Peyronie’s disease/ Penile Curvature Penile enlargement procedures Priapism
Erectile Dysfunction (ED)
Erectile dysfunction (ED) is persistent inability to achieve or maintain an erection that is firm enough to have sexual intercourse.
In a study from John Hopkins Institute in 2007, the overall prevalence of ED in men aged above 20 years was 18.4% suggesting that ED affects 18 million men in the USA. Among men with diabetes, the prevalence of ED was 51.3%, so it’s a fairly common problem.
What causes ED?
- Lifestyle choices (smoking, excessive alcohol, obesity, lack of exercise)
- Medications (Blood pressure, antidepressants)
- Cardiovascular disease (high blood pressure heart disease)
- Hormone problems
- Prostate cancer treatment
- Surgery (Prostate, bladder, colon)
- Spinal cord injuries
Penile Doppler scan with an injection may be required occasionally in special situations.
Whatever is causing ED, there is treatment option that can provide a satisfying solution.
If you try one of the treatment options listed and it doesn’t work for you or you aren’t completely satisfied, don’t be discouraged and give up hope.
These treatment options have varying degrees of success for each man depending on the cause of the ED. Irreversible blood vessel or nerve damage may impact the success of some of these treatments.
It is important to know all of your available options and discuss them with your doctor to determine which will be appropriate for you and your lifestyle.
Life style modifications: Exercise regularly (5 times a week), Healthy weight, avoid smoking, restrict alcohol intake to 2 drinks or less per day, adopt better sleep habits, take care of your other health issues such as high blood sugar and heart, artery or kidney disease.
Non-Surgical options: Oral medications, Penile Injections, Vacuum erection device
Surgical option: Penile Implants
These drugs are known as phosphodiesterase type 5 (PDE-5) inhibitors. They work to relax muscle cells in the penis for better blood flow and to produce a rigid erection. These medicines work in about 7 out of every 10 men with ED. They can be effective regardless of age or race. However, they only work if a man is sexually stimulated. Their effects last for only a set amount of time. Men should take these medications 30-60 minutes before sexual activity. These drugs do not treat a lack of sexual desire. As with any drug, some men may experience side effects when taking PDE-5 inhibitors. The most common are headaches, flushing (redness) of the face, runny or stuffy nose, upset stomach, dizziness and muscle aches. Those side effects are usually mild-moderate, but taking these drugs with alcohol may make them worse. Be sure you tell your doctor about all drugs you are taking, including prescriptions, over-the-counter medications or supplements, or recreational drugs before you take any PDE-5 inhibitors.
Alprostadil (Prostaglandin) Injection therapy uses a needle to inject medication directly into the base or side of the penis. These medications improve blood flow into the penis to cause an erection. The recommended frequency of injection is no more than three times weekly and should produce an erection in 5-20 minutes. Beyond a possible fear of needles, men may experience pain, fibrosis, and risk of a persistent erection with these injections. 60-65% of men discontinue this mode of treatment after 1 year.
Fig: Penile Alprostadil Injection
Vacuum erection devices (VED):
A mechanical ED pump used to pull blood into the penis can cause an erection. The system includes a plastic cylinder, an external penile pump, and a tension band to place at the base of the penis. When the penis is erect, the ring is placed at the base to maintain an erection long enough to have sex (up to 30 minutes). This is a drug-free non-invasive method of treatment, but the person will not be able to ejaculate soon after the orgasm due to constrictive ring at the penile base.
Fig: Vacuum erection device (VED)
In use since the 1971, penile implants have helped many men return to an active sex life. A penile implant is a medical implant that is implanted into the penis in operation theatre. The implant is entirely concealed within the body. Two basic types of implants are available. With malleable or bendable implants, two silicon-type cylinders are inserted into the penis. To have an erection, a man bends his penis upward into an erect position. The second type, an inflatable implant has a pair of inflatable cylinders which is attached to a fluid reservoir and a pump hidden inside the body. To have an erection, a man presses on the pump. This transfers fluid into the cylinders, making the penis rigid. To return the penis to a natural flaccid state, the pump is deflated.
Fig: Malleable Implant
Fig: Malleable Implant- Shah
Fig: Inflatable penile implant
Fig: Inflatable penile Implant in anatomical position
Features of Penile Implant Surgery:
- Permanent ED Treatment
- Small external scar
- Concealed within the body
- Maintain erection as long as desired
- Spontaneous-sex when the mood strikes
- Doesn’t interfere with orgasm or ejaculation
- High patient and partner satisfaction
- Low risk of device failure. Generally inflatable implants last 10-15 years. It is possible to replace them in case that the device fails.
