My Penis Stuff

The decision to proceed with a vasectomy is a very personal one. So it is important that you have a clear understanding of what a vasectomy is and what it is not. The following will provide you with information that will assist you in deciding whether or not a vasectomy is an appropriate form of contraception for you.

What happens under normal conditions?
The testicles produce sperm and testosterone and are located in the scrotum at the base of the penis. Once produced, the sperm exit the testicle through a delicate, coiled tube called the epididymis, where they stay until they are fully matured. Each epididymis is connected to the prostate by a tube called the vas deferens. This muscular tube generally extends from the lower portion of the scrotum into the inguinal canal (site of most hernias) and then into the pelvis continuing behind the bladder. It is at this point that the vas deferens joins with the seminal vesicle and forms the ejaculatory duct. During ejaculation, seminal fluid and seminal vesicles mixes with sperm to form semen which is expelled through the urethra.

What is a vasectomy?
A vasectomy is a minor surgical procedure designed to interrupt the sperm transportation system between the testicle and the urethra by blocking the vasa deferentia.

How is a vasectomy performed?
In general, vasectomies are performed in the urologist’s office. However, the procedure may be done at an ambulatory surgery center or in a hospital setting if the patient and urologist have determined that intravenous sedation is preferable. The decision to proceed in that type of setting may be based upon the patient’s anatomy, anxiety or the need for associated surgical procedures.

On the day of the procedure, the patient will be asked to sign a surgical consent form. Certain states have regulations regarding the type and timing of the surgical consent for permanent sterilization.

Once the patient has signed the consent form and has been brought into the procedure room, his scrotal area will be shaved. Some urologists will have the patient shave this area at home. The area will then be washed with an antiseptic solution. Local anesthesia will be injected to numb the area but the patient will be aware of touch, tension and movement during the procedure. However, the local anesthetic should eliminate any sharp pain. The patient is awake during the procedure so, if necessary, he can let the urologist know if he is experiencing pain so more local anesthesia can be given.

With a conventional vasectomy, a urologist makes one or two small cuts in the skin of the scrotum to access the vas deferens. The vas deferens is cut, and a small piece may be removed leaving a short gap between the two remaining ends. Next, the urologist may cauterize the lumen or ends of the vas, then ties the cut ends with suture material. The scrotal incisions may be closed with dissolvable stitches or allowed to close on its own. The entire procedure is then repeated on the other side either through the same initial incision or through a second scrotal incision.

During a no-scalpel vasectomy, the urologist feels for the vas under the skin of the scrotum and holds it in place with a small clamp. A special instrument is then used to make a tiny puncture in the skin and stretch the opening so the vas deferens can gently be lifted out, cut, then tied or cauterized and put back in place.

What should the patient expect after a vasectomy?
Your urologist should provide you with specific recommendations for your care after a vasectomy. It is generally wise to return home immediately after the procedure and avoid strenuous or sexual activity. Swelling and discomfort can be minimized by placing an ice pack on the scrotum and by wearing a supportive undergarment, such as a jockstrap. Most patients can expect to recover completely in less than a week and many are able to return to their job as early as a day after the procedure. Sexual activity can usually be resumed within a week following a vasectomy. However, it is important that all patients recognize that a vasectomy, even though successful, is not effective immediately. The effectiveness of the vasectomy must be proven by having the patient submit at least one semen analysis , which demonstrates that there are no sperm in the ejaculate. The time until disappearance of sperm from the ejaculate varies from patient to patient. Most urologists do not recommend checking the semen for sperm for at least three months or 20 ejaculates, whichever comes first. If sperm continue to be present in the ejaculate, that patient must continue to use contraception. After waiting for three months or 20 ejaculates, one in five men will still have sperm in their ejaculate, and will need to wait longer for the sperm to clear. The patient should not assume that his vasectomy is effective until his semen analysis demonstrates the absence of sperm.

Are there any risks associated with a vasectomy?
In the immediate postoperative period there is the risk of bleeding into the scrotum. If the patient notices a significant increase in the size of his scrotum or significant scrotal discomfort, he should contact his urologist immediately. A patient experiencing fever, scrotal redness or tenderness should also be evaluated by the surgeon as this may indicate an infection. Discomfort is usually minimal and should respond to mild analgesics. More severe pain may indicate infection or other complications. Patients will often complain of mild lower abdominal discomfort similar to what one would experience from getting hit in the genitalia. A benign lump, or granuloma, may develop because there is a leakage of sperm from the cut end of the vas into the scrotal tissues. It may occasionally be painful or sensitive to touch or pressure.

Post-vasectomy pain syndrome is a chronic pain syndrome that follows vasectomy. The cause of this syndrome and its incidence are unclear. It is generally treated with anti-inflammatory agents. Occasionally, patients will elect to undergo vasectomy reversal in an attempt to alleviate this syndrome. Unfortunately, the response to surgical intervention is unpredictable. There has been some debate in the past as to whether vasectomies predispose a man to any future health problems. However, there is no conclusive evidence that men who have undergone a vasectomy have a higher risk of cardiovascular disease, prostate cancer, testicular cancer or other health problems.

