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Many elderly patients suffer from urologic conditions particular to their age group. Often times physicians are unfamiliar with the treatment of such conditions. Furthermore, many urologists are unfamiliar with the side effects in the elderly of commonly used urologic medications. Dr. Tomas Griebling focuses on urologic problems in the elderly, their diagnosis and their treatment. Having completed a fellowship to address urologic problems in the elderly, Dr. Griebling is a nationally recognized leader in the field of Geriatric Urology. In addition, he is the only urologist in the state of Kansas with such specialized training.
Sexual dysfunction is an extremely common problem affecting over 50% of men between the ages of 40 and 70. With newer treatments available, public awareness of the problem has increased greatly. Impotence, or erectile dysfunction (ED), as with many disease processes, has a spectrum of severity. The most frequent symptom that we see is the inability to achieve any penile erection at all. Commonly, however, one may experience partial erection with either incomplete rigidity or loss of rigidity before ejaculation. In the past physicians often attributed ED to psychological causes. However, we now know that psychogenic impotence is responsible for less than 10% of cases of serious erectile dysfunction. Common causes of ED include medications for other conditions, arterial blockage due to atherosclerosis, peripheral nerve damage due to diabetes, pelvic fracture, and spinal cord injury. Fortunately, determining the specific cause of erectile dysfunction is usually not necessary as treatment is fairly standard.
Often times, ED can be treated easily with prescription oral medications. The physicians at the University of Kansas Hospital will evaluate your erectile dysfunction and select the best medication for you. If one of these medications is not effective, our physicians are equipped with a wide range of options to treat erectile dysfunction including intercavernosal injections, vacuum erection devices, intraurethral therapy, and surgical placement of a penile prosthesis.
In the event that surgery is needed for your erectile dysfunction, Dr. Ajay Nangia and Dr. Joshua Broghammer are currently one of the few physicians in the Kansas City area who are placing penile protheses and doing complex protheses for the treatment of erectile dysfunction. This procedure which uses an artificial device to provide erections has been reported to result in satisfaction rates greater than 90%. With extensive experience in these techniques, they offer the latest approaches for this surgical correction of impotence.
Watch the Multimedia Webcast: Sexual Dysfunction In The American Male as presented at the American Urological Association national meeting in 2009.
The Department of Urology at the University of Kansas Medical Center specializes in the latest treatment options for erectile dysfunction (ED) – the persistent inability to maintain an erection that is firm enough or lasts long enough to have sexual intercourse. This common problem is often caused by physical conditions, including prostate cancer, diabetes and cardiovascular disease.
ED can limit your intimacy, affect your self-esteem and impact your most important relationships. But the good news is that nearly every case is treatable today…You don’t have to simply live with it.
Treatment Options
The Satisfying Solution
The Department of Urology at the University of Kansas Medical Center has extensive experience with penile prosthetic surgery. Penile prostheses have been in use for over 30 years, and offer a satisfying long-term solution for ED. In a study comparing ED treatment options, patients reported a 93% satisfaction rate with penile prostheses1 – which far surpasses satisfaction with other treatment options.
Benefits & Risks of a Penile Prosthesis
Benefits
Risks
A penile implant is entirely concealed within the body and is designed to be simple and discrete to operate. It may offer a permanent, long-term solution to ED, and can help you return to an active, satisfying sex life.
How AMS Penile Prostheses Work
Choosing the penile prosthesis that is best for you is a very personal decision. Because each type of prosthesis offers unique features, you will want to discuss the choices with your doctor in order to choose the option that is right for you.
One-Piece Positionable Prosthesis (Malleable)
One-piece positionable prostheses are the simplest types of penile prostheses. The prosthesis consists of a pair of cylinders that are surgically inserted into the penis. The prosthesis is positioned up for intercourse or down for everyday activities.
Advantages
Disadvantages
Two-Piece Inflatable Prosthesis
The two-piece inflatable prosthesis consists of a fluid-filled pair of cylinders implanted in the penis and a small pump implanted in the scrotum. To get an erection, you simply squeeze and release the pump several times. When the fluid is pumped into the cylinders, it creates an erection that provides rigidity.
