Posts Tagged ‘vas deferens’

Ejaculation: His and Hers

March 12, 2016

Andrew Siegel, MD   3/12/2016

One of the advantages of the specialty of urology is that it encompasses patients of both genders, unlike gynecology, which strictly involves females. Since I am board certified in Urology as well as in Female Pelvic Medicine, my practice allows me to have an equal balance of male and female patients. This gives me the opportunity to appreciate comparative male and female pelvic anatomy and function, which in reality are remarkably similar–a fact that may surprise you.

 A Few Brief Words on the Embryology of the Genitals.

Who Knew? Female and male external genitals are remarkably similar. In fact, in the first few weeks of existence as an embryo, the external genitals are identical.

The female external genitals are the “default” model, which will remain female in the absence of the male hormone testosterone. In this circumstance, the genital tubercle (a midline swelling) becomes the clitoris; the urogenital folds (two vertically-oriented folds of tissue below the genital tubercle) become the labia minora (inner lips); and the labio-scrotal swellings (two vertically-oriented bulges outside the urogenital folds) fuse to become the labia majora (outer lips).

Gray1119

(Comparison of genital anatomy,  1918 Gray’s Anatomy, Dr. Henry Gray, public domain)

In the presence of testosterone, the genital tubercle morphs into the penis; the urogenital folds fuse and become the urethra and part of the shaft of the penis; and the labio-scrotal swellings fuse to become the scrotal sac.  So, the clitoris and the penis are essentially the same structure, as are the outer labia and the scrotum.                                                                                              

Ejaculation

Ejaculation is the expulsion of fluids at the time of sexual climax. The word “ejaculation” derives from ex, meaning out and jaculari, meaning to throw, shoot, hurl, cast. We are all familiar with male ejaculation, an event that is obvious and well understood and well studied. However, female ejaculation is a mysterious phenomenon and a curiosity to many and remains poorly understood and studied.

Male Ejaculation

Men often “dribble” before they “shoot.” The bulbo-urethral glands, a.k.a. Cowper’s glands, are paired, pea-sized structures whose ducts drain into the urethra (urinary channel). During sexual arousal, these glands produce a sticky, clear fluid that provides lubrication to the urethra. (These glands are the male versions of Bartholin’s glands in the female, discussed below).

Once a threshold of sexual stimulation is surpassed, men reach the “point of no return,” in which ejaculation becomes inevitable. Secretions from the prostate gland, seminal vesicles, epididymis, and vas deferens are deposited into the urethra within the prostate gland. Shortly thereafter, the bladder neck pinches closed while the prostate and seminal vesicles contract and the pelvic floor muscles (the bulbocavernosus and ischiocavernosus) spasm rhythmically, sending wave-like contractions rippling down the urethra to forcibly propel the semen out in a pulsatile and explosive eruption. Ejaculation is the physical act of expulsion of the semen, whereas orgasm is the intense emotional excitement and climax, the blissful emotions that accompany ejaculation.

Male_anatomy

(Male Internal Sexual Anatomy, permission CC BY-SA 3.0, created 18 April 2009)

What’s in the Ejaculate?

Less than 5% of the volume is sperm and the other 95+% is a cocktail of genital secretions that provides nourishment, support and chemical safekeeping for sperm. About 70% of the volume comes from the seminal vesicles, which secrete a thick, viscous fluid and 25% from the prostate gland, which produces a milky-white fluid. A negligible amount is from the bulbo-urethral glands, which release a clear viscous fluid that has a lubrication function. The average ejaculate volume is 2-5 milliliters (one teaspoon is the equivalent of 5 milliliters).

Who Knew?  While a huge ejaculatory load sounds desirable, in reality it is correlated with having fertility issues. The sperm can literally “drown” in the excess seminal fluid.

Female Ejaculation

This is a much less familiar subject than male ejaculation and a curiosity to many. Only a small percentage of women are capable of expelling fluid at the time of sexual climax.

The nature of this fluid is controversial, thought by some to be excessive vaginal lubrication and others to be glandular secretions. Although the volume of ejaculated fluid is typically small, there are certain women who ejaculate very large volumes of fluid at climax. Expulsion of fluid at climax may come from four possible sources: vaginal secretions; Bartholin’s glands; Skene’s glands; and the urinary bladder.

Skenes_gland

(Skene’s and Bartholin’s Glands, created 22 January 2007, original uploader Nicholasolan  en.wikipedia, Permission: CC-BY-SA-2.5, 2.0, 1.0; GFDL-WITH-DISCLAIMERS; CC-BY-S)

During female arousal and sexual stimulation, the vaginal walls lubricate with a “sweating-like” reaction as a result of the increased blood flow to the genitals and pelvic blood congestion, creating a slippery and glistening film. The amount of this lubrication is highly variable. Some women with female ejaculation can release some of this fluid at the time of climax by virtue of powerful contractions of the vaginal and pelvic floor muscles.

Bartholin’s glands are paired, pea-size glands that drain just below and to each side of the vaginal opening. They are the female versions of the male bulbo-urethral glands and during sexual arousal they secrete small drops of fluid, resulting in moistening of the opening of the vagina.

