Posts Tagged ‘testes’

Chronic Testes Pain

March 7, 2018

Andrew Siegel MD    3/7/2018

New Jersey is shut down because of the impending Nor’easter, surgery and office hours are cancelled, so I have plenty of free time and am going to post this entry today rather than on Saturday morning.

Orchialgia is medical-speak for chronic testes (ball) pain, defined as constant or intermittent pain perceived in the testicles, lasting for 3 or more months and interfering with one’s quality of life.  It is a not uncommon problem of men of all ages, but is more frequently seen in young adults.  It certainly keeps us busy in the office…some morning sessions seem like “ball clinics”!

Testes 101


Image above, public domain from Wikipedia

The testes are paired, oval-shaped organs that are housed in the scrotal sac. They have two functions, testosterone and sperm production.  Encased within the tough and protective cover of the testes (tunica albuginea) are tiny tubes called seminiferous tubules which make sperm cells.  The testes also contain specialized cells called Leydig cells that produce testosterone.  Sperm from the testes travels to the epididymis for storage and maturation. The epididymis empties into the vas deferens, which conducts sperm to the ejaculatory ducts.

The testes are suspended in the scrotal sac via the spermatic cord, a “rope” of tissue containing connective tissue, the vas deferens, the testes arteries, veins, lymphatics, and nerves. The spermatic cord is enveloped by tissues that are extensions of the connective tissue coverings of three of the abdominal core muscles. The most important of these coverings surrounding the spermatic cord is the cremaster muscle, which elevates the testes in a northern direction when it contracts.

The scrotal sac has several roles, packaging the testes as well as aiding in their function by regulating their temperature. For optimal sperm production, the testes need to be a few degrees cooler than core temperature.  The dartos muscle within the scrotal wall relaxes or contracts depending on the ambient temperature, allowing the testes to elevate or descend to help maintain this optimal temperature. Under conditions of cold exposure, the dartos contracts, causing the scrotal skin to wrinkle and to bring the testicles closer to the body.  When exposed to heat, dartos relaxation allows the testicles to descend and the scrotal skin to smoothen.

Good news/bad news:

The good news about the testes location dangling between one’s legs is is ready and easy access for examination, unlike the female counterpart (ovaries), which are within the abdomen.  This is one reason why testes cancer is so much easier to diagnose at an early stage than ovarian cancer.

The bad news is that their precarious location dangling between one’s legs as well as their delicate packaging in the thin sac makes them subject to trauma and injury.

Chronic orchialgia

Chronic testes pain can be caused by numerous different conditions and it is important to rule out the following possibilities:

  • Infection: An infection of the testes (orchitis), epididymis (epididymitis), both (epididymo-orchitis), or the spermatic cord (funiculitis). Infections can be bacterial, viral, and at times inflammatory without an actual infection.
  • Tumor: A benign or malignant mass of the testes or epididymis.
  • Groin hernia: A prolapse of intra-abdominal contents through a weakness in the connective tissue support of the groin.
  • Torsion: A twist of the testes or one of the testes or epididymal appendages.
  • Hydrocele: An excess fluid collection in the sac surrounding the testes.
  • Spermatocele: A cyst resulting from a blockage of one of the sperm ducts within the epididymis.
  • Varicocele: Varicose veins of the spermatic cord.
  • Trauma: Injury.
  • Prior operations: Groin hernias are most commonly associated with chronic testes pain; less commonly, vasectomies and any other type of groin or pelvic surgery.
  • Referred pain: Pain perceived in the testes, but originating elsewhere, e.g., a kidney stone that has dropped into the ureter, or a lower spine issue affecting the nerves to the testes.
  • Tendonitis: There are numerous muscles with tendons that insert into the pubic bone region that can be subject to injury and inflammation.
  • Pelvic floor muscle tension myalgia: Excessive muscle tension in these muscles can cause pelvic pain, including pain in the testes.
  • Idiopathic: This fancy medical term means that we are clueless about the origin of the pain. Unfortunately, many men have idiopathic orchialgia, a distressing and frustrating experience for both patient and urologist.


The evaluation of the patient with chronic testes pain includes a detailed history, a careful examination of the scrotal contents, groin and prostate, if necessary, as well as a urinalysis and possibly urine culture. It is helpful to obtain an ultrasound of the scrotum, a study which utilizes sound waves to image the testicle and epididymis. On occasion, it is warranted to obtain imaging studies of the upper urinary tract and pelvis and possibly a CT or MRI of the spine if there is back or hip pain.


