My Penis Stuff

A semen analysis measures the amount of semen a man produces and determines the number and quality of sperm in the semen sample.

A semen analysis is usually one of the first tests done to help determine whether a man has a problem fathering a child (infertility). A problem with the semen or sperm affects more than one-third of the couples who are unable to have children (infertile).

Tests that may be done during a semen analysis include:

• Volume. This is a measure of how much semen is present in one ejaculation.
• Liquefaction time. Semen is a thick gel at the time of ejaculation and normally becomes liquid within 20 minutes after ejaculation. Liquefaction time is a measure of the time it takes for the semen to liquefy.
• Sperm count. This is a count of the number of sperm present per milliliter (mL) of semen in one ejaculation.
• Sperm morphology. This is a measure of the percentage of sperm that have a normal shape.
• Sperm motility. This is a measure of the percentage of sperm that can move forward normally. The number of sperm that show normal forward movement in a certain amount of semen can also be measured (motile density).
• pH. This is a measure of the acidity (low pH) or alkalinity (high pH) of the semen.
• White blood cell count. White blood cells are not normally present in semen.
• Fructose level. This is a measure of the amount of a sugar called fructose in the semen. The fructose provides energy for the sperm.

Why It Is Done

A semen analysis is done to determine whether:

• A man has a reproductive problem that is causing infertility.
• A vasectomy has been successful.
• The reversal of a vasectomy has been successful.

How To Prepare

You may be asked to avoid any sexual activity that results in ejaculation for 2 to 5 days before a semen analysis. This helps ensure that your sperm count will be at its highest, and it improves the reliability of the test. If possible, do not avoid sexual activity for more than 1 to 2 weeks before this test, because a long period of sexual inactivity can result in less active sperm.

You may be asked to avoid drinking alcohol for a few days before the test.

Be sure to tell your health professional about any medications or herbal supplements you are taking.

How It Is Done

You will need to produce a semen sample, usually by ejaculating into a clean sample cup. You can do this in a private room or in a bathroom at your health professional’s office or clinic. If you live close to your health professional’s office or clinic, you may be able to collect the semen sample at home and then transport it to the office or clinic for testing.

• The most common way to collect semen is by masturbation, directing the semen into a clean sample cup.
• You can collect a semen sample during sex by withdrawing your penis from your partner just before ejaculating (coitus interruptus). You then ejaculate into a clean sample cup. This method can be used after a vasectomy to test for the presence of sperm, but other methods will likely be recommended if you are testing for infertility.
• You can also collect a semen sample during sex by using a condom. If you use a regular condom, you will need to wash it thoroughly before using it to remove any powder or lubricant on it that might kill sperm. You may also be given a special condom that does not contain any substance that kills sperm (spermicide). After you have ejaculated, carefully remove the condom from your penis. Tie a knot in the open end of the condom and place it in a container that can be sealed in case the condom leaks or breaks.

If you collect the semen sample at home, the sample must be received at the laboratory or clinic within 1 hour. Keep the sample out of direct sunlight and do not allow it to get cold or hot. If it is a cold day, carry the semen sample container against your body to keep it as close to body temperature as possible. Do not refrigerate the semen sample.

Since semen samples may vary from day to day, 2 or 3 different samples may be evaluated within a 3-month period for accurate testing.

A semen analysis to test the effectiveness of a vasectomy is usually done 6 weeks after the vasectomy.

How It Feels

Producing a semen sample does not cause any discomfort. However, you may feel embarrassed about the method used to collect it. If masturbation is against your religious beliefs, discuss alternate methods of collection with your health professional.

Risks

There are no risks associated with collecting a semen sample.

Results

A semen analysis measures the amount of semen a man produces and determines the number and quality of sperm in the semen sample. Results of a semen analysis are usually available within a day. Normal values may vary from lab to lab.

Certain conditions may be associated with a low or absent sperm count. These conditions include orchitis, varicocele, Klinefelter syndrome, radiation treatment to the testicles, or diseases that can cause shrinking (atrophy) of the testicles (such as mumps).

If a low sperm count or a high percentage of sperm abnormalities are found, further testing may be done. Other tests may include measuring hormones, such as testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), or prolactin. A small sample (biopsy) of the testicles may be needed for further evaluation if the sperm count or motility is extremely low.

What Affects the Test

Factors that can interfere with your test or the accuracy of the results include:

• Medicines, such as cimetidine (Tagamet), male and female hormones (testosterone, estrogen), sulfasalazine, nitrofurantoin, and some chemotherapy medicines.
• Caffeine, alcohol, cocaine, marijuana, and smoking tobacco.
• Herbal medicines, such as St. John’s wort and high doses of echinacea.
• A semen sample that gets cold. The sperm motility value will be inaccurately low if the semen sample gets cold.
• Exposure to radiation, some chemicals (such as certain pesticides or spermicides), and prolonged heat exposure.
• An incomplete semen sample. This is more common if a sample is collected by methods other than masturbation.
• Not ejaculating for several days. This may affect the semen volume.

What To Think About

• A semen sample collected at home must be received at the laboratory or clinic within 1 hour. Keep the sample out of direct sunlight and do not allow it to get cold or hot. If it is a cold day, carry the semen sample container against your body to keep it as close to body temperature as possible. Do not refrigerate the semen sample.
• Consistently detecting sperm in the semen of a man who has had a vasectomy indicates that his surgery was not successful, and another form of birth control should be used to prevent pregnancy. A low number of sperm may be present in a semen sample taken initially after a vasectomy. However, sperm should not be present in subsequent samples.
• A man whose mother took the medicine diethylstilbestrol (DES) during her pregnancy with him has a greater-than-normal risk of being unable to father a child (infertile).
• Additional tests may include measuring hormone levels, such as testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), or prolactin. For more information, see the medical tests Testosterone, Luteinizing Hormone, Follicle-Stimulating Hormone, and Prolactin.
• Other fertility testing, including sperm penetration, the presence of antisperm antibodies, or analysis after sexual intercourse (postcoital), may be recommended for infertility problems. For more information, see the medical test Infertility Testing.