Skene’s glands (para-urethral glands) are paired glands that drain just above and to each side of the urethral opening. They are the female homologue of the male prostate gland and secrete fluid with arousal.

Scientific studies have shown that those women who are capable of ejaculating very large volumes are actually having urinary incontinence due to an involuntary contraction of the urinary bladder that accompanies orgasm. This is often referred to as “squirting.”

Bottom Line: In the animal kingdom (including human beings), sex is a clever “bait and switch” scheme. In the seeming pursuit of a feel-good activity, in reality—determined by nature’s evolutionary sleight of hand—participants are hoodwinked into reproducing. The ultimate goal of the reproductive process is the fusion of genetic material from two individuals to perpetuate the species.

The penis functions as a “pistol” to place DNA deeply into the female’s reproductive tract with ejaculation a necessity for the process. Similarly, the female genitals need to be sufficiently lubricated to optimize this process and the combination of vaginal lubrication from enhanced blood flow contributed to by Skene’s and Bartholin’s secretions will optimize nature’s ultimate goal.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym and PelvicRx, comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Arnold Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store that is home to quality urology products for men and women.  Use code UROLOGY10 at check out for 10% discount. 

 

 

 

 

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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.

Risks: 

  • 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. 

HAPPY VALENTINE’S DAY!!!

Andrew Siegel, M.D.

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What The Heck is Urology?

August 24, 2013

Andrew Siegel, MD  Blog #116

“Urology” (uro—urinary tract and logos—study of) is a medical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in females and of the genitourinary tract in males. The organs under the “domain” of urology include the adrenal glands, kidneys, the ureters (tubes connecting the kidneys to the urinary bladder), the urinary bladder and the urethra (the channel that conducts urine from the bladder to the outside).  The male reproductive organs include the testes (i.e., testicles), epididymis (structures above and behind the testicle where sperm mature and are stored), vas deferens (sperm duct), seminal vesicles (the structure that produces the bulk of semen), prostate gland and, of course, the scrotum and penis.  The reproductive and urinary tracts are closely connected, and disorders of one oftentimes affect the other…thus urologists are referred to as  “genitourinary” specialists. Urology involves both medical and surgical strategies to approach a variety of conditions.

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

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

Very common reasons for a referral to a urologist are the following: blood in the urine, whether it is visible or picked up on a urinalysis done as part of an annual physical; an elevated PSA (Prostate Specific Antigen) or an accelerated increase of PSA over time; prostate enlargement; irregularities of the prostate on examination; urinary difficulties ranging the gamut from urinary incontinence to the inability to urinate (urinary retention).

Urologists manage a variety of non-cancer issues. Kidney stones, which can be extraordinarily painful, keep us very busy, especially in the hot summer months when dehydration (a major risk factor) is more prevalent. Infections are a large part of our practice and can involve the bladder, kidneys, prostate, or the testicles and epididymis.  Urinary infections is one problem that is much more prevalent in women than in men.  Sexual dysfunction is a very prevalent condition that occupies much of the time of the urologist—under this category are problems of erectile dysfunction, problems of ejaculation, and testosterone issues. Urologists treat not only male infertility, but create male infertility when it is desired by performing voluntary male sterilization (vasectomy).   Urologists are responsible for caring for scrotal issues including testicular pain and swelling.   Many referrals are made to urologists for blood in the semen.

Training to become a urologist involves attending 4 years of medical school after college and 1–2 years of general surgery training followed by 4 years of urology residency. Thereafter, many urologists like myself pursue additional sub-specialty training in the form of a fellowship that can last anywhere from 1–3 years.  Urology board certification can be achieved if one graduates from an accredited residency and passes a written exam and an oral exam and has an appropriate log of cases that are reviewed by the board committee.  One must thereafter maintain board certification by participating in continuing medical education and passing a recertification exam every ten years.  Becoming board certified is the equivalent of a lawyer passing the bar exam.

In addition to obtaining board certification in general urology, there are 2 sub-specialties within the scope of urology in which sub-specialty board certification can be obtained—pediatric urology, which is the practice of urology limited to children and female pelvic medicine and reconstructive surgery (FPMRS), which involves female urinary incontinence, pelvic organ prolapse, and other female uro-gynecological issues.  The FPMRS boards were offered for the very first time in June 2013, and I am pleased to announce that I am now board certified in both general urology and FPMRS.  There are approximately 100 or so urologists in the entire country who are board certified in the urology subspecialty of FPMRS.

In terms of the demographics of urology, although urology is largely a male specialty, women have been entering the urological workforce with increasing frequency.  This is because female students now comprise approximately 50% of United States medical school population. There are 10,000 practicing urologists in the USA, of which about 500 are women. Urologists have a median age of 53, so we are not a particularly young specialty. The aging population will demand more urological health services and the Affordable Care Act will result in the dramatic expansion of the number of American citizens with health insurance. These factors combined with the aging of the urological workforce and the contraction due to retirement, all in the face of growing demands, does not augur well for a balance of supply and demand in the forthcoming years.  Hopefully there will be enough of us to provide urological care to those in the population that need it.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

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Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, in press and available in e-book and paperback formats in the Autumn 2013.

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