Practical Approach To Erectile Dysfunction

September 16, 2017

Andrew Siegel MD  9/16/17

shutterstock_side view manjpeg

ED is a highly prevalent condition and a common reason for a urology consultation.  A pragmatic approach to its diagnosis and treatment–the topic of today’s entry–has always worked well for my patients.  A practical approach starts with simple and sensible measures, and only in the event that these are not successful, proceeding with more complex and involved strategies, dividing management options into four tiers of complexity. 

 Principles to managing male sexual issues are the following:

  • If it ‘ain’t broke,’ don’t fix it: “First do no harm.”
  • Educate to enable informed decisions: “The best prescription is knowledge.”
  • Try simple, conservative options before complex and aggressive ones: “Simple is good.”
  • Healthy lifestyle is vital: “Genes load the gun, but lifestyle pulls the trigger.”

Questions that need to be asked in order to evaluate ED include the following:

AS and DM

  • How long has your problem been present?
  • Was the onset sudden or gradual?
  • How is your sexual desire?
  • How is your erection quality on a scale of 0-5 (0 = flaccid; 5 = rigid)?
  • Can you achieve an erection capable of penetration?
  • Is your problem obtaining an erection, maintaining an erection, or both?
  • Is your problem situational? Consistent? Variable?
  • Are nocturnal, early morning and spontaneous erections present?
  • Do you have a bend or deformity to the erect penis?
  • How confident are you about your ability to complete the sexual act?
  • Are there ejaculation issues (rapid, delayed, painful, inability)?
  • Do you have symptoms of low testosterone?
  • What treatments have been tried?

Of equal relevance are medical, nutritional, exercise and surgical history, medications, and use of tobacco, alcohol and recreational drugs.  A tailored physical includes blood pressure, pulses and an exam of the penis, testes and prostate.  Basic lab tests including urinalysis, serum glucose, HbA1c, lipid profile and testosterone.

Information derived from the evaluation as described above will provide a working diagnosis and the ability to formulate a treatment approach.  Although a nuanced and individualized approach is always best, four lines of treatment for ED are defined—from simple to complex—in a similar way that four lines of treatment can be considered for arthritis.  For arthritis of the knee, for example, first-line therapy is weight loss to lessen the mechanical stress on the joint, in conjunction with physical therapy and muscle strengthening exercises. Second-line therapy is anti-inflammatory and other oral medications that can help alleviate the pain and inflammation. Third-line therapy is injections of steroids and other formulations.  Fourth-line therapy is surgery.

If the initial evaluation indicates a high likelihood that the ED is largely psychological/emotional in origin, referral to a qualified psychologist/counselor is often in order.  If the lab evaluation is indicative of low testosterone, additional hormone blood tests to determine the precise cause of the low testosterone are done prior to consideration for treatment aimed at getting the testosterone in normal range.  If the lab evaluation demonstrates unrecognized or poorly controlled diabetes or a risky lipid and cholesterol profile, appropriate medical referral is important.

Practical treatment of ED


elephant penis
 Credit for photo above goes to one of my patients; note the 7 prodigious appendages!

First-line: Lifestyle makeover

 A healthy lifestyle can “reverse” ED naturally, as opposed to “managing” it. ED can be considered a “chronic disease,” and as such, changes in diet and lifestyle can reverse it, prevent its progression and even prevent its onset.

My initial approach is to think “big picture” (and not just one particular aspect of the body working poorly).  Since sexual functioning is based upon many body components working harmoniously (central and peripheral nerve system, hormone system, blood vessel system, smooth and skeletal muscles), the first-line approach is to do what nurtures every cell, tissue and organ in the body. This translates to getting down to “fighting” weight, adopting a heart-healthy and penis-healthy diet (whole foods, nutrient-dense, calorie-light, avoiding processed and refined junk foods), exercising moderately, losing the tobacco habit, consuming alcohol in moderation, managing stress (yoga, meditation, massage, hot baths, whatever it takes, etc.), and getting adequate quantity and quality of sleep. Aside from general exercises (cardio, core, strength and flexibility training), specific pelvic floor muscle exercises (“man-Kegels”) are beneficial to improve the strength, power and endurance of the penile “rigidity” muscles.

If a healthy lifestyle can be adopted, sexual function will often improve dramatically, in parallel to overall health improvements. Many medications have side effects that negatively impact sexual function. A bonus of improved lifestyle is potentially allowing lower dosages or elimination of medications (blood pressure, cholesterol, diabetic meds, etc.), which can further improve sexual function.

“The food you eat is so profoundly instrumental to your health that breakfast, lunch and dinner are in fact exercises in medical decision making.”  Thomas Campbell MD

 

healthy meal

Above: A nice, healthy meal consisting of salmon, salad, veggies and quinoa

 

fat belly

Above: Not the kind of belly you want–visceral obesity is a virtual guarantee of pre-diabetes–if not diabetes–and greatly increases one’s risk of cardiovascular disease, including ED

Bottom line: Drop pounds, eat better, move more, stress less, sleep soundly = love better!

Second-line: ED pills and mechanical devices

In my opinion, the oral ED medications should be reserved for when lifestyle optimization fails to improve the sexual issues. This may be at odds with other physicians who find it convenient to simply prescribe meds, and with patients who want the quick and easy fix.  However, as good as Viagra, Levitra, Cialis and Stendra may be, they are expensive, have side effects, are not effective for every patient and cannot be used in everyone, as there are medical situations and medications that you might be on that preclude their use. In the second-line category, I also include the mechanical, non-pharmacological, non-surgical devices, including the Viberect and the vacuum suction devices.

Viagra (Sildenefil). Available in three doses—25, 50, and 100 mg—it is taken on demand and once swallowed, it will increase penile blood flow and produce an erection in most men within 30-60 minutes if they are sexually stimulated, and will remain active for up to 8 hours.

 Levitra (Vardenefil). Similar to Viagra, it is available in 5, 10, and 20 mg doses. Its effectiveness and side effect profile is similar to Viagra.

Cialis (Tadalafil).  Available in 2.5, 5 mg, 10mg, and 20 mg doses, its effectiveness and side effect profile is similar to Viagra. Its duration of action is approximately 36 hours, which has earned it the nickname of “the weekender.” Daily lower doses of Cialis are also FDA-approved for the management of urinary symptoms due to benign prostate enlargement.

Stendra (Avanafil). Similar to Viagra, it is available in 50, 100 and 200 mg doses. Its advantage is rapid onset.

Vacuum suction device                                                                                                                          This is a mechanical means of producing an erection in which the penis is placed within a plastic cylinder connected to a manual or battery-powered vacuum. The negative pressure engorges the penis with blood and a constriction band is temporarily placed around the base of the penis to maintain the erection.

Viberect device                                                                                                                               Initially employed as a means of triggering ejaculation in men with spinal cord injuries using vibrational energy, it has achieved wider use in provoking erections in men with ED. The device has dual arms that are placed in direct contact with the penile shaft. The vibratory stimulation will cause an erection and ultimately induce ejaculation.