A prostate-specific antigen (PSA) test measures the amount of prostate-specific antigen in the blood. PSA is released into a man’s blood by his prostate gland. Healthy men have low amounts of PSA in the blood. The amount of PSA in the blood normally increases as a man’s prostate enlarges with age. PSA may increase as a result of an injury, a digital rectal exam, sexual activity (ejaculation), inflammation of the prostate gland (prostatitis), or prostate cancer.

Prostate cancer often grows very slowly, without causing major problems. Detecting prostate cancer early and treating it may prevent some health problems and reduce the risk of dying from the cancer. However, some treatments for prostate cancer can cause other problems, such as controlling urination (incontinence) or erection problems (erectile dysfunction). Some men may choose not to have a PSA test or treat prostate cancer if it is detected. For example, a man older than age 75 who has no bothersome symptoms of prostate cancer may choose not to treat the cancer if it is found, so he would not need a PSA test.

Why It Is Done

The prostate-specific antigen (PSA) test is done to:

• Watch prostate cancer and see if treatment is working. If PSA levels increase, the cancer may be growing or spreading. PSA is usually not present in a man who has had his prostate gland removed. A PSA level that rises after prostate removal may mean the cancer has returned or has spread.
• Check if cancer may be present when results from other tests, such as a digital rectal exam, are not normal. A PSA test does not diagnose cancer, but it can be used along with other tests to determine if cancer is present.
• Check men for prostate cancer. Experts disagree on the usefulness of PSA testing as a screening tool for prostate cancer. If a PSA test is used for screening, it is usually done for men older than age 50 or for those at high risk for prostate cancer, such as men with a family history of prostate cancer, or for African-American men who have a higher chance of developing cancer than other men. Since other common medical conditions, such as prostatitis, can cause high PSA levels, a prostate biopsy is needed to confirm a diagnosis of cancer.

How To Prepare

Before you have a prostate-specific antigen (PSA), tell your doctor if you have had a:

• Test to look at your bladder (cystoscopy) in the past several weeks.
• Prostate needle biopsy in the past several weeks.
• Prostate infection (prostatitis) or an urinary tract infection (UTI) that has not gone away.
• Tube (catheter) inserted into your bladder to drain urine recently.

Do not ejaculate during the 2 days before your PSA blood test, either during sex or masturbation.

Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will indicate.

How It Is Done

The health professional taking a sample of your blood will:

• Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein.
• Clean the needle site with alcohol.
• Put the needle into the vein. More than one needle stick may be needed.
• Attach a tube to the needle to fill it with blood.
• Remove the band from your arm when enough blood is collected.
• Put a gauze pad or cotton ball over the needle site as the needle is removed.
• Put pressure to the site and then a bandage.

How It Feels

The blood sample is taken from a vein in your arm. An elastic band is wrapped around your upper arm. It may feel tight. You may feel nothing at all from the needle, or you may feel a quick sting or pinch.

Risks

There is very little chance of a problem from having a blood sample taken from a vein.

• You may get a small bruise at the site. You can lower the chance of bruising by keeping pressure on the site for several minutes.
• In rare cases, the vein may become swollen after the blood sample is taken. This problem is called phlebitis. A warm compress can be used several times a day to treat this.
• Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medicines can make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medicine, tell your doctor before your blood sample is taken.

Results

A prostate-specific antigen (PSA) test measures the amount of prostate-specific antigen in the blood. Normal values may vary from lab to lab.

Normal

Because normal PSA levels seem to increase with age, age-specific ranges may be used. However, the use of age-specific ranges is controversial, and some doctors prefer to use one range for all ages. For this reason, it is important to discuss your test results with your doctor. This table is a reference for white males. Results for black and Asian males are slightly different.

High values

• PSA levels from 4 to 10 ng/mL: About 20% to 30% of men (20 to 30 men in 100) with PSA levels in this range may have prostate cancer. A transrectal ultrasound (TRUS) and prostate biopsy are needed to confirm a diagnosis of cancer.
• PSA levels above 10 ng/mL: About 40% to 60% of men (40 to 60 men in 100) with PSA levels in this range may have prostate cancer. A transrectal ultrasound (TRUS) and prostate biopsy are needed to confirm cancer.
• High levels do not always mean prostate cancer is present. PSA levels may be high if the prostate gland is enlarged (benign prostatic hypertrophy, or BPH) or inflamed (prostatitis).

A follow-up test, percent free prostate-specific antigen (free PSA), may be used to see if a prostate biopsy should be done to check for cancer. Men with a low percentage of free PSA have a higher chance of developing cancer as shown in the table below.

Low free PSA values (less than 15%) are more likely to be caused by prostate cancer than high free PSA values.

What Affects the Test

Factors that can interfere with your test or the accuracy of the results include:

• Recent sexual activity (ejaculation) or a cystoscopy.
• Recent use of a tube (catheter) to drain urine.
• Recent urinary tract infection (UTI) or prostatitis.
• Large doses of medicines, such as cyclophosphamide (Cytoxan, Neosar), diethylstilbestrol, and methotrexate for cancer treatment.
• The medicine finasteride, such as Proscar or Avodart, which is used to prevent further enlargement of the prostate gland in men with BPH.

