Urologic Topics

Vasectomy	Impotence
Vasectomy Reversal	Self Injection Therapy
Enlarged Prostate	Inflatable Penile Prosthesis
Incontinence	Prostate Cancer
Male Infertility

The information here is intended to give you an overview of a particular topic; however it is important that you talk further with your doctor and consider other factors in making any decision.

A vasectomy should be considered a permanent form of birth control for men. It is a sterilization process achieved by interrupting the tubes that carry the sperm from the testes to the penis. This prevents sperm from being released in the semen during ejaculation. A vasectomy usually is done in the doctor's office in about twenty minutes under local anesthesia with the no scalpel technique. A small puncture is made on both sides of the scrotum and the tubes are isolated, cut and tied with sutures. The skin then is repaired with a few small stitches. There may be some pain and bruising for a few days following the procedure. The male sexual performance is not affected by this surgery, and sexual activity may resume as soon as discomfort subsides. It is important to remember that it can take up to six weeks to clear residual sperm from the tubes, so a reliable form of birth control should be used until no sperm are seen in the ejaculate.

A man who has had a vasectomy can undergo vasectomy reversal in order to restore fertility. Successful pregnancy (75%) rates are best if reversal is done within seven years of the vasectomy. This surgery is done in an operating room with discharge to home on the same day as surgery. The surgery is performed with a surgical microscope using very fine (10-0) suture material. The two layer technique is probably the most effective procedure to re-establish the flow of sperm through the vas deferens.

After a man reaches the age of 40, his prostate frequently begins to enlarge, a condition known as benign prostatic hyperplasia (BPH). The likelihood of developing BPH increases with age. Eventually about 80 percent of men have enlarged prostates, but many will never have any symptoms.

When BPH interferes with urine flow, however, some characteristic symptoms can include:

If you have bothersome BPH symptoms, you may decide with your doctor to choose treatment. Surgical resection of the prostate using a scope (TURP) is currently the most effective treatment. In addition, several minimally invasive techniques are available, including microwave therapy and laser treatment. Several medications are available to help relieve the symptoms of BPH. Although less effective than surgery, these medications have less risk.

TUMT - transurethral microwave therapy involves placing a probe into the urethra under local anesthesia. The probe sends microwaves into the prostatic tissue and causes heat damage. Several weeks after the procedure the prostate will shrink and allow easier passage of urine. This procedure is performed on an outpatient basis.

Indigo laser treatment is usually performed under spinal or general anesthetic. A scope is used to place the laser fiber into the prostatic tissue. The laser is subsequently activated and causes heat-generated tissue destruction. A urethral catheter is left in place 5-7 days and the patient is sent home the same day.

Incontinence or loss of bladder or bowel control is a symptom - not a disease in itself. A broad range of conditions and disorders can cause incontinence, including birth defects, pelvic surgery, injuries to the pelvic region or to the spinal cord, neurological disease, multiple sclerosis, poliomyelitis, infection, and degenerative changes associated with aging. It can also occur as a result of pregnancy or childbirth.

Incontinence is a problem of the urinary system, which is composed of two kidneys, two ureters, a bladder, and a urethra. The kidneys remove waste products from the blood and continuously produce urine. The muscular, tube-like ureters move urine from the kidneys to the bladder, where it is stored until it flows out of the body through the tube-like urethra. A circular muscle called the sphincter controls the activity of the urethra. It is not a part of the urinary system but can play a role in incontinence. Normally, the bladder stores the urine that is continually produced by the kidneys until it is convenient to urinate, but when any part of the urinary system malfunctions, incontinence can result.

At least 13 million Americans are incontinent - 85% of them are women. It is estimated that one in four women ages 30-59 have experienced an episode of urinary incontinence. It occurs in children and young adults, but the largest number affected is the elderly. Fifty percent or more of elderly persons living at home or in long-term care facilities are incontinent. Sufferers may experience emotional as well as physical discomfort.

Stress Incontinence occurs when sphincter of pelvic muscles have been damaged, causing the bladder to leak during exercise, coughing, sneezing, laughing, or any body movement which puts pressure on the bladder.

Urge Incontinence, the urgent need to pass urine and the inability to get to a toilet in time, occurs when nerve passages along the pathway from the bladder to the brain are damaged, causing a sudden bladder contraction that cannot be consciously inhibited.

