Sexual Dysfunction

The sexual act passes through phases of desire, arousal, plateau, orgasm and resolution. Male sexual dysfunction occurs when they have difficulty experiencing any of these phases which may either affect enjoyment or completion of the sexual act. Sexual dysfunction in men may include:

• Desire disorders: Problems with desire or interest in sex
• Arousal disorders: Problems with achieving and maintaining an erection necessary for sex. They may include erectile dysfunction, delayed ejaculation or premature ejaculation.
• Orgasm disorders: Achieving ejaculation or orgasm too early, too late or not at all
• Pain disorders: Experiencing pain during intercourse

The reason for sexual dysfunction may either be physical or psychological. Physical causes include:

• Neurological disorders
• Hormonal imbalances
• Diseases such as diabetes, vascular disease, heart disease, kidney and liver failure
• Alcoholism, drug abuse
• Certain medications such as antidepressants

Psychological causes include:

• Performance anxiety
• Relationship problems
• Feeling of guilt
• Depression
• Poor self-image
• Past sexual failures

When you or your partner recognize that you are having sexual difficulties, it is necessary to seek assistance as many forms of sexual dysfunction are treatable. Your doctor will review your symptoms and history and perform a physical examination with tests to identify any medical problems which might be causing your sexual dysfunction. You will also be interviewed to identify if you have an underlying marital problem, substance abuse, or psychological causes such as anxiety, fear, and negative past experiences or relationship problems.

Sexual dysfunction is usually treated by managing the underlying cause. Your doctor may prescribe medication to increase the blood supply to your penis to strengthen your erection. Certain mechanical aids or penile implants may also be recommended. Hormonal imbalances are treated by supplementation. Medications having sexual side effects may be stopped or altered. Therapy may be recommended for psychological, marital or substance abuse problems, as well as education about different sexual techniques that may be useful to you.

Men’s Health

Hypogonadism

Male hypogonadism is a clinical syndrome caused by a failure of the testes to produce adequate levels of testosterone that are needed for the normal growth and development of a male. The condition may be congenital or may develop later in life.

Causes

Hypogonadism can be classified into primary and secondary hypogonadism. Primary hypogonadism may be due to testicular failure that refers to any dysfunction of the testicles which interrupts the normal hormone production. The common causes of primary hypogonadism include Klinefelter syndrome, which is a congenital abnormality of the sex chromosomes (an extra X chromosome) causing abnormal development of the testicles. Other causes of primary hypogonadism include undescended testicles, mumps orchitis, hemochromatosis, testicular injury, chemotherapy and radiotherapy.

Secondary hypogonadism may result from a dysfunctioning of the hypothalamus or pituitary gland that interrupts their normal functions. Certain conditions such as Kallmann syndrome (abnormal development of the hypothalamus), pituitary disorders, inflammatory diseases, HIV, certain medications, obesity and normal aging may also result in hypogonadism.

Symptoms

The symptoms of hypogonadism generally depend on the age of the affected individual. During fetal development it may result in impaired growth or underdevelopment of external male or ambiguous genitals. The symptoms during pre-puberty include impaired growth of external male genitals, improper distribution of body hair, decreased muscle mass, gynecomastia or development of breast tissues, lack of deepening of the voice and disproportional growth of arms and legs in relation to the trunk of the body. Certain symptoms such as erectile dysfunction, infertility, lack of facial or body hair, reduced muscle mass and gynecomastia may be seen in adult patients. Sometimes affected individuals may experience emotional and mental disturbances, fatigue, and loss of libido, hot flushes and lack of concentration.

Diagnosis

The diagnosis of male hypogonadism includes medical history, physical examination and laboratory investigations. Other tests such as estimation of hormonal levels, semen analysis, pituitary imaging, testicular biopsy and other genetic studies may be used to diagnose the underlying causes of the disorder.

Treatment

Hormone replacement therapy is the most common approach for the management of male hypogonadism. Testosterone replacement therapy can be used in young as well as adult patients. Testosterone replacement therapy is useful for restoring sexual function, muscle and bone strength as well as to provide a sense of wellbeing in adult patients. In young patients it stimulates puberty and the development of secondary sexual characteristics.

Peyronies Disease

A man's penis is an important part of his identity as a man. It serves a critical role in urinary function. Its function as a sexual organ is also important; sexuality is a source of physical pleasure, emotional bonding, and procreation. Unfortunately, the penis is prone to injuries and problems just like any other part of the human body and some of these injuries may have an impact on a man's enjoyment of sex. One particular problem that has received increasing attention in recent years is Peyronie's disease, a condition in which painful, hard plaques form underneath the skin of the penis leading to penile curvature. If you have pain and penile curvature characteristic of Peyronie's disease, the following information may help you understand your condition.