What To Think About

• When combined with a digital rectal exam, the prostate-specific antigen (PSA) test increases the chance of detecting prostate cancer. For more information, see the medical test Digital Rectal Examination (DRE).
• A PSA level within the normal ranges does not mean that prostate cancer is not present. Some men with prostate cancer have normal PSA levels.
• Experts disagree about the frequency of PSA testing to screen for prostate cancer.
  • The American Cancer Society (ACS) recommends an annual PSA test and DRE for men age 50 and older. ACS also recommends annual screening, beginning at age 45, for men who are at high risk for prostate cancer, such as black men and men who have a family history of prostate cancer.
  • Other expert groups, such as the National Cancer Institute and the U.S. Preventive Services Task Force, believe there is not enough evidence to recommend routine screening with the PSA test for all men. Experts that do not recommend annual screening say the high rate of false-negative and false-positive results and the costs and risks of further tests do not support annual screening tests.
• Experts disagree about the type of testing that is appropriate if the PSA level is high. The decision may depend on:
  • Results of your digital rectal exam.
  • Results of any PSA tests you have had in the past. If your PSA level gets higher in a short amount of time, follow-up testing may be recommended.
  • Your age and health.
  • The costs and risks of more tests and treatments.
• Other prostate tests are being evaluated to determine how well they tell the difference between prostate cancer and benign prostatic hypertrophy.
  • The prostate-specific antigen density (PSAD) test compares the PSA value to the size of the prostate gland. The size of the prostate is measured using transrectal ultrasound (TRUS).
  • The PSA velocity test is a measure of how rapidly PSA levels increase over time. PSA levels increase more rapidly in men with prostate cancer and more slowly in men with prostate enlargement (benign prostatic hypertrophy).
• Complexed prostate-specific antigen (cPSA) when used in combination with a digital rectal exam can detect prostate cancer. The cPSA test currently is not widely available.

A prostate gland biopsy is a test to remove small samples of prostate tissue to be examined under a microscope.

For a prostate biopsy, a thin needle is inserted through the rectum (transrectal biopsy), through the urethra, or through the area between the anus and scrotum (perineum). A transrectal biopsy is the most common method used. The tissue samples taken during the biopsy are examined for cancer cells.

A biopsy may be done when a blood test shows a high level of prostate-specific antigen (PSA) or after a digital rectal examination finds an abnormal prostate or a lump.

Why It Is Done

A prostate biopsy is done to determine:

• If a lump found in the prostate gland is cancer.
• The cause of a high level of prostate-specific antigen (PSA) in the blood.

How To Prepare

Tell your doctor if you:

• Have had any bleeding problems.
• Are allergic to any medications, including anesthetics.
• Take any medications regularly. Be sure your doctor knows the names and doses of all your medications.
• Are taking any blood-thinning medications, such as warfarin (Coumadin), heparin, enoxaparin (Lovenox), aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).

You will need to sign a consent form that says you understand the risks of a prostate biopsy and agree to have the biopsy done. Talk to your health professional about any concerns you have regarding the need for the biopsy, its risks, how it will be done, or what the results will indicate.

If a prostate biopsy is done under local anesthesia through the area between the anus and scrotum (perineum), no other special preparation is needed.

If the biopsy is done through the rectum, you may need to have an enema before the biopsy.

If the biopsy is done under general anesthesia, do not eat or drink anything for 8 to 12 hours before the biopsy. During preparation for the biopsy, an intravenous line (IV) is inserted in your arm, and a sedative medication is given about an hour before the biopsy.

How It Is Done

This biopsy is done by a doctor who specializes in men’s genital and urinary problems (urologist) in the doctor’s office, a day surgery clinic, or a hospital operating room.

Before your prostate biopsy, you may be given antibiotics to prevent infection. You may be asked to take off all of your clothes and put on a hospital gown.

Your skin at the biopsy site is cleaned with an antiseptic solution, and the area around it is covered with sterile cloth. Your doctor will wear sterile gloves. It is very important that you do not touch this sterile area.

Transrectal ultrasound (TRUS) is commonly used to guide the placement of the needle during a prostate biopsy.

Through the rectum (transrectal biopsy)

Several positions are possible for this method. You may be asked to kneel, lie on your side, or lie on your back with your feet resting in stirrups. Your doctor may inject a local anesthetic around the prostate gland before the biopsy is taken.

Transrectal ultrasound (TRUS) is generally used to guide the needle to the correct biopsy location. A prostate biopsy is usually done with a spring-loaded needle. The needle quickly enters the prostate gland and removes a tissue sample.

The biopsy can also be done with a needle guide attached to your doctor’s finger. He or she inserts the finger into the rectum. Then the needle is slid along the guide, through the wall of the rectum, and into the prostate gland. The needle is turned to collect a tissue sample and then pulled out.

A transrectal biopsy takes about 30 minutes. See an illustration of transrectal prostate biopsy.

Through the urethra (transurethral biopsy)

For this method, you will lie on your back with your feet resting in stirrups. General or local anesthesia may be used.

A lighted scope (cystoscope) is inserted into your urethra. It allows your doctor to look directly at the prostate gland. A cutting loop is passed through the cystoscope to remove small pieces of prostate tissue.

A transurethral biopsy usually takes about 30 to 45 minutes.