Third-line: Vasodilating (increase blood flow) urethral suppositories and penile injections

These drugs are not pills, but other formulations (suppositories and injections) that increase penile blood flow and induce an erection.

M.U.S.E. (Medical urethral system for erection).  This is a vasodilator pellet—available in 125, 250, 500, and 1000 microgram dosages—that is 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.

Caverject and Edex (Prostaglandin E1) are vasodilators that when injected directly into the erectile chambers result in increased blood flow and erectile rigidity. After one is taught the technique of self-injection, the medication can be used on demand, resulting in rigid and durable erections.  A combination of medications can be used for optimal results– this combination is known as Trimix and consists of Papaverine, Phentolamine, and Alprostadil.

Fourth-line: Penile implants

There are two types of these devices that are surgically implanted into the erectile chambers under anesthesia, most often on an outpatient basis. Penile implants are totally internal, with no visible external parts, and aim to provide sufficient penile rigidity to permit vaginal penetration.

The semi-rigid device is a simple one-piece flexible unit consisting of paired rods that are implanted into the erectile chambers. The penis with implanted flexible rods is bent up for sexual intercourse and bent down for concealment. The inflatable device is a three-piece unit that is capable of inflation and deflation. Inflatable inner tubes are implanted within the erectile chambers, a fluid reservoir is implanted behind the pubic bone and a control pump in the scrotum, adjacent to the testes. When the patient desires an erection, he pumps the control pump several times, which transfers fluid from the reservoir to the inflatable inner tubes, creating a hydraulic erection which can be used for as long as desired. When the sexual act is completed, he deflates the mechanism via the control pump, transferring fluid back to the reservoir.

Penile implants can be a life changer for a man who cannot achieve a sustainable erection. They provide the necessary penile rigidity to have intercourse whenever and for however long that is desirable.

 

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”:  www.HealthDoc13.WordPress.com

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.

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How Strong Are Your Pelvic Floor Muscles?

September 9, 2017

Andrew Siegel MD  9/9/17

Note: Although the image below is that of a woman who has likely has a strong pelvic floor, this entry is equally relevant for both women and men. 

Mr-yoga-leg-extended-bridge-pose

Attribution of above image: By Mr. Yoga (http://mryoga.com/) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)%5D, via Wikimedia Commons

 

The Pelvic Floor Muscles in Men and Women (really not so different)

1116_Muscle_of_the_Perineum

Attribution of above image: By OpenStax [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)%5D, via Wikimedia Commons

A Few Questions & Answers About the PFM

Q. Why should you give a hoot about your PFM?                               

A. PFM integrity, strength and endurance are vital for optimal sexual, urinary, and bowel function in both females and males. If you don’t think bladder/intestinal control, pelvic organ support or sex is important, don’t bother to read on!

Q. Why do your PFM weaken?                                                                                  

A. The PFM lose strength with aging, obesity and not using them (disuse atrophy).  Their integrity is deeply impacted by pregnancy, labor and delivery in females and pelvic surgery (radical prostatectomy, colon/rectum operations, etc.) in males.

Q.  How can your PFM be strengthened?                                                                        

A. Like any skeletal muscles, the PFM can be strengthened through targeted exercise.

Q. What are important parameters of PFM function?

A. Strength at rest and with actively contracting the PFM; ability to voluntarily relax the PFM; endurance (ability to sustain a PFM contraction before fatigue sets in); and repeatability (the number of times a PFM contraction can be performed before fatigue sets in).

Q.  How is PFM strength tested?  

A. There are many ways to assess PFM strength.  Some clues as to female PFM strength are a snug and firm vagina with no urinary control issues, dropped pelvic organs or sexual problems. Some clues as to male PFM strength are good quality erections and ejaculation and no dribbling of urine after completing urinating. The ability to briskly lift up the erect penis (while in the standing position) when contracting the PFM is a sign of PFM strength. 

Other means of assessing PFM strength are the following:

1. Visual Inspection: Observe the perineum (area between anus and scrotum/vagina) prior to and during the PFM contraction.  The perineum should lift upwards and inwards and the anus should contract (anal wink). 

2. Vaginal (or Anal) Palpation: Place a finger in the vagina or anus, contract the PFM and subjective judge PFM strength using the Oxford scale (0-5). 0: no contraction; 1: flicker; 2: weak; 3: moderate;  4: good; 5: strong 

3. Perineometry: A pressure-measuring probe is placed in the vagina or rectum.  The device registers the squeeze pressure on the probe during a PFM contraction.

4. Electromyography: Patch electrodes (that resemble EKG electrodes) are placed on the  perineum. A recording of electrical activity generated by PFM contractions is made.

5. Dynamometry: A cylindrical steel tube that measures compressive strength is placed in the vagina or rectum. The device registers the squeeze pressure on the load cell built into the steel tube.

6. Ultrasound: Sound wave technology images the perineum and PFM during an active contraction.

Bottom Line:  Unlike the external, mirror-appealing muscles, the PFM are humble muscles that are shrouded in secrecy,  unseen and behind the scenes and often unrecognized and misunderstood. Their mysterious powers straddle the gamut of being vital for what may be considered the most pleasurable and sublime of human pursuits—sex—but equally integral to what may be considered the least refined of human activities—bowel and bladder function. Because they are out of sight and out of mind, they are often neglected. However, there is great merit in exercising important hidden muscles, including the heart, diaphragm and PFM. Although they are not the muscles of “glamour,” the PFM are the muscles of “amour” and merit the respect that is accorded the external glamour muscles of 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”:  www.HealthDoc13.WordPress.com

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 dire need of bridging.

For more information on the pelvic floor muscles and how to properly condition them, please consult the following books by the author:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

Bloody Semen: Frightening, But Usually Not To Worry

September 2, 2017

Andrew Siegel MD  9/2/17

Hematospermia is medical speak for a bloody ejaculation. It is a not uncommon occurrence, usually resulting from inflammation of one of the male reproductive parts, typically the prostate or seminal vesicles.  As scary as it is, it is rarely indicative of a serious underlying disorder.  Like a nosebleed, it can be due simply to a ruptured blood vessel. It is almost always benign and self-limited,  typically resolving within several weeks. On occasion it may become recurrent or chronic, causing concern and anxiety, but again, rarely due to a serious problem.

Factoid: The most common cause of a bloody ejaculation is following a prostate biopsy.

 

Illu_repdt_male

Thank you, Wikipedia, for image above, public domain

What is semen?

Semen is a nutrient vehicle for sperm that is a concoction of secretions from the testes, epididymis, urethral glands, prostate gland, and seminal vesicles.  The clear secretions from the urethral glands account for a tiny component, the milky white prostate gland secretions for a small amount of the fluid, and the viscous secretions from the seminal vesicles for the bulk of the semen. Sperm makes up only a minimal contribution.

Factoid:  After vasectomy the semen appears no different since sperm make up a negligible portion of the total seminal volume.

What exactly occurs during ejaculation?