Advantages
Disadvantages
Three-Piece Inflatable Prosthesis
The three-piece, fluid-filled inflatable prosthesis features a pair of cylinders implanted in the penis, a pump implanted in the scrotum, and a reservoir implanted in the lower abdomen. When the fluid is pumped into the cylinders, it creates an erection that provides rigidity and girth expansion.
Advantages
Disadvantages
The AMS 700 LGX may not be appropriate for all patients, please consult with your physician to determine if it is right for you.
Finding the Right Treatment for You
Of course, a surgical solution is generally not the first course of action. Many men with ED benefit from other therapies like oral medications, injections or vacuum devices. But for those men who are not satisfied with those treatments – or not getting the results they desire – a penile prosthesis may provide a permanent, satisfying option.
Make an Appointment to Learn More
If you suffer from ED and are interested in reclaiming your sex life, make an appointment to discuss your options and learn more about today’s satisfying solutions.
As with any medical procedure, there are risks involved and not all patients are candidates for a penile implant. Discuss the risks and benefits of this procedure in more detail with your doctor.
Summary of Warnings, Precautions and Contraindications for Penile Prostheses
For a complete list of indications, contraindications and precautions, contact your urologist.
Viagra is a registered trademark of Pfizer Inc. Levitra is a registered trademark of Bayer and GlaxoSmithKline. Cialis is a registered trademark of Lilly ICOS.
1 Rajpurkar A, Dhabuwala C. Comparison of Satisfaction Rates and Erectile Function. J Urol. 2003 July; 170: 159-163
2 Levine LA, Estrada CR, Morgentaler A. Mechanical reliability and safety of, and patient satisfaction with the Ambicor inflatable penile prosthesis; results of a 2 center study. J Urol. 2001 Sep; 166 (3): 932-7
3 Kearse WS Jr, Sago AL, Peretsman SJ, Bolton JO, Holcomb RG, Reddy PK, Bernard PH, Eppel SM, Lewis JH, Gladshteyn M, Melman AA. Report of a multicenter clinical evaluation of the Dura II penile prothesis. J Urol 1996 May v. 155 p. 1613-1616
4 Natali A, Olianas R, Fisch M. Penile implantation in Europe: successes and complications with 253 implants in Italy and Germany. J Sex Med. 2008 June; 5(6):1503-12
5 Montorsi F, et al. AMS Three-piece Inflatable Implants for Erectile Dysfunction: A Long-Term Multi-Institution Study in 200 Consecutive Patients: Eur Urol. 2000; 37: 50-55
Penile curvature also known as Peyronie’s disease is one of the most challenging problems facing urologists today. Our understanding of the disease is currently a topic of much research, but remains largely unknown. However, the physicians in the Department of Urology are providing state of the art care, using the latest treatments available.
For those with a recent onset of Peyronie’s disease, treatments provided in the office might be successful. However, patients who have a long history of penile curvature often require surgical intervention. Whatever your needs, the Department of Urology at KU provides all of the options available.
Infertility is a common problem affecting up to 15% of couples. An estimated 4.6 to 7.3 million U.S. couples seek infertility care in the United States. 50% of cases have a female factor, 20% have a male factor, and 30% have combined factors. That means 50% of infertile couples will have an element of male factor infertility. Diagnosis and treatment of male infertility can lead to lower intensity of infertility treatments possibly associated with improved success and decreased treatment costs. What is male factor infertility?