Through the perineum (transperineal biopsy)

Transperineal biopsy is not done as commonly as transrectal or transurethral biopsy. You will lie on an examining table either on your side or on your back with your knees bent. General or local anesthesia may be used.

A small incision is made in your perineum. Your doctor inserts a finger into the rectum to hold the prostate gland and then inserts the needle through the incision and into the prostate gland. To collect a sample of tissue, the needle is gently turned and then pulled out. Biopsy samples may be taken from several areas of the prostate. Pressure is applied to stop the bleeding, and a small bandage is placed over the cut. The biopsy usually takes about 15 to 30 minutes.

How It Feels

You may feel a slight sting when you receive an injection of medication to numb your skin. You may feel a dull pressure as the biopsy needle is inserted. For a transrectal biopsy, you may feel pressure in the rectum while the ultrasound probe or guiding finger is in place. You also may feel a brief, sharp pain as the biopsy needle is inserted into the prostate gland. Usually several biopsy samples are collected.

Following the biopsy, you will be asked to avoid strenuous activities for about 4 hours. You may have mild pain in the pelvic area and blood in your urine for up to 5 days. Also, you may have some discoloration of your semen for up to one month after the biopsy. If you had a transrectal biopsy, you may experience a small amount of bleeding from your rectum for 2 to 3 days after the biopsy.

If you have a transurethral biopsy, you may have a urinary catheter in place for a few hours after the biopsy. You also may need to take an antibiotic medication for several days after the biopsy.

If you have a general anesthetic, you will be in a recovery room for a few hours after the biopsy. You will need someone to drive you home when you are released. When you get home, your muscles may ache and you may feel tired for the rest of the day.

Risks

A prostate biopsy has a slight risk of causing problems such as:

• Infection. This is more common in men who have undiagnosed prostatitis. Usually, taking antibiotic medication before the biopsy prevents an infection from developing.
• Bleeding into the urethra or bladder. This can cause a blood blister (hematoma), an inability to urinate, or a need to urinate often.
• Bleeding from the rectum. If you have a transrectal biopsy, you may experience a small amount of bleeding from your rectum for 2 to 3 days after the biopsy.
• An allergic reaction to the anesthetic medications used during the biopsy.

After the biopsy

Call your doctor immediately if you:

• Have heavy bleeding or bleeding continues longer than 2 to 3 days.
• Have increased pain.
• Have a fever.
• Are unable to urinate within 8 hours or have blood in the urine for longer than 2 to 3 days.

Results

A prostate gland biopsy is a test to remove small samples of prostate tissue to be examined under a microscope. Results are usually available within 10 days.

If cancer cells are present, a grade (Gleason score) will be given, which your doctor will discuss with you. The Gleason score is considered a tool for predicting how aggressive the cancer is.

What Affects the Test

Factors that can interfere with your test or the accuracy of the results include:

• The biopsy may not contain enough tissue to make a diagnosis.
• A chance that a cancer may be missed since the biopsy takes a small amount of tissue.

What To Think About

• Normal prostate biopsy results do not rule out cancer.
• If the prostate biopsy results show cancer, other tests may be needed to determine the spread of the cancer. These tests may include a blood test (prostate-specific antigen), bone scan, lymph node biopsy, or computed tomography (CT) scan. For more information, see the medical tests Prostate-Specific Antigen (PSA), Bone Scan, Lymph Node Biopsy, and Computed Tomography (CT) Scan.
• Not all types of prostate cancer are treated. There are many factors to consider when deciding on a treatment plan. For more information, see the topic Prostate Cancer.
• A prostate gland biopsy does not cause problems with erections and will not make a man infertile.

A vasectomy is considered a permanent method of birth control. Vasectomy reversal (vasovasostomy) reconnects the tubes (vas deferens) that were cut during a vasectomy.

Vasectomy reversal is usually an outpatient procedure without an overnight stay in the hospital. Spinal or general anesthesia is commonly used to ensure that you remain completely still during the surgery.

The chances of vasectomy reversal success depend on how much time has passed between the vasectomy and the reversal. Over time, additional blockages can form, and some men develop antibodies to their own sperm.

The surgery is more complicated and takes more time when blockage between the vas deferens and the epididymis requires correction (vasoepididymostomy).

What To Expect After Surgery

Vasectomy reversal usually takes from 2 to 4 hours, followed by a few more hours for recovery from the anesthetic. You can expect to go home the same day.

Pain may be mild to moderate. You should be able to resume normal activities, including sex, within 3 weeks.

Why It Is Done

Vasectomy reversal is performed when you have had a vasectomy and now want to be fertile.

How Well It Works

Chances of a successful vasectomy reversal decline over time. Reversals are more successful during the first 10 years after vasectomy.

In general, vasectomy reversal:

• Leads to overall pregnancy rates of greater than 50%.
• Has the greatest chance of success within 3 years of the vasectomy.
• Leads to pregnancy only about 30% of the time if the reversal is done 10 years after vasectomy.

Risks

Risks of vasectomy reversal include:

• Infection at the site of surgery.
• Fluid buildup in the scrotum (hydrocele) that may require draining.
• Injury to the arteries or nerves in the scrotum.

What To Think About

Before a vasectomy reversal is performed, your doctor will want to confirm that you were fertile before your vasectomy.

You can have tests to see whether you have sperm antibodies in your semen before and after vasectomy reversal. If there are sperm antibodies in your semen after surgery, your partner is unlikely to become pregnant. In such a case, you may wish to try in vitro fertilization with intracytoplasmic sperm injection.

A vasectomy is considered a permanent method of birth control. A vasectomy prevents the release of sperm when a man ejaculates.