How does the penis become erect (hard) under normal conditions?

The penis is a cylindrical organ consisting of three separate chambers. On the upper (dorsal) portion of the penis there are two corpora cavernosa that are surrounded by a tough but elastic layer of connective tissue called the tunica albuginea. The third chamber is called the corpus spongiosum; it is located below the corpora cavernosa and is surrounded by a thin connective tissue sheath. It contains the urethra, the narrow tube that carries urine and semen out of the body.

These three chambers are made up of highly specialized, sponge-like erectile tissue filled with thousands of venous cavities, spaces that contain very little blood when the penis is soft.

During erection, blood fills these cavities, causing the corpora cavernosa to balloon and push against the tunica albuginea. While the penis hardens and stretches, the skin and connective tissue of the penis remain loose and elastic to accommodate the changes.

What is Peyronie's disease?

Peyronie's disease (also known as induratio plastica penis) is an acquired inflammatory condition of the penis. The principle manifestation of Peyronie's disease is the formation of a plaque (a segment of flat scar tissue) within the tunica albuginea of the penis. This plaque can usually be felt through the penile skin. This plaque is not a tumor but it may lead to serious problems such as curved and/or painful erections
The name "Peyronie's Disease" is derived from the physician Francois Gigot de la Peyronie, personal physician to King Louis XV of France. De la Peyronie wrote an authoritative description of the disorder in 1743 and his name has been associated with the condition since that time.

What are the symptoms of Peyronie's disease?

The plaques of Peyronie's disease most commonly develop on the upper (dorsal) side of the penis. Plaques reduce the elasticity of the tunica albuginea and may cause the penis to bend upwards during the process of erection. Although Peyronie's plaques are most commonly located on the top of the penis, they may also occur on the bottom (ventral) or side (lateral) of the penis, causing a downward or sideways bend, respectively. Some men have more than one plaque, which may cause complex curvatures.

In some men an extensive plaque that goes all the way around the penis may develop. These plaques typically do not cause curvature but may cause a "waisting" or "bottleneck" deformity of the penile shaft. In other severe cases, the plaque may accumulate calcium and become very hard, almost like a bone. In addition to penile curvature, many patients also report shrinkage or shortening of their penis.
Since there is great variability in this condition, men with Peyronie's disease may complain of a variety of symptoms. Penile curvature, lumps in the penis, painful erections, soft erections, and difficulty with penile penetration due to curvature are common concerns that bring men with Peyronie's disease to see their doctors.

Peyronie's disease can be a serious quality-of-life issue. Studies have shown that over 75% of men with Peyronie's disease have stress related to the condition. Unfortunately, many men with Peyronie's disease are embarrassed about the condition and choose to suffer in silence rather than speaking with their health care provider about it.

How common is Peyronie's disease?

Recent demographic surveys have reported that Peyronie's disease can be found in up to 9% of men between the ages of 40 and 70. The condition is rare in young men but has been reported in men in their 30s. The actual prevalence of Peyronie's disease may be much higher than 9% due to patient embarrassment and limited reporting by physicians.

Interestingly, more Peyronie's disease cases have been reported in recent years. This is likely due to the availability within the last decade of highly effective oral medications for the treatment of erectile dysfunction (ED). With more men seeking treatment for erectile problems, many cases of Peyronie's disease that would have gone undiagnosed in the past have come to the attention of the medical establishment. It is likely that the number of men being treated for erectile dysfunction will continue to increase in the future. For this reason, the number of men presenting with Peyronie's disease will likely continue to increase in the future.

What causes Peyronie's disease?

Scientists have been mystified by the cause of Peyronie's disease since before it was characterized by Francois Gigot de la Peyronie. Although the process by which Peyronie's disease occurs is still not entirely understood, much progress in our understanding of the disorder has been made in recent years.

Most experts believe that Peyronie's disease is likely the consequence of a minor penile trauma. The most common source of this type of penile trauma is thought to be vigorous sexual activity (e.g., bending of the penis during penetration, pressure from a partner's pubic bone, etc.) although injuries from sports or accidents may also play a role. Injury to the tunica albuginea may trigger a cascade of inflammatory and cellular events resulting in a process called fibrosis, a medical term for formation of excessive scar tissue. This abnormal scar tissue in turn forms the plaque of Peyronie's disease.