Overflow Incontinence refers to leakage that occurs when the quantity of urine produced exceeds the bladder's holding capacity.

Reflex Incontinence, the loss of urine when the person is unaware of the need to urinate, may result from an abnormal opening between the bladder and another structure, or from a leak in the bladder, urethra, or ureter.

Incontinence from surgery follows such operations as hysterectomies, caesarean sections, prostatectomies, lower intestinal surgery, or rectal surgery.

Every person with urinary incontinence deserves a complete medical evaluation. The doctor first will go through a careful medical history, including questions about bladder control in the past, other illnesses, medications, and lifestyle. After a physical examination, the doctor will suggest one or more of the following tests to help guide the diagnosis and treatment.

1. Urine culture. The urine is tested for the presence of bacteria that may cause infection leading to incontinence.

2. Voiding cystourethrogram (VCUG). X-rays of the bladder are taken which give information about its position and function.

3. Cystoscopy. A small tube called a cystoscope is inserted into the urethral opening, allowing the doctor to see inside the urethra and bladder.

4. Urodynamics. Pressures inside the bladder and abdomen, as well as volume, many of the types of incontinence result in similar symptoms. Urodynamics is the key to sorting out these symptoms so that appropriate treatment is selected. In addition, x-rays can be taken of the bladder and urethra during filling and voiding to aid in the diagnosis. This is known as video urodynamics.

Approximately 80% of those affected by urinary incontinence can be cured or improved. Some people improve significantly with simple changes in diet or the elimination of medications such as diuretics. More frequently, treatment involves a combination of medicine, biofeedback, exercises, urethral inserts or collection devices, and absorbent products. Surgery is safe and effective in those patients who have lost their pelvic support. The first step in solving the problem of incontinence is seeking help.

Impotence is defined as the inability either to obtain or to maintain an erection so as to satisfy both partners during sexual intercourse. Ninety percent of impotence is due to a physical cause, while 10% of impotence is psychological in origin.

The physical causes of impotence are classified into three categories: failure to initiate an erection because the nerves to the erectile tissue do not function; failure to fill the penis because of poor arterial blood flow; and failure to store blood within the erection tissue because of damage to the smooth muscle of the penis.

The major causes of impotence today are diabetes, atherosclerosis or hardening of the arteries, and impotence following radical pelvic surgery. Other causes include spinal cord injuries, hormonal problems and multiple sclerosis. The abuse of drugs, alcoholism and smoking can interfere with normal erections, and well over 200 different prescription medications can cause impotence as a side effect.

A complete history and physical, along with some psychological screening and an evaluation of the hormonal levels, are most important. Other tests may include an evaluation of erections while sleeping. A healthy male might have four to five erections during a night of restful sleep. This is something that cannot be suppressed by psychological means, and measuring these erections can be helpful in determining the cause of impotence. Other studies include evaluation of nerve function, blood flow measurements to the penis, ultrasound of the penis, and x-rays of the arteries and veins of the penis.

Medical treatment for impotence includes counseling when a psychological problem is discovered. Working with couples as well as reducing tension, improving communications, and trying to obtain realistic expectations are areas where counseling can help.

Hormone treatments, namely testosterone, can be used in men whose production of male hormones is low. Testosterone injections can not really help men who do not have low levels, which can be measured by the physicians at the initial evaluation.

Viagra is a medication that affects an enzyme in penile erectile tissue. It will enable many men with erectile dysfunction to respond to sexual stimulation. When a man becomes sexually excited, Viagra helps the penis fill with blood to cause an erection. After intercourse, the erection subsides. Viagra is contraindicated in men taking nitrates, significant cardiovascular disease, angina retinitis pigmentation.

This involves the patient or his partner giving an injection of medication directly into the side of the penis to create an erection. This erection created is a natural one and usually begins 5 to 10 minutes after injection. Not all patients respond to this type of treatment but those who do should develop an erection that lasts anywhere from 30 to 120 minutes. About 70% of men find their erections are satisfactory with self-injection therapy. The drugs used include prostaglandin (PGE-1 or Prostin or Alprostadil or Caverject), papaverine hydrochloride and phentolamine (Regitine). All of these drugs have been approved by the FDA for uses other than impotence treatment. Only prostaglandin has been approved by the FDA for uses other than impotence treatment. Papaverine and phentolamine have not yet been approved by the FDA for this specific purpose.