Can my partner tell if I have had a vasectomy?
There is no significant change in one’s ejaculate after a vasectomy since the sperm contributes a small amount to the overall ejaculate volume. Your partner may on occasion be able to feel the vasectomy site. This is particularly true if you have developed a granuloma.

Will my sense of orgasm be altered by having a vasectomy?
Ejaculation and orgasm are generally not affected by vasectomy. The only exception to this is the occasional patient who has developed post-vasectomy pain syndrome.

Can I become impotent after a vasectomy?
An uncomplicated vasectomy cannot cause impotence.

Can a vasectomy fail?
First, it is important to be certain that a vasectomy has been successful and that all sperm are absent from the ejaculate prior to stopping other forms of contraception. Even if the vasectomy has been demonstrated to be effective, there is a small chance that a vasectomy may fail. This occurs as a result of sperm leaking from one end of the cut vas deferens (the testicular end) and finding a channel to the other end (the abdominal end).

Can something happen to my testicles?
Rarely, the testicles may be injured during a vasectomy as a result of injury to the testicular artery. Other complications such as a mass of blood (hematoma) or infection may also affect the testicles.

Can I have children after my vasectomy?
Yes, but if you have not stored frozen sperm, you will require an additional procedure. The vas deferens can be microsurgically reconnected (in a procedure called a vasectomy reversal) to allow normal conception to occur. Alternatively, sperm can be extracted from the testicle or the epididymis and utilized for in vitro fertilization. These procedures are costly and may or may not be covered by insurance. Additionally, they are not successful 100 percent of the time. Therefore, one should carefully consider nonsurgical alternatives for contraception prior to deciding to proceed with a vasectomy.

The male reproductive tract is responsible for the production, maturation of sperm, and delivery of sperm. This tract is a complex and highly integrated entity. Sperm are produced in the testicles and then are transported through the genital duct system to the penis and out of the urethra during ejaculation. Each component of the reproductive tract is highly specialized.

Abnormalities within the male reproductive tract may appear as scrotal masses. Masses may be of little significance or may represent life-threatening illnesses. It is necessary to follow a set course of action to determine the nature of the masses and the most appropriate treatment option. For example, testicular cancer is a source of great concern and uniformly requires prompt intervention. Other masses, such as varicoceles, can cause pain or impair reproductive function. Thus, it is important for a patient to seek prompt medical attention when he identifies a scrotal mass or abnormality while performing a testicular self examination. The following information will assist you when talking to a urologist about varicoceles.

What are varicoceles?
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.

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 varicoceles are more common than right-sided varicoceles, likely due to anatomical differences between the two sides.

What can cause varicoceles?
Several causes of varicoceles have been suggested. Incompetent or absent valves within the gonadal or spermatic veins may lead to pooling of blood and the abnormal enlargement in the pampiniform plexus of veins. Additionally, the angle at which the gonadal vein enters the renal (kidney) vein may produce relatively high pressure within this venous system, leading to the swelling (dilation) of the pampiniform plexus. 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 gonadal veins, leading to increased pampiniform venous pressure and varicocele formation. This mechanism is only of concern when one develops a new varicocele.

How common are varicoceles?
Varicoceles are present in an estimated 15 percent of all men, whereas approximately 40 percent of men undergoing evaluation for infertility are diagnosed with this condition. No racial or ethnic groups are known to be at higher risk for development of a varicocele.

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?
Large varicoceles can be discovered through self-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. Asymptomatic varicoceles are often diagnosed on physical examination at the time of routine medical evaluation. 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. However, most varicoceles are diagnosed in most patients on the basis of physical examination alone. Most physicians do not believe that ultrasonography should be utilized to identify small or subclinical varicoceles since several studies have shown that “subclinical” varicoceles – those detected on the basis of ultrasound or other radiographic study alone – are usually not clinically relevant. Thus, routine radiographic screening for varicoceles in the absence of physical findings is not encouraged.

What are the treatment options for varicoceles?
Treatment of varicoceles is an appropriate consideration in some 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) the spermatic or gonadal veins thus interrupting blood flow in the vessels of the pampiniform plexus. The surgical approaches include open surgical repairs performed through a single 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 not generally used since they are thought by most to have greater potential for serious complications than standard surgical techniques without significant advantage. 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.

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 usually 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.

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, with the affected side measuring greater than 2 cm3 less in volume than the unaffected side. Additionally, correction is a consideration in patients with pain. Treatment of adolescents is highly individualized, and consultation with a urologist to further discuss the appropriateness of treatment for a particular patient is highly recommended. Often patients or families will choose to repair varicoceles to minimize the potential risk for future fertility or minimize the concerns about this complication.

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.

Sometimes, the tissue surrounding a testicle is not well attached to the scrotum. As a result, the testicle may become twisted around the spermatic cord resulting in the blood supply being cut off. The following information should help you better understand this potentially serious health hazard.

What happens under normal conditions?

The testicle (testis) receives its blood supply through the spermatic cord, which arises in the abdomen, courses through the inguinal canal and then enters the scrotum. This cord also includes the vas deferens, which transports sperm to the urethra. While there is more than one source of arterial blood to the testicle, they all enter the testicle via the spermatic cord. Interruption of this arterial route, therefore, will result in a complete cutoff of blood supply and demise of the testicle.