One in a hundred of all men referred for infertility have been shown to have a previously unsuspected medical condition diagnosed on evaluation including genetic disorders, endocrine diseases, and malignancies. Importantly, semen analysis alone was unable to identify the men at highest risk for disease. Kolettis and Sabanegh found that 6% of all men referred for infertility had other medical diseases that were only brought to the attention of the doctor because the couple were being seen for male related infertility. We have also reported a number of cases of medical diseases that have been found during the male evaluation at the the time of infertility diagnosis. Research suggests that male infertility is associated with a higher testicular and prostate cancer risk. Childless men may also have a higher risk of cardiovascular mortality later in life. Higher risk of shorter life expectancy in men with abnormal semen parameters has been reported. There are potentially later problems from low testosterone related bone health, cardiovascular and sexual issues. It is important for the overall men's health, that we at the Dept of Urology here in Kansas City care about the long term consequences of a diagnosis of male infertility in the reproductive years. Cutting edge research is ongoing also under the guidance of Dr Ajay Nangia (Director of Andrology in the Dept of Urology), to better understand the causes of male infertility. New treatment options are being investigated. Dr Nangia is a urologist that specializes in the care of men locally in Kansas City, the MidWest and nationally. He specializes in the sophisiticated and complex genetic, hormonal, ejaculation and erection problems, microsurgical correction of blockage probems (due to infections, vasectomy and other traumas/surgeries) that could potentially be corrected. Men will be guided to to better men's health monitoring and hopefully improving quality of sperm if assisted reproductive technology is needed. Since women see gynecologists who specialize in their reproductive needs, shouldn't men be seen by a male specialist? Dr Nangia works closely with all the female reproductive specialists in the Kansas City area that perform assisted reproductive techniques i.e. intrauterine insemination (IUI) and in vitro fertilization (IVF). The overall joint care of the male and female partners as a couple is the key to succeeding in the joy of achieving a pregnancy and healthy baby.
Many causes of male infertility exist ranging from hormonal, blockages, genetic, environmental/lifestyle, medications or unexplained to name a few. Certain potentially life-threatening medical conditions may present for the first time as the inability to achieve a pregnancy and lower sperm counts, such as testicular tumors and some brain tumors. They are uncommon, and the reason why male patients should be evaluated in couples that have infertility.
The evaluation should involve a thorough history and physical and evaluate some of the risk factors that are known to cause male infertility e.g. some childhood disorders that do not become a concern until later in life e/g undescended testicle(s); infections; smoking, alcohol and drug use; certain issues with heat (not boxers or briefs – a myth); cancer treatments; spinal cord injury and other medical conditions. Blockages of the reproductive tract can sometimes be the cause and possible reconstruction using microsurgery can be performed to reverse this and avoid assisted reproduction techniques (ART) and have children naturally. Unfortunately these blockages sometimes cannot be corrected and sperm retrieval techniques and sperm freezing are required for in vitro fertilization (IVF) with intracytoplasmic injection (ICSI) – one sperm injected into an egg outside the body.
Correction of men with low counts and/or motility can also be corrected with a full evaluation, correcting any treatable causes e.g. manipulation of hormones, and correction of certain conditions such as:
Varicoceles – dilated veins in the scrotum that are thought to increase scrotal temperature and affect sperm production. Up to 40% of men who present with infertility have a varicocele on exam. Treatment for this requires careful patient selection and can result in 40-70% improvement in sperm production and up to 40% improvement in pregnancy rates. Even some men with no sperm in their semen who have a varicocele may get return of sperm (approx 17%). It is important to know that the number of sperm is usually not enough for natural conception in these cases and would require ART with IVF. Correction of the varicocele is a same day surgery as an outpatient but is in the operating room and requires an operating microscope to tie off the veins accurately and completely without causing damage to the blood supply to the testicle. Embolization of the veins can also be performed.
Other conditions that can cause male infertility are:
Hormonal Problems: Up to 10% of male infertility may have a hormonal association and determination of how important that is requires expertize in the field of male infertility. Many of these hormonal issues arise from childhood, but a recent trend on the rise is the overuse of testosterone for "low T" in men still in their reproductive years and who still want children. Dr Nangia specializes in the management of these men, many of whom have male infertility. Male patients who want children should not be placed on testosterone - this will shut down sperm production. Correction of the testosterone level has limited success for male fertility but is becoming more and more recognized as a potential health concern for later heart disease, insulin resistance and diabetes. To correct the testosterone in such men, non testosterone methods/medications are an option. Dr Nangia has a special interest and expertise in this field and will be able to discuss this with you and how it relates to male reproductive and post reproductive health.
