparoscopic approach often chosen in children because of smaller caliber veins present in children.  Open surgery is done via a small groin incision with magnification. Each varicose vein is identified and tied off with suture to prevent the back flow of blood.  Potential side effects of surgery include testes arterial injury, hydrocele, testes atrophy and recurrent varicocele.

Percutaneous embolization is a non-surgical alternative done by interventional radiology. Using fluoroscopic guidance, the varicose veins are identified and occluded with permanent coils that are placed percutaneously.  Potential side effects include blood vessel perforation and coil migration.

Outcomes

Men can expect an average increase in sperm count of 10 million/cc, a 10% increase in motility and increased overall pregnancy rates.  Serum testosterone levels often increase as well.  About 70% of men will experience an improved semen analyses following varicocele repair with resulting conception in about 50%.

What you can do to keep your testes cool and functional

 Careful with the following habits:

  • Hot baths, saunas, steam rooms
  • Heated car seats
  • Keeping your laptop on your lap
  • Cycling in tight shorts
  • Wearing tight underwear

 

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

New video on female pelvic floor exercises:  Learn about your pelvic floor

 

Big Ball Series: What You Need to Know About Epididymitis

November 10, 2018

Andrew Siegel MD  11/10/2018

This is a continuation of the “Big Ball” series of entries, which provide information about common maladies that affect the contents of the scrotum.

The epididymis is a comet-shaped organ located above and behind each testicle. It consists of multiple tiny twisted tubules and is the site where sperm mature, are stored and are transported.  At the time of sexual climax, sperm move from the epididymis into the vas deferens (sperm duct).

Epididymis-KDS

A. epididymal head, B. body, C. tail, D. vas deferens (sperm duct)                                             Attribution: By KDS444 [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)%5D, from Wikimedia Commons  

Epididymitis is an inflammation, pain, and swelling of the epididymis, a common inflammatory and/or infectious condition seen in men of all ages.  The vast majority of the time it involves only one side.  If left untreated, it can spread to the testicle in which case it is known as epidiymo-orchitis.

Epididymitis can be caused by the spread of infection from the prostate, bladder or urethra. The most common cause in young, sexually-active men is from organisms that cause urethritis, an infection or inflammation of the channel that conducts urine through the penis. This is often due to a non-bacterial organism such as chlamydia. In older men, bacterial infection caused by an obstruction in the lower urinary tract is a common cause of epididymitis.  In this older population, typical microorganisms are pathogens that normally reside in the colon such as E.Coli. In about 5% of cases, epididymitis is viral in origin, often from the spread of a viral upper respiratory tract infection.  Epididymitis can be an inflammatory as opposed to an infectious process, with no infecting organisms responsible.  For uncertain reasons, epididymitis is more commonly seen in men who do weight training or are employed in occupations that require heavy lifting.  On occasion it can be induced by certain medications, e.g., amiodarone.

Acute epididymitis can vary greatly in severity, ranging from mild to severe. Mild epididymitis causes a low-grade discomfort, swelling, and tenderness of the epididymis. In moderate epididymitis, the extent of pain, swelling, discomfort, and tenderness are appreciably increased.  In severe epididymitis, the epididymis often cannot be differentiated from the testes on exam because of the extensive infectious/inflammatory process and it is common to have fever, chills, malaise and other systemic symptoms.  The entire scrotum can be swollen and red, its contents hard, irregular and exquisitely tender.

Scrotal ultrasonography is extremely helpful to ensure making the proper diagnosis and to rule out an abscess or infarction (tissue death) that might require surgical intervention.  In acute epididymitis, the ultrasound often reveals epididymal enlargement and increased blood flow because of the inflammatory process.  Ultrasound is essential in severe epididymitis, persistent infection, or when physical exam is hampered from pain, scrotal wall inflammation or a reactive hydrocele (a collection of fluid surrounding the testes). Ultrasound can distinguish epididymitis from other processes including a twisted testes or twisted appendix testes, testes cancer, groin hernia, varicocele, trauma and scrotal abscess. In years preceding the ready availability of ultrasound it was not uncommon to have to perform scrotal surgical exploration to sort out the problem.  Urinalysis and urine culture are useful to help identify a specific bacterial source and to guide the choice of antibiotic.  Sexual transmitted infection testing is important when appropriate.