The testicles are organs suspended in a pouch-like skin sac — the scrotum — below the penis. By looking at the scrotum, both the right and left testicle should be approximately equal in size. An asymmetric enlargement, especially if acute, suggests an underlying pathologic condition on one side. Similarly, the skin color on both sides of the scrotum should be identical. Any change in color, especially redness or darkening, also suggests a problem. Finally, testicles are normally not painful and any pain or discomfort should alert the individual to seek medical attention, even if there is no swelling or skin color change.

What is testicular torsion?

Testicular torsion, or twisting of the testicle resulting in a strangulation of the blood supply, occurs in men whose tissue surrounding the testicle is not well attached to the scrotum. It is important to emphasize that testicular torsion is a medical emergency. The testicle will die (infarct) and diminish in size (atrophy) if the blood supply is not restored within approximately six hours. Restoration of the blood supply requires untwisting the cord (de-torsion).

Torsion is relatively rare, occurring in approximately one in 4,000 males under the age of 25.  However, it can also occur in newborns and in older men.

What causes testicular torsion?

In most individuals a testicle cannot twist because the surrounding tissue is well attached to the scrotum. The term “bell clapper” deformity is often used to describe a congenital condition in those individuals, whose testes hang within the scrotum and can “swing” like a bell clapper in a bell, allowing for easy twisting. It must be emphasized that boys and men born with the “bell clapper” deformity have no attachments around either testicle, so that torsion can potentially occur on either side. Bilateral testicular torsion, however, is an exceedingly rare event.

What are the symptoms of testicular torsion?

The hallmark of testicular torsion is sudden, severe, one-sided testicular pain. Torsion can occur at any time, while sitting or standing, or may awaken an individual from sleep. Physical activity does not cause torsion, but it may occur during sports or physical exercise. There is often associated nausea and vomiting. Slow-onset testicular pain, over several hours or days, can represent torsion, but it is less common. Problems with urination, such as burning or frequency, are not normally associated with torsion. Torsion is not a painless event, except perhaps in the newborn.

Early in the process, there may be no scrotal swelling. However very shortly thereafter, there will be swelling and redness of the scrotal skin. Testicles that have died (infarcted), after many hours of torsion, cause the greatest scrotal changes. The scrotum will be very tender, reddened and swollen. Often the individual will not be able to find a comfortable position.

How is testicular torsion diagnosed?

Clinical evaluation by the urologist, consisting of medical history and physical examination, is often sufficient to diagnose torsion. Time is of the essence, so if the urologist cannot exclude torsion or suspects it, surgical intervention must be undertaken without further delay. There are X-ray tests which may be used, especially in those individuals whose examination and history may not be characteristic. Both ultrasound and nuclear medicine techniques can be used to assess blood flow to the testicle, and therefore, can also exclude or confirm torsion.

How is testicular torsion treated?

Ultimately, all individuals with torsion require surgery. The testicle can at times be manually untwisted in the emergency room, but whether this is successful or not, surgery should follow. At surgery, the affected testicle will be untwisted and then sutures placed around both testicles to prevent future torsion. Most often this is performed through the scrotum, although an inguinal approach may be used. Unfortunately, there are individuals whose testicles cannot be saved, because it has already infarcted. This is determined at surgery. These individuals will undergo removal of the affected testicle at the time of surgery and then placement of sutures around the remaining opposite testicle to prevent future torsion.

The testicles of newborns with torsion can rarely be salvaged by untwisting, because they are almost always infarcted. Neonatal torsion is, therefore, not the same sort of surgical emergency as torsion in older boys and men. On the other hand, there have been instances of the other non-involved testicle twisting shortly after birth, leaving the baby with no testicles. In addition, there have been great improvements in pediatric anesthesia and postoperative care of even the smallest newborns. Many pediatric urologists will therefore take a newborn to surgery within the first few hours or days of life to remove the affected testicle and to place sutures around the opposite testicle to prevent future torsion.

What can be expected after treatment for testicular torsion?

Whether the testicle is removed or not, scrotal exploration results in minimal and short-lived discomfort. Oral pain medication may be necessary for a few days. Most surgeons will allow the patient to return to work or school within a few days to a week. However, strenuous physical activity or exercise might be best avoided for several weeks. The sutures that are placed around the testicles are not perceived by the patient and are not bothersome. It would be very rare for torsion to recur after the placement of fixation sutures. Patients and families should be wary of any testicular pain or swelling, however, especially if there is only one remaining testicle. In that case they should seek medical attention immediately.

If the torted testicle is left in place, it still might diminish in size slightly, since there may have been some permanent damage during the hours that the testicle was twisted. It is not possible to predict in whom this will happen, except that testicles torted for the longest time, in general, may have more size reduction. In addition, if one testicle is removed, the opposite testicle may increase in size to greater than normal, which is known as compensatory hypertrophy. Torsion of the testicle cannot be prevented by changes in activity or by taking medication. Only fixation sutures placed around the testis at surgery will prevent future torsion.

How will my future fertility be affected after the loss of a testicle?

Only one functioning testicle is necessary for normal fertility potential and full masculinization. A single testicle will produce normal amounts of sperm and testosterone. While there has been some experimental evidence to suggest that mechanisms might exist to diminish fertility in these patients, they do not appear to be clinically relevant in the vast majority of men who have had torsion.

