Posts Tagged ‘Andrew Siegel MD’

Vesico-Vaginal Fistula (VVF): What You Need to Know

December 8, 2018

Andrew Siegel MD 12/8/2018

The last few entries have been geared towards men.  This week’s and next week’s entries address female urogenital maladies.  Today I cover a specific type of fistula–an abnormal connection between two body parts that are normally not connected –specifically one that occurs between the bladder and the vagina and that often leads to miserable urinary leakage issues. 

Vesicovaginal_Fistula

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

A vesico-vaginal fistula (VVF) is an abnormal hole or connection between the bladder and the vagina that causes continuous and persistent urinary leakage. Urine from the bladder drains from the fistula into the vagina, resulting in high-volume, continuous urinary leakage out of the vagina.

In the USA the most common cause is gynecological surgery, with abdominal hysterectomy accounting for the majority.  Other causes are urological and pelvic surgery, pelvic cancers and radiation therapy. My most recent patient with a VVF had a retained (long forgotten about) pessary used to treat her pelvic organ prolapse, which eroded from the vagina into the urinary bladder creating the fistula.

However, on a worldwide basis, the most common cause of VVF is an obstetrical fistula that occurs in third-world nations, particularly in West Africa. This is the most extreme form of birth trauma, a not uncommon, horrific problem endemic in poverty-stricken countries where pregnant women have poor access to obstetric care. It happens after enduring days of “obstructed” labor, with the baby’s head persistently pushing against the mother’s pelvic bones during labor contractions. This prevents pelvic blood flow and causes tissue death, resulting in a fistula between the vagina and the bladder and/or vagina and rectum. These fistulas are often huge and are totally different entities compared to the fistulas resulting from hysterectomies that are seen in first-world nations. When birth finally occurs, the baby is often stillborn.  The long-term consequences for the mother are severe urinary and bowel incontinence, shame and social isolation.

Fistulas can vary in size from tiny, pinpoint fistulas to those that are several centimeters in diameter.  A simple fistula is solitary and small in diameter; complex fistulas include those that are large, multiple, recurrent after previous repairs and those associated with pelvic radiation.  Most fistulas occur because of tissue “necrosis” (tissue death) and do not cause symptoms for several days to several weeks following the initial instigating surgery. The tissue necrosis is often caused by sutures inadvertently placed in the bladder wall in an effort to control pelvic bleeding.

The classic presentation of a VVF is urinary leakage from the vagina that occurs a few days to a few weeks following a hysterectomy. Evaluation is via pelvic examination in conjunction with cystoscopy (using a small lighted instrument to visualize the bladder) and vaginoscopy (using a small lighted instrument to visualize the vagina).  The location, size and number of fistulas present are determined as well as the extent of inflammation associated with the VVF.

Small fistulas may occasionally heal spontaneously with prolonged urinary catheter drainage.  Tiny fistulas can sometimes be dealt with via cauterization (searing them with electrical current), although most fistulas will be need to be repaired with surgery.

Surgical repair of a VVF can be via a vaginal or abdominal approach depending on circumstances and surgeon preference. In general, simple fistulas involving the more superficial vagina can be treated using vaginal approaches. Advantages of the vaginal approach are avoiding opening the bladder, minimal blood loss and less post-operative discomfort and the ability to do the procedure on an outpatient basis.

Complex fistulas that involve the deeper vagina can be repaired vaginally, although the abdominal approach is often preferred.  Vaginal repair can be facilitated with the use of either a flap of the labial fat pad (Martius repair) or alternatively, with the use of a flap of muscle tissue attached to its blood supply (often gracilis muscle).  Nowadays, the abdominal approach is often a robotic-assisted laparoscopic technique that has numerous advantages over the older, open technique.

In either case, important principles of surgical repair of a VVF are the following:

  • Waiting a sufficient time period after diagnosis to allow the inflammation and tissue swelling to subside to optimize tissue health and suppleness. The repair should not be attempted if devitalized tissues, infection, inflammation or encrusted deposits on the tissues are present. The timing needs to find middle ground between optimal conditions for closure and the desire to minimize the duration of the annoying and distressing constant urinary leakage.
  • Any urinary infection needs to be treated with antibiotics in advance of the surgery
  • Topical estrogen can be used to optimize vaginal tissue integrity
  • Careful tension-free closure of the VVF in several non-overlapping suture lines (bladder layer and vaginal layer) often with interposition of additional tissue (interposition flaps include omentum or peritoneum for abdominal repairs; peritoneum or labial fat for vaginal repairs) between the bladder and vaginal walls to buttress the repair. A flap of vaginal wall is advanced to cover the repair.
  • Urinary catheter for several weeks after the repair for purposes of continuous urinary drainage to facilitate the healing process by keeping the bladder decompressed of urine
  • Bladder relaxant medication post-operatively to minimize involuntary bladder contractions
  • Post-operative antibiotics

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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Medical “Urban” Myths in Urology

December 1, 2018

Andrew Siegel MD  12/1/2018

I am pleased to announce that with this entry I have surpassed 400 blogs composed over the past seven years.

