(The following article is contributed by Dr. Howard Woo)
Benign prostatic hyperplasia (BPH) is one of the most common diseases to affect men beyond middle age. Histological disease is present in more than 60% of men in their 60s, and over 40% of men beyond this age have lower urinary tract symptoms (LUTS); about half of this group has an impaired quality of life. The prevalence increases with age, and thus the absolute number of patients affected is rising worldwide as a result of aging populations.
At current intervention rates, about one fifth of patients with symptomatic disease who present to a doctor will eventually be treated surgically. The remainder will often be managed initially by ‘watchful waiting’. However, the majority of these individuals suffer gradual progression of symptoms and the bother associated with them, and increasingly require treatment either with medication or surgery.
Nowadays, BPH is rarely a life-threatening condition. Deterioration of symptoms and urinary flow is usually slow, and serious outcomes, such as renal insufficiency, are uncommon. The risk of acute urinary retention (AUR), however, increases with prostate size, and requires urgent hospitalization and often surgery. The relatively less serious symptoms of frequency, nocturia, and incomplete bladder emptying can nevertheless be very bothersome, and may impact substantially on the patient’s quality of life. In addition, men with LUTS due to BPH are also prone to erectile dysfunction (ED) and disorders of ejaculation.
Extensive research into BPH in recent years has resulted in not only a clearer understanding of its pathogenesis, but also the development of new medical and minimally invasive surgical treatments. At the same time, patients’ awareness of prostate disease has grown. Today, therefore, the choice of treatment for BPH requires a balance between several factors:
- clinical need and considerations concerning the prevention of disease progression for the individual
- the preferences of the patient and of his immediate family
- cost-benefit ratio and long-term effectiveness of therapy
Treatment that carries the proven possibility of safely enhancing the quality of life has to be tailored to the affected individual with these factors in mind.
Most men with BPH have a constellation of symptoms broadly categorized as obstructive or irritative. Obstructive symptoms include hesitancy, weak stream, straining to pass urine, prolonged micturition, feeling of incomplete bladder emptying, and urinary retention. Irritative symptoms include urgency, frequency, nocturia, and urge incontinence.
The severity of LUTS can be evaluated using the American Urologic Association Symptom Index (AUA-SI). The AUA-SI is a seven-item, patient-rated questionnaire that evaluates the severity of 7 symptoms (incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia) by rating each item on a scale of 0 to 5. The maximum total AUA-SI score is 35. A total AUA-SI score ≤ 7 indicates mild symptoms, 8-19 indicates moderate symptoms, and 20--35 indicates severe symptoms.
International Prostate Symptom Score (IPSS) includes AUA-SI plus additional on quality of life (QOL) as a function of urinary symptoms. A question like, “if you were to spend the rest of your life with your urinary condition just the way it is now, how would you fell about that?” can assess the severity of bother experienced by a patient from his urinary symptoms.
History and symptom assessment
BPH symptoms, characterized by obstructive and irritative symptoms, can be quantified with the AUA-SI or IPSS. It should be remembered, however, that these symptoms are not specific to BPH and may also occur in patients with prostate cancer, prostatitis or other disorders. Conditions such as Parkinson’s disease or stroke, polyuria from diabetes or congestive heart failure, history of urethral strictures, or treatment with anticholinergic or antidepressant drugs should be excluded of similar urinary symptoms.
A digital rectal examination (DRE) should form the cornerstone of the physical examination of patients with BPH. DRE provides useful information about the size, consistency and anatomical limits of the prostate.
Urinalysis, either by dipstick or by microscopic examination of sediment, should be performed in all me presenting with LUTS. Such investigations help to distinguish BPH from urinary tract infection or bladder cancer, which may produce symptoms similar to those of BPH.
Prostate-specific antigen (PSA)
PSA is a glycoprotein released from the epithelial cells of the prostate. In normal men, only small amounts (< 4.0 ng/mL) enter the circulation. In prostate cancer, large amounts (>4.0 ng/mL) enter the circulation. Patients with BPH usually have only minor elevations of serum PSA values.