During a vasectomy, the vas deferens from each testicle is clamped, cut, or otherwise sealed. This prevents sperm from mixing with the semen that is ejaculated from the penis. An egg cannot be fertilized when there are no sperm in the semen. The testicles continue to produce sperm, but the sperm are reabsorbed by the body. Because the tubes are blocked before the seminal vesicles and prostate, you still ejaculate about the same amount of fluid.

It usually takes several months after a vasectomy for all remaining sperm to be ejaculated or reabsorbed. You must use another method of birth control until you have a semen sample tested and it shows a zero sperm count. Otherwise, you can still get your partner pregnant.

During a vasectomy:

• Your testicles and scrotum are cleaned with an antiseptic and possibly shaved.
• You may be given an oral or intravenous (IV) medicine to reduce anxiety and make you sleepy. If you do take this medicine, you may not remember much about the procedure.
• Each vas deferens is located by touch.
• A local anesthetic is injected into the area.
• Your doctor makes one or two small openings in your scrotum. Through an opening, the two vas deferens tubes are cut. The two ends of the vas deferens are tied, stitched, or sealed. Electrocautery may be used to seal the ends with heat. Scar tissue from the surgery helps block the tubes.
• The vas deferens is then replaced inside the scrotum and the skin is closed with stitches that dissolve and do not have to be removed.

The procedure takes about 20 to 30 minutes and can be done in an office or clinic. It may be done by a family medicine doctor, a urologist, or a general surgeon.

No-scalpel vasectomy is a technique that uses a small clamp with pointed ends. Instead of using a scalpel to cut the skin, the clamp is poked through the skin of the scrotum and then opened. The benefits of this procedure include less bleeding, a smaller hole in the skin, and fewer complications. No-scalpel vasectomy is as effective as traditional vasectomy.

In the Vasclip implant procedure, the vas deferens is locked closed with a device called a Vasclip. The vas deferens is not cut, sutured, or cauterized (sealed by burning), which possibly reduces the potential for pain and complications. Some studies show that clipping is not as effective as other methods of sealing off the vas deferens.

What To Expect After Surgery

Your scrotum will be numb for 1 to 2 hours after a vasectomy. Apply cold packs to the area and lie on your back as much as possible for the rest of the day. Wearing snug underwear or a jockstrap will help ease discomfort and protect the area.

You may have some swelling and minor pain in your scrotum for several days after the surgery. Unless your work is strenuous, you will be able to return to work in 1 or 2 days. Avoid heavy lifting for a week.

You can resume sexual intercourse as soon as you are comfortable, usually in about a week. However, you can still get your partner pregnant until your sperm count is zero. You must use another method of birth control until you have a follow-up sperm count test 2 months after the vasectomy (or after 10 to 20 ejaculations over a shorter period of time). Once your sperm count is zero, no other birth control method is necessary.

A vasectomy will not interfere with your sex drive, ability to have erections, sensation of orgasm, or ability to ejaculate. You may have occasional mild aching in your testicles during sexual arousal for a few months after the surgery.

Why It Is Done

A vasectomy is a permanent method of birth control. Only consider this method when you are sure that you do not want to have a child in the future.

How Well It Works

Vasectomy is a very effective (99.85%) birth control method. Only 1 to 2 women out of 1,000 will have an unplanned pregnancy in the first year after their partners have had a vasectomy.³

Risk of failure

Pregnancy may occur after vasectomy because of:

• Failure to use another birth control method until the sperm count is confirmed to be zero. It usually takes 10 to 20 ejaculations to completely clear sperm from the semen.
• Spontaneous reconnection of a vas deferens or an opening in one end that allows sperm to mix with the semen again. This is very rare.

Risks

The risk of complications after a vasectomy is very low. Complications may include:

• Bleeding under the skin, which may cause swelling or bruising.
• Infection at the site of the incision. In rare instances, an infection develops inside the scrotum.
• Sperm leaking from a vas deferens into the tissue around it and forming a small lump (sperm granuloma). This condition is usually not painful, and it can be treated with rest and pain medication. Occasionally, surgery may be needed to remove the granuloma.
• Inflammation of the tubes that move sperm from the testicles (congestive epididymitis).
• In rare cases, the vas deferens grows back together (recanalization), and the man becomes fertile again.

What To Think About

Advantages

Vasectomy is a permanent method of birth control. Once your semen does not contain sperm, you do not need to worry about using other birth control methods.

Vasectomy is a safer, cheaper procedure that causes fewer complications than tubal ligation in women.

Although vasectomy is expensive, it is a one-time cost and is often covered by medical insurance. The cost of other methods, such as birth control pills or condoms and spermicide, is likely to be greater over time.

Disadvantages

A vasectomy does not protect against sexually transmitted diseases (STDs), including infection with the human immunodeficiency virus (HIV). Condoms are the most effective method for preventing STDs. To protect yourself and your partner from STDs, use a condom every time you have sex.

Other considerations

If you are considering a vasectomy, be absolutely certain that you will never want to father a child. Think through whether this might change after any of the following life events:

• One of your living children dies (if you are a father).
• You divorce and lose custody of your children.
• You have a new partner who wants children.
• Your financial situation improves and you can afford another child.
• Your children grow up and leave home.

A vasectomy is not usually recommended for men who are considering banking sperm in case they decide later to have children. Discuss other options with your partner and your health professional.

Surgery to reconnect the vas deferens (vasectomy reversal) is available. However, the reversal procedure is difficult. Sometimes a doctor can remove sperm from the testicle in men who have had a vasectomy or a reversal that didn’t work. The sperm can then be used for in vitro fertilization. Both vasectomy reversal and sperm retrieval can be expensive, may not be covered by insurance, and may not always work.