After a sufficient level of sexual stimulation is achieved (the “ejaculatory threshold”), secretions from the prostate gland, seminal vesicles, epididymis, and vas deferens are deposited into the part of the urethra within the prostate gland.  Shortly thereafter, the bladder neck pinches closed while the prostate and seminal vesicles contract and the pelvic floor muscles spasm rhythmically, sending wave-like contractions rippling down the urethra to propel the semen out.

Factoid:  Ejaculation is an event that takes place in the penis; orgasm occurs in the brain.

Factoid: It is the pelvic floor muscles that are the muscle power behind ejaculation.  Remember this: strong pelvic muscles = strong ejaculation.

Since the prostate and seminal vesicles contribute most of the volume of the semen, bleeding, inflammation or other pathology of these organs is usually responsible for bloody ejaculations. The bleeding may cause blood in the initial, middle, or terminal portions of the ejaculate.  Typically, blood arising from the prostate occurs in the initial portion, whereas blood arising from the seminal vesicles occurs later. The color of the semen can vary from bright red, indicative of recent or active bleeding, to a rust or brown color, indicative of old bleeding.

What are some of the causes of blood in the semen?

  • Infection or inflammation (urethritis, epididymitis, orchitis, prostatitis, seminal vesiculitis, etc.)
  • Ruptured blood vessel, often from intense sexual activity
  • Reproductive organ cysts or stones
  • Following prostate biopsy (from numerous needle punctures); following vasectomy
  • Pelvic trauma
  • Rarely malignancy, most commonly prostate cancer and less commonly, urethral cancer
  • Coagulation issues or use of blood thinners

 How is hematospermia evaluated and treated?

A brief history reveals how long the problem has been ongoing, the number of episodes, the appearance of the semen and the presence of any inciting factors and associated urinary or sexual symptoms. Physical examination involves examination of the genitals and a digital rectal examination to check the size and consistency of the prostate. Laboratory evaluation is a urinalysis to check for urinary infection and blood in the urine, and a PSA (prostate specific antigen) blood test.  At times a urine culture and/or semen culture needs to be done.

Hematospermia is typically managed with a course of oral antibiotics because of the infection/inflammation that is often the underlying cause.  In most cases, the situation resolves rapidly.

If the bloody ejaculations continue, further workup is required.  This may involve imaging with either trans-rectal ultrasonography (TRUS) or magnetic resonance imaging (MRI) and at times, cystoscopy. TRUS is an office procedure in which the prostate and seminal vesicles are imaged by placing an ultrasound probe in the rectum. MRI imaging is performed at an imaging center under the supervision of a radiologist. The MRI provides a more thorough diagnostic evaluation, but is more expensive and time consuming.  Both TRUS and MRI can show dilated seminal vesicles, cysts of the ejaculatory ducts, prostate or other reproductive organs, and ejaculatory or seminal vesicle stones.  MRI can also show sites suspicious for prostate cancer. Cystoscopy is a visual inspection of the inner lining of the urethra, prostate and bladder with a small-caliber, flexible instrument. Treatment is based on the findings of the imaging and diagnostic studies, but again, it is important to emphasize the typical benign and self-limited nature of hematospermia.

Bottom Line: Blood in the ejaculation is not uncommon and is frightening, but is usually benign and self-limited and easily treated. In the rare situation where it persists, it can be thoroughly evaluated to assess the underlying cause.  If you experience hematospermia, visit your friendly urologist to have it checked out.

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”:  www.HealthDoc13.WordPress.com

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 

The aforementioned books will teach men and women, respectively, how to strengthen their pelvic floor muscles.

Urologic Injuries Among U.S. Soldiers Deployed To The Middle East

August 26, 2017

Andrew Siegel MD   8/26/17

Urological trauma (Urotrauma) is not uncommon among members of the USA military deployed in the Middle East. From October 2001-August 2013, approximately 1500 male soldiers suffered genital and/or urinary injuries.  Most were external, involving the penis, scrotum, testicles and urethra. At least one-third of these external injuries were severe, with 150 men losing either one or both testicles. The increased survival following complex traumatic injuries, which in prior conflicts would have likely resulted in death, now often result in survival of men with severe injuries, including those of the urological system. These injuries significantly affected sexual, urinary and reproductive health.

Defense.gov_News_Photo_110109-A-6521C-047_-_U.S._Army_soldiers_Staff_Sgt._Chad_Kair_Sgt._1st_Class_Travis_Leonhardt_and_Sgt._1st_Class_Charles_Houston_coordinate_security_during_a_meeting_to.jpg

Attribution of image above: By English: Sgt. Sean P. Casey, U.S. Army (www.defense.gov) [Public domain], via Wikimedia Commons

Improvements in battlefield medicine have significantly increased survival rates among injured soldiers.  However, these improvements have resulted in unprecedented numbers of soldiers—who previously would have died—surviving with injuries.  When traumatic injuries to the urinary and genital tract occur, they often result in urinary and sexual dysfunction, fertility issues and severe psychological trauma.

During the 12-year period under review, there were 30,000 injuries to deployed soldiers. 5% of soldiers sustained one or more urological injuries.  The majority of the injured were junior enlisted and members of the US Army or US Marine Corps, under 30 years old.  Most urological injuries occurred during battle and were predominately caused by explosive devices causing penetrating injuries. The scrotum was most commonly injured, followed by the testicles, penis, and urethra.  Loss of the entire penis and/or one or both testicles occurred in about 150 men. The consequence of severe genital injury is often a shortened, disfigured, nonfunctional penis, even despite conventional reconstructive surgery. Commonly accompanying urological trauma are brain trauma, pelvic fracture, colon and rectal injury and lower extremity injuries resulting in amputation.

The current pattern of urological injury represents a shift from internal urological structures—including the kidney, ureter, and bladder—to external urological structures.  This is attributed to the use of body armor that protects the chest and abdomen, but not the external genitals.  Furthermore, the rugged terrain in Afghanistan exposes soldiers patrolling on foot to genital blast trauma from ground-based explosive devices. Traditionally, the protective clothing to minimize genital trauma from ground-based explosive high-energy projectiles devices is a lightweight boxer brief undergarment and a thicker brief-type outer garment that is worn over combat trousers.  The US Army has introduced a new “pelvic protector” designed to shield the soldier’s genital and perineal areas from debris generated by improvise explosive devices.

Bottom Line:  Male external genitals were the predominant structures injured in recent warfare. Severe testicular and/or penile injury occurred in a substantial portion of the soldiers, with urological injuries often accompanying general body trauma. Sadly, most injuries—many of which are disfiguring genital injuries—occur at the time of peak sexual and reproductive potential, negatively affecting relationships and paternity.  Fortunately, advances in injury prevention, organ reconstruction/replacement, penile transplantation, regenerative medicine and advanced sperm salvage have the potential of making a significant difference in the health and well-being of soldiers with significant genital/urinary trauma.