For all men with an age of 50 or greater and a life expectancy of 10 years or more, a blood test PSA is an important tool to detect a possible prostate cancer beside DRE alone. A patient with a PSA value of 2.5 ng/mL and greater should be seen by an urologist for further evaluation to rule out possible prostate cancer. Besides detecting prostate cancer, PSA value can provide a useful indication of overall prostate volume. For example, PSA ≥ 1.5 ng/mL has shown to be related to an enlarged prostate of 30 cm3 or greater. Therefore, a higher PSA without prostate cancer, in turn, can predict those patients most likely to suffer BPH progression and in turn facilitate the selection of agents for medical therapy of BPH.
Electronic measurement of urine flow rates is an extremely useful non-invasive test in most patients with BPH. Uroflometry measures a number of parameters of obstruction, of which the most important is the peak flow rate. In general, those men with severe impairment of urine flow (< 10 mL/second) more often suffer disease progression and eventually require medical or surgical intervention.
Measurement of residual urine
Measurement of post-void residual (PVR) urine is also a useful optional test in the evaluation of BPH, as it can identify patients who are likely to respond less well to watchful waiting or medical therapy. In general, PVR values above 200-300 mL usually indicate a higher likelihood of conservative therapy failing, and probably also indicate a higher risk of acute urinary retention (AUR).
Urodynamic study involves introducing a small catheter urethrally to measure pressure within the bladder to evaluate the functions of the bladder (storage and emptying) and can be used to distinguish outflow obstruction (such as BPH) from impaired bladder contractility.
Transrectal ultrasonography (TRUS)
TRUS is indicated when DRE findings and / or PSA values suggest the presence of prostate cancer; it also serves to guide the automatic prostate biopsy needle. In addition, it can be used to estimate prostate volume, which may facilitate treatment decisions.
Cystoscopy is an endoscopic examination of the lower urinary tract including the urethra, prostate, and bladder. Typically, it is done under local anesthesia. It helps an urologist to evaluate the degree of obstruction and the shape of the prostate causing bladder outlet obstruction. In addition, it allows an urologist to look inside and evaluate the bladder under direct vision.
A ‘watchful waiting’ strategy is appropriate for patients with very mild BPH symptoms (AUA-SI 7 or less) in whom prostate cancer has been excluded, and for more symptomatic patients who are not unduly bothered by their symptoms.
Various plant extracts have been used to treat BPH in Europe for many years and are becoming increasingly popular in the USA. There are, however, few controlled data to suggest that many of these compounds have anything much other than a placebo effect. Two phytochemical extracts have acquired world-wide acceptance due to increasing scientific support of their use. These plant extracts are from Saw Palmetto (Serenoa repens) and Pygeum (Prunus africana).
Medical management of BPH is suitable for most patients with moderate symptoms as well as some patients with severe symptoms. Contraindications to medical management include urinary retention and complications of BPH, such as renal impairment, bladder stones, recurrent hematuria or recurrent UTI.
There are two kinds of medical treatments for BPH: alpha-blockers and 5 alpha-reductase inhibitors. Medication is usually taken once daily for a long-term.
- Alpha-blockers: Selective alpha-blockers, such as Tamsulosin (Flomax), Alfuzosin (Uroxatral), Doxazosin (Cardura), Terazosin (Hytrin), have all been shown to increase peak urine flow rate and improve symptoms in about 60% of patients with symptomatic BPH. Symptoms usually improve within the first 2-3 weeks of treatment. The main side-effects of alpha-blockers include tiredness, dizziness, and headache, occurring in 10-15% of patients. Postural hypotension occurs in only 2-5% of patients, and this may be minimized by using new slow release formulations and more uroselective agents and perhaps taking the medication at night. Flomax is also related to retrograde ejaculation and floppy iris syndrome in some patients.
- 5 alpha-reductase inhibitors: 5 alpha-reductase inhibitors, such as Dutasteride (Avodart) and Finasteride (Proscar), act by inhibiting the enzyme 5 alpha-reductase (type I and type II) which converts testosterone to DHT. DHT plays a key role in controlling prostate growth; inhibition of these reductases causes the hyperplasia to regress. Thus, unlike alpha-blockers, 5 alpha-reductase inhibitors can potentially reverse the progress of pathological BPH by causing prostate shrinkage. The main clinical effects of these drugs may take 3-6 months to become apparent, and patients who benefit most tend to be those with larger prostates (volume 40cm3 or greater) and serum PSA values > 1.6 ng/mL. The changes in symptom scores and flow rates have been shown to be maintained in a long-term study (over 4years). The main side-effects associated with these drugs are reduced libido and erectile dysfunction, each of which occurs in 3-5% of patients. Some may also experience tender and / or enlarged breasts.