MUSE is the name of a new drug treatment and represents a unique approach for the treatment of erectile dysfunction. It is based on the discovery that the urethra can absorb certain medications into the surrounding erectile tissues, thereby creating an erection. The MUSE system uses prostaglandin E₁, the same medication used in self-injection therapy, and has been approved by the FDA for the treatment of impotence.

The vacuum erection device is a simple mechanical tool which allows the man to develop an erection which is suitable for sexual intercourse. The vacuum erection device works by bringing more blood into the penis and then trapping it there.

One of the options for treatment of erectile dysfunction is the placement of prosthetic inner tubes within the penis to mimic the inflation process and create an erection. Penile implants were first used in the 1950's, and hundreds of thousands of men throughout the world have been treated successfully with penile implants. There are three types of penile prostheses which include the semi-rigid implant, the inflatable implant, and the self-contained inflatable implant.

Semi-rigid implants are paired silicone-covered malleable or bendable metal rods. The semi-rigid prosthesis allows the penis to be rigid enough for penetration, but flexible enough to allow concealment in a curved position. It is the simplest of all the prostheses and has the least chance of mechanical failure.

Inflatable penile prostheses ar the most natural of the implants. These are soft, paired inner tubes made of silicone or bioflex, which are inert plastics. The inner tubes are filled with a solution that comes from a small reservoir placed under the muscles of the abdomen. A pump is used to transfer the fluid from the reservoir to the penile cylinders. When the erection is no longer desired, the fluid is returned to the reservoir leaving the penis soft and pliable. The major advantage of an inflatable penile implant is a more natural erection with total patient control.

A small percentage of patients may be candidates for some form of reconstruction of the penile blood flow. These include patients with poor arterial blood supply and those with venous leakage.

Administered by dissolving it under the tongue, Apomorphine seems to promote erections in men with psychogenic problems. Large studies are underway currently in the United States to determine the safety and effectiveness of this drug.

The exact cause of prostate cancer is unknown. What is known about the disease is that it begins with a group of cancerous cells with a group of cancerous cells within the prostate gland. Initially, the tumor may not cause any symptoms. As the cancer progresses, the tumor can enlarge and eventually put pressure on surrounding parts of the body such as the urethra. This process causes a blockage in the flow of urine out of the bladder. Because the same symptom can be caused by a non-cancerous condition of the prostate, it does not always mean that prostate cancer is present.

The most common method of detecting prostate cancer is through a digital rectal examination which takes very little time and involves minimal discomfort to the patient. The PSA is the newest monitoring tool developed for use in prostate cancer. This test measures the prostatic specific antigen, a substance produced only by the prostate. In even the earliest stages of prostate disease, the patient's level of PSA begins to increase and is detectable with this test.

A procedure called prostatectomy can be performed to prevent early-stage prostate cancer from spreading further. A pelvic node dissection (removal of possible cancer carrying lymph nodes near the prostate) is often performed at the same time.

This process uses high-energy x-rays to kill prostate cancer cells. As an alternative, small nonhazardous radioactive pellets can be surgically implanted into the patient's prostate.

The goal of the hormonal therapy is to decrease the testicle's production of testosterone, which fuels prostate cancer.

Traditional treatment for advanced prostate cancer has involved the surgical removal of the testicles. This procedure, called orchiectomy, removes the testicles that produces most of the body's testosterone.

Another method is to administer a female hormone such as estrogen or DES. Female hormones reduce the production of testosterone by the testicles.

A newer method of treatment consists of giving a drug called a luteinizing hormone-releasing hormone or LHRH analogue. An LHRH analogue is a drug that works just as well as removal of the testicles but without surgery.

Couples commonly are considered infertile if they have been unable to conceive during one year of unprotected intercourse. This problem affects 15% of couples. Male infertility alone or in combination with a female infertility factor contributes to approximately 50% of these cases. With the newer diagnostic and therapeutic techniques available, many male infertility problems can be treated successfully by a urologist.

Advances in diagnostic techniques have enabled physicians to identify a number of conditions that may lead to male infertility.