Not all men who suffer occasional mild trauma to the penis develop Peyronie's disease. For this reason, most researchers believe that there must be genetic or environmental factors that contribute to the formation of Peyronie's disease plaques. Men with certain connective tissue disorders (such as Dupuytren's contractures or tympanosclerosis) and men who have a close relative with Peyronie's disease have a greater risk of developing the condition. Certain health conditions such as diabetes, tobacco use, or a history of pelvic trauma may also lead to abnormal wound healing and may contribute to the development of Peyronie's disease.

Peyronie's disease is in essence a derangement of normal wound healing. Because it is related to normal wound healing, Peyronie's disease is a very dynamic process early on but over time, the inflammatory changes may decrease. In fact, this disease is usually divided into two distinct stages. The first phase is the acute phase; this portion of the disease persists for six to 18 months and is usually characterized by pain, worsening penile curvature and formation of penile plaques. The second phase is the chronic phase where the deformity remains in a stable state. As in the first stage the deformity may interfere with sexual activity and there may be associated erectile dysfunction. Pain with erection has typically resolved during this phase.

How is Peyronie's disease diagnosed?

A physical examination by an experienced physician is usually sufficient to diagnose Peyronie's disease. The hard plaques can usually be felt with or without erection. It may be necessary to induce an erection in the clinic for proper evaluation of the penile curvature; this is usually done by direct injection of a medication that causes penile erection. Pictures of the erect penis may also be useful in the evaluation of penile curvature. In some cases an ultrasound or x-ray examination of the penis is used to characterize the plaque and check for the presence of calcification.

How is Peyronie's disease treated?

In about 13% of cases, Peyronie's disease goes away without treatment. Many physicians recommend conservative (non-surgical) treatment for at least the first 12 months after symptoms present.

Men with small plaques, minimal penile curvature, no pain, and satisfactory sexual function do not require treatment. Men with active phase disease who do have one or more of the above problems may benefit from medical therapy. Unfortunately, very few well designed clinical trials of medications for Peyronie's disease have been performed and therefore the true effectiveness of many of these treatments is unclear.

Oral Medications

Oral vitamin E: An antioxidant that is a popular treatment for acute stage Peyronie's disease because of its mild side effects and low cost. While studies as far back as 1948 have demonstrated decreases in penile curvature and plaque size from vitamin E treatment, most of these studies have not used placebo controls. Those few studies of vitamin E that have included a placebo treatment group have demonstrated that vitamin E does not appear to give better results than the placebo, which calls into question whether or not vitamin E is an effective treatment.

Potassium amino-benzoate: Also known as Potaba®. Small placebo controlled studies have shown that this B-complex substance popular in Central Europe yields some benefits with respect to plaque size, but not curvature. Unfortunately, it is somewhat expensive and use of the medication requires taking 24 pills a day for three to six months. This medication has also been associated with a high rate of stomach upset, which leads many men to stop taking it.

Tamoxifen: This non-steroidal, anti-estrogen medication has been used in the treatment of desmoid tumors, a condition with properties similar to Peyronie's disease. Unfortunately, placebo controlled trials of this drug are rare and the few that have been conducted have not shown that Tamoxifen is better than placebo.

Colchicine: An anti-inflammatory agent that decreases collagen development. Colchicine has been shown to be slightly beneficial in a few small, uncontrolled studies. Many patients taking colchicine over the long term develop gastrointestinal problems and must discontinue the drug early in treatment. It has not been proven to be superior to placebo.

Carnitine: An antioxidant medication that is designed to reduce inflammation and thereby decrease abnormal wound healing. Like many other Peyronie's therapies, uncontrolled trials have demonstrated some benefit to this treatment but a recent controlled trial has not demonstrated it to be superior to placebo.

Penile Injections

Injecting a drug directly into the plaque of Peyronie's disease is an attractive alternative to oral medications. Injection permits direct introduction of drugs into the plaque, permitting higher doses and more local effects. To improve patient comfort a local anesthetic is usually given prior to the injection.

Because plaque injection is a minimally invasive approach, it is a popular option amongst men with active phase disease and men who are reluctant to have surgery.

Verapamil Injections: Verapamil is a calcium channel blocker usually used in the treatment of high blood pressure.

