My Penis Stuff

There are many reasons why a person can have blood in their urine. This condition, known as hematuria, can be an indication of a serious problem or conversely, have no negative connotation. What should you do if you find out that there’s blood in your urine? Read the following to learn more.

What is hematuria?
Hematuria is defined as the presence of red blood cells in the urine. It can be characterized as either “gross” (visible to the naked eye) or “microscopic” (visible only under the microscope). Microscopic hematuria is an incidental finding often discovered on urine tests as part of a routine medical evaluation, whereas gross hematuria could prompt you to visit the doctor. Hematuria can originate from any site along the urinary tract, including the kidneys, ureters, bladder, prostate and urethra. It is estimated that hematuria occurs in 2.5 to 21 percent of the population. In many patients no specific cause is found; however, hematuria may be a marker for infection, stone disease or urinary tract cancer. Risk factors for significant underlying disease include: smoking, radiation, overuse of some pain medicines and exposure to certain chemicals.

What are the common causes of hematuria?
Blood in the urine is often not a sign of significant disease. Studies have shown that between nine to 18 percent of normal individuals can have some degree of hematuria. However, hematuria can be a sign of an important medical condition requiring treatment. Below is a list of common causes of hematuria:

• Bladder Cancer
• Kidney Cancer
• Prostate Cancer
• Ureteral Cancer
• Urethral Cancer
• Urinary Stone Disease
• Urinary Tract Infection
• Pyelonephritis (Kidney Infection)
• Benign Prostatic Hypertrophy (Enlarged Prostate)
• Renal (Kidney) Disease
• Radiation or Chemical Induced Cystitis (Bladder Irritation)
• Injury to the Urinary Tract
• Prostatitis (Prostate Infection)
• Exercise Hematuria

How is hematuria diagnosed?
Visible hematuria is often worrisome to the patient and prompts them to seek medical attention; however, microscopic hematuria can be just as severe. It often has no symptoms and is detected on a urine dipstick test (A measuring rod is dipped into a container to test urine for chemicals that suggest whether blood might be present and whether white blood cells might be present. This test can also show the pH (acidity) of your urine and how concentrated your urine is.). If the dipstick test is positive for blood the amount of blood is often determined by looking at the urine with a microscope. If three or more red blood cells (RBC) are seen per high power field on two of three specimens, further evaluation to determine a cause is recommended.

What additional tests are needed?
Any patient with gross hematuria or significant microscopic hematuria should have further evaluation of the urinary tract. The first step is a careful history and physical examination. Laboratory analysis consists of a urinalysis (A test of a urine sample that can reveal many problems of the urinary system and other body systems. The sample may be observed for physical characteristics, chemistry, the presence of drugs or germs or other signs of disease.) and examination of urinary sediment under a microscope. The urine should be evaluated for protein (a sign of kidney disease) and evidence of urinary tract infection (Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.). The number of red blood cells per high-powered field should be determined. In addition the shape of the blood cells should be evaluated. This can help determine where the bleeding is coming from. In patients with white blood cells in the urine, a urine culture should be performed as well. A urinary cytology (The examination of cells obtained from the body tissue or fluids, especially to establish if they are cancerous.) is also obtained to look for abnormal cells in the urine. A blood test should also be done to measure serum creatinine (a measure of kidney function). Those patients with significant protein in their urine, abnormally shaped red blood cells, or an elevated creatinine level should undergo general medical evaluation for the presence of kidney disease.

A complete urologic evaluation for hematuria also includes X-rays of the kidneys and ureters to detect kidney masses, tumors of the ureters and the presence of urinary stones. This traditionally consisted of an intravenous pyelogram (IVP). In this study, a radiographic dye is injected into the blood stream and X-rays are taken as the kidneys excrete the dye. This study has trouble detecting small renal (Pertaining to the kidneys.) masses and is often combined with a renal ultrasound.

Many physicians may opt for other imaging studies such as a computerized tomography (CT) (Also known as computerized tomography, computerized axial tomography or CT scan. A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce cross-sectional images of the body. Shows detailed images of any part of the body, including bones, muscles, fat and organs. CT scans are more detailed than general X-rays.) scan. This is the preferred method of evaluating kidney masses and is the best modality for the evaluation of urinary stones. Recently many urologists have been using CT urography. This allows the urologist to look at the kidneys and ureters with one X-ray test. In patients with an elevated creatinine or an allergy to X-ray dye, magnetic resonance imaging (MRI) (Also referred to a MRI. A diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.) or retrograde pyelography is used to evaluate the upper urinary tract. During retrograde pyelography, the patient is taken to the operating room and dye is injected up the ureters from the bladder and then images are taken.