Combination therapy using both alpha-blocker and 5 alpha-reductase inhibitor has recently been shown to be the most effective medical means of preventing BPH progression and treating symptomatic BPH.
Surgical treatment is usually indicated for patients who have complications of BPH and for those who have symptoms that are inadequately controlled by medical therapy or who elect to forgo a trial of medical therapy and to receive more definitive treatment. Three standard options are available:
- Transurethral resection of the prostate (TURP)
- Transurethral incision of the prostate (TUIP)
- Open prostatectomy
In general, the operation requires hospitalization and is done under general anesthesia or spinal anesthesia. Patient is usually able to go home after 1 to 3 days. Return to normal routine takes 4 to 6 weeks. Surgical treatment produces the best improvements in symptoms and urine flow rates, and has a lower requirement for further therapy but higher incidence of complications than medical or minimally invasive treatments.
Laser ablation transurethral surgery, such as Revolix laser, Greenlight laser, and Holmium laser, has shown to be as effective as traditional TURP, and lowers bleeding and potential peri-operative electrolyte problems compared to TURP using electrical loop resectoscope. It also shortens hospitalization and recovery time. It is often done as an outpatient surgery.
Minimally Invasive Therapy
Main advantage of minimally invasive therapy is that it reduces surgical side effects such as bleeding, possible impotence (3 %), incontinence ( 1%) and retrograde ejaculation (5%). In addition, it requires no hospitalization or general anesthesia; it is done as outpatient base in an office setting under oral sedation. The treatment takes less than a hour. A patient is able to go home immediately after the procedure. The following options are available:
- Interstitial laser therapy (Indigo laser coagulation of prostate)
- Transurethral needle ablation of the prostate (TUNA)
- Intraurethral stents
- Transurethral balloon dilation of the prostate
Hyperthermia using microwave energy is most commonly delivered with a transurethral catheter. The device cools the urethral mucosa to decrease the risk of injury and causes a thermal damage to the enlarged portion of the prostate surrounding the prostate urethra.
Prolieve Thermodilation of prostate combines microwave hyperthermia therapy with transurethral balloon dilation of the prostate. It reduces post-treatment catheterization and provides symptomatic relief from an enlarged prostate in 4 to 6 weeks as the treated prostate internally shrinks. The followings are data related to Prolieve Thermodilation of prostate. At 2 weeks post procedure, 51% of patients treated had a >30% improvement in AUA symptom score. At 12 months post procedure, 74% had a >30% improvement in AUA symptom score. Results based on percent of patients present at the 12 month visit (68/92). 82% of patients go home without a catheter. Patients return to normal daily activities. 99% of patients studied reported no effect to sexual function.
The following algorithm summarizes the current evaluation and management of BPH.
Bladder Cancer is the fourth most common type of cancer in men and the eighth most common type in women. Each year in the United States, 38,000 men and 15,000 women are diagnosed with bladder cancer. The exact cause of bladder cancer is unknown; however, there are many known risk factors. A smoking history is a major risk factor. Smokers have a 2-3 times risk of getting bladder cancer compared to non-smokers.
Other risk factors include age, occupation, recurrent infections, exposure to some chemotherapy agents or arsenic and a personal or family history of bladder cancer. Your risk of bladder cancer increases as you get older. It is rare to have bladder cancer diagnosed in individuals under the age of 40. Men and Caucasians are twice as likely as women and non-Caucasians to develop bladder cancer. Hairdressers, painters, metal workers, printers, textile workers, machinists, truck drivers and those who work in the rubber, chemical and leather industries can be at an increased risk of developing bladder cancer secondary to exposure to occupational carcinogens.
The bladder is made up of four layers. These layers are the epithelium or mucosa, lamina propria, detrusor muscle and the outer perivesical fat. Superficial bladder cancer only involves the mucosa of the bladder, the inner lining. This type of cancer can recur after treatment. If it does, it typically remain superficial.
Invasive cancer of the bladder extends beyond the inner mucosal lining and may involve the muscle. If the cancer extends into the muscular layer, it is at risk for spreading to nearby organs and lymph nodes. This spread of cancerous cells to lymph nodes and other tissue is commonly referred to as metastatic disease.