Resource for this entry: “Epidemiology Of Genitourinary Injuries Among Male United States Service Members Deployed To Iraq And Afghanistan: Early Findings From The Trauma Outcomes And Your General Health Project” J Janak, J Orman, D Soderdahl and S Hudak, Journal of Urology: Volume 197, pages 414 – 419, February 2017

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”:  www.HealthDoc13.WordPress.com

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 Healt

 

Men’s Health: Holistic Urology Approach

August 19, 2017

Andrew Siegel MD   8/19/17

pixabay

Thank you, Pixabay, for image above

Men Don’t Ask For Directions, Etc…

With respect to their health, women are usually adept at preventive care and commonly see an internist or gynecologist regularly.  On the other hand, men—who could certainly take a lesson from the fairer sex—are generally not good at seeing doctors for routine checkups. Not only has our culture indoctrinated in men the philosophy of “playing through pain,” but also the lack of necessity of seeking medical care when not having a specific problem or pain (and even when men do develop dangerous health warning signs, many choose to ignore them.). Consequently, many men have missed out on some vital opportunities: To be screened for risks that can lead to future medical issues; be diagnosed with problems that cause no symptoms (such as high blood pressure, glaucoma and prostate cancer); and counseled regarding means of modifying risk factors and optimizing health.

Many Men Don’t Have A Doc

Urologists evaluate and treat a large roster of male patients, a surprising number of whom have not sought healthcare elsewhere and do not have a primary physician. Urological visits offer an opportunity to not only focus on the specific urological complaint that drives the visit (usually urinary or sexual problems), but also to take a more encompassing holistic health approach, emphasizing modifications in diet, physical activity, and other lifestyle factors that can prevent many untoward consequences and maximize health. By getting men engaged in the healthcare system on a timely basis, they can be helped to minimize those risk factors that typically cause the illnesses that afflict men as they age.

Identifying and modifying risk factors can mitigate, if not prevent, a number of common maladies.  Modifiable risk factors for the primary killer of men—cardiovascular disease—include poor diet, obesity, physical inactivity, excessive alcohol, tobacco consumption, stress, high blood pressure, high blood glucose and diabetes, high cholesterol, obstructive sleep apnea, low testosterone and depression. The bottom line is that every patient contact provides an opportunity for so much more than merely treating the sexual or urinary complaint that brought the patient into the office. Furthermore, many systemic disease processes—including diabetes, obstructive sleep apnea, cardiovascular diseases, etc.—have urological manifestations and symptoms that can be identified by the urologist who in turn can make a referral to the appropriate health care provider.

Erections are an Indicator of Health

Many men may not cherish seeing doctors on a routine basis, but a tipping point occurs when it comes to their penises not functioning!  Erectile dysfunction (ED) is a common reason for men to “bite the bullet” and call their friendly urologist for a consultation. The holistic approach by the consultant urologist is to not only manage the ED, but to diagnose the underlying risk factors that can be a sign of broader health issues than simply poor quality erections. Importantly, ED can be a warning sign of an underlying medical problem, since the quality of erections serves as a barometer of cardiovascular health.

    “A man with ED and no known cardiovascular disease                                                                      is a cardiac patient until proven otherwise.”

Graham Jackson, M.D., cardiologist from the U.K.

Since the penile arteries are small in diameter and the coronary (heart) arteries larger, it stands to reason that if vascular disease—generally a systemic process that is diffuse and not localized—is affecting the tiny penile arteries, it may affect the larger coronary arteries as well, if not now, then at some time in the future. In other words, the fatty deposits that compromise blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a “stress test.” In fact, the presence of ED is as much of a predictor of cardiovascular disease as is a strong family history of cardiac problems, tobacco smoking, or elevated cholesterol.

Dr. Jackson cleverly expanded the initials ED to mean: Endothelial dysfunction (endothelial cells line the insides of arteries); early detection (of heart disease); and early death (if missed). For this reason, men with ED should undergo a medical evaluation seeking arterial disease elsewhere in the body (heart, brain, aorta, and peripheral blood vessels).

Urologists have a broad network of colleagues (including internists, cardiologists, pulmonologists, gastroenterologists, medical oncologists, radiologists, radiation oncologists, general surgeons, etc.) that can be collaborated with and to whom patients can be referred to if and when their expertise is needed.

Urine is Golden

Of all the bodily secretions that humans produce, urine uniquely provides one of the best “tells” regarding health.  A simple and inexpensive urinary dipstick can diagnose diabetes, kidney disease, urinary tract infection, the presence of blood and hydration status, in a matter of moments.

What a dipstick can reveal:

specific gravity… hydration status

pH…acidity of urine

leukocytes…urinary infection

blood…many urological disorders including kidney and bladder cancer

nitrite…urinary infection

bilirubin…a yellow pigment found in bile, a substance made by the liver; its presence may be indicative of jaundice

protein…kidney disease

glucose…diabetes

Case report of a recent patient

54-year-old male with six-month history of frequent daytime urination as well as awakening 3-4 times during sleep hours to urinate. Additionally, he has difficulty maintaining erections and premature ejaculation. Physical examination of the abdomen, genitalia and prostate was unremarkable. Urinalysis showed large glucose. Lab studies showed glucose 204 (normally < 100); HbA1c 10.6% (normally < 5.6); testosterone 202 (normally > 300) and PSA 4.2 (elevated for his age). 

He was referred to an internist for management of diabetes that manifested with urinary frequency, elevated urine and blood glucose and elevated HbA1c (a measure of blood glucose levels over the past 6 weeks).  With appropriate management of the diabetes, the urinary frequency resolved. Because of the PSA elevation he is scheduled for an MRI of the prostate, and because of the low testosterone, he is undergoing additional endocrine testing to see if the problem is testicular or pituitary in origin and certainly will be a candidate for medical therapy if improved lifestyle measures fail to sufficiently elevate the testosterone.

Bottom Line: Preventive and proactive care—as many pursue regularly for their prized automobiles (e.g., lubrication and oil changes, replacing worn belts before they snap while on the road, etc.)—provides numerous advantages.  The same strategy should be applied to the human machine!  Since contact with a urologist may be a man’s only connection with the healthcare system, a vital opportunity exists for the urologist to offer holistic care in addition to specialty genital and urinary care.  The goal is to empower men by getting them invested in their own health in order to minimize disease risk and optimize vitality. 

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”:  www.HealthDoc13.WordPress.com

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 

 

Diabetes And Urological Health

August 12, 2017

Andrew Siegel MD  8/12/17

Your taste buds may crave sugar (glucose), but the rest of your body sure doesn’t!

A common presenting symptom of undiagnosed diabetes is frequent urination because of the urine-producing effect of glucose in the urine. People with such urinary frequency will often consult a urologist (urinary tract specialist) erroneously, thinking that the problem is kidney, bladder or prostate in origin, when in actuality it is the sugar in the urine that is the source of the problem.

Because of this urinary frequency presentation of diabetes, urologists often have the opportunity to make the initial diagnosis and refer the patient for appropriate care. Similarly, many uncircumcised men who have foreskin problems–particularly when the foreskin becomes stuck down over the head of the penis and will not retract (phimosis)–have undiagnosed diabetes. A simple dipstick of urine in conjunction with the typical presenting symptoms of frequent daytime and nighttime urination and/or foreskin issues directs the proper diagnosis.