Myth:  a widely held but false belief or idea; a misrepresentation of the truth; a fictitious or imaginary thing; exaggerated or idealized conception

thank you Pixabay for image above

Part I of today’s entry confronts widely held but false medical concepts that run rampant in the general population. Part II addresses widely held but false medical concepts that run rampant within the medical field. The medical mythology I attempt to debunk is largely urological in nature.

General population medical myths: Some myths are perpetuated by the general (non-medical) community, consisting of erroneous beliefs and inaccurate presumptions. These falsehoods often require a great deal of physician time in an effort to disabuse patients of them. 

Medical community medical myths: Some aspects of the practice of medicine are on the basis of customs perpetuated by medical personnel (most often not physicians) that seem logical or justified and ultimately become accepted dogma. However, they often do not hold muster, crumble under scientific scrutiny and can be categorized as medical myths.   

GENERAL POPULATION MEDICAL MYTHS

“A vaccine caused my child’s autism.”

(This is a non-urological myth, but nonetheless needs to be addressed.)

Myth: Vaccines, particularly MMR (measles, mumps, rubella) cause neurological injuries including autism spectrum disorder.

Reality: Scientific evidence overwhelmingly shows no correlation between vaccines in general, MMR vaccine in specific, and thimerosal (a mercury-based preservative) in vaccines with autism spectrum disorders or other neuro-developmental issues. 

We have come a long way on the immunization and vaccination front, wiping out a significant number of diseases completely.  In children, vaccines have been among our most effective interventions to protect individual as well as public health. What a great means of reducing  risk for certain infections that are potentially lethal, if not capable of incurring significant morbidity.  Vaccinations are now available for hepatitis A and B, diphtheria, tetanus, pertusis, polio, hemophilus, measles, mumps, rubella, varicella, meningitis, cervical cancer/human papilloma virus, influenza and pneumococcal pneumonia and herpes zoster (shingles).

“Doing a prostate biopsy will spread any cancer that may be present.”

Myth: Using a needle to obtain tissue samples of the prostate allows cancer cells to seed and implant along the needle track, or alternatively, into blood or lymphatic vessels. 

Reality: Although this is a theoretical consideration, the truth of the matter is that based upon millions of prostate biopsies performed annually in the USA, the incidence of seeding is virtually non-existent and the potential risk can be thought of as being negligible at best.

“Cancer spreads when exposed to oxygen.”

Myth: When a body is opened up and exposed to oxygen any cancer present can readily spread.

Reality: There is no scientific evidence that supports cancer advancing because of exposure to air/oxygen.  At times, upon doing an exploratory surgery, more cancer is discovered than was anticipated based upon imaging studies. This has nothing to do with the surgical incision nor exposure to air/oxygen, but is simply on the basis of cancer that did not show up on the diagnostic evaluation.

“All prostate cancer is slow growing and can be ignored.”

Myth: Prostate cancer grows so slowly that it can be disregarded. 

Reality:  Every case of prostate cancer is unique and has a variable biological behavior.

Yes, some are so unaggressive that no cure is necessary and can be managed with surveillance; however, others are so aggressive that no treatment is curative, and many are in between these two extremes, being moderately aggressive and highly curable. A major advance in the last few decades is the vast improvement in the ability to predict which prostate cancers need to be actively treated and which can be watched, a nuanced and individualized approach.

Those who feel that prostate cancer should not be sought out and treated should be attentive to the fact that it is the second leading cause of cancer death, with an estimated 30,000 deaths in 2018, and furthermore, that death from prostate cancer is typically an unpleasant one

MEDICAL COMMUNITY MEDICAL MYTHS

“Drink lots of fluids to flush out kidney stones.”

Myth: Drinking copiously will help promote passage of kidney and ureteral stones. The rationale of this advice is that by hydrating massively, a head of pressure will be created to help passage of a stone present in the kidney or ureter.