The treatment of acute epididymitis is directed at the specific organism responsible. In young men, this is often a course of a tetracycline-derivative antibiotic such as Doxycycline in conjunction with activity restriction, scrotal elevation and anti-inflammatory medication. Supportive jockey shorts are particularly useful to help elevate and immobilize the testes. Locally applied heat can be beneficial as well. In older men, an antibiotic directed at the likely source, the colonic bacteria, is appropriate.  Epididymitis may require a prolonged course of antibiotics and several weeks before it normalizes. Occasionally, after resolution, there will be an irregularly firm and sensitive epididymis as a result of scar formation and inflammation. In the case of severe epididymitis, after complete resolution of the infection it is important to undergo urological evaluation to rule out structural abnormalities that could have given rise to the process.

Occasionally, epididymitis can be so severe as to require hospitalization for intravenous antibiotics. Rarely, surgery is necessary to drain an epididymal abscess or remove the epididymis and at times, the infected testicle as well.

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

New video on female pelvic floor exercises:  Learn about your pelvic floor

 

 

 

Big Ball Series: What You Need to Know About Spermatoceles

November 3, 2018

Andrew Siegel MD 11/3/2018

This is a continuation of the “Big Ball” series of entries, which provide information about common maladies that affect the contents of the scrotum.  The previous entry was on hydroceles and next week will cover epididymitis. 

Epididymis-KDS

A. epididymal head, B. body, C. tail, D. vas deferens (sperm duct)                             Attribution: By KDS444 [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)%5D, from Wikimedia Commons  

A spermatocele (“spermato” = sperm + “cele” = sac) is a benign cystic enlargement within the scrotum that results from a partial obstruction of the tubular system of the epididymis.   The epididymis is the comet-shaped organ located above and behind each testicle that consists of multiple tiny twisted tubules. The epididymis is the site where sperm cells mature and are stored until the time of sexual climax when they move from the epididymis into the vas deferens (sperm duct).     

Spermatoceles typically arise from the head of the epididymis and are found to contain sperm, hence the name.  They can vary greatly in size, ranging from a pea-size lump that does not cause any symptoms to a grapefruit-size enlargement that causes annoying symptoms.  Many men with spermatoceles often present to the urologist with the complaint of “growing a third testicle.”  They are evaluated by physical examination where they are found to be smooth, soft and regular masses typically located above the testicle.  They are often further characterized by scrotal ultrasonography that provides detailed anatomical imaging of the testes and epididymis and can differentiate a spermatocele from other causes of scrotal enlargement such as a hydrocele. However, an epididymal cyst may be impossible to distinguish from a spermatocele, the only difference being that an epididymal cyst does not contain sperm as does a spermatocele. 

Spermatocele

Ultrasound image of spermatocele,  public domain (spermatocele on left immediately adjacent to testes on right)

The majority of spermatoceles arise from the epididymal head, although they can arise from the body or tail. Many spermatoceles are not symptomatic, causing only a painless enlargement or are discovered on a routine physical exam or incidentally on a scrotal ultrasound done for another reason.  Larger spermatoceles can cause an uncomfortable dragging sensation, particularly while sitting or driving. Most small and moderate-size spermatoceles can be managed simply by careful periodic observation to ensure that they do not continue to enlarge or cause progressive symptoms. When a spermatocele progresses to the point where it causes discomfort, pain, or deformity, it can be repaired by a relatively simple surgical procedure performed on an outpatient basis.  The incision is typically through the midline “seam” of the scrotum; the involved testicle is delivered through the incision, the epididymis is exposed and the spermatocele is carefully excised, after which the scrotal contents are repositioned and the scrotal wall is closed.  This procedure is a highly successful means of treatment of the spermatocele.

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

New video on female pelvic floor exercises:  Learn about your pelvic floor