The main limitation of these imaging studies is the inability to evaluate the bladder; therefore a cystoscopic evaluation is required. This is usually performed in the office under local anesthesia (Loss of sensation only in one part of the body induced by application of an anesthetic agent.) with either a rigid, or more commonly, a flexible cystoscope. After applying a topical analgesic (A drug applied directly to the surface of the body to alleviate pain.) to the urethra (In males, this narrow tube carries urine from the bladder to the outside of the body and also serves as the channel through which semen is ejaculated. Extends from the bladder to the tip of the penis. In females, this short, narrow tube carries urine from the bladder to the outside of the body.) the urologist inserts an instrument called a cystoscope through the urethra and into the bladder. Looking through the cystoscope the doctor can examine the inner lining of the bladder and urethra for abnormalities.

What happens if no abnormality is found?
In at least eight to 10 percent of cases no cause for hematuria is found. Some studies have demonstrated an even higher percentage of patients have no cause. Unfortunately, studies have shown that urologic malignancy is later discovered in one to three percent of patients with negative work-ups. Therefore, some form of follow-up is recommended. Recommendations regarding follow-up are sparse and no clear consensus has been agreed upon. Consideration should be given to repeating the urinalysis and urine cytology at six, 12, 24 and 36 months. Immediate re-evaluation with possible cystoscopy and repeat imaging should be performed in the face of gross hematuria, abnormal urinary cytology or irritating urinary symptoms such as pain with urination or increased frequency of urination. If none of these symptoms occur within three years, no further urologic testing is needed.

How will hematuria be treated?
Treatment will be based on a physician’s evaluation of the patient’s condition, symptoms and medical history along with the cause of the hematuria.

If you are a male and experiencing pain the scrotum or testicle, then it might be attributed to epididymitis, orchitis or a combination of the two. The information below will give you a head start in learning more about these conditions and aid in you in your discussions with a urologist.

What are epididymitis, orchitis and epididymo-orchitis?

Epididymitis is inflammation of the epididymis — the coiled tube that collects sperm from the testicle (Also known as testis. Either of the paired, egg-shaped glands contained in a pouch (scrotum) below the penis. They produce sperm and the male hormone testosterone.) and passes it on to the vas deferens (Also referred to as vas. The cordlike structure that carries sperm from the testicle to the ejaculatory duct, whicn in turn carries it to the urethra.). There are two forms of this disease, acute and chronic. Acute epididymitis comes on suddenly with severe symptoms and subsides with treatment. Chronic epididymitis is a long-standing condition, usually of gradual onset, for which the symptoms can be improved with treatment but may not completely be eradicated. Most cases of epididymitis occur in adults.

Orchitis is inflammation of the testicle. It is almost always comes on suddenly and subsides with treatment. Chronic orchitis is not well-defined, and instead is considered to be one of the many conditions related to chronic testicular pain (orchalgia).
Epididymo-orchitis is the sudden inflammation of both the epididymis and the testicle.

What are the causes of such conditions?

Acute epididymitis is usually caused by a bacterial infection. In children who haven’t reached puberty, the infection usually starts in the bladder (The balloon-shaped pouch of thin, flexible muscle in which urine is temporarily stored before being discharged through the urethra.) or kidney (One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.) and then spreads to the testicle. This is often associated with a birth-related abnormality that predisposes to urinary tract infection. In sexually active men, the most common infection causing epididymitis is a sexually transmitted disease such as gonorrhea or chlamydia infection. These infections start in the urethra, causing urethritis (Inflammation of the urethra.), which can then move into the testicle. In men over 40 years of age, the most common cause is bacteria from the urinary tract. Other causes can include: bladder outlet obstruction due to enlargement of the prostate (In men, a walnut-shaped gland that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.); partial blockage of the urethra (In males, this narrow tube carries urine from the bladder to the outside of the body and also serves as the channel through which semen is ejaculated. Extends from the bladder to the tip of the penis. In females, this short, narrow tube carries urine from the bladder to the outside of the body.); or recent catheterization (Insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.) of the urethra. In any of these cases, the original infection may not cause symptoms, and the first sign of a problem may be epididymitis. Bacterial epididymitis rarely occurs when a bacterial infection spreads from the bloodstream into the epididymis, although this is the typical way that tuberculosis infection can involve the epididymis. Epididymitis is occasionally due to causes other than infection. Chemical epididymitis occurs when sterile urine flows backward from the urethra to the epididymis, which most commonly occurs with heavy lifting or straining. The urine causes inflammation without infection. The drug amiodarone also can cause a non-infectious epididymitis, and there are other cases of non-infectious epididymitis without known cause.