Interferon Injections: Interferon is a protein that is normally made in the body and plays an important role in inflammation. It has been shown to have anti-fibrotic effects in the treatment of keloid scars and scleroderma, a rare autoimmune disease affecting the body's connective tissue. This effect is thought to occur by inhibition of collagen producing cells and by production of collagenase, an enzyme that breaks down collagen that has already been produced.It has also been shown to disrupt collagen production and this property has made it of interest in the treatment of Peyronie's disease.Several uncontrolled studies have suggested that verapamil injection is an effective treatment for penile pain and curvature; unfortunately, there are no large scale placebo controlled trials of this treatment. Verapamil appears to be a reasonable and affordable treatment option for Peyronie's disease, but further controlled studies are needed to verify the effectiveness of this treatment.

A large scale placebo controlled trial of interferon injection for Peyronie's disease was recently published. This trial demonstrated modestly better improvements in penile curvature, pain, and sexual function in men treated with interferon compared to those treated with placebo. While this is an encouraging result interferon is a relatively expensive treatment with flu-like syndrome side-effects.
Collagenase Injections: Direct injection of the enzyme collagenase to break down the plaque of Peyronie's disease has been a topic of interest among some researchers. A small trial from the early 1990's demonstrated some modest improvements in Peyronie's disease after treatment with collagenase injections. A larger trial is currently underway. The role of collagenase in the treatment of Peyronie's disease is at this time unclear.

Other investigative therapies:

Many alternative methods for treating Peyronie's disease have been reported. Examples include high-intensity focused ultrasound, radiation therapy, shock-wave treatment, topical verapamil, hyperthermia, and many others. While the scientific rationale for these other approaches is sound, at this time there is not enough data to support their use outside of a research setting at this time. A recent pilot study (2007) using external penile traction therapy demonstrated measured improvements in girth, length and curvature after 6 months of daily stretch therapy lasting from 2-8 hours per day.

Surgical Treatment of Peyronie's Disease:

Surgery is reserved for men with severe, disabling penile deformities that prevent satisfactory sexual intercourse. Most physicians recommend avoiding surgery until the plaque and deformity have been stable and the patient pain-free for at least six months. An evaluation of the penile blood supply using injection of erection producing medications is often done prior to any surgery. A penile ultrasound may be performed at the same time. These two tests permit assessment of whether or not the man has significant ED and may also provide important anatomical information that will help guide the choice of surgical procedure.

There are three general approaches to surgical correction of Peyronie's disease:

Procedures that shorten the side of the penis opposite the plaque/curvature

These procedures are generally safe, technically easy, and carry a low risk of complications such as bleeding or worsening erectile function. One particular disadvantage of these approaches is that they tend to be associated with some loss of penile length. For this reason shortening procedures are generally preferred in men with mild or no ED, mild to moderate curvatures, and long penises.

Examples of this type of procedure include the Nesbit procedure, in which small pieces of tunica tissue are excised from the convex (the side opposite the direction of the curvature) side of the penis. The edges of the tunica are then sewed together, causing penile straightening. There are several variations of the Nesbit procedure including tunica plication and the 16 dot penile plication, in which sutures are used to "cinch" (or bunch) together a segment of the tunica on the convex side of the penis.

Procedures that lengthen the side of the penis that is curved

These procedures are indicated when the curvature severe or there is significant indentation causing a hinge-effect or buckling of the penis due to the narrowed segment in the penile shaft. In these cases, the surgeon incises (cuts) the plaque to release tension. In some cases a segment of the plaque may be removed. After the plaque has been incised, the resulting hole in the tunica must be filled with a graft. These procedures can correct severe curvatures, in most cases without significant shortening of the penis. Unfortunately, this type of procedure is technically challenging and carries a risk of worsening erectile function. Therefore, lengthening/grafting procedures are typically not recommended except in cases of severe deformity in men with adequate erectile function at baseline.

A number of different materials are available as grafts and the choice of graft should be based on patient and surgeon preference.

Autologous tissue grafts: These grafts are made of tissue taken from another part of the patient's body during surgery. Examples of grafts used for Peyronie's disease include saphenous vein (taken from leg) and temporalis fascia (harvested from behind the ear). Autologous grafts are living tissue and generally incorporate into surgical sites much more readily than some other materials. Disadvantages of autologous grafts include the need for a second incision to harvest the graft.

Non-autologous allografts: These grafts are sheets of tissue that are commercially produced using human or animal sources. Prior to use they are sterilized and processed to remove all potentially infectious particles. These grafts are gradually digested by the body but they serve as scaffolds for the growth of fresh healthy tissues produced by the patient's own body. Allografts are uniformly strong, easy to work with and readily available because they are "off-the-shelf" in the operating room. They are generally well tolerated by most patients and negate the need for a second incision although they are somewhat expensive.