Diabetes has detrimental effects on all body systems, with the urinary and genital systems no exception. Today’s entry reviews the impact of diabetes on urological health. Many urological problems occur as a result of diabetes, including urinary infections, kidney and bladder conditions, foreskin issues and sexual problems.  Additionally, diabetes increases the risk of kidney stones. Although many of the same urinary issues that are present in diabetics commonly also occur with the aging process (in the absence of diabetes), the presence of diabetes hastens their onset and severity.  Diabetes can have catastrophic consequences including the following: heart disease, stroke, blindness, kidney failure requiring dialysis and vascular disease resulting in amputations.

Wickipedia public domain copy

Thank you, Wikipedia, for the above public domain image

Diabetes 101

Diabetes is a disease in which blood glucose levels are elevated. Glucose is the body’s main fuel source, derived from the diet.  Insulin, a hormone secreted by the pancreas, is responsible for moving glucose from the blood into the body’s cells so that life processes can be fueled. In diabetes, either there is no insulin, or alternatively, plenty of insulin, but the body cannot use it properly. Without functioning insulin, the glucose stays in the blood and not the cells that need it, resulting in potential harm to many organs.

Two distinct types of diabetes exist. Type 1 is an autoimmune condition in which the body’s immune system destroys insulin-producing cells, severely limiting or completely stopping all insulin production.  It is often inherited and is responsible for about 5% of diabetes. It is managed by insulin injections or an insulin pump.

Type 2 diabetes is caused by overeating and sedentary living and is responsible for 95% of diabetes. This form of diabetes is caused by insulin resistance, a condition in which the body cannot process insulin and is resistant to its actions. Anybody with excessive abdominal fat is on the pathway from insulin resistance towards diabetes.  Type 2 diabetes is a classic example of an avoidable and “elective” chronic disease that occurs because of an unhealthy lifestyle.

Sad, but true: Chances are that if you have a big abdomen (“visceral” obesity marked by internal fat) you are pre-diabetic. This leaves you with two pathways: the active pathway – cleaning up your diet, losing weight and getting serious about exercise, in which this potential problem can be nipped in the bud. However, if you take the passive pathway, you’ll likely end up with full-blown diabetes.

Common presenting symptoms of diabetes are frequent urination, thirst, extreme hunger, weight loss, fatigue and irritability, recurrent infections, blurry vision, cuts that are slow to heal, and tingling or numbness in the hands or feet.

Complications of diabetes occur because of chronic elevated blood glucose and consequent damage to blood vessels and nerves.  Diabetes accelerates atherosclerosis, a condition in which fatty deposits occur within the walls of arteries, compromising blood flow and the delivery of oxygen and nutrients to tissues. Diabetic “small blood vessel” disease can lead to retinopathy (visual problems leading to blindness), nephropathy (kidney damage leading to dialysis), and neuropathy (nerve damage causing loss of sensation).  Diabetic “large vessel disease” can cause coronary artery disease, stroke, and peripheral vascular disease.  Diabetes increases the risk of infections because of poor blood flow and impaired function of infection-fighting white blood cells.

Diabetes and the bladder

Many diabetics have urological problems on the basis of the neuropathy that affects the bladder.  These issues include impaired sensation in which the bladder becomes “numb” and the patient gets no signal to urinate as well as impaired bladder contractility in which the bladder muscle does not function properly, causing inability to empty the bladder completely.  Other diabetics develop involuntary bladder contractions (overactive bladder), causing urinary urgency, frequency and incontinence.

Diabetes and the kidneys

Diabetes is the most common cause of kidney failure, accounting for almost half of all new cases. Even with diabetic control, the disease can lead to chronic kidney disease, kidney failure and the need for dialysis or kidney transplantation.

Diabetes and urinary/genital Infections

Diabetics have more frequent urinary tract infections than the general population because of factors including improper functioning of the infection-fighting white blood cells, glucose in the urine (a delightful treat for bacteria) and compromised blood flow. Diabetics have a greater risk of asymptomatic bacteriuria and pyuria (the presence of white cells and bacteria in the urine without infection), cystitis (bladder infections), and pyelonephritis (kidney infections).  Impaired bladder emptying further complicates the potential for infections.  Diabetics have more serious complications of pyelonephritis including kidney abscess, emphysematous pyelonephritis (infection with gas-forming bacteria), and urosepsis (a very serious systemic infection originating in the urinary tract requiring hospitalization and intravenous antibiotics).  Fournier’s gangrene (necrotizing fasciitis) is a soft tissue infection of the male genitals that often requires emergency surgery (that can be disfiguring) and has a very high mortality rate.  Over 90% of patients with Fournier’s gangrene are diabetic. Diabetic patients also have an increased prevalence of infections with surgical procedures, particularly those involving prosthetic implants, including penile implants, artificial urinary sphincters, and mesh implants for pelvic organ prolapse.

Diabetes and the foreskin

Balanoposthitis is medical speak for inflammation of the head of the penis and foreskin. As mentioned previously, a tight foreskin that cannot be pulled back to expose the head of the penis (phimosis) can be the first clinical sign of diabetes in uncircumcised men. At least 25% of men with this problem have underlying diabetes.  It is common for these men to have fungal infections under the foreskin because of the risk factors of a warm, moist, dark environment in conjunction with the presence of glucose in the urine. The good news is that phimosis and fungal infections often respond nicely to diabetic control.

Who Knew? I learned from a patient of mine that this issue is referred to in slang as “sugar dick.”

Diabetes and sexual function

Sexual functioning is based upon good blood flow and an intact nerve supply to the genitals and pelvis.  Diabetics often develop sexual problems (in fact, diabetes is the most common cause of erectile dysfunction) because of the combination of neuropathy and blood vessel disease.  Men commonly have a reduced sex drive and have difficulty achieving and maintaining erections.  Diabetes increases the risk of erectile dysfunction threefold.  Diabetes has clearly been linked with testosterone deficiency, which can negatively impact sex drive and sexual function.  Because of the neuropathy, many diabetic males have retrograde ejaculation, a situation in which semen goes backwards into the bladder and not out the urethra.  Female diabetics are not spared from sexual problems and commonly have reduced desire, decreased arousal and sexual response, vaginal lubrication issues and painful sexual intercourse.

Diabetic management

With Type 2 diabetes it is vital to modify lifestyle, including dietary changes that avoid diabetic-promoting foods and replacement with healthier foods in order to have appropriate sugar control to help prevent diabetic complications. Diabetics should refrain from high glycemic index foods (those that are rapidly absorbed) including sugars and refined white carbohydrates and instead should consume high-fiber vegetables, fresh fruits, and whole-grain products.  Regular exercise is equally as important as healthy eating, and the combination of healthy eating, physical activity, and weight loss can often adequately address Type 2 diabetes.