Reality: The presence of a stone often causes urinary tract obstruction.  Over-hydration in the presence of obstruction will further distend the already bloated and inflated portion of the urinary collecting system located above the stone. This increased distension can exacerbate pain and nausea that are often symptoms of colic. The collecting system of the kidney and the ureter have natural peristalsis—similar to that of the intestine—and over-hydration has no physiological basis in terms of helping this process along, being pointless and perhaps even dangerous.  Drinking moderately in the face of a kidney or ureteral stone is sound advice.

“Everyone must drink 8-12 glasses of water a day.”

Myth: Many sources of information (mostly non-medical and of dubious reliability) dogmatically assert that humans need 8-12 glasses of water daily to stay well hydrated and thrive.

Reality: Many people take the 8-12 glass/day rule literally and as a result end up in urologists’ offices with urinary urgency, frequency and often urinary leakage. The truth of the matter is that although some urinary issues are brought on or worsened by insufficient fluid intake–including kidney stones and urinary infections–other urinary woes are brought on or worsened by excessive fluid intake, including the aforementioned “overactive bladder” symptoms.  Water requirements are based upon ambient temperature and activity level. If you are sedentary and in a cool environment, your water requirements are significantly less than when exercising vigorously in 90-degree temperatures.

Humans are extraordinarily sophisticated and well-engineered “machines” and your body lets you know when you are hungry, ill, sleepy, thirsty, etc.  Heeding your thirst is one of the best ways of maintaining good hydration status, in other words, drinking when thirsty and not otherwise. Another method of maintaining good hydration status is to pay attention to your urine color.  Urine color can vary from deep amber to as clear as water.  If your urine is dark amber, you need to drink more as a lighter color is ideal and indicative of satisfactory hydration

“When a patient needs to have a catheter placed because he or she is unable to urinate, clamp the catheter intermittently to allow for gradual drainage instead of allowing it to drain at once.”

Myth: Rapid bladder decompression with a catheter can cause problems including bleeding that may require intervention, kidney failure and circulatory collapse. 

Reality: Science has clearly shown that concerns for kidney failure and circulatory collapse due to rapid bladder decompression are untruths.  Yes, on occasion some bleeding can occur (with or without) rapid decompression, but it is usually self-limited and inconsequential.

“A patient is experiencing leakage around a urinary catheter, so it must be too small and replaced with a larger one.”

Myth: A catheter that leaks needs to be replaced with a larger bore catheter so as to provide a better seal and reduce the leakage. This practice is commonly applied in nursing homes where many patients have long-term indwelling catheters for a variety of reasons.

Reality:  Leakage of urine around indwelling catheters is a common scenario. Although it can be due to a blocked catheter, most often the cause is bladder spasms induced by the catheter or catheter balloon irritating the bladder. The sensible management is to irrigate the catheter to ensure no obstruction, deflate the balloon to some extent, and thereafter consider the use of a bladder relaxant medication to minimize the bladder spasms.  The best practice is always to use the smallest catheter that is effective and remove it as soon as feasible. The longer a catheter stays in, the greater the chance for infections and long-term catheters that are upsized are clearly associated with urethral erosion and urethral stricture (scarring).

“If a patient has bacteria in the urine they must have a urinary infection that needs to be treated.”

Myth: There are bacteria present in the urine on urinalysis, so there must be an underlying infection that demands antibiotic treatment.  This is one of the medical myths perpetuated by internists and general practitioners.

Reality: The thought process that the presence of bacteria in the urine without symptoms means an infection is erroneous. It is vital to distinguish a symptomatic urinary infection from asymptomatic bacteriuria. Asymptomatic bacteriuria, common in elderly and diabetics, is the presence of bacteria within the bladder without causing an infection. This does not require treatment, which is futile and promotes selection of resistant bacteria.  Asymptomatic bacteriuria should be treated only in select circumstances:  pregnant women; in patients undergoing urological-gynecological surgical procedures; and in those undergoing prosthetic surgery (total knee replacement, etc.).

An extension of this myth is that bacteria in the urine in the face of an indwelling catheter is an infection that must be treated. The reality is that in the vast amount of cases, this is bacterial colonization without infection.

Bottom Line: Lay and even medical populations are subject to medical myths—mistaken beliefs that are often passed down like memes with little to no basis in fact. These myths have no place in the art and craft of medicine and need to be challenged with real science.  

“What is dogma today is dog crap tomorrow.”