Obesity can cause hormonal abnormalities that need to be corrected. Of course weight loss is the best way for many reasons. Life threatening conditions e.g. prolactinoma of the pituitary gland can show up for the first time during a couples difficulty getting pregnant and male infertility. This condition requires urgent care and in the early stages can be managed with medication alone.
Retrograde ejaculation: when semen goes backwards into the bladder and not outwards. Retrograde ejaculation can be caused by previous surgery such as prostate; medications such as alpha blockers; or diseases affecting the nervous system such as diabetes and spinal cord injuries. Sometimes this occurs in men with no known medical conditions. It may be corrected with the use of medications.
Blockage/Obstruction: when a blockage of the sperm system occurs from the back of the testicle (epididymis) to the sperm duct (vas deferens) and the prostate. Sometimes this happens because of injury or infection. Most times it is due to a vasectomy. These blockages can be corrected with microsurgery and can lead to pregnancy without the need of assisted reproduction such as IVF. Dr Nangia specializes in such cases. It is sometimes necessary to perform a biopsy of the testicle to prove that sperm are present. Sometimes reconstruction is not possible and consideration for freezing sperm/tissue from the testicle needs to be considered at the same time as the diagnostic biopsy.
Medications, Lifestyle and Environmental: Certain medications and environmental toxins are known to cause male infertility and affect sperm function e.g. pesticides and petroleum products. Lifestyle issues such as smoking, chewing tobacco, excessive alcohol use and drug use (including anabolic steroids) are know to cause infertility. Dr Nangia has extensive experience in the management of many of these issues and correction of hormonal problems that may occur as a result that cause male infertility. Obesity is a known cause for male infertility. The issue of lap tops and cell phones has recently been popular in the press as possible causes of male infertility. The data from the papers written is completely convincing at the moment but certainly needs to be considered especially the heat issue from lap tops.
Genetic: Some causes of male infertility such as men with no sperm (azoospermia) or very low counts can be due to a production problem, 5-25% of these cases can be due to a abnormal number of X and Y chromosomes or due to a piece of male Y chromosome missing. Other conditions such as Klinefelter Syndrome and Congenital Bilateral Absence of the Vas Deferens both are well described genetic conditions that cause male infertility and need be diagnosed for issues with the general health of the male that can be an issue later in life.
Unexplained: A large number of male infertility cases are unfortunately still unexplained. This is called idiopathic. For this there are a number of methods that can be tried to improve the situation and hopefully achieve natural conception or possibly improve the quality of any assisted reproductive techniques used. Dr Nangia specializes in helping couples maximize all the cutting edge knowledge on the subject to improve such issues.