Chronic epididymitis may develop after several episodes of acute epididymitis that do not subside, but also can occur without any symptomatic episodes of acute epididymitis or prior infection—in which case the cause is unknown.

In most cases of acute orchitis, the testicle is inflamed due to the spread of a bacterial infection from the epididymis, and therefore “epididymo-orchitits” is the correct term. Although orchitis without epididymitis can occur from a bacterial infection, orchitis without epididymitis usually results from an infection related to the mumps virus. “Mumps orchitis” occurs in approximately one-third of males who contract mumps after puberty.

Acute epididymo-orchitis is usually a primary bacterial or tuberculous infection of the epididymis that has spread to the testicle to involve both structures. Rarely, it can start in the testicle and spread to the epididymis. Mumps orchitis does not spread to the epididymis.

What are the symptoms and how are they diagnosed?

Acute epididymitis and acute epididymo-orchitis: Symptoms occur not only from the local infection, but also from the original source of the infection. Common symptoms from the original source of the infection include: urethral discharge and urethral pain or itching (from urethritis); pelvic pain and urinary frequency, urgency or painful/burning urination (from infection of the bladder, called cystitis); fever, perineal (Related to the area between the anus and the scrotum in males and the area between the anus and the vagina in females.) pain, urinary frequency, urinary urgency or painful/burning urination (from infection of the prostate, called prostatitis); fever and flank (The area on the side of the body between the rib and hip.) pain (from infection of the kidney, called pyelonephritis (Also referred to as kidney infection usually caused by a germ that has traveled up through the urethra, bladder and ureters from outside the body. Typical symptoms include abdominal or back pain, fever, malaise and nausea or vomiting.)). In some cases, pain in the scrotum (Also referred to as the scrotal sac. The sac of tissue that hangs below the penis and contains the testicles.) from the local infection is the only noticeable symptom. The pain starts at the back of one testicle but can soon spread to the entire testicle, the scrotum and occasionally the groin (The area where the upper thigh meets the lower abdomen.). Swelling, tenderness, redness, firmness and warmth of the skin may also accompany the pain. The entire scrotum can swell up with fluid (hydrocele (A painless swelling of the scrotum caused by collection of fluid around the testicle.)). To make the diagnosis, the doctor will ask you about your medical history and examine you. The doctor may test a urine sample and look at it under the microscope to assess for bacterial infection, culture a urine sample as a more definitive way to see if there is bacterial infection, or examine a swab obtained from the urethra (if urethritis is suggested by your symptoms). If your pain came on very suddenly and severely, then an ultrasound, which is a non-invasive test that uses sound waves to look at the epididymis and measure blood flow, might be used to distinguish epididymitis from another condition called testicular torsion (A twisting of the testicles and the spermatic cord (the structure extending from the groin to the testicles that contains nerves, ducts and blood vessels).). This is managed very differently than epididymitis, so making the distinction is very important. Tuberculous epididymitis presents in the same way, although chemical and amiodarone epididymitis are less severe.

Chronic epididymitis: The pain occurs only in the scrotal contents, and is less severe and more localized than acute epididymitis. Swelling, tenderness, redness and warmth of the skin do not occur. Additional tests may be used as for acute epididymitis, but are less frequently required. In acute epididymitis the urine is usually infected, whereas in chronic epididymitis it is usually not.

Acute orchitis: During the acute phase of mumps orchitis, symptoms include pain of varying severity, tenderness and swelling. The parotiditis (swelling of facial glands) of mumps usually precedes orchitis by three to seven days. Isolated orchitis from bacterial infection has the same symptoms of acute epididymitis or epididymo-orchitits.

What are the treatment options?

Acute epididymitis and acute epididymo-orchitis: Treatment in cases suspected to be from bacteria (most) includes at least two weeks of antibiotics. Most cases can be treated with oral antibiotics as an outpatient. Your doctor can choose one of several, including: doxycycline, azithromycin, ofloxacin, ciprofloxacin, levofloxacin or trimethoprim-sulfamethoxazole. Tuberculous epididymitis is treated with anti-tuberculous medications, although many cases surgical removal of the testicle (orchiectomy, which includes removal of the epididymis) is required because the damage is so severe. Cases of severe infection, with intractable pain, vomiting, very high fever or overall severe illness, may require admission to the hospital. Aside from treatment of amidarone epididymitis by reducing the dose or stopping the drug, there is no specific therapy for non-infectious epididymitis. General therapy for epididymitis includes bed rest for one to two days combined with elevation of the scrotum. The aim is to get the inflamed epididymis above the level of the heart. This improves blood flow out of the testicle, which promotes more rapid healing and reduces swelling and discomfort. Intermittent application of ice might also be of assistance and, in cases due to infection, intake of plenty of fluids. Nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen are useful since they not only relieve pain but also reduce the inflammation that is the cause of the pain.