When lifestyle measures cannot be successfully implemented or do not achieve complete resolution, there are different classes of medications that can be used to manage the diabetes. However, lifestyle modification should always be the initial approach, since lifestyle (in large part) caused the problem and is capable of improving/reversing it.  At times, when diet, exercise and drugs are unable to control the diabetes, bariatric (weight loss) surgery may be needed to control and even potentially eliminate the diabetes.

Bottom Line:  Diabetes is a serious chronic illness with potentially devastating complications. Type 1 diabetes is relatively rare and unavoidable, but is manageable with insulin replacement. Type 2 diabetes is epidemic and its prevalence has increased dramatically coincident with the expanding American waistline. It can be improved/reversed through integration of healthy eating habits, weight management, and exercise. Lifestyle modifications can be amazingly restorative to general, urological and sexual health and overall wellbeing. After all, our greatest wealth is health.

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”:  www.HealthDoc13.WordPress.com

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 

Amazon page for Dr. Siegel’s books

 

 

Urology 101:  Much More Than “Pecker Checking”!

August 5, 2017

Andrew Siegel MD  8/5/17

CME2P

I am a second-generation urologist. It is unlikely that there will be a third-generation urologist as my oldest child is a film-maker, my middle child works in tech marketing and my youngest is off to college later this month, intent on becoming a child psychologist. After she spent a day in the office with me, she told me that the experience caused her to have post-traumatic stress disorder!

As a youngster, I attended summer camp in New Hampshire at Camp Moosilauke . My friends made fun of my father’s profession, referring to him as a “pecker checker.”  Today’s entry is a brief review of what urology really is and what urologists do for a living. One thing is for sure…sooner or later most everyone will need the service of a urologist. 

“Urology” (uro—urinary tract and logos—study of) is the branch of medicine that deals with the diagnosis and treatment of diseases of the urinary tract in males and females and of the reproductive tract in males. The urinary organs under the “domain” of urology include the kidneys, the ureters (tubes connecting the kidneys to the urinary bladder), the urinary bladder, and the urethra (channel that conducts urine from the bladder to the outside).  These body parts are responsible for the production, storage and release of urine.

The male reproductive organs under the “domain” of urology include the testes, epididymis (structures above and behind the testicle where sperm mature and are stored), vas deferens (sperm duct), seminal vesicles (structures that produce the bulk of semen), prostate gland and, of course, the scrotum and penis.  These body parts are responsible for the production, storage and release of reproductive fluids.  The reproductive and urinary tracts are closely connected, and disorders of one oftentimes affect the other…thus urologists are referred to as “genitourinary” specialists.

Urology is a balanced specialty– urologists treat men and women, young and old, from pediatric to geriatric.  Whereas most physicians are either medical doctors or surgeons, a urologist is both, with time divided between a busy office practice and the operating room.  Although most urologists are men, more and more women than every before have been entering the urological workforce.

Factoid: My pathway to urology was 4 years of college, 4 years of medical school, 2 years of general surgery residency, 4 years of urology residency and 1 year of specialty fellowship in pelvic medicine and reconstructive urology.  I started practicing at age 33.

Factoid: Becoming board certified is the equivalent of a lawyer passing the bar exam. There are three possible board certifications in urology: general urology, pediatric urology, and female pelvic medicine and reconstructive surgery.  Thereafter, one must maintain board certification by participating in continuing medical education and pass a recertification exam every ten years.  I am dually certified in general urology as well as female pelvic medicine.  The common problems I take care of in my female pelvic medicine practice are urinary incontinence (stress urinary incontinence and overactive bladder), pelvic organ prolapse and recurrent urinary tract infections

Urologists are the male counterparts to gynecologists and the go-to physicians when it comes to expertise in male pelvic health.  Urological surgery involves operating on patients with potentially life-threatening illnesses, particularly cancers of the genital and urinary tracts.  In terms of new cancer cases per year in American men, prostate cancer is number one accounting for almost 30% of cases; bladder cancer is number four accounting for 6% of cases; and cancer of the kidney and renal pelvis (the inner part of the kidney that collects the urine) is number six accounting for 5% of cases.  Urologists are also the specialists who treat testicular cancer.  Urologists also treat women with kidney and bladder cancer, although the prevalence of these cancers is much less in women than in males.

Urology has always been on the cutting edge of surgical advancements (no pun intended) and urologists use minimally invasive technologies including fiber-optic scopes to view the entire inside of the urinary tract, as well as ultrasound, lasers, laparoscopy and robotics.  There is overlap in what urologists do with other medical and surgical disciplines, including nephrology (doctors who specialize in medical diseases of the kidney); oncology (medical cancer specialists); radiation oncologists (radiation cancer specialists); radiology (imaging); gynecology (female specialists); and endocrinology (hormone specialists).

Common reasons for a referral to a urologist include: blood in the urine, whether it is visible or picked up on a urine test; an elevated or an accelerated PSA (Prostate Specific Antigen); prostate enlargement; irregularities of the prostate on digital rectal examination; and urinary difficulties ranging the gamut from urinary leakage to the inability to urinate (urinary retention).

Urologists manage a variety of other issues. Kidney stones, which can be extraordinarily painful, keep us very busy, especially during the hot summer months when dehydration is more common. Infections are a large part of our practice and can involve the bladder, kidneys, prostate, testicles and epididymis.  Sexual dysfunction is a very common condition that occupies much of the time of the urologist—under this category are problems with obtaining and maintaining an erection, problems of ejaculation, and testosterone issues. Urologists treat not only male infertility, but also create male infertility when it is desired by performing voluntary male sterilization (vasectomy).   Urologists are responsible for caring for scrotal issues including testicular pain and swelling. Many referrals are made to urologists for blood in the semen.

 

RUPNOK

 

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”:  www.HealthDoc13.WordPress.com

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 

Amazon page for Dr. Siegel’s books

Percutaneous Tibial Nerve Stimulation (PTNS) For Overactive Bladder (OAB)

July 29, 2017

Andrew Siegel MD   7/29/17

ptns-v2@2x

PTNS therapy is a non-drug, non-surgical option to treat OAB symptoms including urinary urgency, frequency and urgency incontinence. PTNS consists of 12 weekly sessions in the office, followed by a maintenance regimen. During each 30-minute session, a thin needle electrode is placed into the ankle region and is connected to an external electrical stimulator. Up to 80% of patients improve with minimal, if any, side-effects.

OAB

Overactive bladder is a common and annoying condition present in both females and males marked by episodes of urinary urgency, frequency and, at times, incontinence. A variety of methods can be used to improve symptoms and quality of life, including the following: behavioral modifications, bladder retraining, pelvic floor muscle training, bladder relaxant medications and Botox injections.  Although medications are commonly used for OAB, the problem is that side effects and expense often limit their continued usage.

Neuromodulation

An effective alternative is neuromodulation, the least invasive technique of which is known as PTNS.  PTNS uses a thin, acupuncture-style needle placed in the ankle that is attached to a hand-held device that generates electrical stimulation.  This is a significantly less invasive means of neuromodulation than is Interstim, which requires implantable wire electrodes to be placed in the spine and continuous electrical stimulation with an implantable battery-powered pulse generator. In both instances, the sacral plexus—responsible for regulating bladder and pelvic floor function—is “modulated” by the electrical stimulation, causing a beneficial effect with improvement of OAB symptoms. With PTNS, the electrical stimulation travels up the tibial nerve to the sacral plexus, whereas with Interstim, the sacral plexus is directly stimulated by electrodes.