Sporting Injuries and Male Infertility: Have you ever watched boys at high school sports all the way to professional sports and winced when a player takes a hit in the groin? So you should. It hurts and has some serious potential consequences. Not only does it cause the player to double over in pain, but can cause a rupture of the testicle and injury to the reproductive and urinary system. All of these issues can lead to problems with erections and cause infertility i.e. prevents men fathering children. This may not concern young men who feel that they are indestructible and feel that they are forever virile. In fact not getting a sexually transmitted infection or having children is usually more paramount in their minds, but at some point in their lives they may want children. In these situations an injury earlier in life can be tragic to the hopes and aspirations of a couple and cause serious social, psychological and economical distress in a relationship and change hopes for the future. It is primarily because of this potential tragedy that many specialists see that prevention of injury is needed through education about protection. Education of boys/young men at the time of sports physicals is essential – ranging from testicular self exams to detect testicular cancer early; education about contraception; STD prevention; to injury prevention. This is also important because most males who engage in sports are in their reproductive years; in an age group with the highest risk of risky/dangerous and care-free behavior; as well as the age group most likely to develop testicular cancer. A number of studies have revealed that young males lack knowledge of genital health. Young women are educated from an early age with earlier sexual development and also the start of the menstrual cycle, birth control and cervical cancer screening. There is no equivalent reason to see a medical provider for boys/young men, which is why the sports physical becomes an important venue to start preventative health care. A study in 2005 showed that 50% of young athletes did not understand why a genital examination is done. Most were unaware of the risk of testicular cancer and did not appreciate the difference in urgency of seeking medical treatment of painless versus painful testicular swelling. Routine male genitourinary examination during the preparticipation physical evaluation, including testicular and hernia evaluation, is recommended by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. This is somewhat concerning because in 2008 the US Preventive Services Task Force (USPSTF) made a recommendation against routine screening for testicular cancer in asymptomatic adolescents and adults based on the lack of written evidence that it helps. The USPSTF consensus has been that screening does not provide any benefit over current case-finding practices i.e. when a young man may feel a lump in his testicle and/or have pain. The problem is that Dr Congeni and colleagues from Akron, Ohio showed in 2005 that no more than 15% of athletes correctly differentiated the urgency of seeking medical treatment of painless versus painful testicular swelling. 34% still reported they would delay seeking medical care for painful testicular swelling. Only 38% knew that young men had the highest risk of testicular cancer. The majority believed older men to have the highest risk. This highlights the problem completely and stresses the need for improved education in junior high schools and upwards, as well as in sports teams and government and recreational health policy groups. This is very concerning because self exams are free and testicular cancer is very treatable if detected early. In the face of poor evidence, we strongly encourage adolescents and young men to continue to perform self exams until the issue has strong evidence to support that screening is not needed. Lance Armstrong is a classic example of someone who left it too late and had spread of his testicular cancer into his belly, lungs and even brain. He was lucky to have survived. Now he promotes “Livestrong” but and he should also promote “Live Smart”. The added issue in testicular cancer treatment is that the later the diagnosis, the more aggressive the treatment with not only removal of the testicle but also abdominal, lung and brain surgery and chemotherapy. All have an increased risk of effecting later fertility. The more aggressive the treatment beyond removal of a testicle, the more risk of damaging later fertility permanently. Genital injuries during sports have been described mostly in case studies. However, The National Electronic Injury Surveillance System (NEISS) showed that between 1990 and 2000, 883 sports-related genital injuries occurred in males less than 26 years old requiring emergency department evaluation. Blunt trauma (such as being hit by a bat, ball or hockey puck in the genitals without breaking though the skin) accounts for approximately 85% of injuries, and penetrating trauma (punctures the skin and underlying organs) accounts for 15%. Blunt testicular injuries can be managed with either observation or immediate surgery depending on the situation. Early surgery intervention for blunt trauma is associated with testicles more likely to be saved. Most blunt trauma to the testicles is minor and usually requires only conservative therapy. However, the injury can be underestimated and up to nearly half of patients presenting with blunt scrotal trauma in one study underwent surgery and were found to have rupture of the testicle. The NEISS showed that serious injuries to the genital area were most commonly seen with baseball, followed by basketball and football. Approximately 20% of emergency department visits for sports-related genital trauma had a risk of permanent injury, and up to 7% resulted in staying in the hospital