Some older studies showed a risk of prostate cancer in men who have had vasectomies. However, many years of research have found no clear evidence that vasectomy is linked to prostate cancer.

Some doctors or health insurance plans may require a waiting period from the time you request a vasectomy and the time the procedure is done. This time allows you to be certain about your decision.

Researchers are studying other male birth control methods, such as reversible vasectomy or hormonal methods. Reversible vasectomy involves plugging the vas deferens and then removing the plug when birth control is no longer wanted. Hormonal methods include pills or injections that the man would use to prevent sperm production. So far, no new method has been shown to be effective enough, with low side effects, to be marketed for men.

Varicoceles are enlarged varicose veins that occur in the scrotum. They are fairly common, affecting 15% of men overall, and 40% of men with known infertility. Varicoceles occur most often in the left testicle.

Varicocele repair is performed to improve male fertility. It can usually be done surgically on an outpatient basis using local or general anesthetic. A small incision is made in the abdomen close to where the testicles originally descended through the abdominal wall. The veins that produce the varicocele are identified and cut to eliminate blood flow to the varicocele.

Alternatively, a nonsurgical procedure called percutaneous embolization can be done to repair a varicocele. A small catheter is inserted through a large vein in the groin or neck and advanced to the varicocele, which is then blocked off by a balloon, coil, or medication.

What To Expect After Surgery

Varicocele repair typically is done on an outpatient basis. You can expect to go home within 4 hours of a routine varicocele surgery. Pain medicine is prescribed for a few days after surgery.

You should be able to resume light work duties 1 to 2 days after surgery and full strenuous activities within 1 week.

Why It Is Done

Varicoceles are thought to raise the temperature of the testicles or cause blood to back up in the veins supplying the testicles. Although the mechanism by which varicoceles affect fertility is poorly understood, varicoceles seem to help damage or kill the sperm. Varicocele repair is typically performed to improve the fertility of men who have both a varicocele and impaired sperm.

Varicocele repair is a controversial practice. Many infertility experts express concern that it is not effective as an infertility treatment.

How Well It Works

While some researchers have observed that varicocele repair produces favorable pregnancy rates, others have noted that these pregnancy rates are the same as the rates of couples who have chosen not to have a varicocele repaired.

A recent review of research has found no benefit of varicocele repair for male or unexplained infertility.

Risks

• Infection at the site of surgery
• Fluid buildup in the scrotum (hydrocele) that requires draining
• Injury to the arteries or nerves in the pubic area

What To Think About

There is no proof that fertility rates improve after this surgery. However, some doctors think that larger varicoceles are linked to sperm problems. It is also possible that varicocele surgery would improve the semen quality, making other fertility treatments easier.

Small varicoceles that are only apparent with ultrasound testing do not require repair.

What is urinary incontinence in men?

Urinary incontinence is the accidental release of urine. It is not a disease but rather a symptom of a problem with a man’s urinary tract.

Urine is produced by the kidneys and stored in a muscular sac called the urinary bladder. A tube called the urethra, which is surrounded by a special ring of muscles called the urinary sphincter, leads from the bladder through the prostate and penis to the outside of the body. As the bladder becomes filled with urine, complex nerve signals ensure that the sphincter stays contracted and the bladder stays relaxed. This interaction between nerves and muscles prevents urine from leaking out of the body.

During urination, nerve signals cause the muscles in the walls of the bladder to contract, forcing urine out of the bladder and into the urethra. At the same time the bladder contracts, nerve signals cause the muscles surrounding the urethra to relax, allowing urine to pass through and out of the body.

Incontinence may occur if the bladder suddenly contracts or if it doesn’t contract when it should, leading to a buildup of too much urine in the bladder, which can cause leakage. Incontinence may also occur if the muscles around the urethra are damaged or suddenly relax or if the urethra is blocked, keeping urine from draining properly and causing eventual leakage around the blockage.

Incontinence affects 13 million Americans and occurs twice as often in women as in men.¹ Although incontinence occurs more often in older men than in young men, it is not considered a normal part of the aging process.

How is urinary incontinence in men classified?

Urinary incontinence may occur for only a short time (acute) or may become an ongoing problem (chronic). Acute incontinence is often related to other medical problems and treatments. This topic will focus on types of chronic urinary incontinence.

• Stress incontinence occurs when you sneeze, cough, laugh, lift objects, or do other activities that increase stress on your bladder.
• Urge incontinence is an urge to urinate that is so strong that you often cannot make it to the toilet in time. Urge incontinence occurs when your bladder contracts when it shouldn’t. This can happen even when you only have a small amount of urine in your bladder. Overactive bladder is a kind of urge incontinence. Overactive bladder is a kind of urge incontinence. But not everyone with overactive bladder leaks urine.
• Overflow incontinence is leakage that occurs when the bladder fails to empty properly, due to a blockage or weak bladder muscle contractions. Obstruction is usually related to either enlargement of the prostate or narrowing of the urethra from scar tissue.
• Total incontinence is a continual leakage of urine due to loss of sphincter function.

Functional incontinence is a rare form of urinary incontinence related to physical or mental limitations that restrict a man’s ability to reach the toilet in time.

What causes urinary incontinence in men?

Urinary incontinence occurs when the muscle (sphincter) that holds your bladder’s outlet closed is not strong enough to hold back the urine. This may happen if the sphincter is too weak, if the bladder muscles contract too strongly, or if the bladder is overfull. In men, urinary incontinence often is related to a problem or a treatment involving the prostate gland, such as enlargement of the prostate (benign prostatic hyperplasia, or BPH).