A varicocele occurs when one or more veins carrying blood from the testicles become dilated. This allows blood to pool around the testicle, causing the temperature of the testicle to rise above normal. This appears to influence the number and motility of sperm produced by the affected testicle, causing infertility.

Obstruction in the ducts that transport sperm cells account for 7.4% of male infertility cases. These obstructions may result from scarring that develops as a result of infections, especially urinary tract infections, gonorrhea, and other sexually transmitted disease. In some cases, genetic defects and illnesses may create obstructions. Obstructions normally occur in one of these locations: the epididymis, the vas deferens or the ejaculatory duct.

About 6% of infertile men experience an early developmental problem known as undescended testicles. Even if this condition is corrected surgically in childhood, overall semen quality may be poor.

Past surgical procedures can interfere with fertility. These include bladder and other urinary tract surgery. In addition, men who undergo lymph node surgery for testicular cancer, especially if accompanied by chemotherapy or radiotherapy, are at risk for infertility.

Drugs and substances on our environment can bring on infertility either through a direct effect upon the testes, or by affecting hormones that cause sperm to be produced. These substances are classified as gonadotoxins. Among the more common gonadotoxins are radiation, chemotherapy agents, pesticides, excessive heat and drugs such as nicotine, alcohol, marijuana and steroids. In many cases, the gonadotoxic effects are reversible if one eliminates exposure to the toxin.

Infections usually can be treated effectively with antibiotics or patients who have a testosterone deficiency can receive medication to stimulate production.

Varicoceles are one of the most common factors accounting for poor semen quality. Surgical correction of a varicocele involves making an incision in the groin and exposing and tying off the abnormal vein. After completion of this procedure, blood no longer pools in the varicocele and proper blood flow is established. Successful surgery has been reported to improve semen quality in approximately 51 to 78% of patients.

A microscopic surgical procedure can be conducted to reverse what was once thought to be a permanent sterilization (vasectomy). A vasectomy reversal, performed on an outpatient basis, involves bypassing the obstructed portion of the vas deferens. Depending on the circumstances and the length of time passed since the vasectomy, the pregnancy rates can be as high as 76%.

When sperm cannot move through the genital tract due to an uncorrectable blockage, sperm can be extracted directly from the epididymis by microsurgical techniques. Usually performed as an outpatient procedure, MESA can provide sperm for in vitro fertilization cycles.

Obstruction of the ejaculatory ducts can be relieved with an instrument inserted into the urethra. This procedure is performed on an outpatient basis.

A man's semen can be specially processed so that dead cells and other natural impurities are removed. Then, through intrauterine insemination, the sperm are injected into the woman's uterus, where they may fertilize the egg and establish a pregnancy.

Another technique, in vitro fertilization, involves fertilizing the woman's egg in a laboratory dish and implanting the resulting embryo in her uterus.

A recent adaption of this process, gamete intrafallopian transfer, involves combining the egg and sperm in a dish and transferring them into the woman's fallopian tubes, where they can fertilize naturally.

A new technique, intracytoplasmic sperm injection, can achieve pregnancy with as few as one sperm.

CATHETER CARE: Your catheter is very important to allow healing of the bladder and the urethra. You may use either leg bags or bedside bags. Drain before the bags get too full. The tip of the penis may get sore from the catheter rubbing. Use plain soap and water to wash this area daily or more often as needed. You may see some blood in the drainage tubing or bag on and off during the time that the catheter is in place. As long as the catheter is draining well, a little blood is normal and requires no treatment.

DIET: You may return to your normal diet immediately. Because of the raw surface, alcohol, spicy foods and drinks with caffeine may cause some irritation or sense of the need to void despite the fact that the catheter is emptying the bladder. If these foods don't bother you, however, there is no reason to avoid them completely, but eat them in moderation. To keep your urine flowing freely, drink plenty of fluids during the day (8 - 10 glasses). The type of fluid (except alcohol) is not as important as the amount. Water is best, but juices, coffee, tea, soda are all acceptable.

ACTIVITY: Your physical activity is to be restricted, especially during the first two weeks home. During this time, use the following guidelines:

BOWELS: The rectum and the prostate are next to each other and any very large and hard stools that require straining to pass can cause bleeding. You will be given stool softeners (usually) but these are not laxatives. A bowel movement every other day is reasonable. Use a mild laxative if needed (Milk of Magnesia 2-3 Tablespoons, or 2 Dulcolax tablets). Call if you are having problems.