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: 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

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

 

 

 

 

Big Ball Series: What You Need to Know About Hydroceles

October 27, 2018

Andrew Siegel MD  October 27, 2018

This is the first entry in the “Big Ball” series, which  provides information about common male issues that affect the contents of the scrotum.

 

huge hydrocele

 

Image above, a very large hydrocele

A hydrocele (“hydro” = water + “cele” = sac) is an accumulation of fluid within the sac that surrounds the testicle, resulting in ballooning and enlargement of the scrotum.  It can vary in size from just slightly bigger than the actual testes to larger than a cantaloupe.

Each testicle is surrounded by a thin sac known as the tunica vaginalis. The tunica  has an inner layer and an outer layer, with a small amount of fluid present between these 2 layers that serves a lubrication function, providing the means for the testes to rotate and move freely within the scrotum. The inner layer is responsible for the manufacture of this fluid and the outer layer for its reabsorption. This is a dynamic and ongoing process. A hydrocele is simply a disorder of production/reabsorption such that the outer layer of the tunica is unable to reabsorb all of the fluid that is produced by the inner layer, with the gradual accumulation of a collection of fluid. The fluid content of most hydroceles is straw-colored and odorless.

Hydroceles may also result from trauma, infections, tumors or operations such as a hernia and varicocele repairs. They are evaluated by physical examination and are often further characterized by an ultrasound of the scrotum, allowing for a detailed examination of the underlying testicle that often cannot be provided by physical examination because the size of the hydrocele.

Ultrasonography_of_hydrocele

Ultrasound image, public domain (testes is the ball-like structure that appears gray, hydrocele is the surrounding fluid that appears black)

Most small and moderate size hydroceles that are minimally symptomatic can be managed simply by periodic checkups. If a hydrocele progresses to the point where it causes discomfort, pain, tightness, deformity, or embarrassment, an option is to pass a needle into the hydrocele sac and drain the fluid, but this is most often just a temporary fix, as the root cause is unchanged and the fluid generally will re-accumulate.

The most definitive means of management is a relatively simple outpatient surgical procedure called a “hydrocele repair” or “hydrocelectomy.”  The incision is typically through the midline “seam” of the scrotum; the involved testicle and surrounding hydrocele sac are delivered through the incision, the sac opened, fluid drained and generally the sac is excised and oversewn or alternatively, the opened sac is turned back on itself and sewn to itself.  Either method results in exposing the testes to the scrotal wall (as opposed to the outer layer of the tunica), which functions to resorb the fluid produced by the inner layer of the tunica.  This procedure is a highly successful means of treatment of the hydrocele.

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

When He’s Interested and She’s Not: A Common Dilemma of the Aging Couple

October 20, 2018

Andrew Siegel MD   10/20/2018

2018-05-26 16.21.35

Photo taken at Icelandic Phallological Museum, Reykjavik: note that the stallion is braying, stomping and ready in every respect, while the mare seems rather indifferent

This entry is based upon my more than 30 years of experience in the urological “trenches” with innumerable daily interactions with male patients (often accompanied by their spouses). I have observed that much of the time when it comes to sexuality, “men are from Mars and women from Venus.”  I do not intend in any way to be disparaging or offend females, but only to report—as I see it—the not uncommon finding of the discrepant and diverging sexual appetites of the aging male as opposed to the aging female.  When I use the term “aging,” I am not referring only to octogenarians, but also to middle-aged and perhaps even younger couples.

Sex is a vital aspect of human existence—instinctual, hard-wired and a biological imperative. Nature has created the ultimate “bait and switch” in which reproduction (procreation) is linked with a pleasurable physical act (recreation), ensuring mating and, ultimately, perpetuation of the species.

Yet sex is so much more than an act of physical pleasure. For men, it is emblematic of potency, virility, fertility, and masculine identity. For women, it represents femininity, desirability and vitality. For both genders, it is an expression of physical and emotional intimacy, a means of communication and bonding that occurs in the context of skin-to-skin, face-time contact that gives rise to happiness, confidence, self-esteem and quality of life. In addition to sexual health being an important piece of overall health, it also provides comfort, security and ritual that permeate positively into many other areas of our existence. No matter what our chronological age, our need for physical and emotional intimacy never perishes.

Considering that nature’s ultimate purpose of sex is for reproduction, perhaps it is not surprising that when the body is no longer capable of producing offspring, changes occur that affect the anatomy and function of the genital organs.  However, long after the reproductive years are over and parenthood is no longer a consideration, many humans still wish to be able to function sexually.  For men this entails possessing a satisfactory libido (sex drive), the ability to obtain and maintain a reasonably rigid and durable erection, the capacity to ejaculate and experience a climax and, of course, to please their partners.  For women this entails having adequate sexual desire and interest, the ability to become aroused and lubricated, and the capacity to achieve orgasm as well as please their partners.