Blood in the urine, hematuria, is the most common sign of bladder cancer. It may be blood that you can see, gross hematuria, or blood that only your doctor can see under the microscope, microscopic hematuria. Some common symptoms are pain during urination or frequent urination.
Your doctor will first review your medical history and then perform a physical examination. The abdomen and pelvis are felt for any tumors. A rectal or vaginal exam may also be performed. A urine test may also be performed evaluating for blood, cancer cells or infection. Imaging studies such as a computed tomography (CT) scan, magnetic resonance imaging (MRI), or intravenous pyelogram (IVP) may be ordered.
Commonly cystoscopy is utilized. This is where your doctor uses a very small lighted tube, a cystoscope, to look directly into your bladder. This is usually done in the clinic setting. Your doctor may take a biopsy of the bladder tissues and send it to a pathologist to examine for the presence of cancer cells.
- Transurethral resection: The doctor may remove early (superficial) bladder cancer with a transurethral resection (TUR). A cystoscope is inserted into the bladder and a small loop is used to remove the cancer and burn away any remaining cancer cells. Some patients are treated immediately after surgery with a single instillation of chemotherapy that is placed directly into the bladder. This is referred to as intravesical chemotherapy.
- Radical cystectomy: This is the most common type of surgery for invasive bladder cancer. This surgery involves removing the bladder, part of the urethra, nearby lymph nodes and nearby organs that may be involved with cancer cells. In men, these organs are the prostate, seminal vesicles and parts of the vas deferens. In women, these organs may be the uterus, ovaries, fallopian tubes and part of the vagina. When the entire bladder is removed, a new bladder is created using a small portion of your intestine. This new bladder may drain into a bag on the outside of the body or into a pouch created inside the body.
- Partial Cystectomy: In some cases, removal of a segment of the bladder may be performed for low grade invasive cancers in one area of the bladder. A patient can still have the entire bladder removed at a later date if the cancer recurs.
- Radiation: Some patients may be treated with radiation. Radiation uses high-energy rays to kill cancer cells. It is used as local therapy to the bladder.
- Chemotherapy: Some drugs can be used to kill cancer cells. Intravesical chemotherapy is a commonly used local chemotherapy directed at tumor cells in the bladder. It may be used directly after surgery or in the clinic setting. A catheter is inserted into the bladder and the liquid drugs are delivered through the catheter. The drug is left in the bladder for several hours. This treatment is used once a week for many weeks and may be repeated. If the bladder cancer is invasive or has spread to the lymph nodes, intravenous chemotherapy may be used, which is chemotherapy that is injected into the veins. The drug used gets into the bloodstream and can treat cancer cells throughout the body.
- Biologic Therapy (Immunotherapy): This treatment uses a patient’s immune system to fight cancer. These treatments may boost, direct or restore the body’s natural defenses against cancer. The most common solution used is BCG, which is a live, weakened bacteria that stimulates the immune system to kill cancer cells in the bladder. This solution is placed into the bladder via a catheter and left for up to 2 hours. This treatment is usually done once a week for 6 weeks.
Hematuria can occur in up to 10% of the population. Hematuria is defined as the presence of blood, or red blood cells, in the urine. Microscopic hematuria is blood that is only seen under a microscope. Gross hematuria is blood that is actually seen by the naked eye. One may see bright red blood, brown urine, pink urine or blood clots. Bleeding can occur once or it may be recurrent. The amount of blood in the urine often does not correlate with the severity of the underlying problem.
Hematuria can be a sign that there is an abnormality of any part of the genitourinary tract. This includes the kidneys, the ureter (the tube that connect the kidney to the bladder), the bladder, the prostate (in men) and the urethra (the tube through which one urinates. Some causes found include kidney stones, urinary tract infections, cancer and kidney diseases. There are some occasions where microscopic hematuria has no cause that can be found, this is called idiopathic hematuria.
Some causes of hematuria include kidney stones, urinary tract infections, benign prostatic hyperplasia, trauma, cancer and kidney diseases. There are some occasions where microscopic hematuria has no cause that can be found, this is called idiopathic hematuria.
Signs and Symptoms:
Blood in the urine (gross or microscopic) often is the only sign of an underlying disorder. A variety of other symptoms may be present depending on the individual patient. Such findings may be urinary hesitancy, urinary frequency, incomplete voiding, painful urination or abdominal pain.