Nuts and Bolts of PTNS

PTNS involves once weekly visits to the office for 12 weeks, 30 minutes per session.  It can be performed on both female and male patients.

At each session, the patient is seated comfortably with the treatment leg elevated and supported.  A fine caliber needle electrode—similar to an acupuncture needle—is inserted into the inner ankle in the vicinity of the tibial nerve.  A grounding surface electrode is placed as well.  An adjustable electrical pulse is applied to the needle electrode via an external pulse generator. Activation of the tibial nerve is confirmed with a sensory (mild sensation in ankle or sole) and/or a motor (toe flex/fan or foot extension) response. Thereafter, the power of electrical stimulation is adjusted to an appropriate level and the 30-minute session begins. The patient can read, listen to music, nap, meditate, etc.

Clinical Response

Improvement in OAB symptoms often occurs by session 6, sometimes sooner. Patients who respond well to the 12-week protocol may require occasional maintenance treatments.  70-80% of patients will achieve long-term improvement in OAB symptoms. PTNS incurs minimal risks with the most common side effects being mild pain and skin irritation where the needle electrode is placed.

Insurance

PTNS is covered by most insurances, including Medicare.  PTNS cannot be used in patients with pacemakers or implantable defibrillators, those prone to excessive bleeding, those with nerve damage or women who are pregnant or planning to get pregnant during the treatment period.

YouTube on PTNS

“My PTNS” educational program

My nurse practitioner and I will be giving a seminar (free of charge) on PTNS on 7PM on Thursday, September 14, 2017 at the Marriott Hotel, 138 New Pehle Avenue, Saddle Brook, NJ.  Light refreshments will be served.  Space is limited, so if interested, please call 201-487-8866 to reserve a spot.

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”:  www.HealthDoc13.WordPress.com

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 

Amazon page for Dr. Siegel’s books

 

 

Maintaining Masculinity With Aging

July 21, 2017

Andrew Siegel MD  7/21/17

“Time has a nasty way with human materials.”…Zadie Smith

“The reality of our bodies is that they are born and grow and in time suffer and decline.”  …Senator Ben Sasse

Bona Lane

No matter how old, most men wish to be able to travel down this road until their final breath.

Although the term masculinity may be better understood conceptually than described in words, it can be defined as possessing positive qualities traditionally associated with men: virility, drive, strength, vigor, resiliency, confidence, self-sufficiency, etc. Carried to an extreme, it can sometimes be associated with alpha behaviors including aggression, hyper-sexuality and supreme authority. Certainly, masculinity implies a certain “swagger” that clearly is unique from femininity. Sadly, aging and natural deterioration gradually rob men of many masculine attributes with the ultimate result–at some point in time–infirmity and frailty.

The Inevitable Loss of Horsepower

Our bodies-as-machines slowly lose their maximal horsepower and morph into less performative and functional machines.  The realities and challenges that accompany reaching senior years–the anatomical and functional deterioration that affect every organ system–are a direct blow to masculinity. A central premise of masculinity is having a strong and fit body; however, aging is at direct odds with masculinity because of the loss of bone and muscle mass, slower healing, accumulation of injuries and the occurrence of disease processes, resulting in declining strength and fitness.

All systems go to ground, as eventually we do. The senses–vision, hearing, taste, smell, touch–slowly rust away. Locomotion, nervous system, urinary system, bowel system, cognition and memory deteriorate. There is a good reason that athletes are considered “old” in their thirties. Rigidity of erections, the literal totem of masculinity, declines in proportion to age in years.

The silver lining is that although the degenerative process is inevitable and there will come a time when frailty will ensue, with the combination of strength training, cardiovascular conditioning, core and balance work, this process can be deferred substantially. Thinned bones, wasted muscles and hunched posture can be largely prevented by proactive and preemptive strikes against their onset.

I have an amazingly fit and cognitively intact 95-year-old patient who goes to the gym three times a week.  He lamented to me that because of an injury he was unable to work out for a few weeks and as a result he felt flabby and listless.

Retirement: Death with Benefits

At some point in the aging process, retirement from work becomes a reality for the vast majority of men.  Leaving work is one of the more challenging aspects of aging as our careers can often be considered “masculine” experiences from a primal perspective, since our roles as “hunter”—“warrior”—“gatherer” provide for our families.  Aside from financial resources, works provides benefits on so many levels—engendering a sense of usefulness and purpose, identity, dignity, self-worth, achievement, recognition, respect, (particularly self-respect), status and influence.  Furthermore, work also provides connection, collaboration and networking that are central to the human experience.  There is something special about having purpose and being productive, both of which give real meaning to one’s existence and help maintain vitality. This does not necessarily involve continuing to work full-time and compromising our fun and leisure activities, but rather achieving a healthy balance between work and play with part-time work, an encore career, volunteering, etc.

As a urologist with many years of clinical experience, I can attest to the fact that one of the shared attributes of my older patients who have aged well (Youthful Elderly Persons, a.k.a. Yeppies) is that they have NOT retired, often working well into their eighties and beyond.

Mitigate Risks

Typically associated with “masculinity” is risk-taking behavior.  Men are more likely than women to engage in activities such as smoking, heavy drinking, fast driving without seat belts, participating in sports with high injury rates, etc.  However, as we age, continued participation in such activities will not help the masculine cause, so at some point those who wish to maintain their masculinity will need to curtail unhealthy lifestyle activities and tailor sport participation in such a way as to maximize benefits, but minimize risks, for example, playing doubles tennis instead of singles.

Masculine to be Feminine

Masculinity often entails “alpha” behavior, which typically implies stoicism and self-reliance, in contrast to the female gender that is generally more emotive, communicative and willing to seek help from others. This translates to less preventive health care as men tend to be more reactive than proactive.  Furthermore, it generally leads to men having less meaningful and more superficial relationships than our female counterparts. This cool and independent alpha manner does not foster the skillset necessary to deal with many of the unpleasant circumstances that often accompany aging. It behooves men to seek preventive health care as well as nourish internal health by developing deeper and more meaningful relationships with our significant other, children, family and friends. We are a species who exists to coexist and connect and it is this social web that provides a safety net for us, valuable always, but particularly so when isolation, depression, fear, anxiety, etc., strike.

Bottom LineThe aging process gradually and insidiously erodes “masculinity.” Continuing to work in some capacity, working out regularity, working towards minimizing high-risk activities and maintaining a healthy lifestyle, and working “inwards”—fighting the culturally-based stoicism and self-reliance that runs counter to humans as highly social creatures–in concert can preserve “masculine capital” to an advanced age.  Although aging can be considered the “enemy” and will ultimately prevail, it is all about the possibilities as opposed to the limitations of the process.