The management of chronic testis pain is directed at the underlying cause, although unfortunately this cannot always be precisely determined. Often, a course of antibiotics may prove helpful even if the physical findings are indeterminate.  Anti-inflammatory medications such as Advil and ibuprofen are often useful in the short-term management. Supportive, elastic jockey shorts as well as local application of a heating pad can be helpful. At times, amitriptyline or Neurontin can be helpful for neurologically-derived pain.  If the source of the pain is felt to be tension myalgia, referral to a pelvic floor physical therapist can be beneficial.  A referral to a pain specialist, typically an anesthesiologist who focuses on this discipline, can be advantageous.

An injection of a local anesthetic into the spermatic cord (spermatic cord block) can be a useful diagnostic test and a means of alleviating the pain.  If spermatic cord block proves successful in relieving the pain, it may be necessary to surgically denervate the spermatic cord, a procedure in which the nerve fibers in the spermatic cord are divided.  Under extremely rare circumstances, removal of the epididymis or the testicle is necessary. Often chronic testis pain remains elusive with the source undetermined and is thought to be similar to other chronic inflammatory conditions.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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



Testosterone Update 2017: Untangling The Web

January 21, 2017

Andrew Siegel, MD   1/21/17

Testosterone deficiency (TD) is a not uncommon male medical condition marked by characteristic symptoms and physical findings in the face of low levels or low activity of testosterone (T). TD is most often seen in men above the age of 50 years and is a frequent reason for why men make appointments with urologists.


What are the 3 best predictors of TD?

1. Decreased sex drive

2. Erectile dysfunction (ED)

3. Decreased frequency of morning erections

T is a hormone that is essential to male vitality. TD can affect the function of many different organ systems and negatively impact one’s quality of life. Its signs and symptoms can vary greatly. Since T regulates the male sexual response—including desire, arousal, erections, ejaculation and orgasm—sexual dysfunction is a common component of TD and is often the presenting symptom. Low T can give rise to diminished libido, altered penile rigidity, decreased morning and nocturnal erections, decreased ejaculate volume and has been associated with delayed ejaculation. Other common symptoms are decreased energy and vigor, fatigue, muscle weakness, increased body fat, depression and impaired concentration and cognitive ability. Common signs are weight gain, visceral obesity (increased waist circumference), decreased muscle mass and bone density, decreased body and pubic hair, gynecomastia (male breast development) and anemia.

TD is often seen in men with chronic diseases including obesity, diabetes, metabolic syndrome, osteoporosis, HIV infection, opioid drug abuse, and chronic steroid usage.

Why does TD occur?

TD can result from a problem with the ability of the testes to produce T, or alternatively, because of an issue with the hypothalamus or pituitary gland in which there is inadequate production of the hormones that trigger testes production of T. At times there is adequate T, but impairment of T action because of inability of T to bind to the appropriate receptors. Additionally, increased levels of sex hormone binding globulin (SHBG), a molecule that binds T, can result in decreased levels of “available” T despite normal T levels.

Not an Exact Science

It is important to note that not everybody who has a low T level will have characteristic signs and symptoms and also that it is possible to have signs and symptoms of TD with a normal T level.

 Checking for TD should be done under the circumstance of a male complaining of any of the aforementioned symptoms and signs. Shortcomings of measuring T levels are results that can vary from laboratory to laboratory, a lack of a consistent and clinically relevant reference range for T, the variability of T levels depending on time of day that levels are drawn (values are highest in the early morning) and the fact that it is the free T and not the total T (TT) that is “available” to most tissues. T circulates in the blood mainly bound to proteins (SHBG and albumin). It is free T and albumin-bound T that are tissue “available” and active.

If TT and/or free T are low, the levels of the pituitary hormones luteinizing hormone (LH) and prolactin (P) levels should be obtained to distinguish between a pituitary versus a testes issue. Symptomatic men with a TT < 350 are candidates for treatment. A 3-6 month trial of treatment may also be considered in men with symptoms and signs, but without definitive TD on lab testing since there is no absolute T level that will reliably distinguish who will or will not respond to treatment.