Synthetic inert substances: Materials such as Dacron® mesh or GORE-TEX® are seldom used for Peyronie's surgeries in the modern era. When used as a tunical grafts these substances often cause significant recurrent fibrosis and hence worsening of Peyronie's type deformities.
Placement of penile prosthetic devices

Placement of an inflatable penile pump or malleable silicone rods inside the corpora is a good treatment option for men with Peyronie's disease and moderate to severe erectile dysfunction. In most cases, implanting such a device alone will straighten the penis, correcting its rigidity. When device placement alone does not sufficiently straighten the penis, the surgeon may further straighten the penis by cracking the plaque against the rigid prosthesis or by incising the plaque and subsequently covering the incision with a graft material.

What can be expected after surgery for Peyronie's disease?

A light pressure dressing is typically left on the penis for 24 to 72 hours after the surgery to prevent bleeding and hold the repair in place. In some cases, patients will wake up with a catheter in the bladder but this is usually removed in the recovery room. Most patients are discharged later the same day or the following morning. The patient is also often given several days of antibiotics to reduce the risk of infection and inflammation and a pain medication for discomfort. In most cases surgeons recommend not engaging in sexual activity for at least 4-6 weeks after surgery, longer in some cases of complex repairs.

Frequently asked questions:

What happens at the molecular level following penile trauma?

Following any penile trauma, injured cells release a veritable stew of chemical messengers that have a number of important effects, including the activation of fibroblasts, cells that produce connective tissue. Normally these cells produce organized collagen sheets that restore the normal architecture of the penis. Some fibroblasts transform into cells called myofibroblasts, cells that not only produce collagen but also contract to help bring wound edges together. Myofibroblasts are designed to do their job and then die off. However, in some cases, fibroblasts produce abnormal, disorganized collagen and myofibroblasts do not die, leading to persistent wound contraction and inflammation. These two processes lead to overgrowth of dense scar tissue, which in some cases becomes the plaque of Peyronie's disease.

About 30 percent of men with Peyronie's disease develop fibrosis in other areas of the body. The most common sites are the hands and feet. Dupuytren's contracture is a condition classically associated with Peyronie's disease in which fibrosis occurs in the tissue of the palm. Dupuytren's contracture may lead to progressive permanent bending of the fingers. While the fibrotic process in Peyronie's disease and Dupuytren's contracture is similar, it is not clear at this time what causes either plaque to develop and why men with Peyronie's disease are more likely to develop Dupuytren's contracture.Are men with Peyronie's disease prone to any other conditions?

Does Peyronie's disease turn into cancer?

Cells obtained from Peyronie's plaques have shown a number of characteristics similar to cancer cells, such as the ability to resist a process of programmed cell death called apoptosis, and to form tumors when transplanted into mice with no immune systems. However, there has never been a case of Peyronie's disease that has turned into a cancer in a human. However, if your doctor observes other findings that are not typical with this disease—such as external bleeding, obstructed urination, or prolonged severe penile pain—he or she may elect to perform a biopsy on the tissue for pathological examination.

What are the most important things to know about Peyronie's disease?

Peyronie's disease is a poorly understood urological condition characterized by penile deformity and pain. Treatment for this condition needs to be individualized to each patient based on the timing and severity of the disease. The objective of any treatment should be to reduce pain, normalize penile anatomy so that intercourse is comfortable, and restore erectile function in patients who suffer from concomitant erectile dysfunction. The early phase of the disease is treated with either oral medications and/or plaque injections approaches. Traction therapy is emerging as a potential valuable non-surgical treatment. The late phase of the disease is usually managed with surgery if penile deformity is preventing a man from enjoying sex. As medical researchers continue to develop basic and clinical research for a better understanding of this disease, more therapies and targets for intervention will become available.

Male Infertility

Varicocele

The male reproductive tract is responsible for the production, maturation, and transport of sperm. This tract is a complex and highly integrated entity. Sperm produced in the testicles are transported through the genital duct system and deposited in the urethra during ejaculation followed by emission.