The aging process can be unkind and Father Time (as well as the ravages of poor lifestyle habits, medical issues and their treatment and other factors) does not spare sexual function.  For men, all aspects of sexuality decline, although sexual interest and drive suffer the least depreciation, leading to men who are eager, but frequently unable to achieve a rigid erection—a frustrating combination.  Age-related changes that affect male sexuality include penile shrinkage, decreased libido, diminished erectile rigidity and durability, more feeble ejaculations (less semen, less force, less arc) and less climactic orgasms.  The male downswing in sexual function usually has a slow and gradual trajectory that is based on many factors, with the progressive decline in testosterone production that occurs with aging (“andropause”) one of the key contributing factors.

For women, all aspects of sexuality decline as well. Age-related changes that affect female sexuality include vaginal and vulval dryness, irritation and thinning, vaginal narrowing and shortening, reduced sex drive, decreased arousal and lubrication, diminished ability to achieve an orgasm and a tendency for painful intercourse. Issues such as urinary incontinence and pelvic organ prolapse can put a further damper on sexual function.  The female downswing in sexual function occurs more precipitously than the male decline—although on the basis of numerous factors, an important one is the cessation of estrogen production by the ovaries that occurs after menopause, typically in the early 50s.

In addition to the physical and hormonal factors that may contribute to decreased sexual activity of the aging couple, there are many other considerations that come into play: After many years of marriage, the novelty factor wears off; priorities change; couples are often busy and fatigued with work, child-rearing and other responsibilities; emergence of urological, gynecological, orthopedic/joint problems, etc., psychological conditions (anxiety, stress and depression having to do with aging, health and other causes); and side effects from medications.   Ultimately, emotional intimacy can become more important to one (or both) partner(s) than physical intimacy.

In the population of patients that I care for (which may be skewed since I am a urologist who often treat men with sexual issues), I have perceived that in general—with exception—the aging male has a more robust sexual desire than his partner.  I have observed many men eager for the possibility of improving erectile function via chemical and other means (Viagra, Cialis, etc.), while his partner does not share his enthusiasm.

In most first marriages (commonly age late 20s to early 30s), men are typically a few years older than the women they marry. However, the older that men are when they marry, the greater the differential in age between them and their spouses, holding true in both first and second marriages. Perhaps age-related diverging sexual desires among males and females are among the factors that may help explain this phenomenon.

So, what to do?

Each partner in a relationship should make an effort to be more understanding of and sympathetic to their partner’s situation and needs and strive to compromise and find middle ground. Psychological counseling may be of great benefit to the couple suffering with the issue of libido imbalance.  Urologists and gynecologists can help male and female patients, respectively, with libido and other issues of sexual dysfunction.

Whereas male sexual dysfunction has received considerable attention and many management options are available, female sexual dysfunction by comparison has received short shrift.  Fortunately, the tides are changing and female sexual dysfunction—paralleling the male situation—has come out of the closet, is the subject of ongoing research and is now a subspecialty of gynecology with numerous management choices available.

Decreased sexual desire in males and females can often be successfully managed with hormone replacement therapy, estrogen and testosterone, respectively, when used in the proper circumstances under medical supervision.  Addyi (Flibanserin)—sometimes referred to as “female Viagra”—is a recently available pill that can effectively manage decreased female sexual desire.  Over the counter lubricants and moisturizers can help manage vaginal dryness and discomfort associated with sexual intercourse. Small amounts of topically applied estrogen or DHEA can be helpful as well. Oral ospemifene (a selective estrogen receptor modulator) may also be used successfully for vaginal dryness and painful intercourse related to menopause.  Fractional carbon dioxide laser treatments applied to the vagina may also prove beneficial when used under the right circumstances.  For the male with erectile dysfunction, there are numerous options to help restore erectile rigidity in the event that the oral pharmaceuticals are ineffective.

Despite the importance of sex, for many couples emotional intimacy can be equally important to, if not more so, than physical intimacy. Furthermore, all forms of sex can be enjoyable and there are numerous ways one can sexually satisfy one’s partner aside from penetrative penile-vaginal intercourse with both partners capable of achieving sexual gratification and climax without the involvement of an erect penis.