overnight or transfer to a more comprehensive trauma center. Football had the highest risk of resulting in hospitalization or transfer to a trauma center for genital injury. Interesting the risk of genital injury in baseball was 1 in 383 versus 1 in 669 in football and 1 in 799 in basketball. When it comes to protection against injury, a study in 2005 showed that 47% of males playing sports did not wear genital protection during sports. Overall, only 33% of football players wore a cup versus 78% of baseball players. There are no clear statements or recommendations by any medical organizations on the issue. Protection is recommended and common sense prevails on the degree of contact involved and protection needed with certain sports more than others being high risk (e.g. football, ice hockey and baseball) as well as certain positions such as goalie and catcher. Overall, cups are often not worn by players due to the relative uncomfortable nature of the device during fast motion sports. This is an important focus of public awareness in this discussion and coaches, local recreational committees as well as college and professional leagues need to educate players on these simple means to prevent injuries by wearing their cups. Other sports or fitness activities like bicycle riding or spinning may result in testicular pain. Repeated and/or prolonged bike riding without coming off the seat and remaining in a forward leaning aerodynamic position may cause numbness of the groin and in some cases affect the ability to get and maintain an erection. All these issues can potentially compromise male reproductive health especially with repeated trauma. Extreme sports like skate boarding to BMX and motor cross have been associated with urological injuries especially straddle injuries and damage to the male urethra which can result in strictures (narrowing) which make urinating and ejaculation difficult. Even recreational sports such as paintballing have resulted in testicular fractures and hospitalization. Excess exercise may represent a physical stress that challenges the body at several levels. The beneficial effects of exercise are well known, but there is evidence of exercise-related short- and long-term consequences concerning male reproductive function – such as hormonal disturbances or effects directly on the testicles. Sperm and erectile function can be affected. Training intensity, duration and type of exercise as well as level of fitness of individuals will influence these effects. Current research overall has not been conclusive. It is important that physicians and the general public pay attention to exercise as a possible cause of male infertility and be precautionary until future research has thoroughly elucidated this relationship. Other injuries such as neck injuries/spinal cord injuries and concussions from high contact sports like football are not rare and associated with a number of health issues, with some of the most extreme being inability to move arms and/or walk (paraplegia and quadriplegia). All these issues can affect fertility, ejaculation and erections. This brings up the issue of neck supports and of course helmets that have been discussed more recently in connection with concussion risk/injuries. This is another extension of the same issue. All these issues do not take into account other effects of sports on male reproduction such as the abuse of anabolic steroids. This is the focus of a separate topic in this series. Overall, sporting activities highlight the need to discuss men’s health issues at preparticipation physicals at all levels but also in schools from an early age. Sports also highlight the need to re-iterate education and enforcing protection of the male genitals. At present there is a lack of adequate information provided to young men and also inadequate technology to make such protection comfortable to wear. More work is needed to educate sports equipment companies and sporting leagues of the importance of this issue. Great advances have been made with bike seats through better knowledge and health promotion, now it is time to improve other genital protection. We urge boys and men who participate in sports on a regular basis to help and educate themselves to ensure a successful reproductive life and good long term men’s health.
Dr. Ajay Nangia along with a large group of scientists at the University of Kansas Medical Center are advancing the treatment of men with male infertility especially unexplained cases with better insight into the reasons for the infertility problem. The Center for Idiopathic Male Infertility has been develooped at the University of Kansas Medical Center. They hope to correct the problems that men have with their fertility and achieve a pregnancy and allow couples to achieve a pregnancy without need for assisted reproduction if possible or to make the quality and function of the sperm better to more likely achieve a pregnancy if assisted reproduction is needed. Dr. Nangia is a leading member in the field of male infertility on a regional (Kansas, Missouri and the Midwest) and national level and will be able to advise couples on all the latest information in the filed of male infertility and best advise couples of options and alternatives. He recently was a member of the Best Practice Statement in Male Infertility prepared by the American Urological Association and will be happy to discuss current standards of care in the field of male reproduction and infertility, along with new testing techniques and their limitations. Treatment options need to be determined after thorough evaluation of both the history and also careful examination.
Recently, the WHO (World Health Organization) updated their guidelines for normal semen analysis to define fertility. The methodology, study and findings can be viewed by clicking here.