Chronic epididymitis: Primary therapy is with medications and other treatments directed towards reducing the discomfort. Non-steroidal anti-inflammatory medications and local application of heat are the mainstays of treatment. If symptoms persist, your physician may recommend other medications to alter the perception of pain in the area, or might refer you to a specialist in pain management. If all else fails the epididymis can be surgically removed (epididymectomy) while leaving the testicle in place.

Acute orchitis: There is no specific treatment for acute mumps orchitis. In cases of bacterial infection, treatment is as for acute epididymitis and acute epididymo-orchitits.

What can be expected after treatment?

Acute epididymitis and acute epididymo-orchitis: In the typical infectious case, it will take two to three days for you to notice improvement. If the redness does not subside and you do not start to feel better by that time, contact your physician. Complete resolution of symptoms will take longer. Discomfort can persist until the entire course of antibiotics is completed, and the firmness and swelling can takes months to resolve. Following the instructions to stay at bed rest with scrotal elevation for the first one to two days will help speed recovery. You should follow-up with your physician after treatment. In cases of tuberculous epididymitis that do not require orchiectomy, it takes months to resolve on medications, and there will likely be some shrinking of the testicle. Amidarone epididymitis improves after reducing the dose or stopping the drug, without any residual problems. Chemical epididymitis also resolves completely.

Chronic epididymitis: Treatment is ongoing, and not curative. You may need to take medications for years, or until the symptoms resolve spontaneously. If epididymectomy is performed, relief of symptoms occurs in three out of four patients after a few weeks for surgical recovery. If surgery has not resolved your symptoms, then your doctor will try medical therapy again.

Acute orchitis: Following the acute phase of mumps orchitis, the pain resolves but there is often atrophy (When an organ diminishes in size.) of the testicle.

Frequently Asked Questions:

What if the swelling and pain do not get better after the first three days of antibiotics?
Most cases of acute epididymitis or epididymo-orchitits are treated well by antibiotics, but in some cases a different antibiotic needs to be used. Tuberculous epididymitis should also be considered when symptoms do not resolve appropriately. On occasion, surgery needs to be performed. If an abscess (pocket of pus) has formed, antibiotics alone are rarely sufficient and surgery to drain the abscess or remove part or all of the epididymis and testicle might be required. Other complications that might require surgery include testicular infarction (death of the testicle due to destruction of the blood vessels) and cutaneous fistula (infection that continues to drain out through the skin).

Can I pass the infection to my sexual partner?
If the acute epididymitis or epididymo-orchitits is from a sexually transmitted disease (usually in sexually active men under 40 years of age), then your sexual partner needs to be treated as well since the infection can be passed back and forth through sexual contact. The urinary tract bacteria that cause other cases of epididymitis or epididymo-orchitits are not sexually transmitted. Treatment of your partner is not required, and there is no risk of infecting your partner.

Will the ability to father children be reduced?
The atrophy associated with mumps orchitis and tuberculous epididymitis is associated with reduced production of sperm in the affected testicle in some cases. After an episode of acute epididymitis or epididymo-orchitits there can rarely be blockage of the epididymis, which would reduce delivery of sperm from that testicle. In any of these cases, if the other testicle is unaffected then most men are able to father a child normally.

Will hormone production by the testicle be affected?
The ability of the affected testicle to produce testosterone (Male hormone responsible for sexual desire and for regulating a number of body functions.) is lost in some men with atrophy associated with mumps orchitis and tuberculous epididymitis. The rare epididymal blockage that occurs after acute epididymitis or epididymo-orchitits does not affect hormone production.

Do epididymal or testicular infections lead to cancer?
There is no association of these infections with cancer.

Until the late 1990s, there were no truly effective oral medications for erectile dysfunction — the inability to achieve or sustain an adequate erection for sexual activity. The useful drugs that were available had to be injected into the penis or inserted into the urethra.

Treatment of erectile dysfunction is much easier now, thanks to a class of drugs called phosphodiesterase-5 (PDE-5) inhibitors. The medications — sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) — all improve erectile function in the same basic way, but they differ in how quickly they take effect and how long their effects last.