• Stress incontinence may develop when a man’s prostate gland is removed and there has been dysfunction of or damage to the nerves or the sphincter, resulting in inadequate support for the lower bladder (bladder neck). The sphincter must then do all the work of maintaining continence, and the extra pressure (stress) of sneezing, coughing, or straining forces urine past the sphincter and through the urethra.
• Urge incontinence is caused by bladder contractions that are too strong to be stopped by the sphincter, causing an irresistible need to urinate. In many cases, the cause of urge incontinence and overactive bladder cannot be determined, but sometimes it can be traced to urinary tract infections, early BPH, interstitial cystitis, or early bladder cancer.
• Overflow incontinence is usually caused by a blockage of the urethra that forces urine to build up in the bladder. Often the blockage stems from an enlarged prostate gland (benign prostatic hyperplasia) or a narrowing of the urethra. Eventually the pressure from the full bladder forces excess urine past the obstruction. Overflow incontinence may also occur because of muscle weakness of the bladder.

Urinary incontinence can sometimes be aggravated by drinking alcohol or by taking diuretics, antidepressants, sedatives, narcotics, or nonprescription cold or diet medicines.

What are the symptoms?

The main symptom of urinary incontinence is the accidental release of urine. Additional symptoms will vary depending on the type of urinary incontinence.

• Stress incontinence: Unintentional release of a small amount of urine occurs with coughing, straining, lifting, or changing posture.
• Urge incontinence: The need to urinate is so strong that you cannot reach the toilet in time.
• Overflow incontinence: You have uncontrolled dribbling of urine, or you have the urge to urinate but can only release a small volume of urine.

How is urinary incontinence in men diagnosed?

Your medical history and a physical examination, along with some simple diagnostic tests such as a urinalysis, often provide enough information for your health professional to determine the cause of your incontinence. Additional tests called urodynamics may be needed if the incontinence is caused by more than one problem or if the cause is unclear.

How is it treated?

Incontinence is usually treatable with medicines, specific exercises, or surgery, after a health professional has determined what is causing the problem. Treatment varies based on the type of incontinence and how much it is affecting your life.

Incontinence can be an embarrassing problem, and men are sometimes reluctant to seek help. Some men might find it more of a problem than others and choose more aggressive treatment. Most men don’t require surgery to treat their symptoms. All men with symptoms of urinary incontinence should see their health professional.

During transurethral resection of the prostate (TURP), an instrument is inserted up the urethra to remove the section of the prostate that is blocking urine flow.

TURP usually requires hospitalization and is done using a general or spinal anesthetic.

What To Expect After Surgery

The hospital stay after TURP is commonly 1 to 2 days.

Following surgery, a catheter is used to remove blood or blood clots in the bladder that may result from the procedure. When the urine is free of significant bleeding or blood clots, the catheter can be removed and you can go home.

Strenuous activity, constipation, and sexual activity should be avoided for about 6 weeks. Symptoms such as frequent urination will continue for a while because of irritation and inflammation caused by the surgery, but they should ease during the first 6 weeks.

Why It Is Done

Your doctor may recommend TURP if symptoms caused by benign prostatic hyperplasia (BPH) have not improved in response to home treatment and medications.

TURP is now the most common surgery used to remove part of an enlarged prostate. Open prostatectomies (in which an incision is made into the abdomen) generally are needed only when the prostate is very large.

How Well It Works

On the average, men experience an 85% improvement in their American Urological Association (AUA) symptom index scores. For example, if you had a score of 25, after this surgery it might be reduced to about 4. Men who are very bothered by their symptoms are most likely to notice great improvement in their symptoms after TURP; men who are not very bothered by their symptoms are less likely to notice a significant change.

In men who have moderate to severe symptoms of prostate enlargement, TURP is more effective than watchful waiting in relieving urinary symptoms. Studies have found that:²

• 90% of men who had TURP had reduced symptoms compared with 39% of those who used watchful waiting.
• After 5 years, 10% of those who had TURP had a “treatment failure,” mainly an inability to urinate, urine left in the bladder, and an increase in the severity of symptoms. This compares with 21% of men using watchful waiting during the same period who had an increase in symptom severity or complications.

TURP and transurethral incision of the prostate (TUIP) had equal effectiveness.

Compared with visual laser ablation, TURP was more effective at relieving symptoms but required a longer hospital stay. Another laser treatment method, contact laser vaporization, is as effective at reducing symptoms as TURP.

Risks

The risks of transurethral resection of the prostate (TURP) include problems with sexual performance, incontinence, and problems from surgery.

Problems with sexual performance

• Erection problems may develop in men who did not have problems before the procedure. The risk of this may depend on how sexual performance is defined and measured, how sexually active the man was before the surgery, and how old he is. Many men in the age group who are likely to have BPH also have some problems with getting an erection. Subsequent erection problems are reported by about 3 to 34 men out of 100. Viagra (sildenafil) is effective in helping most men achieve an erection after they have had TURP.
• A study comparing TURP with watchful waiting and laser surgery indicated that men who had TURP were no more likely to have erection problems, pain on ejaculation, or a perception of an inferior sex life than men who either had laser therapy or practiced watchful waiting.
• Some older studies that reported high rates of erection problems in men after TURP may have failed to assess the sexual function of the men before surgery and may have had differing definitions of what an erection problem is, so they may have overestimated the numbers of men who had an erection problem as a side effect of TURP.
• Ejaculation backward into the bladder (retrograde ejaculation) is very common, occurring in about 25 to 99 men out of 100. This does not affect sexual function.