MEDICATION: You should resume your pre-surgery medication unless told not to. You may be discharged with iron tablets to build up your blood count and stool softeners to keep the stool soft. Pain pills (Tylox or Tylenol with Codeine) may also be given to help with wound and catheter discomfort. Tylenol (aceto-amenophen) or Advil (Ibuprofen) which have no narcotics are better if the pain is not too bad (and you can tolerate those medications!).

FOLLOW-UP: You will need a follow-up appointment to monitor your progress. Call for this appointment at the number above when you get home, or from the phone in your hospital room before leaving.

You and your doctor have decided to proceed with removal of your prostate (along with the regional lymph nodes) for the treatment of your prostate cancer. The hospital stay usually last 2-4 days, but obviously, everyone is different and every operation is different. You will not be able to go home until you are able to eat and the intravenous feedings have been discontinued.

Hopefully, this pamphlet will answer most of your questions about your hospital stay. Perhaps not every question will be answered, so feel free to call us if more information is needed.

You have developed a cancer in the prostate gland which we feel is localized to just the prostate. That is, no spread from the prostate has been found. This means that removal of the prostate has a good chance of curing the cancer by removing all of the cancer.

Any surgical procedure of this magnitude is done in a hospital. Unless there are some extraordinary circumstances, you will probably be admitted on the day of surgery. You may need blood tests, an electrocardiogram (EKG), and other tests done prior to your surgical date, or on the morning of admission. It is very important that you refrain from eating or drinking anything for at least eight hours prior to your scheduled operation time. In most circumstances, this means nothing should pass your lips after midnight before your surgical procedure. If you have been on a special bowel preparation or diet, adhere to the diet until midnight before the surgery. You may take your regular medications until midnight. Any other medications should be checked out with us. You should NOT be taking any aspirin or aspirin products for 7-10 days before the surgery.

After coming through the admitting area and, perhaps, the blood drawing area, you will arrive at the nursing station on one of the floors and be given a bed and hospital gown. You may or may not be given an enema and have an intravenous line started to replenish your body's fluids. You will be brought down to a surgical holding area where an anesthesiologist will talk to you about the anesthesia, usually general anesthesia. General anesthesia means that you are completely asleep. This is usually induced by a fast-acting barbiturate, essentially an intravenous sleeping pill. Once asleep, you will be kept asleep by breathing an anesthetic agent, of which there are many kinds. Spinal anesthesia is not usually used with radical prostate surgery.

You will be transported into the operating room when the surgeons and anesthetists are ready. Special inflatable stockings to prevent blood clots in the legs may be put on before you are asleep. Monitor electrodes for the EKG and a blood pressure cuff

will also be put on. The anesthetic is then started and the surgery is completed within 2-3 hours. After the surgery is completed, the anesthetic will be discontinued and you will be taken to a recovery room.

In the recovery room, nurses will watch you very carefully until your anesthetic effects have worn off. The nurses will apply an oxygen tube or mask to your face and start checking your blood pressure and pulse frequently. While asleep, the anesthetist may have inserted a special intravenous line into your neck. This line helps measure the blood pressure directly from your heart and usually will stay in place for two days or so. Your lower abdomen or belly will hurt from the incision. Pain medication will be given to you as needed. You will note that the nurses are constantly watching the rubber tube or catheter that leads from your penis to a drainage bag on the side of the bed. This tube has been placed through your penis (or urethra to be more exact), into your bladder, acting as a splint for the new connection between bladder and urethra, now that the prostate is absent. It is held in position by a small balloon at the end of the tube which is inflated after it is placed. The nurses will be watching the tube drainage carefully. It will contain urine from the bladder and any bloody drainage from the operative site. The catheter is very important for your postoperative recovery. Occasionally, clots will form and the tube will stop draining. The nurses will then use a special syringe with water to hand irrigate the catheter to free it of clots. Hand irrigation might be somewhat uncomfortable, but necessary, to clear any plugging of the channel and allow the urine to flow. Once your anesthetic has worn off and the urine is draining satisfactorily, you will be transported to a hospital room.