How Viagra, Levitra and Cialis work

Viagra, Levitra and Cialis prevent the breakdown of nitric oxide, a chemical messenger that promotes relaxation and opening of the blood vessels that supply erectile tissue in the penis. Under the influence of nitric oxide, these vessels expand and stay dilated. Increased blood flow makes erectile tissue swell and compress the veins that carry blood out of the penis, resulting in a full erection.

PDE-5 inhibitors do not automatically trigger erections. Sexual stimulation also is needed to start the whole process. The medications enable a more complete response to sexual stimulation.

Many clinical trials have shown that PDE-5 inhibitors improve erectile function regardless of the underlying cause or causes. Viagra, Levitra and Cialis increase the number and quality of erections and sexual experiences in men with erectile dysfunction due to arteriosclerosis, diabetes, spinal cord injury, depression or the aftereffects of prostate cancer surgery.

Similarities and differences

The drugs have slightly different chemical compositions that affect how quickly they work and wear off. Other distinctions — for example, which drug may be best for men of different ages or with different medical conditions — aren’t known. No study has directly compared these three medications.

Several factors may affect your choice of medication, including how well your body responds to one drug over another and how long you want the effects of each dose to last. Talk to your doctor about your options and personal preferences to help decide which one of these medications might work for you.

Not safe for everyone

Although these medications can help many people, not all men can safely take them. PDE-5 inhibitors may worsen certain medical conditions and interact with a number of drugs. Erectile dysfunction medications are dangerous when used with nitrate medications, such as nitroglycerin (Nitro-Dur, others), often prescribed to prevent or treat acute angina (chest pain due to coronary artery disease). Both types of medication dilate blood vessels, and their combined effects can cause dizziness, low blood pressure and loss of consciousness.

In rare cases, men using PDE-5 inhibitors have suffered permanent, total vision loss due to nonarteritic anterior ischemic optic neuropathy (NAION). Because NAION and erectile dysfunction share many of the same risk factors, it’s unclear whether the drug or an underlying condition is responsible. If you’re considering an erectile dysfunction drug but have a retinal disorder, such as diabetic retinopathy, see your eye doctor first.

Realistic expectations

Occasional erectile dysfunction is a common problem, particularly as men age. Medication won’t make you feel like you’re 20 again, but it can help you achieve satisfying sexual relations more often. Be willing to work with your doctor to find which medication and dosage is best for you.

The American Urological Association, Inc.® (AUA) believes that circumcision, removal of the foreskin of the penis, performed on a newborn (neonatal) has potential medical benefits and advantages as well as disadvantages and risks.

Neonatal circumcision is generally a rapid and safe procedure when performed by an experienced physician. There are immediate risks to circumcision such as bleeding, infection and penile injury, as well as complications recognized later that may include buried penis (Also referred to as concealed or hidden penis. Condition where the penile shaft is buried below the surface of the pubic skin.), meatal stenosis (Narrowing at the end of the urine channel at the tip of the penis.), skin bridges (Adherence of two skin surfaces.), chordee (Abnormal downward bend of the penis during an erection.) and poor cosmetic appearance. Some of these complications might require surgical correction. Nevertheless, when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low. The minor complications are reported to be three percent.

Properly performed neonatal circumcision prevents phimosis (Condition in which the foreskin cannot be pulled back behind the head of the penis.), paraphimosis (Condition in which the foreskin is trapped behind the glans penis and cannot be pulled down to cover the head of the penis.) and balanoposthitis (Inflammation of glans and foreskin.), and is associated with a decreased incidence of cancer of the penis among U.S. males. In addition, there is a connection between the foreskin and urinary tract infections in the neonate. For the first three to six months of life, the incidence of urinary tract infections is at least ten times higher in uncircumcised than circumcised boys. Evidence associating circumcision with reduced incidence of sexually transmitted diseases (Also referred to as STDs. Any of a diverse group of infections caused by biologically dissimilar pathogens and transmitted by sexual contact.) is conflicting. Circumcision may be required in a small number of uncircumcised boys when phimosis, paraphimosis or recurrent balanoposthitis occur and may be requested for ethnic and cultural reasons after the newborn period. Circumcision in these children usually requires general anesthesia.

When circumcision is being discussed with parents and informed consent obtained, medical benefits and risks, and ethnic, cultural, religious and individual preferences should be considered. The risks and disadvantages of circumcision are encountered early whereas the advantages and benefits may be prospective.