Your doctor will obtain a detailed history and physical examination. Your urine will be examined under the microscope for the presence of red blood cells and other abnormalities. Your doctor may order a radiology imaging study called a CT scan, intravenous pyelogram (IVP) or a magnetic resonance imaging (MRI). Your doctor may also send the urine for cytology looking for cancer cells. Finally you may be scheduled for cystoscopy. This is a minimally invasive test where your doctor can pass a small flexible tube through your urethra to evaluate your urethra, bladder, prostate (in men) and ureteral openings.
Treatment for hematuria will depend on what your doctor finds after a thorough evaluation.
A kidney stone occurs when urine contains small crystal-like material which gradually builds up to become larger, solid crystals known as stones.
The most common symptoms for kidney stones are blood in the urine or pain in the flank, abdomen, groin, penis, vaginal, or even legs. This is quite often associated with nausea and vomiting. Patients may experience blood in their urine either seen microscopically or seen visually with the naked eye. Cloudy, foul smelling urine, fever, or chills may be a sign of serious infection which is usually dealt with on an emergency basis. Some kidney stones are called are called silent stones because there are no symptoms involved.
Some people are more likely to develop stones than others. A few of the factors includes:
- Age- more common during middle age
- Sex- twice as common in men than women
- Activity level- stones are more common in patients with a sedentary life style or in patients who lose excess fluid due to sweating, diarrhea, etc.
- Climate- stones are more common in hot climates during the summer months.
- Certain stones are associated with a family history of stones.
Urine testing – the physician will examine a urine specimen looking for blood, infection, and crystals.
X-rays- different stones are diagnosis with different types of x-rays.
- KUB - this is a plain x-ray of the abdomen. KUB stands for kidney, ureter, and bladder. Stones that are seen on KUB are known as radio opaque stones (calcium, oxylate, struvite). Stones that are not visibile on KUB are known as radiolucent ( uric acid stones, some cystine stones) they are best diagnosed with CT scan or ultrasound
- CT scan –computerized tomography is now the most commonly used test for diagnosis of kidney stones.
- Ultrasound - kidneys are examined with sound waves
- Stones - are often visualized with other tests such as MRI scans however; these are not cost effective and typically are not used in diagnosis of stones.
- Patients are usually questioned about their diet, medication, lifestyle and family medical history.
Types of Stones:
- Calcium oxylate – the most common type of stone, this is usually visualized on plan KUB.
- Uric acid- these stones are radiolucent (not visualized on KUB and are often treated by a alkalinizing the urine causing them to dissolve).
- Struvite Stones – these stones are also known as infection stones or magnesium, ammonium phosphate stones. They are associated with recurrent infection.
- Cystine stones – these stones are usually present during childhood and are a result of a genetic defect.
Treatment of Stones:
- Conservative therapy- many stones can pass on their own. Patients are given pain medication and typically a medication which will dilate the urinary tract. They are asked to drink plenty of water and to strain their urine. Most stones will pass spontaneously if given time.
- Lithotripsy – this is the main stay of treatment. Patients are sedated and shock waves are passed through the body to break a large stone up into smaller pieces. This is general successful 80 – 85% of the time depending on the type of stone. The procedure lasts approximately 40 minutes. Patients are typically treated on an out-patient basis. Some patients are not suitable candidates due to the size of the stones, location, and number of stones, height, and weight, pregnancy status of the patient or overall medical status such as severe heart problems.
- Ureteroscopy- a lighted tube is passed up the urethra through the bladder, up the ureter to the stone; the stone is visualized and is removed with a basket. Many times a laser is used to break a large stone into smaller pieces.
- Percutaneous stone removal- a tube is placed through the patient’s side directly into the kidney. This tract is gently dilatated and a lighted tube is passed through the patient’s side and under direct vision the surgeon can remove stones with a grasper or break a large stone into small pieces using an ultrasonic wand or laser.
- Open surgery- rarely used however in some circumstances it is a procedure of last resort in extremely large stones.
Prevention of Kidney Stones:
- Water, water, water- drinking water keeps urine diluted therefore decreasing the chance of stone formation. . Many stones form in hot environment as a result of dehydration due to sweating. We should drink 10 -12 glasses of liquid each day with at least half of this intake being water. Don’t forget to drink one large glass of water at bedtime.