T and Prostate Cancer

Although testosterone deprivation has proven effective in treating advanced prostate cancer, there is no evidence to support that treatment of TD with T will increase the risk of prostate cancer. Studies indicate that if T < 250, increasing levels of T will stimulate prostate growth, but once T > 250, a saturation point (threshold) is reached with further increases in T causing little or no additional prostate growth.

T and Cardiac Disease

 A broad review of many articles fails to support the view that T use is associated with cardiovascular risks. In fact, the weight of evidence suggests that treating TD offers cardiovascular benefits.

T and Fertility

T causes impaired sperm production as T is a natural contraception and T replacement should not be used in men desiring to initiate a pregnancy.

TD Treatment

There are numerous different means of T treatment. T pills are not a satisfactory option since testosterone is inactivated in its pass through the liver. There is a buccal formulation that is placed and absorbed between the gum and cheek. There are numerous skin formulations including patches and gels. These skin formulations are commonly used, but are expensive, carry the risk of transference to children, spouses, and pets, and can cause skin irritation. They have the advantage of flexible dosing, easy administration, and immediate decrease in T levels after stopping treatment. Long-acting T pellets can be implanted in the fatty tissue of the buttocks, generally effective for 3 to 4 months or so. The insurance hoops that are required to get this formulation approved and covered have proven to be a major challenge. T injections are also commonly used, typically using a slowly absorbed “depot” injection that, depending on the dosage, can last 1-3 weeks. There is also a very long-acting formulation that, like the T pellets, requires a very taxing process to gain insurance approval.

As an alternative to T replacement, clomiphene citrate is a selective estrogen receptor modulator that when taken on a daily basis will increase both testosterone levels and sperm count by stimulating natural testes production. Human chorionic gonadotropin (hCG) can be used as well. Advantages are that they stimulate natural testosterone production and do not impair sperm count.

Adverse Effects of T Treatment

Careful monitoring is imperative for anybody on T treatment. T levels must be checked in order to assure levels in the proper range. Prostate exams and PSA levels are used to monitor the prostate gland and a periodic blood count is performed to ensure that one’s red blood cell count does not becoming too elevated, which can incur the risk of developing blood clots.

It is important to understand that external T will suppress whatever natural T is being made by the testes, since the body recognizes the T and the testes loses its stimulation to produce both T and sperm. Long term T use can cause atrophy (shrinkage) of the testes.

Ongoing Treatment

Those patients who are experiencing benefits of T treatment can have periodic “holidays” of discontinuation to reassess the continued need for the treatment.

Excellent resource: Diagnosis And Treatment Of Testosterone Deficiency: Recommendations From The Fourth International Consultation For Sexual Medicine, Journal of Sexual Medicine 2016; 13:1787 – 1804

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

What You Don’t Know About Testosterone Treatment…and Perhaps A Better Option

January 10, 2015

Andrew Siegel MD  1/10/15

shutterstock_orange gu tract

The Magic Of T

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

Some Necessary Science

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

The Effects of Being on Long-Term Testosterone Replacement

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

Thus, using T results in the testes shutting down production of natural T and sperm and after long-term T use, the testes can actually shrivel, becoming ghosts of their former functional selves. And if you stop the T after long-term use, natural function does not resume anytime quickly.  Although recovery of natural testosterone and sperm production after stopping T replacement usually occurs within 6 months or so, it may take several years and permanent detrimental effects are possible.  So, at the time that you are receiving the benefits of exogenous T, your natural T is shut off and you can end up infertile, with smaller testicles (testicular atrophy, in urology parlance)!

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

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

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

Works Like A Charm

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

Not FDA Approved For Low T

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

Bottom Line: Treatment to boost T levels should only be done when one has genuine symptoms of low T and a low T level documented on lab testing. It is imperative to monitor those on such treatment on a regular basis. Using T to boost T can result in shutting down the testes and the possibility of atrophied, non-functional testes that do not produce sperm or natural testosterone. CC is an oral, less expensive alternative that stimulates natural T production.

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

Wishing you the best of health,

2014-04-23 20:16:29


A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health:

Co-creator of Private Gym pelvic floor muscle training program for men

Snippety Snip: Should You Get a Vasectomy???