Bottom Line: A mismatch in sexual desire is a common issue among partners. Important factors are gradually declining testosterone levels in men and the more sudden decrease in estrogen levels in women.  The recently introduced concept of “couple-pause” is a couple-oriented approach that strives to address the sexual needs of the couple as a whole, rather than an isolated approach to one individual of the pair.  The good news is that disparity of intensity of sexual drive and interest among partners as well as other forms of sexual dysfunction are issues that can be addressed and improved, if not resolved.

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

Cover

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

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

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

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

 

Sleep: The (Undeserved) Least Respected Piece of a Healthy Lifestyle

October 13, 2018

Andrew Siegel MD  10/13/2018

DSC00702

Photo above: my two daughters in peaceful repose (quite a few years ago!)

 

Exercise is king. Nutrition is queen. Put them together and you’ve got a kingdom.
Jack Lalanne

In addition to Lalanne’s emphasis on exercise and healthy eating as the key pieces to a healthy lifestyle, modern science supports adequate quality and quantity of sleep as a third component of equal importance.  More than one- third of Americans suffer with chronic sleep deprivation and today’s entry explores the consequences and solutions to  this.

Nature has not intended mankind to work from 8 in the morning to midnight without the refreshment of blessed oblivion which, even if it only lasts 20 minutes, is sufficient to renew all the vital forces.

Winston Churchill

What’s Obvious

That adequate quantity and quality of sleep is vital to our well-being and optimal functioning is readily apparent. We have all enjoyed the blissful experience of a great night’s sleep, awakening well-rested, energetic, optimistic and ready to approach the new day with vigor. Conversely, we have all experienced a poor night’s sleep, awakening feeling physically exhausted, mentally spent, lids heavy, dark circles under our eyes, and often in a disassociated “zombie” state, totally unmotivated and unenthusiastic about facing the new day (a situation not unlike jet lag).

The amount of sleep one needs is biologically determined and different for each person. Some can make do with five hours of sleep while others require ten hours, but as a general rule, seven to eight hours is recommended.  Regardless, sleeping has an essential restorative function as our brains and bodies require this important down time for optimal functioning.

What’s not so obvious

Good quality sleep is an important component of overall health, wellness, and fitness with potential dire consequences to the chronically deprived. Sleep disruption or deprivation has numerous negative mental and physical effects including disturbed cognitive, endocrine, metabolic, cardiovascular, gastrointestinal and immune function. While sleeping, there is an increased rate of anabolism (cellular growth and synthesis) and a decreased rate of catabolism (cellular breakdown), processes that are disrupted by sleep deprivation. Chronic sleep issues can result in making one feel ill and appearing much older than they are chronologically.

Sleep disruption results in decreased levels of leptin (a chemical appetite suppressant), increased ghrelin levels (a chemical appetite stimulant), increased corticosteroids (stress hormones) and increased glucose levels (higher amounts of sugar in the bloodstream). As a result, chronic sleep deprivation commonly gives rise to increased appetite, increased caloric intake and the disassociated “zombie” state lends itself to dysfunctional eating patterns and consumption of unhealthy foods, and as such, weight gain is a predictable consequence.  Compounding the issue, a chronically-fatigued state impairs one’s ability to exercise properly, if at all.

Chronic sleep deficits results in irritability, impaired cognitive function and poor judgment.  The inability to be attentive and focused interferes with work and school performance and causes increased injuries (such as falls) and motor vehicle accidents.

Fact: Shift work sleep disorder.   Non-standard shift workers (health professionals, emergency workers, airline pilots, plant and manufacturing operators, etc.) make up nearly 20% of the U.S. work force. Their irregular working hours are often associated with disturbance of circadian rhythms and resultant insomnia and poor quality and quantity of sleep.  Scientific evidence shows an increased risk of developing diabetes, high blood pressure, high cholesterol, cardiovascular disease, peptic ulcer disease and depression.

What to do

The good news is that sleep deprivation is a modifiable risk factor, with a variety of ways to facilitate a good night’s sleep.