The spermatic cord is the structure that provides the blood supply to the testicle and contains the vas deferens which transports sperm from the testicle to the penis and urethra. The spermatic cord passes through the inguinal canal and continues into the scrotum. The pampiniform plexus is a group of interconnected veins, which drain the blood from the testicles and lies within the spermatic cord. The pampiniform plexus is believed to have an important functional role in maintaining testicular temperature in the appropriate range for sperm production. The pampiniform plexus cools blood in the testicular artery before it enters the testicles, helping to maintain an ideal testicular temperature, essential for optimal sperm production.Abnormalities within the male reproductive tract may present as a scrotal masse. Masses may have little or no health significance or may represent life-threatening illnesses. Therefore, it is necessary to follow a set course of action to determine the nature of the masse and the most appropriate treatment. For example, testicular cancer which can present as a scrotal mass, is a source of great concern and uniformly requires prompt intervention. Other masses, such as varicoceles,may be benign or cause testicular growth retardation in adolescent boys or impair fertility in adults. Thus, it is important for a patient to seek prompt medical attention when he identifies a scrotal mass or any lump or bump while performing a testicular self examination. The following information will assist you when talking to a urologist about varicoceles.


What are varicoceles?

Varicoceles are abnormal enlargements (dilations) of the pampiniform plexus of veins within the scrotum. They are similar to varicose veins of the leg, and often form during puberty. They can become larger and thus more noticeable with time. Left-sided varicocoele are more common than right-sided varicocoele, likely due to anatomical differences between the two sides. Ten to fifteen percent of boys have a varicocoele. A fraction will develop testicular growth retardation during puberty.

What can cause varicoceles?

Several causes of varicoceles have been suggested. Incompetent or absent valves within the spermatic veins may lead to pooling of blood from sluggish or even backflow.. Additionally, the acute angle at which the left spermatic vein enters the renal (kidney) vein may transmit the relatively high pressure to result in backflow manifested in enlargement of the scrotal veins. This explains why varicoceles are more common on the left side since the gonadal vein on the left side enters the renal vein. The right gonadal vein is not as long and does not join with the right venal vein. Rarely, enlarged lymph nodes or other abnormal masses in the retroperitoneum (the space behind the abdominal cavity) will block the flow of blood in the spermatic veins, leading to acute enlargement of scrotal veins. This phenomenon is rare and is usually associated with pain.

How common are varicoceles?

Varicoceles are present in an estimated 15 percent of all men. It is not know how many lead to infertility but approximately 40 percent of men undergoing evaluation for infertility are found to have a varicocoele and decrease sperm motility. There is no association other anomalies, race, geographic or ethnic origin.

What are the symptoms of varicoceles?

Most men diagnosed with a varicocele have no symptoms, but varicoceles are important for several reasons. Varicoceles are thought to cause infertility and testicular atrophy (shrinkage). Approximately 40 percent of cases of primary male infertility and 80 percent of cases of secondary male infertility are believed to be due to varicoceles. Varicoceles rarely cause pain. When pain is present, it can vary from a dull, heavy discomfort to a sharp pain. The associated symptoms may increase with sitting, standing or physical exertion - particularly if any one of these activities occurs over long periods of time. Symptoms often progress over the course of the day, and they are typically relieved when the patient lies on his back, allowing improved drainage of the veins of the pampiniform plexus.

How are varicoceles diagnosed?

Varicoceles can be discovered through self-examination or during routine physical examination. They may look or feel like a mass in the scrotum, and they have been described as having a "bag of worms" both because of their appearance and the way they feel. Physicians typically diagnose varicoceles with the patient in the standing position. The patient may be asked to take in a deep breath, hold it, and bear down while the physician feels the scrotum above the testicle. This technique, known as the Valsalva maneuver, assists the physician in detecting abnormal enlargement or increased fullness of the pampiniform plexus of veins. A physician may order a scrotal ultrasound test to help make the diagnosis, particularly if the physical examination is difficult or inconclusive. Radiographic hallmarks of varicoceles on scrotal ultrasonography are veins greater than three millimeters in size with reversal of blood flow within the veins of the pampiniform plexus during the Valsalva maneuver. In addition, the ultrasound study can provide testicular size measurements which is factored in the medical decision process in adolescents. However, routine radiographic screening for varicoceles in the absence of physical findings is not indicated.

What are the treatment options for varicoceles?

Treatment of varicoceles is an appropriate consideration in patients with infertility, pain or testicular atrophy. No medical therapies are available for either treatment or prevention; however analgesic agents may alleviate associated pain when present.