Ejaculatory dysfunction: Premature ejaculation, Retrograde ejaculation, Anejaculation
Premature ejaculation is when semen is released sooner than a man or his partner would like. PE might not be a cause for worry. But, PE can be frustrating if it makes sex less enjoyable and impacts your relationship.
A study looking at 500 couples from five different countries found the average time taken to ejaculate during intercourse was around 5 minutes. However, it's up to each couple to decide if they’re happy with the time taken – there’s no definition of how long sex should last. Occasional episodes of premature ejaculation are common and aren't a cause for concern. However, if you're finding that around half of your attempts at sex result in premature ejaculation, it might help to get treatment.
There are many reasons why men have PE. There can be biological, chemical and/or emotional reasons. There may be issues with the brain signals that rule sexual excitement.
Common treatments are behavioral therapy, tablets and creams. Many people try more than one option at the same time.
- Behavioural Therapy: Makes men aware of the feelings that lead to the climax, so they can delay ejaculation. The goal is to train your body and increase control. The stop-start method is when you stop stimulation, regain control, and then start again. You will need your partner’s help with these exercises.
- Medical Therapy: They lower serotonin levels. You’ll usually be advised to take it one hour before sex, but not more than once a day. Your response to the treatment will then be reviewed after four weeks (or after six doses), and again every six months.
- Numbing Creams or Sprays: There are creams and sprays that you can put on the head and shaft of the penis before sex to lower sensation. They also cause vaginal numbness, so should be washed off before sex.
It happens when semen travels backwards into the bladder instead of through the urethra (the tube that urine passes through).
Men with retrograde ejaculation still experience the feeling of an orgasm and the condition doesn't pose a danger to health. However, it can affect the ability to father a child.
Prostate gland surgery or bladder surgery is the most common cause of retrograde ejaculation. Other causes are diabetes, multiple sclerosis, and a class of medicines known as alpha blockers, which are often used to treat high blood pressure (hypertension).
Most men do not need treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not have adverse effects on their health.
Men who want to have children can have sperm taken from their urine for use in artificial intrauterine insemination (IUI) or in-vitro fertilisation (IVF).
Anejaculation is the inability to ejaculate semen despite stimulation of the penis by intercourse or masturbation. If anejaculation is caused by medications, stopping the medicine will most likely restore normal function.
Vibrostimuation: The vibrator acts by providing a strong stimulus for a long duration (20-30min) to the penis. Vibrator stimulation results in ejaculation in about 60% of men suffering from a neurological (spinal cord) injury. This is a simple and quite effective way of retrieving semen in order to proceed with artificial insemination (inserting sperm directly into the uterus).
Low testosterone (Hypogonadism)
Male hypogonadism means the testicles do not produce enough of the male sex hormone testosterone. When levels are low, men might have decreased sex drive, less muscle mass, erectile dysfunction, and fatigue. Testosterone is responsible for male reproductive and sexual functions. It affects puberty, fertility, muscle mass, body composition, bone strength, fat metabolism, sex drive, mood and mental processes.
Types of Hypogonadism:
Primary hypogonadism is caused by a problem in the testes. This type is most frequent and usually affects development in childhood and adolescence.
Secondary hypogonadism is caused by a problem in glands (pituitary gland, hypothalamus) that tell the testes to make testosterone. This type is more common among older men.
Hypogonadism can occur at any age. The symptoms will be different depending on your age when it develops. Common symptoms in adult men include:
- Hot flushes
- Low sex drive
- Erectile dysfunction
- Mood changes
- Difficulty concentrating
- Problem in sleeping
- Loss of muscle mass
- Decreased bone density
- Enlarged breasts
- Loss of body hair
Male hypogonadism is diagnosed based on:
- Long-term discomfort from symptoms
- Low testosterone levels in the blood
- Size of the testes on clinical examination
Penile curvature / Peyronie’s disease:
Penile curvature could be from birth (congenital penile curvature) or acquired later in life (Peyronie’s disease). One will usually notice a curved penis only during the penile erection and not when the penis is flaccid (resting state).
Congenital penile curvature although present since birth, will become obvious during erection when he reaches puberty or early adult life.
Peyronie’s Disease is caused by the way a person’s body heals wounds. Injury or damage to the outer tissues of the penis causes scar-like tissue (plaque) to form.
“Peyronie’s was named after the French surgeon François Gigot de La Peyronie, who described it in 1743”
PEYRONIE’S DISEASE IS NOT A DISEASE YOU CAN CATCH FROM SOMEONE ELSE AND IT IS NOT CAUSED BY ANY KNOWN DISEASE THAT CAN BE PASSED TO OTHERS.