February 15, 2014

Blog # 141

Screen Shot 2014-02-14 at 4.30.30 PM

(Image designed by Jeff Siegel)

With February 14, 2014 having just passed—a day filled with roses and chocolates—it is interesting to note that there are those who believe that it is a vasectomy that makes the ultimate Valentine’s Day gift!  If you are comfortable with the size of your family, tired and unhappy with birth control, or you have determined that you do not want to have more children, than a vasectomy may be a consideration. Every year, half a million men in the USA decide to have a vasectomy as a means of permanent birth control.  Vasectomy is the most effective means of contraception, second only to abstinence. During a vasectomy, each vas deferens, aka, vas (the tube that transports sperm) is cut and sealed, preventing the sperm from being present in the semen. It is a simple, safe, and time-honored means of achieving permanent male fertility control.

The female version of a vasectomy is a tubal ligation  (blocking the fallopian tubes to prevent pregnancy). This is an effective technique as well; however, vasectomy is a skin-deep procedure versus a tubal ligation, a much more invasive procedure because it requires going into the abdomen. Additionally, a vasectomy can be performed under local anesthesia with or without intravenous sedation whereas tubal ligation requires general anesthesia, and there exists a simple test for the effectiveness of vasectomy, but no such tests for tubal ligations (aside from a costly and uncomfortable x-ray test).  Vasectomy is safer and cheaper than a tubal ligation. Something else to consider is that the one-time cost of a vasectomy may prove less expensive over time than the cost of other birth control methods including oral contraceptives and condoms.   In general, insurance companies are very willing to cover vasectomy for no reason other than they are less expensive to their bottom line than are more pregnancies.

Basic anatomy:  The testicles are responsible for sperm production.  After sperm cells are manufactured, they ascend into the epididymis, a comet-shaped structure located behind the testicles. From the epididymis arises the vas deferens that runs up the groin in the spermatic cord, then courses behind the bladder where its terminal end forms the ejaculatory duct. This duct empties into the urethra, the channel that conducts urine and semen through the penis.

Consultation:  Before considering a vasectomy, it is important to have an initial consultation with a urologist, the surgeon who performs this procedure. This includes a medical history and physical examination that is brief and painless, with ample time allotted for a detailed discussion about the vasectomy process and for answering any questions that you or your spouse might have.

Procedure: Vasectomy is considered to be a minor surgical procedure, which is typically performed in the office or ambulatory surgery setting. It usually takes 20 minutes or so to perform. It can be done under local anesthesia with or without intravenous sedation. It has been my experience that intravenous sedation makes the procedure much more comfortable for the patient and easier for the surgeon.  With sedation, you will be conscious yet calm and comfortable while monitored under the expert care of an anesthesiologist.

After sedation is established, the scrotum is shaved and cleansed.  The area is draped with sterile surgical towels so that only a small area of skin is exposed.  Local anesthesia is administered and via two tiny punctures in the scrotum, the vas is accessed.   There are many different ways to interrupt the sperm flow—I prefer removing a ½ inch segment of vas, doubly clipping each end, and using cautery to seal the edges. The small puncture in the skin may be closed with a suture that will dissolve, or alternatively, skin glue.  The vas specimens are sent out to a pathologist for standard review.

Recovery:   Restrictions of activities for the first 24 hours will reduce the chance of swelling, bruising, bleeding, and pain.  An application of an ice pack to the scrotum intermittently for the first 24 hours—20 minutes on and 20 minutes off—is effective to help reduce swelling. Mild discomfort is typical and is best treated with an anti-inflammatory such as ibuprofen. Wearing elastic, supportive jockey shorts is helpful to keep the scrotum immobilized. It is normal to experience swelling, minor pain, and spotting from the incision for several days. It is important to restrict heavy lifting and exercise for approximately 5-7 days, but the activities of daily living including walking, stair climbing, working and sex can be resumed as soon as you are feeling well enough.

Follow-Up: It is imperative to obtain a semen analysis to ensure absence of sperm in the semen. It can take weeks to months until all the sperm are cleared, but typically after 20 or so ejaculations most men will no longer have sperm in the semen.  It is very important to continue using contraception until the sperm count is determined to be zero.