Vasectomy is a common procedure for permanent birth control in the US with over 520,000 performed a year. This is a form of secondary infertility. Six percent of men who have undergone a vasectomy desire a reversal with 12 times higher desire for reversal if the vasectomy was performed under the age of 30. Options for men who wish to have more children either with the same or new partner include vasectomy reversal, sperm aspiration (not undoing the vasectomy) with IVF-ICSI, donor sperm insemination, adoption or doing nothing. The decision to follow a particular option is determined on a case-by-case basis and depends on important factors such as length of time from vasectomy, experience and training of the surgeon and use of an operating microscope; age of the female partner; gynecological history of the female partner; and economic/financial issues since post vasectomy fertility management is most often not covered by insurance. A common myth is that men over 10 years should not have a vasectomy reversal – this is not correct, with the decision making based on the whole evaluation including examination and couples desires and time line as well as issues of views on family planning hopes of the couple. Vasectomy reversal is performed either as an end to end connection – removing the area of vasectomy and reconnecting, and this is called a vasovasostomy. The other type of reversal is a connection between the vas and the back of the testicle (the epididymis) called a vasoepididymostomy. The decision to perform one or the other of these operations depends on the fluid seen at the vasectomy site at the time of the vas reversal. The vasoepididymostomy is a very specialized microsurgery operation that requires significant training. Dr Nangiais trained in this operation. Vasectomy reversal is an outpatient surgery and then semen analysis checked 4 weeks after surgery and periodically there after until pregnancy occurs. Success rates are approximately 75% pregnancy if the vasectomy was performed under 3-5 years prior to approximately 30% if vasectomy was 15 or more years previously.
Sperm aspiration/retrieval techniques for use with IVF-ICSI can be performed in many ways (MESA, TESA, TESE, microTESE) depending on the situation for each patient/couple – ranging from men who have had a vasectomy to men who do not have sperm in the ejaculated semen, known as azoospermia. The reason men have no sperm in the semen and who do not have a blockage (known as non obstructive azoospermia) can be genetic, hormonal or unknown. In up to 10% of cases the genetic reason is felt to be due to missing a piece of the Y chromosome (the male chromosome), known as the AZF region. Some men may also have pieces of one chromosome on another (translocation) or too many X chromosomes. These can be checked by performing blood work. Azoospermia is not the end of the road for having biological children. Even though a man may not have sperm in the semen, there may still be pockets of sperm in the testicles that are not getting out and can be retrieved in up to 60% of cases. This does require a special type of sperm retrieval called micro TESE – which is an extensive biopsy using an operating microscope. This does have to be performed in the operating room. The number of sperm can only be used with IVF-ICSI. Genetic counseling of a couple is sometimes needed especially if a known genetic problem is found.
Another group of patients may develop infertility – those who receive chemotherapy or radiation for cancer. In these cases men should try to freeze sperm prior to treatment for later use if their counts are too low or zero. Hope is not lost in those who did not freeze and may require micro TESE or use of ART. Spinal cord injury in a young man is another reason for problems with fertility – mainly because of ejaculatory issues. In this situation special methods are required to retrieve sperm for couples to have children. Sometimes men have retrograde ejaculation – sperm going into the bladder e.g diabetics, spinal cord injuries, neurological issues, urological/prostate surgery and medications. Retrieval of the sperm from the bladder can be performed to use with assisted reproduction. Sometimes medications can be used to reverse retrograde ejaculation.
At the University of Kansas Medical Center, we have a comprehensive male infertility center that includes an andrology laboratory capable of semen analysis, cryopreservation, and other sophisticated sperm testing. Dr. Ajay Nangia works closely with the reproductive endocrinologists at KU and in the community when couples desire to pursue assisted reproduction – insemination or in vitro fertilization (IVF). Dr. Nangia is fellowship trained from the Cleveland Clinic in male infertility and microsurgery and specializes in vas and epididymis reconstruction, sophisticated sperm retrieval techniques, as well as problems of fertility following cancer and other illnesses including spinal cord injury. Dr. Nangia is a national leader in this field, as well as issues of male contraception.
Vasectomy is a common urological procedure to result in permanent birth control. Over 520, 000 are performed a year in the USA. It is an outpatient procedure that is done in the clinic/office. It takes about half an hour. A piece of the vas is removed and either clips or ties are applied and some urologists turn the vas back or place the two ends in different levels. Ice pack, rest and pain medication are recommended after the surgery. Protected intercourse is needed until no sperm in the semen is confirmed. This is checked after a certain number of ejaculations (e.g. 15-20) or based on time frame (6 weeks or more after vasectomy). The patient is NOT CLEARED FOR UNPROTECTED INERCOURSE until the follow up semen analysis shows no sperm. Certain questions often asked are listed below:
Will a man have normal erections after vasectomy?