How will my lifestyle be impacted if I have lost a testicle or have a weakened testicle?

Patients who have lost a testicle or who have a weakened testicle should remain cautious about the remaining testicle. They should always wear protection when engaging in contact sports. They should always seek medical attention if they have any discomfort or notice anything abnormal in the scrotum or remaining testicle.

Should I consider a testicular prosthesis?

Testicular prostheses are manufactured to replace a lost testicle. The products available include a solid, soft silicone polymer and a saline-filled silicone, which have not yet achieved full FDA approval. Most often, these prostheses are inserted when the individual is fully grown and through puberty. Placement of a smaller prosthesis in a younger boy would necessitate a second surgery to replace it with an adult sized prosthesis. Surgery for placement of a prosthetic testicle is not done at the time of removal of the infarcted testis, but may be performed some months later. The decision to place a prosthesis is highly personal and should be discussed with the urologist.

Can a newborn have testicular torsion?

Yes, although neonatal (newborn) testicular torsion is even more rare than torsion in older individuals. It is diagnosed right after birth, and may relate to prolonged or difficult labor. The torsion most often occurs prior to delivery. Its exact cause is unknown and location of the twisting of the spermatic cord is in a different location, as compared to older boys and men. They usually present with a hard scrotal mass, with some darkening of the scrotal skin. Unlike older patients, these infants most often are comfortable, without irritability. The vast majority of these testes cannot be salvaged and are already dead tissue when the baby is born.

What other torsions can occur?

Torsion of the appendix epididymis or testis deserves special mention, because in younger, prepubescent boys it is far more common than torsion of the testicle itself. This may occur in older boys and men, but is much less common in that age group. As in testicular torsion, there are no predisposing factors or activities that cause these structures to twist, and it can occur at any time. The testicular appendages are embryologic remnants that have no function in men. They are located at the upper pole of the testicle and epididymis. They have their own small blood supply and they can also twist, resulting in infarction. These individuals also present with scrotal pain, followed by swelling and redness. However, the pain is most often less severe and can gradually worsen over several hours or days. At times this diagnosis will be determined at the time of surgery, since the history and clinical findings are so similar to testicular torsion. At other times, the urologist may be able to make this diagnosis on physical examination or through the use of radiographic means, such as ultrasound or nuclear medicine scan. If the diagnosis is certain and testicular torsion is excluded, surgery might be avoided in those instances, since the pain and swelling will subside after several days. If there is any doubt at all, though, surgery will be suggested to rule out testicular torsion.

Scientists once believed erectile dysfunction (ED)—was a problem only of the mind and not of the body. But recent data suggest a physical (or organic) cause in more than half of all cases, especially those involving older men. In any case, experts believe it affects up to 30 million American men. But what is involved in impotence and what is available to correct it? The following information should help you talk to your urologist about this frustrating issue, and some of the options—including vascular surgery—that may help solve it.

What happens under normal conditions?

The internal structure of the penis includes two cylinder-shaped chambers, the corpora cavernosa. Filled with spongy tissue containing smooth muscles, fibrous tissue, veins and arteries, these chambers run the length of the organ and are surrounded by a membrane cover, called the tunica albuginea. The urethra, the channel through which urine and semen exit the body, is located on the underside of the corpora cavernosa and is surrounded by spongy tissue. The longest part of the penis is the shaft, which ends in the glans. The meatus is the opening at the end of the urethra.

Erection is the culmination of a complex set of physical, sensory and mental events, involving both the nervous and vascular systems. It begins when physical or psychological stimulation (arousal) causes neurotransmitters or impulses in the brain (chemicals such as dopamine, acetylcholine and nitric oxide) to tell the muscles of the corpora cavernosa to relax, allowing blood to fill the organ’s tiny open spaces. As the tunica’s fibrous or elastic tissues trap the blood, the penis engorges, or increases, in an erection. When stimulation finally ends, usually after ejaculation, pressure inside the organ decreases, as the muscles contract. Blood then flows from the penis and the penis returns to its normal shape and size.

What is erectile dysfunction (ED)?

Erectile dysfunction refers to the inability of a man to attain and maintain an erection sufficient for intercourse. It occurs when there is reduced blood flow to the penis or nerve damage, both of which can be triggered by a variety of factors. Scientists once believed that ED was an emotional issue alone. But today they know that physical factors are just as important as psychological triggers—stress, marital/family discord, job instability, depression and performance anxiety—in provoking this problem. It is important to note that hundreds of medications can also contribute to impotence while they fight allergic reactions, high blood pressure, ulcers, fungal infections, anxiety, depression and psychoses.

Who is at risk for erectile dysfunction (ED)?

A man is at risk if they suffer from:

Vascular diseases: Hardening or narrowing of arteries, often associated with high cholesterol, can also restrict blood flow to the penis, particularly if you are over 60. Because smoking can lead to any of the factors responsible for vascular problems—such as high blood pressure—it is probably an important factor in both arterial disease (atherosclerosis) and ED.