  • Temporary bleeding, bruising, pain.
  • Ongoing pain due to congestive epididymitis—on occasion the epididymis can become painfully swollen with sperm congestion, which is usually easily treated with ibuprofen and rest
  • Infection—very rare because the scrotum has such a wonderful blood supply
  • Sperm granuloma—a small, hard lump that feels like a bead at the end of the divided vas; this forms when sperm leak from the severed vas and inflame the surrounding tissue. This is usually treated with rest and ibuprofen and, on rare occasions, surgery is required to remove it.
  •  Recanalization (leading to failure of the procedure)—this is when the cut ends of the vas deferens grow back together and you regain fertility, an extremely rare situation occurring in approximately 1/1000 patients.

Q & A (I have collated the ten most commonly asked questions by patients regarding their vasectomy.)

Q.  Will my testicles still make sperm after my vasectomy?

A.  Yes; but your body absorbs and disposes of them.


Q.  Will I notice a difference in my ejaculate volume?

A.  Since the sperm only contributes a small amount of the seminal volume, there should be no noticeable difference in the volume of the semen.


 Q. Does vasectomy protect me against sexually transmitted diseases?

 A. No, no, no…I repeat no!  Use protection!


 Q.  Is sex different after vasectomy?

 A.  Generally no, although some men say that without the worry of accidental pregnancy and the bother of other birth control methods, sex after vasectomy is more relaxed and enjoyable than ever before.


Q.  Does vasectomy affect my ability to get an erection or change the way I urinate?

A. No.


Q.  Does vasectomy affect my testosterone level?

A. No.


Q.  Is vasectomy reversible?

A.  It is reversible with the best results achieved in the initial 10 years following vasectomy. Vasectomy reversal is a complicated procedure requiring general anesthesia and microscopic reconnection of the blocked vas deferens. It typically takes several hours to perform.  It’s a big deal whereas a vasectomy is a little deal.


Q.  A few years ago I heard that vasectomy could cause prostate cancer–is that true?

A.  Vasectomy does not cause prostate cancer; however, men who undergo vasectomies have relationships with urologists, the specialists who are attuned to prostate issues, and therefore, men who undergo vasectomy are more likely to undergo prostate cancer screening and diagnosis than the average man who does not see a urologist.


 Q. Why should I bother with sedation? How about just local anesthesia?

 A.  I never met a patient who enjoyed having a needle placed into his scrotum and local anesthetic injected; with sedation, there will be no awareness of that happening.  Furthermore, with the inevitable anxiety that patients experience concerning surgery on their genitals, there is typically a reflex contraction of several muscles (cremaster and dartos muscles) that effectively lift the testicles high in the scrotum and sometimes into the groin, making the procedure technically more difficult. The sedation promotes emotional and physical relaxation and makes the procedure technically so much easier for the surgeon and so much more pleasant for the patient.=


Q. How does one do a semen analysis?

A.  It involves masturbating into a specimen cup.  Place the cup into a paper bag and bring it to the designated lab along with the prescription for the semen analysis. Try to get it to the lab as quickly as possible.  The specimen will be studied under the microscope for the presence of sperm. 


Andrew Siegel, M.D.

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Testosterone: Not Just For Men; Estrogen: Not Just For Women

October 5, 2013

Andrew Siegel MD Blog # 122

What’s going on with the unrelenting direct–to-consumer television advertising for medications?  On television and radio we are bombarded with ads for drugs for the “ABC” diseases—ED (erectile dysfunction), OAB (overactive bladder), low T (testosterone).  What’s all this hubbub about T (testosterone) anyway?  Why is T suddenly so special, so hot and trendy, the hormone de jour, the “new” Viagra?  Is this for real or mere media hype?

Medicine is truly in its “infancy” with respect to its understanding of the male and female sex hormones, testosterone (T) and estrogen (E), respectively. Not too long ago it was dogma that T was solely the male hormone and that E was solely the female hormone.  As is often the case in science, “dogma” turns to “dog crap” with time, research, and progressive understanding.

Dr. Joel Finkelstein, in the September 13, 2013 New England Journal of Medicine, disrupted the endocrine status quo and provided the scientific basis for the major importance of both T and E for male health and wellness (and there is little doubt that both E and T are also equally crucial for female health and wellness). His study clearly demonstrated that muscle size and strength are controlled by T; fat accumulation is primarily regulated by E; and sexual function is determined by both T and E.