Sensible measures to help ensure a good night’s sleep:

  • Lead an active lifestyle with abundant exercise and stimulation.
  • Whether you are an early riser or a night owl, try to be consistent with respect to wake-up and bedtimes on both weekdays and weekends; if these times vary greatly it is a setup for sleep problems by disturbing your internal body clock.
  • Maintain a comfortable sleeping environment—a good quality supportive bed, comfortable pillows, a dark room, cool temperature and, if you like, “white noise” (I find that the monotonous sound of the sea produced by a sound machine, coupled with the gentle whirring of an overhead fan, is an instant relaxer).
  • Avoid caffeinated beverages—coffee, tea, cola, etc.—particularly after 6:00 p.m.  On the other hand, herbal teas, e.g., chamomile, can be soothing and relaxing.
  • Avoid consuming a large meal at dinner or eating very late at night.
  • Avoid imbibing too much alcohol.
  • Avoid exercising late in the evening.
  • Minimize the stress in your life, as much as is conceivable. Engage in a de-stressing activity immediately before sleep—reading, watching a movie or television show, crossword puzzle, sudoku, sex—whatever helps relax you and bring upon sleepiness.
  • Try to minimize evening exposure to the bright light (“blue light”) of cell phones, tablets and computers that inhibits production of the sleep-promoting hormone melatonin, levels of which under normal circumstances rise coincident with darkness. If possible, dim the light settings on electronic devices that are used at night.
  • Supplemental melatonin seems to help some people, but is ineffective for many others (including myself), but may be worth a try 

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

Cover

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

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

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

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

 

The “Bialy Diet”

October 6, 2018

Andrew Siegel MD  10/6/2018

Today’s entry is, actually, about a healthy eating lifestyle—as opposed to a diet—that works for me and I promise will help you improve your shape and shred excess pounds. I want to emphasize that this is not a fad pursuit, but a style of eating that can be easily incorporated to replace the typical calorie-rich, nutrient-poor Western diet that is overloaded with highly processed and refined foods, junk and fast foods, contributing to avoidable chronic health problems. As opposed to many weight loss programs that are gimmicky, unbalanced, unhealthy, unsustainable and frankly ridiculous, this approach is a no-nonsense, intelligent one—clean, lean, with plenty of green—that will stave off your hunger and hold caloric intake in balance with expenditure, making it effective and durable.

What do I mean by “bialy diet”?   It is sensible and nutritious eating, substituting less caloric and healthier foods for more caloric and unhealthier alternatives, e.g., bialys instead of bagels.  “Bialy diet’ does not imply eating a bialy at every meal, but is simply code for substituting healthier choices for unhealthier ones!

Bialy diet

A Few Words on Bialys

bialy | bēˈälē | noun (plural bialysUS a flat bread roll topped with chopped onions

The bialy is like the bagel’s older, less famous cousin who gets more handsome the longer you look at him.  –Rebecca Orchant

Who doesn’t love a fresh, warm NY bagel with a smear of cream cheese?  Sadly, the answer is our bodies and our health.  The 360-calorie bagel with two tablespoons of cream cheese (100 calories) is 460 calories of mostly refined carbs and fat. A great alternative is a bialy (“bialystoker kuchen” from Poland where it originated), a delicious flat bread roll that contains no hole, is not over-stuffed and bulging like an overinflated tire and has a depressed middle that is flavored with cooked onions and poppy seeds. The 180-calorie toasted bialy with a teaspoon of light butter with canola oil (20 calories) is only 200 calories and smells and tastes delicious. It is crisp and chewy at the same time, totally satisfying and doesn’t leave you feeling bloated. This with a mug of strong black coffee and half a grapefruit with a few strawberries or blueberries thrown on top of the grapefruit is my typical breakfast.  Sometimes on the weekends I will have an egg white omelet on a bialy with a slices of NJ tomato and avocado, a heavenly treat.

IMG_0573

                               Bialy vs. Bagel

Bialy                          Bagel (plain large)

Calories 180             Calories 360

Total fat 0.5 g           Total fat 2.1 g

Cholesterol 0 mg      Cholesterol 0

Sodium 240 mg        Sodium 700 mg

Total carb 38 g         Total carb 70 g

Fiber 3 g                   Fiber 3

Protein 7g                 Protein 14

In addition to the principle of the Bialy diet—substituting healthier alternatives for unhealthier ones—additional principles of this healthy eating style include Michael Pollen’s philosophy, Mediterranean style eating and the 80/20 strategy.

Michael Pollen’s philosophy can be summed up with his famous seven words: “Eat food, not too much, mostly plants.”  Food translates to real, natural, wholesome and unprocessed nourishment (as opposed to processed, refined, fast foods); not too much obviously means in reasonable quantities (as opposed to consuming massive quantities); and mostly plants emphasizes eating foods grown in the soil– whole grains, vegetables, fruits, legumes, seeds, nuts, etc. (with animal sources in moderation).