- Sodium (salt) – salt intake should be kept to a minimum as this may contribute to stone formation.
- Fiber and Fat- a low fat, high fiber diet is recommended. Foods to avoid include: iced tea, chocolate, greens, berries, nuts, asparagus, anchovies, organ meats (liver, kidney, brains), meat extract (broth, consume, and gravy).
- Remember excessive quantities of any food types are bad. Moderation is typically acceptable. Restriction of dairy products is not generally recommended due the risk of osteoporosis.
Ochsner Urology Institute provides confidential evaluation and treatment of sexual problems in men, women, and couples. Examples of sexual dysfunction may involve erectile dysfunction, premature ejaculation, difficulty reaching orgasm, diminished desire, pain during sexual activity, among other problems that interfere with intercourse. These problems may cause great anxiety in couples or individuals, and treatment is strictly confidential.
What do we treat:
- Premature ejaculation- ejaculation is a very complex matter, 1 out every 5 men in the United States between the ages of 18-59 may have difficulty with premature ejaculation. Risk factors include smoking, drug use, cardiovascular disease, and diabetes among others. There is not a universal definition of premature ejaculation. The American Urological Association treatment guidelines for premature ejaculation define this as “Premature ejaculation is an ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to one or both partners”. Premature ejaculation can be treated with medication, therapy, or combination of both.
- Testosterone deficiency (low testosterone) - male hormones affect multiple processes in the body. These may range from mental outlook to growth of structures in organs to general well being. Hormonal deficiency affects only a small portion of the male population. Treatment is usually accomplished with testosterone replacement therapies. These maybe transdermal or scrotal patches, intramuscular injections, transdermal gels. While hormonal therapy does not cause prostate cancer it may enhance the growth of prostate cancer if present, therefore patients are closely followed with digital rectal exams and PSA levels.
- Erectile dysfunction - is defined as the inability to obtain or maintain an erection to permit intercourse to the mutual satisfaction of both partners. This is an extremely common problem in the United States. The causes of erectile dysfunction may be psychological in nature, but usually are organic, secondary to other major medical problems, such as coronary artery diseases, diabetes, smoking, drug abuse, alcoholism, hormonal problem, and neurological diseases.
Diagnosis and Testing:
Diagnosis includes a comprehensive medical history, physical examination, and laboratory tests when indicated. Physical examination should include examination of the testes, assessment of secondary sexual characteristic such as body hair distribution and often a digital rectal examination to check prostate size. Laboratory testing may include testosterone level, LH, FSH, and prolactin levels among others. These blood tests are usually drawn in the early morning and more than one specimen maybe necessary.
Medication such as blood pressure, antihistamines, antidepressants, appetite depressants, diuretics (fluid pills), anti-psychotics, and anti-convulsants can lead to erectile dysfunction. Prescription drugs and elicit drug use may account for a quarter of the cases of erectile dysfunction.
Erectile dysfunction may only be a symptom of a more significant underlying problem. Many times patients who present with erectile dysfunction and no other abnormalities are referred to their primary care providers for a general medical evaluation.
The treatment of erectile dysfunction is grown by leaps and bounds over the pass 15 years.
- Oral medication –such as Viagra, Levitra, and Cialis have allowed medical management of erectile dysfunction. These medications have been proven safe and effective. They are however always contraindicated in patients who are taking nitrates such as IMDUR or nitrogycerine.
- Vacuum erection device- is a cylinder attached to a hand held vacuum pump by a piece of tubing. This devise essentially reduces the atmosphere pressure outside of the penis to allow normal blood pressure to inflate the penis. An elastic ring is placed temporarily at the base of the penis to prevent blood from exiting.
- Injection therapies- patients are taught how to inject medication directly into the penis which causes an erection. These medications can cause an erection lasting approximately 30 – 60 minutes. Side effects include pain, scar tissue formation resulting in curvature of the penis and in some cases priapism (an erection that does not go away within four hours causing patients to seek emergency medical attention).
- Muse- a urethral suppository that uses a similar medication used in penile injection therapy. It is placed directly into the urethra, just inside the head of the penis, resulting in erection.
- Surgical intervention- patients who do not respond to the above mentioned treatment may benefit from implantation of a surgical device. This device consists of two cylinders which are placed in either side of the penis which are connected to a reservoir and pump. The pump is squeezed, removing fluid from the reservoir into the cylinder causing an erection. Surgical management is an excellent way of treating erectile dysfunction however; there are unique complications such as infection, mechanical breakdown of the prosthesis, among others.