Neurologic disorders: Spinal cord diseases or injuries, brain injuries, multiple sclerosis, Parkinson’s disease and other progressive diseases can interrupt nerve impulses to and from the brain. Diabetes poses both neurological and vascular problems because it damages small blood vessels and nerves throughout the body, impairing the impulses and blood flow necessary for an erection.

Other conditions/illnesses: In addition, other chronic illnesses such as cancer and well as hormonal imbalances and penile disorders can disrupt the nerve impulses and blood flow necessary for normal erections.

What are the symptoms of erectile dysfunction (ED)?

Failing to achieve and/or sustain an erection is the primary sign of ED. But diagnosing the specific cause and prescribing appropriate treatment usually require a variety of tests, beginning with a complete history and physical examination.

Your doctor may order additional laboratory tests to assess any conditions that may be interfering with normal erectile function, particularly arterial flow to the penis. A blood test, for instance, is normally used to reveal blood lipids and triglycerides, both of which indicate atherosclerosis if elevated. A urinalysis identifies protein and glucose levels that can suggest diabetes.

While these analyses focus on your chemical status, erectile function tests are the principal tools your doctor will use to tell how the blood vessels, nerves, muscles and other tissues of your penis and pelvic region are working. Among them, penile nerve function tests—squeezing the head of the penis and measuring various responses—can determine if there is sufficient sensation in the penis. Nocturnal penile tumescence (NPT), or healthy involuntary erections during sleep, may rule out psychological issues and instead suggest nerve function or blood supply problems.

An imaging technique called duplex ultrasound may also be used. It monitors the behavior of moving structures and might provide some of the best data since it can evaluate blood flow, vein leaks, scarring of erectile tissue and some signs of atherosclerosis. During the test, an erection may be produced by injecting the stimulator prostaglandin into the body and then measuring vessel expansion and penile blood pressures, both of which are compared to the limp penis. In either case, duplex ultrasound can illustrate a specific blood vessel disease that may rule out a need for vascular surgery.

How is erectile dysfunction (ED) surgically treated?

The past several decades have ushered in a new treatment era for ED. Because of the advent of many advances, today urologists are helping millions of impotent men perform better and longer.

Penile prostheses: Surgically implanted devices to ensure stiffness have become highly reliable therapeutic solutions. Vacuum erection devices have proven to be safe alternatives in stiffening the penis by drawing blood into the organ with a pump and holding it with an “occluding band.” Penile injection therapy is a relatively quick and effective way to send vasoactive drugs directly into the corpora cavernosa where they expand the vessels, relax the tissue and increase blood flow for an erection. Furthermore, the pills: sildenafil, tadalafil and vardenafil have become the treatments of choice for millions of men who have experienced the drugs’ ability to boost levels of cyclic guanosine monophosphate (cGMP), a chemical factor in metabolism responsible for relaxing blood vessels.

Vascular surgery: Although options are varied, not everything is for everyone. In fact, two vascular approaches developed over past decades to restore penile blood flow disrupted by disease or traumas are useful for only a select few.

Penile arterial revascularization: This procedure is designed to keep blood flowing by rerouting it around a blocked or injured vessel. Indicated only for young men (under 45) with no known risk factors for atherosclerosis, this procedure is aimed at correcting any vessel injury at the base of the penis caused by adverse events such as blunt trauma or pelvic facture. When such an event leaves a penile vessel too injured or blocked to transfer blood, the surgeon may microscopically connect a nearby artery to get around the site, clearing the pathway so enough blood can be supplied to the penis to enable an erection.

Venous ligation surgery: This procedure focuses on binding leaky penile vessels that are causing penile rigidity to diminish during erection. Because venous occlusion, necessary for sufficient firmness, depends on arterial blood flow and relaxation of the spongy tissue in the penis, this approach is designed to intentionally block off problematic veins so that there is enough blood trapped in the penis to create an appropriate erection. Since long-term success rates are less than 50 percent, this technique is rarely a choice for correcting ED.

In fact, you are not a candidate for either penile vascular surgery if you have insulin-dependent diabetes or widespread atherosclerosis. You are also not suited if you still use tobacco or experience consistently high blood serum cholesterol levels. Neither of these surgeries will work if you have injured nerves or diseased and/or generalized damaged blood vessels. Also, if you are a candidate, be aware that vascular surgeries are still considered experimental by some urologists and may also not be covered by your insurance.

What can be expected after surgical treatment for erectile dysfunction (ED)?

Most of the best known treatments for ED have excellent track records for being both effective and safe. But in making your choice, make sure to discuss the potential complications of each option with your doctor.

For instance, the good news about a penile prosthesis is that it does not usually affect urination, sex drive, orgasm or ejaculation. But on rare occasions, these semi-rigid, silicone-covered metal rods or hydraulic devices can cause pain or reduced sensation. While injections can initiate erections within 15 minutes to several hours, be aware that they also can produce prolonged or painful ones, not to mention a scarring of penile connective tissue (fibrosis).

At the same time, a vacuum erection device should take only one to three minutes to give an erection, usually with no serious side effects if used properly. However, the use of the erection device to maintain the erection is limited to 30 minutes.

Sildenafil, tadalafil and vardenafil have 75 percent success rates, primarily because they are a subtle solution that works within the hour. But on rare occasions they can cause headaches, flushing, indigestion or muscle aches. Also, if you have heart disease or low blood pressure, the Food and Drug Administration (FDA) cautions a thorough examination before getting a prescription. You cannot take these drugs if you are taking nitroglycerine or any similar drug.