There are two main approaches to the treatment of a varicocele:

Surgical Repair: This approach involves a variety of specific techniques, but all involve ligation (obstructing) of the spermatic veins thus interrupting blood flow in the vessels of the pampiniform plexus. The surgical approaches include open surgical repairs performed through a single 1 inch incision with or without the use of optical magnification (e.g., magnifying glasses or loupes or an operating microscope). Laparoscopic varicocele repair which utilizes telescopes passed through the abdominal wall are advocated by some. The open procedures are performed under a variety of anesthetics, from local to general anesthesia, whereas the laparoscopic approach is uniformly performed under a general anesthetic agent. With the advent of smaller incisions, which avoid muscle transection, the open procedures are becoming closer to the laparoscopic techniques in both speed of recovery and postoperative pain. Complications resulting from either open or laparoscopic approaches are rare, but include varicocele persistence/recurrence, hydrocele formation and injury to the testicular artery leading to loss of the testis (fortunately, this is an extreme complication).

Percutaneous Embolization: This procedure is performed by radiologists using a special tube that is inserted into a vein in either the groin or neck. After radiographic visualization of the enlarged veins of the pampiniform plexus, coils or balloons are released to create an obstruction (blockage) in the veins. This obstruction then typically leads to interruption of blood flow within the pampiniform plexus vessels and disappearance of the varicocele. Percutaneous embolization is typically performed with intravenous sedation anesthesia and usually takes several hours to complete. Complications may include varicocele persistence/recurrence, coil migration and complications at the venous access site. This has not been widely employed in most centers.

What can be expected after treatment?

Recovery time after surgical repair is rapid. Pain is usually mild, and patients are asked to avoid strenuous activity for 10 to 14 days. Office work can typically be done one to two days after surgery. A follow-up visit with the urologist is scheduled. A follow-up semen analysis is obtained three to four months later if the procedure was performed to treat associated infertility. Open procedures performed with optical magnification have a low recurrence rate of approximately one percent.

Recovery time after embolization is also relatively short. Again, pain is typically mild, and patients are asked to avoid strenuous physical activity for seven to 10 days after the procedure.

Patients may return to office work one to two days postoperatively. The recurrence rate with embolization is generally thought to be higher than that achievable with optical magnification. Nevertheless, there are circumstances when embolization may be preferable.

The impact of varicocele correction on fertility is not entirely clear. Some studies demonstrate improvement in fertility after varicocele repair, while other studies fail to document this change. Semen quality is improved in approximately 60 percent of infertile men undergoing correction of a varicocele, and this treatment should be considered in the context of other available treatment options as couples pursue therapy. In adolescents, where the main indication for surgery is testicular growth retardation, catch up growth occurs in over 90% of patients.

Frequently asked questions:

What will happen if I choose to observe my varicocele, rather than undergo treatment?

Failure to treat a varicocele may result in testicular atrophy and/or a decline in semen quality. This may lead to infertility. The varicocele may, over time, lead to permanent, irreversible testicular injury.

I have pain with my varicocele. What can I do to help alleviate the pain?

The use of adequate scrotal support (e.g., athletic supporter, briefs style underwear, etc.) can help the pain associated with a varicocele. Lying on your back facilitates varicocele drainage and often improves episodic discomfort as well. Use of analgesic agents (e.g., acetaminophen, ibuprofen, etc.) may be of benefit in treating the pain associated with a varicocele. Additionally, many patients obtain lasting relief of symptoms with varicocele correction through the above-mentioned techniques.

I am considering having my varicocele corrected for fertility reasons. How long will I have to wait to see improvement in semen parameters?

Semen analyses are typically obtained at three to four month intervals after the procedure. Improvement is often seen within six months, but may not be observed until one year postoperatively.

My adolescent son was recently diagnosed with a varicocele. Should this be corrected?

Indications for correction of a varicocele in an adolescent include disparity in testicular size exceeding 10% by volume. Additionally, correction is a consideration in patients with pain. Treatment of adolescents is highly individualized, and consultation with a urologist or a pediatric urologist to further discuss the appropriateness of treatment for a particular patient is highly recommended.

I am interested in fertility and have no symptoms. Should I have my varicocele repaired?

Generally, asymptomatic varicoceles are not repaired. Most physicians do not believe there are health consequences of untreated asymptomatic varicoceles.

Azoospermia – No Sperm Count

Ejaculatory Dysfunction

Ejaculatory dysfunction is a type of sexual dysfunction in which the male ejaculates too early, too late or not at all during the sexual act. There are three types of ejaculatory dysfunction: premature, delayed or retrograde ejaculation.