- Peyronie’s disease – is a non-malignant plaque or lump that forms in the penis. This may cause pain and ultimately curvature of the penis. The curvature and pain maybe so severe that it prevents intercourse. The cause of Peyronie’s disease is unclear; many believe that it results from repeated trauma which causes localized bleeding inside the penis resulting in scar tissue. Treatment usually begins with vitamin E which is taken on a daily bases. Re-assessment is made in six to twelve months. There are several experimental treatments available which have received mixed reviews. Surgical treatment is an option this may involve incision of the plaque verses removal of the plaque and replacement with a graft. Many times the placement of a penile prothesis is necessitated if severe erectile dysfunction is also present.
Description: Infertility is defined as the inability to conceive, or become pregnant, after one year of unprotected intercourse. Approximately 15% of couples in the United States are affected by infertility. A third of the time the cause is linked to the woman and another third of causes are linked to the man. The remaining third of cases are variable. Some can be linked to both the man and the woman while in other situations, no cause is ever found.
Symptoms: The primary symptom of infertility is the inability to achieve pregnancy. Other symptoms may include abnormal hair growth or sexual dysfunction.
Diagnosis: Evaluation should be performed if the couple is attempting to conceive for over one year with regular unprotected intercourse. This evaluation may be performed sooner if the couple has male or female infertility risk factors or questions the male’s fertility potential.
A detailed history and physical examination will be obtained from the male. Some questions that may be asked involve the timing and frequency of intercourse, use of lubricants (some may be spermicidal), ability to get erections, medical history and past history of pregnancy with other partners. A history of undescended testicles, surgery or trauma in the scrotal or groin area, treatment with radiation or chemotherapy, use of anabolic steroids or a family history of cystic fibrosis are all potential risk factors.
A review of the female’s medical, reproductive and surgical history will also be reviewed.
A semen analysis will likely be requested. It is important to abstain from intercourse at least 3 days prior to collection of the specimen. The sperm specimen must be kept at room or body temperature and be examined within one hour of collection.
If the semen analysis is abnormal, a second semen analysis may be obtained. These specimens should be collected at least one month apart. A blood test may also be ordered to evaluate for abnormal hormone production. Additional testing may also be needed.
Treatment: Potential treatments of infertility will be determined based on the cause. If sperm production is low, a medicine may be tried to increase the number of sperm. Surgery may also be needed to improve the sperm production. The most common types of surgical repair are a varicocele repair and a vasovasotomy. Varicoceles are the most common surgically correctable cause of infertility. Varicoceles are a group of dilated veins that go inside the testicle. Varicocele repair can improve semen parameters by more than 50% and increase pregnancy rates by 35-40%. In cases of blockage of the vas deferens or a previous vasectomy, the vas deferens can be reconnected using outpatient microscopic surgical repair.
Assisted reproductive technology, ART, may be needed in cases where medical or surgical therapy is not indicated or has failed. The female is usually given a medicine to stimulate multiple eggs to mature. These mature eggs are then harvested. Intracytoplasmic sperm injection (ICSI) may also be used by injecting a single sperm directly into a mature egg.
Infertility issues can be extremely stressful and cause significant emotional and financial problems for the individual and couple. It is common for couples to have feelings of depression, inadequacy and severe stress. These individuals commonly benefit from support groups or counselors. Setting limits both emotionally and financially are recommended. It is also important to determine what your personal and financial limits are in trying to conceive a child.
Description: Penile Cancer is a rare cancer that develops in the penis. Human papillomavirus infections may increase the risk of developing penile cancer. Other risk factors include age greater than 60, having phimosis or tight foreskin, genital warts, poor personal hygiene, having many sexual partners and a history of smoking. Circumcision before puberty virtually eliminates the risk of penile cancer.
Symptoms: The majority of penile cancers occur on the glans penis, or the head of the penis. These cancers are usually painless and can be small or large, raised or ulcerated and can be warty in appearance. They can also appear as red patches on the penis or as non-healing penile lesions. Many times the lesions are not fully seen by the patient due to the inability to fully retract the foreskin back.