Peyronie’s disease usually occurs in two phases — the acute (or active) phase and the chronic (or stable) phase. The first painful phase can last up to about 18 months. For most men, the chronic, or stable, phase begins 12-18 months after symptoms first appear.
Fig: Peyronie’s disease with penile curvature and plaque
Signs of peyronie’s disease may involve:
- a curve in the penis
- hard lumps on one or more sides of the penis
- painful erections
- no or soft erections
- Spontaneous-sex when the mood strikes
- having trouble with sex or having sex that hurts because of a bent/curved penis
Andrologist may treat Peyronie’s using non-surgical or surgical treatments.
Non-surgical treatments may include tablets, penile traction devices and shots/injections directly into the plaque which brings higher doses of the drug directly to the problem.
Surgery is an option for men with severe penile curvature that find it difficult to have sex. There are three surgeries used to help men with Peyronie’s Disease:
- Making the side of the penis opposite the plaque shorter (Plication surgery)
- Making the side of the penis with plaque longer with a graft (Graft surgery)
- Making the penis straight with a prosthetic device (Penile implant)
Penile enlargement surgeries
- Penile fillers
- Suprapubic fat reduction
- Pubic lipectomy
- Pubic liposuction
- Penile Implant and multiple corporotomy incisions
Priapism is a rare condition involving an erection that lasts for an unusually long time. It can be painful. This type of erection is not related to sexual stimulus. Immediate treatment is important to prevent tissue damage and erectile dysfunction (ED).
Priapism got the name from Priapus. Roman statue showing Priapus – the god of fertility. The distinguishing feature of the deity is the great erect penis, which was to symbolize the economic well-being of the owners of the House of the Vettii in Pompeii.
There are two types of priapism:
- Ischemic priapism: when blood cannot leave the penis. This erection can last for more than four (4) hours. The penis shaft may be very hard, while the tip is soft. It is known to cause pain and discomfort. This type may stop and start (stuttering priapism).
- Nonischemic priapism: when too much blood flows into the penis. This is a less painful erection, but it can also last for more than four (4) hours. The penis shaft is erect but not rigid.
Priapism can happen in young boys (age 5-10), young adults (around age 20) and mature men (over age 50).
Priapism happens when blood flow to the penis doesn’t work correctly. Some things that could cause this are:
- Blood disorders, like sickle cell anaemia and leukaemia
- Prescription drugs, like some ED drugs, e.g. Sildenafil (Viagra), Tadalafil, mental health drugs, e.g. Fluoxetine, Bupropion, Risperidone and Olanzapine and blood thinners, e.g. Warfarin and heparin
- Alcohol and drug use
- Injury to your genitals, pelvis or the area between the penis and the anus; or to the spinal cord
WHY IS TREATMENT IMPORTANT?
When an erection lasts for too long, blood becomes trapped in the penis. The blood trapped in the penis is unable to go to other parts of the body. The lack of oxygen can damage or destroy tissue in the penis. This can disfigure the penis. It may also cause problems like erectile dysfunction (when the penis cannot become erect) in future.
Ischemic priapism (most common, 95%) calls for emergency care. Blood must be drained from the penis. There are several ways to do this:
- Aspiration (when a surgical needle and syringe is used) to drain excess blood
- Medicine or a saline mix may be injected into penile veins to improve blood flow. The veins are flushed to relieve pain, remove oxygen-poor blood and stop the erection
- A surgeon may perform a “shunt” to vent blood from the penis or penile implant surgery if presented beyond 36 hours of having priapism.
Nonischemic priapism (less common, 5%) often goes away without treatment. Simple ice and pressure on the perineum may help end the erection. A watch and wait approach is used before surgery.
Abnormalities in sperm due to various reasons can deprive an otherwise happy couple of having a child. Of all infertility cases, approximately 40–50% is due to “male factor” infertility.
A recent international study analysis revealed that there is a significant decline in sperm counts between 1973 and 2011, driven by a 50-60% decline among men from North America, Europe, Australia and New Zealand. The reasons could be multifactorial being birth defects, genetic abnormalities, radiation exposure, lifestyle changes, exposure to various toxins, stress or sometimes unknown.
In such conditions with abnormalities in semen/sperm, one has to approach the Andrologist for possible solutions without much delay because fertility potential of a couple decreases significantly with advancing age.
Both male and female partners have to be simultaneously investigated, to categorise infertility.