Loss of ability to control urine flow (incontinence)

• A small number of men (about 1%) say they are completely unable to hold back their urine after the surgery.
• Some men find that they can still hold in their urine after the surgery, but they tend to leak or dribble.

Problems related to having surgery

• About 4 out of 100 men require a blood transfusion during or after surgery.
• TURP syndrome occurs in about 2 out of 100 men who have TURP. This syndrome occurs when the body absorbs too much of the fluid used to wash the area around the prostate while prostate tissue is being removed. The symptoms of TURP syndrome include mental confusion, nausea, vomiting, high blood pressure, slowed heartbeat, and visual disturbances. TURP syndrome is temporary (usually lasting only the first 6 hours after surgery) and is treated with medication that removes excess water from the body (diuretic).
• About 5 out of every 100 men need the operation again after 5 years.
• Repeat surgery because of a complication of the surgery is needed less than 10% of the time.

What To Think About

Surgery usually is not required to treat BPH, although some men may choose it because their symptoms bother them so much. Choosing surgery depends largely on your preferences and comfort with the idea of having surgery. Things to consider include your expectation of the results of the surgery, the severity of your symptoms, and the possibility of developing complications from the surgery.

Men who have severe symptoms often have great improvement in quality of life following surgery. Men whose symptoms are mild may find that surgery does not greatly improve quality of life. Men with only mild symptoms may want to think carefully before deciding to have surgery to treat BPH.

For men who have clear indications for surgery, TURP may be less effective than open prostatectomy in relieving the symptoms of BPH. (See the Surgery section of the topic Benign Prostatic Hyperplasia [BPH].)

About 10% of men who have TURP or open prostatectomy are found to have previously undetected early-stage prostate cancer. Cancer discovered this way generally is slow-growing, often requires no additional treatment, and will not be the eventual cause of death in most men. For more information on prostate cancer, see the topic Prostate Cancer.

This procedure involves removal of part of the prostate gland through the urethra.

A long, thin tube with a viewing instrument (cytoscope) attached is inserted into the urethra. Prostate tissue is removed through the cytoscope.

What To Expect After Surgery

You are usually hospitalized for 2 to 3 days. Complete recovery generally requires 3 to 4 weeks.

Why It Is Done

This surgery may be done for:

• Chronic bacterial prostatitis that resists antibiotic treatment, with or without infected prostate stones (prostatic calculi).
• Repeated urinary tract infections because of another prostate problem for which surgery may be appropriate, such as prostate enlargement (benign prostatic hyperplasia, or BPH).

How Well It Works

Few men with chronic bacterial prostatitis have their symptoms improve after this surgery.

Risks

• Urinary incontinence
• Inability to get or maintain an erection (erectile dysfunction)

What To Think About

To eliminate category II (chronic bacterial) prostatitis successfully, the surgery must completely remove the portion of the prostate that contains the infection.

In transurethral microwave therapy (TUMT), an instrument (called an antenna) that sends out microwave energy is inserted through the urethra to a location inside the prostate. Microwave energy is then used to heat the inside of the prostate. Cooling fluid is circulated around the microwave antenna to prevent heat from damaging the wall of the urethra. To prevent the temperature from getting too high outside the prostate, a temperature sensor is inserted into the man’s rectum during the procedure. If the temperature in the rectum increases too much, the treatment is turned off automatically until the temperature goes back down.

The temperature becomes high enough inside the prostate to kill some of the tissue. As this part of the prostate heals, it shrinks, reducing the blockage of urine flow.

This treatment is done in a single session. It usually does not require an overnight stay in the hospital. A general or spinal anesthetic is needed during the procedure.

Microwave therapy is also known as cooled thermal therapy or by the name of the equipment (Targis or Prostatron).

What To Expect After Surgery

You are generally able to go home after surgery. You may not be able to urinate and may require catheterization to drain your bladder. For most men, this lasts for a week or less. You may also have to take antibiotics or anti-inflammatory medications.

You can generally return to work 1 to 2 days after treatment. Sexual activity can be resumed 1 to 2 weeks after surgery.

Why It Is Done

TUMT is done to help relieve the symptoms of benign prostatic hyperplasia (BPH). It is an option for men who want more than medications for treatment of their symptoms.

How Well It Works

Studies note that TUMT is more effective than treatment with the alpha-blocker terazosin when checked 18 months later.

In one study, transurethral resection of the prostate (TURP) improved symptoms better than TUMT. But in two other studies, there was no major difference in how well the two treatments worked.

Risks

The main complication of TUMT is the inability to urinate (urinary retention) for more than a week. This condition is treated by inserting a tube directly through the abdominal wall into the bladder to drain urine (suprapubic catheter). Erection problems and retrograde ejaculation (ejaculation backward into the bladder) appear to be less common after TUMT than after TURP.

Other complications include persistent irritation of the urethra and blood in the urine.

Recent reports have warned that the procedure has in a small number of cases caused serious injuries and complications, including damage to the penis and urethra. Injuries have required colostomies, partial amputation of the penis, and other procedures. In December 2000, the U.S. Food and Drug Administration (FDA) issued a warning about these injuries.

What To Think About

Most trials using TUMT have been limited by a small number of participants, a short length of time of study, and limited follow-up of the participants after the trial ended.

This procedure is not recommended for men with prostate cancer, men who are suspected of having prostate cancer, or men with prosthetic hip joints or pacemakers.