Thank you to Rick Siegel–my brother–for suggesting an entry on this topic, based upon reading a Wall Street Journal article from 2/27/17: “Need To Redefine Masculinity As We Get Older” by Dana Wechsler Linden.

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”:  www.HealthDoc13.WordPress.com

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

Co-creator of the PelvicRx male pelvic floor muscle training DVD.

 

 

 

Sex And The Female Pelvic Floor Muscles

July 15, 2017

Andrew Siegel MD   7/15/17

The vagina and clitoris are the stars of the show, but the pelvic floor muscles are the behind-the-scenes “powerhouse” of these structures. The relationship between the pelvic muscles and the female sexual organs is similar to that between the diaphragm muscle and the lungs, the lungs as dependent upon the diaphragm for their proper functioning as the vagina and clitoris are on the pelvic muscles for their proper functioning.  The bottom line is that keeping the pelvic muscles fit and vital will not only optimize sexual function and pleasure, but will also benefit urinary, bowel and pelvic support issues as well as help prevent their onset. 15606-illustrated-silhouette-of-a-beautiful-woman-or

Image above, public domain

Size Matters

While penis size is a matter of concern to many, why is vaginal size so much less of an issue?  The reason is that penises are external and visible and vaginas internal and hidden. The average erect penis is 6 inches in length and the average vagina 4 inches in depth, implying that the average man is more than ample for the average woman. The width of the average erect penis is 1.5 inches and the width of the average vaginal opening is virtually zero inches since the vagina is a potential space with the walls touching each other at rest. However, the vagina is a highly accommodative organ that can stretch, expand and adapt to the extent that 10 pound babies can be delivered vaginally (ouch!).

More important than size is the strength and tone of the vaginal and pelvic floor muscles. Possessing well-developed and fit vaginal and pelvic floor muscles is an asset in the bedroom, not only capable of maximizing your own pleasure, but also effective in optimally gripping and “milking” a penis to climax.  Additionally, when partner erectile dysfunction issues exist, strong pelvic floor muscles can help compensate as they can resurrect (great word!) a penis that is becoming flaccid back to full rigidity.

Female Sexuality

Sex is a basic human need and a powerful means of connecting and bonding, central to the intimacy of interpersonal relationships, contributing to wellbeing and quality of life. Healthy sexual functioning is a vital part of general, physical, mental, social and emotional health.

Female sexuality is a complex and dynamic process involving the interplay of anatomical, physiological, hormonal, psychological, emotional and cultural factors that impact desire, arousal, lubrication and climax. Although desire is biologically driven based upon internal hormonal environment, many psychological and emotional factors play into it as well. Arousal requires erotic and/or physical stimulation that results in increased pelvic blood flow, which causes genital engorgement, vaginal lubrication and vaginal anatomical changes that allow the vagina to accommodate an erect penis. The ability to climax depends on the occurrence of a sequence of physiological and emotional responses, culminating in involuntary rhythmic contractions of the pelvic floor muscles.

Sexual research conducted by Masters and Johnson demonstrated that the primary reaction to sexual stimulation is vaso-congestion (increased blood flow) and the secondary reaction is increased muscle tension.  Orgasm is the release from the state of vaso-congestion and muscle tension.

Pelvic Muscle Strength Matters

Strong and fit pelvic muscles optimize sexual function since they play a pivotal role in sexuality. These muscles are highly responsive to sexual stimulation, reacting by contracting and increasing blood flow to the pelvis, thus enhancing arousal.  They also contribute to sensation during intercourse and provide the ability to clench the vagina and firmly “grip” the penis. Upon clitoral stimulation, the pelvic muscles reflexively contract.  When the pelvic muscles are voluntarily engaged, pelvic blood flow and sexual response are further intensified.

The strength and durability of pelvic contractions are directly related to orgasmic potential since the pelvic muscles are the “motor” that drives sexual climax. During orgasm, the pelvic muscles contract involuntarily in a rhythmic fashion and provide the muscle power behind the physical aspect of an orgasm. Women capable of achieving “seismic” orgasms most often have very strong, toned, supple and flexible pelvic muscles. The take home message is that the pleasurable sensation that you perceive during sex is directly related to pelvic muscle function. Supple and pliable pelvic muscles with trampoline-like tone are capable of a “pulling up and in” action that puts bounce into your sex life…and that of your partner!

Factoid:  “Pompoir” is the Tamil, Indian term applied to extreme pelvic muscle control over the vagina. With both partners remaining still, the penis is stroked by rhythmic and rippling pulsations of the pelvic muscles. “Kabbazah” is a parallel South Asian term—translated as “holder”—used to describe a woman with such pelvic floor muscle proficiency.  

Pelvic Floor Dysfunction

As sexual function is optimized when the pelvic floor muscles are working properly, so sexual function can be compromised when the pelvic floor muscles are not working up to par (pelvic floor muscle “dysfunction”).  Weakened pelvic muscles can cause sexual dysfunction and vaginal laxity (looseness), undermining sensation for the female and her partner. On the other hand, overly-tensioned pelvic muscles can also compromise sexual function because sexual intercourse can be painful, if not impossible, when the pelvic muscles are too taut.

Vaginal childbirth is one of the key culprits in causing weakened and stretched pelvic muscles, leading to loss of vaginal tone, diminished sensation with sexual stimulation and impaired ability to tighten the vagina.

Pelvic organ prolapse—a form of pelvic floor dysfunction in which one or more of the pelvic organs fall into the vaginal space and at times beyond the vaginal opening—can reduce sexual gratification on a mechanical basis from vaginal laxity and uncomfortable or painful intercourse. The body image issues that result from vaginal laxity and pelvic prolapse are profound and may be the most important factors that diminish one’s sex life. As the pelvic floor loses strength and tone, there is often an accompanying loss of sexual confidence.

Urinary incontinence—a form of pelvic floor dysfunction in which there is urinary leakage with coughing, sneezing and physical activities (stress incontinence) or leakage associated with the strong urge to urinate (urgency incontinence or overactive bladder)—can also contribute to an unsatisfying sex life because of fears of leakage during intercourse, concerns about odor and not feeling clean, embarrassment about the need for pads, and a negative body image perception. This can adversely influence sex drive, arousal and ability to orgasm.

A healthy sexual response involves being “in the moment,” free of concerns and worries. Women with pelvic floor dysfunction are often distracted during sex, preoccupied with their lack of control over their problem as well as their perception of their vagina being “abnormal” and what consequences this might have on their partner’s sexual experience.

Pelvic Floor Training

Pelvic floor muscle training is the essence of “functional fitness,” a workout program that develops pelvic muscle strength, power and stamina. The goal is to improve and/or prevent specific pelvic functional impairments that may be sexual, urinary, bowel, or involve altered support of the pelvic organs.

Many women exercise regularly but often neglect these hidden–but vitally important muscles– that can be optimized to great benefit via the right exercise regimen.  The key is to find the proper program, and for this I refer you to your source for everything Kegel: The KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health.

Wishing you the best of health,

2014-04-23 20:16:29

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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