Penile arterial revascularization can restore function in men, although only a small percentage of them undergo the procedure. While few patients experience postoperative complications, side effects can include penile scarring, numbness and shortening all of which can cause further impotence.

Venous ligation surgery, although rare, is also known to cause penile shortening, along with other problems. Also, improvements with venous ligation surgery may be temporary.

When is venous surgery for erectile dysfunction successful?

It has been most successful in young men with abnormally draining veins since birth who have never had a full erection. It has also been used in some patients with an injury to the covering tunica albuginea or the corpora cavernosa.

I am interested in vascular surgery, what should I be aware of?

Realize this is not a surgery for everyone. If you meet the criteria mentioned previously, you will want to find a specialist with a track record of having done these microsurgical techniques. Be aware, however, that penile vascular solutions are still experimental; few specialized urologists or vascular surgeons are trained to do either procedure. If your doctor is not one of them, you will need to ask for a referral. You will also want to get a second opinion if this treatment option is recommended, given that there are few patients who are good candidates.

If I choose vascular surgery, what should I ask my surgeon?

Once you have found a surgeon, ask about his or her experience and outcome record with penile arterial revascularization. Make sure that you understand the potential outcomes and possible complications. Also, ask how the particular approach stacks up against other treatment choices for you. For instance, vacuum devices and oral or injection therapies still work for some people. Penile prostheses, the most widely used surgical technique for ED, usually have a more favorable outcome than vascular techniques.

Is age a factor in impotence?

Yes. Data suggest that while not an inevitable part of aging, the risk of impotence increases as we grow older. About 5 percent of men at age 40 complain of the problem, while between 15 and 25 percent at age 65 experience it. Some experts suggest the numbers may be underreported since men are still embarrassed by this physical and psychological issue. However, the reassuring news is that it is treatable in all age groups.

What should I remember about erectile dysfunction?

Also called impotence, ED is the consistent inability to sustain and maintain an erection, is a widespread problem. It may affect as many as 50 percent of men between ages 40 and 70. Luckily, doctors can identify physical causes involving blood flow, nerves or other mechanical issues involving the penis, which can also be addressed with modern technology. In fact, oral drugs, vacuum devices, injectable medications, psychotherapy and even surgery have made impotence very treatable. The promising news is that new drugs are sure to join existing non-invasive treatments while other experimental options, such as gene therapy, are on the horizon. In addition, ongoing modifications of today’s standard treatments will eventually improve the picture for impotent men.

The male reproductive tract is responsible for the production, maturation of sperm, and delivery of sperm. This tract is a complex and highly integrated entity. Sperm are produced in the testicles and then are transported through the genital ductal system to the penis and out of the urethra during ejaculation. Each component of the reproductive tract is highly specialized.

Abnormalities within the male reproductive tract may appear as scrotal masses. Masses may be of little significance or may represent life-threatening illnesses. It is necessary to follow a set course of action to determine the nature of the masses and the most appropriate treatment option. For example, testicular cancer is a source of great concern and uniformly requires prompt intervention. Other masses, such as varicoceles, can cause pain or impair reproductive function. Spermatoceles are benign and generally painless masses that grow at the top of the testicle. Thus, it is important for a patient to seek prompt medical attention when he identifies a scrotal mass or abnormality while performing testicular self examination. The following information will assist you when talking to a urologist about spermatoceles.

What is a spermatoceles?
Spermatocele, also known as a spermatic cyst, are typically painless, noncancerous (benign) cysts that grow from the epididymis near the top of the testicle. Spermatoceles are typically smooth and they are usually filled with a milky or clear colored fluid containing sperm. Over time, spermatoceles may remain stable in size or they may grow. If in fact the size becomes bothersome, or results in pain, then there are several treatment options to rectify the problem. Spermatoceles are generally no more than a nuisance rather than a serious medical condition.

What can cause spermatoceles?
The precise cause of spermatoceles is not known. While spermatoceles may form as a result of trauma or inflammation, these conditions are certainly not required for spermatocele formation. Others suggest that blockage of the efferent ducts and epididymis result in spermatocele formation. Additionally, in utero exposure to diethylstilbestrol (DES), a synthetic form of estrogen, has also been suggested as a possible cause.

How common are spermatoceles?
The precise incidence of spermatoceles is unknown, but an estimated 30 percent of all men have this condition. Incidence increases with age, with peak rates for the diagnosis of spermatoceles occurring in men in their forties and fifties. No racial or ethnic predispositions to spermatocele formation are known.

What are the symptoms of spermatoceles?
Men with spermatoceles usually have no symptoms. However, when associated symptoms are present, they may include scrotal heaviness and/or pain.

How are spermatoceles diagnosed?
Spermatoceles are typically discovered through a man’s self-examination of his testicles or at the time of an evaluation by a physician. Light can be shined through a spermatocele (transillumination), indicating that the mass is not a solid tumor but more likely a benign cyst. Ultrasound examination remains a very reliable means of evaluation and is a relatively quick, noninvasive and inexpensive test. Other diagnostic imaging tests are not generally used although magnetic resonance imaging (MRI) can also be used as an adjunct in cases where scrotal ultrasound is inconclusive.