On average, once the penis enters the vagina, there is a delay of 5 to 6 minutes before ejaculation. Premature ejaculation occurs when the male partner ejaculates too quickly over 50% of the time. Delayed ejaculation occurs when you have difficulty reaching climax after prolonged sexual activity (>30 minutes) even if your erection is adequate. Most cases of premature or delayed ejaculation develop over time, but some cases may be life-long. Retrograde ejaculation is rare type of ejaculatory dysfunction resulting in the backward ejaculation of sperm into the bladder.

Ejaculatory dysfunction may be caused by medical conditions such as high blood pressure, diabetes, neurological disorders, or prostate and thyroid problems. Psychological causes for dysfunction may include stress, anxiety about your problem, causing you to hasten the sexual act, marital problems, depression or the negative effects of past sexual experiences. Certain medications as well as substance abuse can also contribute to ejaculatory dysfunction.

If you or your partner experience dissatisfaction as a result of ejaculatory dysfunction, you must not hesitate to contact your physician as these problems are common and often treatable. Your doctor will review your symptoms as well as your medical and family history and may perform certain tests to rule out physical problems that could be causing ejaculatory dysfunction. You will be asked questions to gauge your mental state, attitude towards sex, and find out if you have any psychological issues contributing to the problem.

Your doctor may prescribe medication to treat ejaculatory dysfunction. Couples therapy or sex therapy may be recommended to resolve marital issues, improve intimacy, remove psychological blocks, and teach you sexual techniques that either delay or enhance ejaculation. Topical anesthetics or thick condoms may be recommended in cases of premature ejaculation to decrease sensation thereby delaying ejaculation. Medications contributing to ejaculatory dysfunction are either stopped or altered. Retrograde ejaculation does not usually affect sexual life, but may affect childbearing for which medication or artificial fertility methods are suggested.

Testicular Disorder

The testes, also called as testicles, are part of the male reproductive system that produces sperm and the hormone testosterone. The testes are two oval shaped glands situated in the scrotum, a loose sac of skin that hangs down behind the penis. Problems with the testes can result in serious complications such as hormonal imbalances, sexual dysfunction and infertility.

Some conditions that can affect the testicles include:

Testicular trauma: Because the testes are located within the scrotum, there are no muscles and bones to protect them. This location makes the testes susceptible to injury. Testes can easily get struck, hit, kicked or crushed, often during contact sports. Trauma to the testes can cause severe pain, bruising, swelling, and even leakage of blood into the scrotum (testicular rupture). For protecting the testicles against injury, males should always wear athletic cups during sports.

Testicular torsion: This is a condition in which the spermatic cord that provides blood flow to the scrotum is twisted. As a result, the blood supply to the testicle is reduced causing sudden and severe pain, swelling, tenderness and enlargement of the affected testicle. It may occur as a result of injury to the testicles or from strenuous activity. Testicular torsion is considered as a medical emergency that usually requires immediate surgery to restore the flow of blood.

Epididymitis: This condition is an inflammation of the epididymis, the coiled tube at the back of each testicle that stores and carries sperm. . Epididymitis is usually caused by a bacterial infection or by a sexually transmitted disease such as chlamydia. The symptoms of epididymitis are scrotal pain, swelling, collection of pus and fever.

Hypogonadism: It is the inability of the testicles to produce enough testosterone, the hormone that is responsible for the development and maintenance of masculine physical characteristics. Primary hypogonadism occurs from a problem in the testicles, whereas secondary hypogonadism may occur from a problem with the pituitary gland in the brain that signals the testicles to produce testosterone.

Testicular cancer: This condition involves an abnormal, uncontrolled growth of the cells within the testicles. The symptoms of testicular cancer include pain, swelling or lumps in testicles or groin area, and a feeling of heaviness in the scrotum. The exact cause of testicular cancer is not known. However, certain factors such as undescended testicles, age and race, and family history may increase your risk of developing the condition.

Undescended testicle (cryptochordidism): It is a condition in which the testicles fail to descend from the abdomen, into the scrotum shortly before birth. It is one of the major risk factors for testicular cancer.

Hydrocele: This is a condition where fluid accumulates around one or both testicles. Hydroceles are usually benign, but can enlarge enough to cause symptoms such as pain or pressure. In most cases, the exact cause of hydrocele is not known, but may develop as a result of inflammation or injury within the scrotum.

Varicocele: It is an enlargement of the veins (blood vessels) along the spermatic cord above the testicle. It is usually harmless, but may occasionally affect fertility or cause mild to moderate pain.