Some basics about T:

In the life of the male embryo, T is first produced during the mid-first trimester, and this hormonal surge causes the male external genitalia (penis and scrotum) and internal genitalia (prostate, seminal vesicles, etc.) to develop. In the absence of T, the fetus becomes a female, making the female gender the “default” sex. Dihydrotestosterone (DHT) is the activated form of T required by the fetus to initiate the development of male physical characteristics. In the absence of DHT, male genitalia do not develop.  DHT is far more potent than T and is the hormone that also gives rise—much later in life—to male pattern baldness and the condition of benign prostate enlargement.

T is produced mostly in the testes, although the adrenal glands also manufacture a small amount. T has a critical role in male development and physical characteristics. It promotes tissue growth via protein synthesis, having “anabolic” effects including building of muscle mass, bone mass and strength, and “androgenic” (masculinizing) effects at the time of puberty.  With the T surge at puberty many changes occur: penis enlargement; development of an interest in sex; increased frequency of erections; pubic, axillary, facial, chest and leg hair; decrease in body fat and increase in muscle and bone mass, growth and strength; deepened voice and prominence of the Adam’s apple; occurrence of fertility; and bone and cartilage changes including growth of jaw, brow, chin, nose and ears and transition from “cute” baby face to “angular” adult face.  Throughout adulthood, T helps maintain libido, masculinity, sexuality, and youthful vigor and vitality. Additionally, T contributes to mood, red blood cell count, energy, and general “mojo.

Thanks to the advertising of Big Pharma, patients now come to the office requesting—if not demanding—to know what their T levels are. Prescriptions for T have increased exponentially over the last five years, creating a $2 billion industry with numerous pharmaceutical companies competing for a piece of the lucrative T pie, as the cost of the product is minimal and the markup is prodigious.  Little did Butenandt and Hanisch—who earned the Nobel Prize in chemistry for their synthesis of testosterone from cholesterol way back in 1939—know of what their discovery would lead to 70 years later!

Who Knew? Humans manufacture T using cholesterol as a precursor, so don’t be under the delusion that all cholesterol is bad. However, don’t get carried away consuming cholesterol-laden foods reasoning that the Big Mac with cheese will raise your T.

T can bind to specialized receptors that are present in many cells in the body and exert numerous anabolic and androgenic effects; alternatively, T can be converted to 5-DHT  (the active form of T) or can be converted to estradiol—a form of E—by the chemical process of aromatization. More than 80% of E in men is derived from T as a source. When levels of T are low, there is a decline in E levels. E deficiency is important in terms of osteopenia (bone thinning) in both men and women.

Dr. Finkelstein’s study was really a more sophisticated and quantitative take on the original study by organic chemist Professor Fred Koch at the University of Chicago in 1927, this time using humans instead of animals, and quantitating the effect of the T replacement as opposed to a qualitative assessment. Professor Koch used capons—roosters castrated surgically (having their testes removed) at a young age.  He then injected them with a substance obtained from bull testicles—readily available from the Chicago stockyards—which essentially was T.   After injecting the capons with this extraction, the capons crowed like roosters, a feat that capons are incapable of.  When the study was repeated in castrated pigs and rats, the substance was found to re-masculinize them as well.  Unlike Professor Koch, who used surgically castrated animals, Dr. Finkelstein used humans who were temporarily “castrated” via a reversible medication.

In Dr. Finkelstein’s study, as reported in the NEJM, there were 2 groupings of 5 populations of men. Both groupings had their T production blocked chemically. One population was given no replacement T, another 1.25 grams T daily, another 2.5 grams T daily, another 5 grams T daily, and the last group 10 grams T daily. The average serum T and E levels of each population were the following: no testosterone replacement: 44/3.6; 1.25 grams: 191/7.9; 2.5 grams: 337/11.9; 5 grams: 470/18.2; 10 grams 805/33. The second grouping of 5 populations had their E blocked as well.  Testing was done to see the effects of T and E levels on lean mass, muscle size and strength, fat mass, and sexual function.

By looking at the aforementioned numbers, one can see a direct relationship between T dose and serum level of both T and E.  The higher the T dose, the greater is the serum T and E.  The study concluded that lean mass, muscle size and strength were T dose-dependent, meaning the higher the T, the more the lean mass, muscle size and strength.  Additionally, fat mass was seen to be E dose-dependent and sexual function was both T and E responsive.