How are spermatoceles treated?
Since spermatoceles generally do not cause discomfort and often go unnoticed by patients, they rarely require treatment. Nevertheless, some affected individuals do experience significant associated symptoms, such as bothersome size or pain. When intervention is indicated, the available treatment options include:

Medical therapy: Oral analgesics or anti-inflammatory agents may be used to relieve pain associated with symptomatic spermatoceles. No other type of medical therapy is specifically indicated for the treatment of spermatoceles.

Surgical therapy: Spermatocelectomy involves surgical removal of the spermatocele from the adjoining epididymal tissue. The overall goal of surgical therapy is removal of the spermatocele with preservation of the continuity of the male reproductive tract.

Other therapies: Aspiration and sclerotherapy are two less commonly utilized approaches to treat spermatoceles. Aspiration involves puncture of the spermatocele with a needle and withdrawal of its contents into a syringe. Sclerotherapy is performed with subsequent injection of an irritating agent directly into the spermatocele sac to cause it to heal or scar closed, removing the spermatocele space and decreasing the odds of fluid reaccumulation. Although several reports describe the effectiveness and tolerability of these treatment options, they are generally not recommended. Spermatocele recurrence is a common complication with both approaches, and chemical epididymitis and pain are common complications with sclerotherapy. Furthermore, aspiration and sclerotherapy have limited applicability in men of reproductive age, due to the significant risk of epididymal damage potentially leading to obstruction and resultant subfertility.

What can be expected after surgical treatment?
Spermatocelectomy is typically performed as an outpatient procedure, under a variety of possible anesthetic agents. Patients are generally discharged home with a pressure dressing consisting of an athletic supporter filled with fluffy gauze. Ice packs are applied for two to three days to minimize swelling. Oral pain medications are generally used for one to two days postoperatively. Patients may shower 24 to 48 hours after surgery, and a follow-up visit is scheduled for one to two weeks after the procedure.

Potential complications of spermatocelectomy include fever, infection, bleeding (scrotal hematoma) and persistent pain. Furthermore, inadvertent epididymal obstruction may result, which can lead to subfertility or infertility. Therefore, intervention should be avoided in men who still desire children. These complications may potentially be minimized by use of meticulous surgical technique (including use of an operating microscope or optical magnification).

Do spermatoceles lead to testicular cancer?
Spermatoceles are benign epididymal lesions. They are separate and distinct from the testicle. Patients with spermatoceles do not have an identified increased risk of testicular cancer.

Are any medications available to cure my spermatocele or prevent the formation of additional ones?
Medications are available to treat associated discomfort or pain, but no medication will lead to resolution or prevention of spermatoceles.

How often should I perform scrotal self-exams?
These exams should be performed at least once per month. Your physician can instruct you in the specific technique. If you detect any suspicious changes, such as increasing size or unusual firmness of scrotal structures, contact your physician.

Sexually transmitted diseases (STDs) are also commonly referred to as venereal disease, and are some of the most common diseases that you can get from another person through sexual contact. With more than 20 STDs in existence, they affect more than 13 million men and women in the United States. Luckily, most are treatable. How do you know if you might have one? What is the best treatment? The following information should help answer these questions.

What are sexually transmitted diseases (STDs)?

STDs are diseases that are normally passed from one person to another through sexual contact. They can be relatively harmless or they can be painful, irritating, debilitating and even life threatening.

What causes STDs?

Bacteria and viruses that thrive in warm, moist environments within the body cause STDs.

How do STDs spread?

Most STDs are spread through bodily fluid transfers during sexual activity. Sexual activity can be defined as vaginal, anal or oral sex. However, there are some STDs that are transmitted by contact with infected blood. For instance, a STD may pass between people who share infected needles, while another STD may be passed from an infected mother to her child during pregnancy, childbirth or nursing.

STDs cannot be transmitted through casual contact (e.g., shaking hands) or objects such as clothing or toilet seats.

What are the symptoms for STDs?

Often there are no symptoms. However, some symptoms that may be indicative of a STD are the following:

• an unusual discharge or odor from the vagina
• pain in the pelvic area – the area between the belly button and genitals
• pain in the groin area – the area around the genitals
• genital burning or itching
• bleeding from the vagina that is not a regular period
• pain deep inside the vagina during sexual intercourse
• penile drip or discharge
• sores, bumps or blisters near the genitals, rectum or mouth
• burning and pain during urination or bowel movement
• frequent urination

Who is at risk for STDs?

STDs can affect men and women of all backgrounds and economic levels. However, some research suggests that STDs may be most prevalent among teenagers and young adults since they are more likely to have multiple sex partners during their lifetime. Individuals who are using dirty needles when injecting intravenous drugs are also at risk.

How are STDs diagnosed?

Most STDs can be diagnosed through an examination by a doctor, a culture of the secretions from the vagina or penis, or a blood test.

What are the most common types of STDs and how are they treated?