Basic evaluation of male infertility involves:
- General physical examination including scrotum and penis
- Basic blood hormone profile such as Testosterone, FSH, LH
- Semen analysis
Semen collection: A dedicated room with adequate privacy would be given. If the male partner is unable to ejaculate, a penile vibrator could be used for stimulation.
Surgical sperm retrieval:
Depending on the several factors such as testicular size, previous scrotal surgery and hormone levels, the Andrologist will decide which would be the best option.
Different surgical options to retrieve sperms:
- PESA: Percutaneous Epididymal Sperm Aspiration
- TESE (Testicular Sperm Extraction)
- Micro- TESE: using a surgical microscope
Fig: TESE (TEsticular Sperm Extraction)
What others options are available if no sperms are found with surgery?
- Donor insemination (DI)
Donor semen is carefully screened for infections and a donor selected to have similar attributes to you. This is the only viable option if you have no sperms at all and you do not have obstruction which can be relieved surgically.
If you are unfortunate and do not to have any success with other treatments, you may wish to consider adopting a child.
A varicocele is when veins become enlarged inside your scrotum (the pouch of skin that holds your testicles). These veins are called the pampiniform plexus.
About 15 out of 100 men have varicoceles. It's hard to predict which of these 15 will have fertility problems caused by their varicocele. But about 4 in every 10 men tested for fertility problems have a varicocele and decreased sperm movement. Varicoceles can affect fertility by reducing blood flow and raising the temperature of the testicles. This can cause the testicles to produce fewer sperm, and sperm that is produced might not be healthy.
Often, varicoceles are not treated. Treatment is offered for males who have:
- fertility problems (problems fathering a child)
- testicular hypotrophy
There are no drugs to treat or prevent varicoceles.
There are many ways to do varicocele surgery. All involve blocking the blood flow in the pampiniform plexus veins. Microscopic varicocelectomy with microdoppler gives the best results.
The patient may be able to return to normal, non-strenuous activities after 2 days. As long as they are not uncomfortable, they may return to more strenuous activity, such as exercising, after 2–4 weeks.
Its time men came forward to get a simple vasectomy done instead of forcing their wives to get complex tubectomy done as a birth control measure. Vasectomy procedure takes around an hour (including the anaesthesia time) and is a day-care procedure. After the surgery, one should wait for 3 months to check the semen (or 20 ejaculates, whichever comes first) to see if you’re sperm-free. Till then, one should wear a condom during sexual intercourse.
Premarital Male Fertility check-up
Males who want to know their fertility status prior to their marriage can get themselves examined and evaluated with appropriate investigations. This involves:
- General Tests: HbA1C (Blood sugars), CBC, Serum Creatinine, Urine analysis
- Blood Hormones: Testosterone, FSH, LH, Estradiol, Prolactin
- Semen analysis
- Ultrasound scrotum
- Andrology Consultation
Men’s Health Clinic
In general, men have poorer health habits and a shorter life expectancy than women. This may be because they are more likely to engage in unhealthy behaviour, and are less likely than women to adopt preventive health measures. But men’s health issues don’t affect only men- they have a significant impact on their family and friends too. Unfortunately a lot of issues particularly the ones having to do with sex or masculinity- are very hard for men to talk about.
Men’s Health Clinic involves evaluation of the following:
- Erectile Dysfunction: Blood Testosterone, Lipid profile, HbA1C (blood sugar)
- Andropause: Blood Total Testosterone, SHBG (Sex Hormone Binding Globulin) and Serum Albumin to calculate Bio-available Testosterone
- Prostate (Prostate enlargement or Prostate cancer): Serum PSA, Digital rectal examination, ultrasound abdomen pelvis (pre void/post-void residual urine) and uroflowmetry
- Testicular cancer: Clinical examination and Ultrasound scrotum
Dr Pramod, as a visiting Andrology Fellow with Prof Dr Craig Niederberger at the University of Illinois at Chicago (UIC), USA.
Dr Pramod with Dr Rados Djinovic at Sava Perovic Foundation, Belgrade (Serbia) during European Urology Scholarship Program (EUSP) in Penile Reconstruction.
Dr Pramod during his European Society of Sexual Medicine (ESSM) Penile Implant Fellowship in Madrid (Spain). Left to right: Dr Enrique Lledo-Garcia, Dr Ignacio Moncada, Dr Pramod and Dr Juan Ignacio Martinez Salamanca.
Dr Pramod received the International Society of Sexual Medicine ( ISSM) Scholarship to attend the ESSM School of Sexual Medicine 2018 in Budapest ( Hungary).