Dr. Finkelstein concluded that E deficiency in men is a manifestation of severe T deficiency and is remediable by T replacement. Fat accumulation seems to occur with a mild T deficiency (T measurements in the 300-350 range); muscle mass and muscle strength are preserved until a more marked T deficiency (T <200) occurs.   E was shown to have a fundamentally important role in the regulation of body fat and sexual function and evidence from previous studies demonstrated a crucial role for E in bone metabolism. Therefore, low T is not just about low T, but is also about E deficiency, which is responsible for some of the key consequences of T deficiency. Measuring levels of E are helpful in assessing sexual dysfunction, bone loss, and fat accumulation in men with low T.

The amount of T made is regulated by the hypothalamus-pituitary-testicular axis, which acts like a thermostat to regulate the levels of T.  Healthy men produce 6-8 mg testosterone daily, in a rhythmic pattern with a peak in the early morning and a lag in the later afternoon. T levels can be low based upon testicular problems or hypothalamus/pituitary problems, although the problem most commonly is due to the aging testicle’s inability to manufacture sufficient levels of T.  T levels gradually decline—approximately a 1% decline each year after age 30—sometimes giving rise to symptoms.  These symptoms may include the following: fatigue; irritability; decreased cognitive abilities; depression; decreased libido; ED; ejaculatory dysfunction; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; and abnormal lipid profile. A simple way to think about the effect of low T is that it accelerates the aging process.

T is commonly prescribed for T deficiency when it becomes symptomatic. There are many means of testosterone replacement therapy (TRT).  Oral replacement is not used because of erratic absorption and liver toxicity. Injections are not the first-line means of TRT because of wide fluctuations in testosterone levels and injection site reactions. There are a number of testosterone gel formulations that are commonly used. There are also skin patches, pellets that are injected into the fatty tissue of the buttocks, and a formulation that is placed in the inner cheek or gum. Currently in the works is a long-acting injection.

Men on replacement T need to be followed carefully to ensure that the TRT is effective, adverse effects are minimal, and blood levels are in-range. Periodic digital rectal exams are important to check the prostate for enlargement and irregularities, and, in addition to T levels, other blood tests are obtained including a blood count and PSA (Prostate Specific Antigen).  Potential complications of TRT include acne and oily skin, increased hematocrit (thicker, richer blood), worsening of sleep apnea, hair loss, and suppression of fertility.

Bottom Line: T and E levels are of vital importance to men (as well as women), greatly impacting physical development, sexuality, mood, energy levels, etc. So while T advertisements may be annoying and confusing, it is wise nonetheless to assess and monitor T levels, particularly if one is experiencing any of the myriad of symptoms associated with low T.

Reference: “Gonadal Steroids and Body Composition, Strength, and Sexual Function in Men by Joel Finkelstein, M.D., et al:  ”The New England Journal of Medicine (September 12, 2013)

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health;  book is in press and will be available in e-book and paperback formats in November 2013.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.

Testicular Torsion

January 5, 2013

Andrew Siegel, M.D.   Blog # 89


All organs and tissues need a blood supply to remain alive and vital.  The blood supply to each testicle is located within a rope-like “cord” of tissue that travels from the groin into the scrotum.  Both the testicular artery and the testicular vein are within this spermatic cord that can be considered to be the life support of the testicle. The artery delivers oxygen and other vital nutrients to the testicle; the veins convey carbon dioxide and other products of cellular metabolism from the testicle to the heart.

Anything that can jeopardize the blood supply to the testicles can affect their vitality. Torsion is defined as a twist of the testes and spermatic cord around a vertical axis, resulting in a kink and thus compromise to the blood flow—this can lead to possible strangulation of the blood supply and infarction (death by lack of blood flow) of the testicle. The testicle can spin 360°, 720° or any conceivable amount.  When this occurs, it typically causes an acute onset of pain and swelling in the testicle, and often the pain radiates to the groin and lower abdomen; it can be easily confused with appendicitis when it involves the right testicle.  Although torsion can occur at any age, it is most common among adolescents at the time of or shortly after puberty, typically ages 12-20.

When torsion occurs, the spermatic cord is foreshortened and the testicle tends to rise higher in the scrotum than its normal anatomical location.  On examination, the twisted testicle is usually very tender and swollen.  Torsion is a surgical emergency, because if the testicle is not untwisted on a timely basis, the testicle can die (suffer an infarction).   However, when diagnosed on a timely basis, the testis can be untwisted and surgically fixated to prevent recurrent episodes.   When it comes to torsion, time is of the essence.  It is for this reason that testicular pain needs to be expediently checked out by a medical professional.