Chlamydia: This is the most common of all bacterial STDs, with an estimated four to eight million new cases each year, and is transmitted through vaginal and anal sex. Sometimes, it goes undiagnosed since it frequently does not produce noticeable symptoms. If symptoms are present in men, they typically include painful urination or a discharge from the penis. Symptoms in women may include bleeding between periods, painful urination, vaginal discharge or mild pain in the lower abdomen. Once diagnosed, a person can be treated with an antibiotic.

Gonorrhea: Approximately 400,000 cases are reported each year in the United States. It is transmitted through vaginal, anal or oral sex. Like chlamydia, this STD is often present without symptoms. However any symptoms would most likely involve penile or vaginal discharge and painful urination. Gonorrhea is treatable with antibiotics.

Syphilis: This is a potentially life-threatening, bacterial STD commonly transmitted through vaginal, anal or oral sex. However, it can also be spread by non-sexual contact if the sores caused by the syphilis come in contact with the broken skin of a non-infected individual. Usually, the first symptom is a painless open sore that frequently appears around the penis or vagina but can also appear near the mouth, anus or hands. To date, penicillin has been proven to be the most effective treatment. If syphilis remains untreated, it may progress to more advanced stages and may result in medical conditions like a stroke or meningitis.

Genital Herpes: This STD is caused by an infection with the Herpes Simplex Virus Type 2 (HSV-2) and spreads by direct skin-to-skin contact with the infected site during vaginal, anal or oral sex. Another strain of the virus, Herpes Simplex Type 1 (HSV-1) is most commonly spread by nonsexual contact and usually causes sores on the lips but it can also be transmitted through oral sex. There is no known cure for HSV but symptoms can be treated with antiviral drugs.

Acquired Immune Deficiency Syndrome (AIDS): AIDS results from an infection with the human immunodeficiency virus (HIV) and is an incurable and deadly STD. It attacks the body’s immune system and is most commonly transmitted through vaginal, oral and anal sex. It may also be transmitted by blood through the sharing of infected needles or other sharp instruments that break the skin or from an infected mother to her child during pregnancy, childbirth or nursing. When first infected, some people experience no symptoms while others have flu-like symptoms. These symptoms usually disappear within one to four weeks and the virus can remain inactive for years. There is no known cure, but antiviral drugs can be used to prolong the life and health of an infected person.

Hepatitis B: This viral STD, also referred to as HBV, is a serious virus that attacks the liver. It can be transmitted through vaginal, oral and anal sex. It may also be transmitted by blood through the sharing of infected needles or other sharp instruments that break the skin. The Centers for Disease Control and Prevention (CDC) estimates that 120,000 new hepatitis B infections occur each year. About a third of the people with hepatitis B have no symptoms. However, when symptoms are present, they can include fever, headache, muscle aches, fatigue, loss of appetite, vomiting and diarrhea. Since hepatitis B attacks liver cells, it can lead to cirrhosis, liver cancer, liver failure and possibly death. Symptoms that indicate involvement of the liver include dark urine, abdominal pain and yellowing of the skin or whites of the eyes. There is no known cure for hepatitis B but there are medications available to treat chronic infection in some patients. A vaccine is now available and is the best protection.

Genital Warts: These warts are caused by the human papillomavirus (HPV) and are transmitted through vaginal, anal or oral sex. The results are painless, fleshy, cauliflower-like warts that grow on the penis and in and around the entrance of the vagina or anus. According to the CDC, there are approximately 5.5 million new cases each year in the United States. There is no known cure but they can be treated by topical medications and can sometimes be removed with minor surgical procedures (e.g., chemicals, freezing, laser).

Trichomoniasis: This common bacterial STD, transmitted through sexual contact, mainly affects young, sexually active women. Sometimes there are no symptoms associated with this STD. However, in women, symptoms can include foul smelling or frothy, yellow-green vaginal discharge, vaginal itching or redness, pain during intercourse, lower abdominal discomfort and/or frequent urination. In men, symptoms can include discharge from the penis, frequent urination and/or painful urination. Trichomoniasis can be easily treated with antibiotics.

How can STDs be prevented?

The following behaviors and conditions can help decrease your risk for STDs:

• avoid sexual contact with infected persons
• have a mutually monogamous sexual relationship with an uninfected partner
• limit your number of sexual partners throughout your lifetime
• correctly and consistently use a condom
• use clean needles if you are injecting intravenous drugs

Can STDs cause any other health problems?

Some STDs can spread into the uterus and fallopian tubes and may subsequently cause pelvic inflammatory disease, which is frequently linked to both infertility and ectopic pregnancy. STDs can also be passed from a mother to her baby before or during birth or through breastfeeding. There has also been some indication that the human papillomavirus infection (HPV) may cause cervical cancer.

Can I get a STD by open-mouth kissing? Open-mouth kissing is considered a very low-risk activity for the transmission of STDs, particularly HIV. However, prolonged open-mouth kissing could damage the mouth or lips and allow HIV to pass from an infected person to a partner and then enter the body through cuts or sores in the mouth. Because of this possible risk, the CDC recommends that a person avoid open-mouth kissing with an infected partner.

Should I be checked for STDs?

If you are at risk for having an STD, if you have any symptoms or if you just have concerns, you should see a doctor. It is recommended that HIV, HBV and syphilis testing and perhaps cultures be performed periodically if you have unprotected sex with multiple partners.