Mediterranean style eating is healthy, tasty and filling—and enjoyable.  It emphasizes less meat and more fish, an abundance of vegetables and fruits (rich in biologically active compounds including anti-oxidants, vitamins, minerals and fiber), whole (unrefined) grains, legumes and healthy vegetable fats from olives, avocados, nuts, seeds, etc.  Herbs and spices are used to flavor food, rather than salt. Dairy products are eaten in moderation.

The other element is the 80/20 (or 85/15 or 90/10 or 95/5) strategy.  This means that 80-95% of the time you adhere to a healthy eating style, but 5-20% of the time you give yourself a break, jump off the wagon and indulge in limited amounts of whatever temptation indulgence you would like.  This avoids deprivation and in my opinion is “an inoculation to prevent the disease.”  On the limited list are sweets including cookies, cakes, donuts, candy, etc. and liquid carbohydrates such as sugary drinks including soda, ice tea, lemonade, sports drinks, fruit juices, etc. (The only liquid carbohydrate I consume is alcohol in moderation, wine being a component of the Mediterranean style eating.)

Some Examples of Substitutions

  • Bialys instead of bagels
  • Seafood and lean poultry instead of red meat (when you do eat red meat, consume only the leanest cuts and grass-fed is preferable to corn-fed)
  • Lean turkey meat instead of beef for hamburgers, meatballs, chili, etc.
  • Vegetable protein sources (e.g. legumes—peas, soybeans and lentils) instead of animal protein sources
  • Avocados instead of cheese
  • Olive oil instead of butter
  • Real fruit (e.g. grapes, plums, apricots, figs) instead of dried fruit (raisins, prunes, dried apricots, dried figs) that are energy-dense
  • Real fruit (e.g. orange, grapefruit, apple, etc.) instead of fruit juice (OJ, grapefruit juice, apple juice, etc.) since real fruit has less calories, more fiber and phyto-nutrients and is more filling than the refined juice products
  • Whole grains (e.g. wheat, brown rice, quinoa, couscous, barley, buckwheat, oats, spelt, etc.) instead of refined grain products
  • Tomato sauces instead of cream sauces
  • Vegetable toppings (e.g. broccoli) on pizza instead of meat toppings (pepperoni)
  • Unshelled peanuts instead of processed peanuts (unshelled are usually unprocessed and are difficult to over-consume because of labor-intensity of shelling, the act of which keeps us busy and occupied)
  • Flavored seltzers or sparkling water instead of soda (liquid candy) with its empty calories
  • Baked, broiled, sautéed, steamed, poached or grilled instead of fried, breaded, gooey
  • If you eat chips, baked instead of fried
  • Wild foods instead of farmed (e.g. salmon)
  • Plain Greek yogurt instead of sour cream on baked potatoes and instead of mayo in salad dressings and dips
  • Frozen yogurt bars, which make a delicious 100 calorie or so dessert instead of ice cream
  • Soy, rice, almond or other nut-based milks instead of dairy
  • Low-fat or non-fat dairy products instead of whole milk products

Additional Valuable Nuggets of Advice

  • Pathway to a healthy weight is slow and steady, demanding patience and time
  • Cook healthy meals at home instead of dining out
  • Eat slowly, deliberately and mindfully
  • Eat as if you were dining with your cardiologist and dentist
  • Get sufficient quality and quantity of sleep to help keep the pounds off
  • Avoid late night meals and excessive snacking
  • Eat only when physically hungry with the goal of satiety and not fullness
  • Stay well hydrated as it is easy to confuse hunger with thirst
  • Exercise portion control, especially at restaurants where portions are often supersized
  • Order dressings and sauces on the side to avoid drowning salads and pasta meals in needless calories
  • Do not skip meals
  • Keep healthy foods accessible
  • Perishable food with a limited shelf life is much healthier than a non-perishable item that lasts indefinitely, as do many processed items
  • Read nutritional labels as carefully as if you were reading the label on a bottle of medicine
  • Avoid foods that contain unfamiliar, unpronounceable, or numerous ingredients
  • Avoid foods that make health claims, since real foods do not have to make claims as their wholesomeness is self-evident
  • Avoid food with preservatives, hormones, antibiotics, pesticides, artificial colors, etc.
  • Plants that are naturally colorful are usually extremely healthy
  • “Organic” does not imply healthy or low-calorie
  • Use small plates and bowls to create the illusion of having “more” on your plate
  • Let the last thing you eat before sleep be healthy, natural and wholesome (e.g., a piece of fruit)—you will feel good about yourself when you get into bed and even better in the morning

Wishing you the best of health,

2014-04-23 20:16:29

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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:

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

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

 

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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