Torsion of the testicle can be misdiagnosed as epididymitis, an infection/inflammation of the epididymis which is the sperm storing structure located immediately above and behind the testicle. If the situation is equivocal, a color Doppler ultrasound or testicular scan can be helpful in making the distinction.  If there is any doubt, a trip to the operating room is in order.

At times, the testicle can be untwisted in the office or emergency room and the patient can then be electively brought to the operating room where the testicle is fixated to the scrotal skin to prevent it from re-torting in the future. Typically the other testicle is fixated as well.  The fixation is done by placing three or so sutures in each testicle, thereby anchoring the testicle to the scrotal wall with this three-point fixation technique.

At other times, the testicle cannot be untwisted and the patient must be brought to the operating room in an emergency (as opposed to elective) basis for a scrotal exploration and untwisting of the testicle under direct vision to determine its viability. Typically once it is untwisted, the testicle shows signs of life (turning from a dusky color to pink), but if too much time has transpired, the testis can appear to be black and necrotic (dead) and instead of being fixed to the scrotal skin, it must be surgically removed.   Correction within 6 hours of the onset of pain usually will salvage a testicle.


Bottom Line:  Torsion of the testicle is a surgical emergency. If you or someone you know has acute onset of unremitting testicular pain, make sure you/they get to the emergency room ASAP, because time is of the essence with respect to being able to salvage a twisted testicle.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.  On the lower right margin of the blog you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Testes Exam

December 8, 2012

Testes Exam


Andrew Siegel, M.D.   Blog # 85

Question: For genital health issues, women have gynecologists, but who do men have for their genital health issues?

 Answer: Urologists


The next five blogs will be dedicated to men’s health issues.  Today’s blog will cover examination of the testicles and the next three will cover penile issues—fracture of the penis, priapism, and Peyronie’s disease—and the final will be on testicular torsion.


Examining one’s testicles is a simple task that can be lifesaving.  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 very good clinical use.  What follows will also be appropriate for the partner of the man in question.  Several times in my career as a urologist, it has been the man’s partner that was astute enough to recognize a problem that prompted the patient visit in which a diagnosis of testicular cancer was made.

Although rare, testicular cancer is the most common solid malignancy in young men, with the greatest incidence being in the late 20’s, striking men at the peak of life.  Lance Armstrong, Scott Hamilton, Eric Shanteau, Tom Green, John Kruk, Brian Piccolo, Richard Belzer, and Bernard Goetz are all members of the testicular cancer club.

The great news is that it is a very treatable cancer, especially so when picked up in its earliest stages, when it is commonly curable.  One of the great advantages of having one’s gonads positioned in such an accessible locale (as opposed to the ovaries) is that examination and early cancer diagnosis is a cinch (once again, as opposed to the ovarian cancer, which most often presents at an advanced stage).

The goal of self or partner-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 lung, which are common sites of metastasis in advanced testicular cancer.

In its earliest phases, testes cancer will cause a lump, irregularity, asymmetry, enlargement or heaviness of the testicle.  It most often does not cause pain, so the absence of pain is not a feature that should dissuade you from getting an abnormality looked into.  If you feel something that was not present previously, please see a urologist—I promise that you will never be chided for being a “hypochondriac” for getting something checked out.  It is truly better to be safe and cautious.

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 testicle feels firm, similar to the consistency of a hard-boiled egg, although it 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.  It is important to know that not every testes abnormality is a cancer; in fact, most are benign.  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.

And to every wife, girlfriend, partner…if your man is a stoic kind of guy who is not likely to examine himself here is what to do—at a passionate moment, pursue a subtle, not-too-clinical exam under the guise of intimacy—it may just end up saving his life.

Bottom line: Have the “cajones” to check your or your partner’s cajones.  Because sperm production requires that the testicles are kept cooler than core temperature, nature has conveniently designed man with his testicles gift wrapped in a satchel dangling from his mid-section. There is no organ in the body—save the breasts—that are more external and easily accessible.  Take advantage of that accessibility to do regular exams—it just might be lifesaving.

For more info:


 Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every Saturday morning.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts by email. Please avail yourself of these educational materials and share them with your friends and family.