Once in the hospital room, the floor nurses will check your 'vital signs' (blood pressure, pulse and respiration) and set up your inflatable stockings and perhaps your oxygen tubes. Most often we use a PCA or Patient Controlled Analgesia for post-operative pain control. This means that you will have a push-button at your bedside that will allow you to give small amount of pain medication intravenously for relief. The push-button is controlled so that you cannot give yourself too much. In some circumstances, you will not be getting enough narcotic to control your pain, and we will be called to consider raising the amount delivered by the PCA.

You will not be able to eat a regular diet on the day of surgery, but you may be able to have sips of water that first evening. Usually by the next morning or day after, you will be started on a light diet, and this will be advanced slowly over the next 1 to 2 days. You cannot be fed until we believe your bowels are ready to move the fluids and food along. Otherwise the stomach will become distended and the nausea and vomiting can result. The intravenous will be removed once you are taking in enough fluids by mouth (usually the second or third day).

You will probably stay at bed rest until the evening of surgery when the nurses will help you dangle your legs at the bedside. By

the next morning, the nurses will begin to get you out of bed. You will be sore, perhaps even sorer than the day of surgery, but we need to get you out of bed to allow the lungs to expand fully. You may also be given a special breathing apparatus that encourages you to breathe deeply in order to keep your lungs well expanded and prevent pneumonia. The nurses or respiratory therapists will instruct you on the proper use of the 'incentive spirometer'.

The nurses on the floor will continue to observe your catheter drainage. You may be started on antibiotics, pain medications and stool softeners when you can tolerate oral medications. Your usual other medications will be restarted (except aspirin-containing products). Once the intravenous line is no longer needed and you are eating normally, you will be ready to go home.

You will also notice a plastic tube or drain that exists in the abdomen to the side of the incision. This is to help remove the fluids that collect internally around the surgical site. This tube and drain are removed usually on the second or third day when the drainage is stopped.

Your incision has been closed with steel staples. These will be removed by the nurse at the time of discharge and replaced with small pieces of tape or 'steri-strip's to keep the incision together. These will start to peel and fall off after the 7th - 10th day. You can remove them if you like after the 7th post-operative day.

We have been particularly anxious to have patients take care of themselves at home as soon as the need for intravenous feeding and monitoring is not necessary. There are many reasons for this, including the sky-rocketing costs of medical care. Also, bacterial infections generated in the hospital are much more difficult to treat than infections that occur as an outpatient. You will be taught how to take care of your catheter and the various types of drainage bags. You will probably be discharged from the hospital with various medications including pain pills and antibiotics. Also, you will receive stool softeners, to keep the stool from becoming too hard and preventing you from having to strain to have a bowel movement.

You will be weak for a couple of months after a surgery of this magnitude. Expect to be tired often and to become fatigued easily. You may shower and walk some immediately after getting home. Every week you will be a little stronger and be able to do more and more. Figure on 6 weeks until you can do heavy lifting and 2 weeks to drive. You will be seen about 2 weeks after the discharge to have your catheter removed. Remember to bring adult diapers or pads (Attends or Depends) as your control will not be good when the catheter is initially removed.

You and your doctor have considered the possibility that you have a transurethral resection of the prostate (TURP). Why? What is it? Where? What can I expect afterwards? The following literature will hopefully give you some of the answers and understanding of prostate surgery. Perhaps not every question will be answered, so feel free to call us if more information is needed.

The prostate gland sits between the bladder (the muscular reservoir for urine coming from the kidneys) and the urethra (the channel in the penis, through which the urine flows). The prostate's function is to make seminal fluid or semen, which is added to the sperm coming from the testicles and then ejaculated during sexual intercourse. However, the urine from the bladder must pass through the prostate to get into the urethra.

As men grow older, the prostate grows in size. This enlargement is also referred to as "BPH", which stands for Benign Prostatic Hyperplasia. Benign means that this growth is NOT cancerous, hyperplasia is something that grows. The prostate's position between the bladder and urethra causes an obstruction to the flow of urine. This obstruction can present in many ways, slowing of the stream, difficulty starting, getting up at night to urinate, urgency, a very strong desire to urinate, urinary infections, bleeding, and total inability to urinate.