Diagnosis: Your doctor will first perform a thorough history and physical examination. If the lesion on the penile is suspicious a biopsy will be performed and the specimen will be evaluated by a pathologist. Other laboratory blood tests and other imaging studies may be performed to determine the extent of the involvement.
- Topical treatment- If the cancer is detected early and is limited to the skin, treatment with a topical anti-cancer drug called 5-flurouracil may be used.
- Radiation- Very few patients are candidates for radiation. It is used in patients who have cancer limited to the skin, patients who refuse surgery or for palliative therapy if the disease has spread. Penile cancer has the tendency to be resistant to radiation.
- Chemotherapy – There are many different chemotherapeutic agents used in treating penile cancer that has spread outside of the penis. Many times the agents have a limited response and a short duration.
- Surgical therapy – The standard for the treatment of penile cancer is local excision with obtaining good margins of about two centimeters. Some patients with small tumors limited to the foreskin may be treated with circumcision alone. Patients with small tumors may be candidates for Mohs surgery, a microsurgical technique that removes thin layers of tissue one at a time and examines then for cancer under a microscope. Other patients require a partial or complete removal of the penis depending on the depth of invasion. Surgical removal of the lymph nodes in the groin may also be required
Description: Testicular Cancer is very rare and only accounts for 1% of all cancer in men in the United States. It is however the most common cancer diagnosed in men ages 15 to 34 and is more common in Caucasian men. It is a highly curable disease with overall survival being greater than 90%. Some associated risk factors may be undescended testicles, prior history of testicular cancer or a family history of testicular cancer.
Testicular cancer is usually classified as seminoma or non-seminoma. Seminoma may be differentiated into one of three types: classic, anaplastic, or spermatocytic. Nonseminomatous cancers include choriocarcinoma, embryonal carcinoma, teratoma, and yolk sac tumors. Testicular tumors may have seminoma and non-seminoma components as well.
Symptoms: Signs and symptoms may include a mass, pain or swelling in the testicle. The majority of testicular tumors are found by the patient.
Diagnosis: Your doctor will perform a detailed medical history and physical examination. Additional imaging studies and laboratory tests may be ordered to help diagnose and stage the testicular cancer. These studies may include a scrotal ultrasound as well as abdominal imaging, like a CT scan.
Treatment: The first step is surgical removal of the testicle from an incision in the groin. This is called an inguinal orchiectomy. The specimen will be sent to a pathologist to determine is the tumor is benign or malignant. Additional treatment with radiation or chemotherapy agents are sometimes required depending on the type of testicular tumor. Occasionally some patients may need an additional surgery to remove lymph nodes in the abdomen that have been involved with the cancer. At Ochsner, this can be performed laparoscopically.
Description: Ureteropelvic Junction Obstruction, UPJ, is a blockage that develops at the junction of the ureter and where it attaches to the kidney, the renal pelvis. The ureter is a thin tube that drains the urine from the kidney and empties it into the bladder. Obstruction can be congenital, something you were born with, or acquired and develop later in life. Some causes in adulthood may include infection, kidney stones, scarring from previous surgeries or tumors.
Signs/Symptoms: Some patients may have no symptoms at all, while other patients may develop pain on the affected side. The pain may be sudden, gradual or intermittent. It may be worse when the patient is drinking heavy amounts of fluid, alcohol or coffee. This blockage causes a dilation or fullness in the kidney which is caused hydronephrosis. This dilatation may be seen during radiological studies such as a CT scan, ultrasound or MRI. Occasionally, patients may develop an infection and require antibiotics or admission to the hospital.
Diagnosis: You doctor will perform a thorough history and physical examination. Your laboratory blood tests, urine tests and imaging studies will all be reviewed. Additional imaging studies may be required.
Treatments: UPJ obstruction is often repaired surgically. This procedure is called a pyeloplasty. At Ochsner, this procedure is often performed laparoscopically. The success rate of this procedure is excellent and most patients are discharged home the next day. An internal drainage tube is usually left for 4-6 weeks.
A second minimally invasive procedure is an Endopyelotomy. This procedure involves using a small flexible tube advanced through the urinary opening, up the ureter and to the area of the blockage. A laser, small internal knife or balloon may be used to open up the blockage. The success rate of this procedure is less, but may be indicated in certain patients. Most patients are discharged home the same day. An internal drainage catheter is usually left for 4-6 weeks.