Answer: yes – any affect on erections may be psychological – there are no changes hormonally that cause a problem. Some residual discomfort may play a role possibly.Will a man still produce fluid?
Answer: yes – the main fluid a man produces is “down stream” from the vasectomy.Will a man still reach climax?
Answer: yes….no further explanation neededWill a man still have normal libido (sex drive)?
Answer: yes. Again the problem may be psychological or if he still has some pain may lead to less desire.Can a vasectomy increase the chance of testicular cancer?
Answer: no. There is no connection between the two. Also there is no connection with prostate cancer or any other cancers.Are there any diseases that a vasectomy can lead to?
Answer: no. There have been some associations made that a vasectomy can lead to an increased risk of heart disease, and Alzheimer’s disease. These have not been supported by adequate studies.Can a vasectomy reverse itself spontaneously?
Answer: This is called “recanalization” and unfortunately the answer is yes but rarely and the statistics range from 1 in a 1000 to 1 in 10,000 chance. The reason for this is that there is a sort of “honey combing effect” that the body manages to do in some cases. This however may be very much related to the technique of vasectomy performed and to the man being compliant with the instructions to get his semen checked to make sure there are no sperm. Under 50% of men get checked to make sure that they have no sperm. It is recommended that the analysis not be performed until at least 15-20 ejaculations have occurred. Some doctors recommend a time line e.g. analysis after 6 weeks. The exact time line is not completely clear.Can a vasectomy be reversed deliberately?
Answer; yes. Of the 520,000 or more men who have a vasectomy in the USA per year, approximately 6% feel that they have made a mistake or a change in their life situation has occurred to consider reversing this permanent means of contraception. It is important to also know that if a man is under 30 years of age, he has a 12 times higher chance of wanting a reversal. See male infertility section.What is the no scalpel vasectomy?
Answer: this isn’t quite what everyone thinks. No scalpel does not mean “no pain” or miraculously the surgery is performed like something out of Star Trek. No scalpel unfortunately doesn’t really mean it is any less anxiety provoking, nor any less of a procedure. The main issue is exactly what the name suggests. In place of a scalpel is an instrument that stretches the skin to open it up…..still requires local anesthetic. The main issue is that most times no stitch in the skin is required and the hole is small. Recovery may be better but I have not noticed any difference.
As a patient some time should be taken thinking about the options. It is an important milestone so it is important to get it right the first time. If a patient is unsure, vasectomy may not be the right option.
Benign
Prostate Hypertrophy (BPH)One of the most common problems in Urology is difficulty with
urination. Since Greek times, physicians have employed different
methods to relieve problems associated with urinary obstruction
due to an enlarging prostate gland. The Urology department at
Kansas University Medical Centers offers a comprehensive array
of diagnostic and treatment options for the enlarged prostate.
These include oral medications, minimally invasive techniques,
and transurethral resection of the prostate. We are the only
major medical facility in this area offering the transurethral
needle ablation (TUNA) of the prostate which involves the use
of radiofrequency to heat the prostate and shrink it over a 3-6
week period. In addition, we are now offering transurethral microwave
therapy (TUMT), which uses microwave therapy to help shrink the
prostate and can be done in the clinic without the need for anesthesia.
These procedures are offered as an out-patient therapy and have
very few complications with excellent results.
For those with more advanced enlargement of the prostate, our
physicians are very experienced in the surgical treatment of
the enlarged prostate gland. The standard transurethral resection
of the prostate formerly was associated with a large number of
complications, however newer technologic advances have decreased
these complications. The Department of Urology at the University
of Kansas Medical Center is always seeking options to improve
the outcomes of our patients who suffer from an enlarged prostate.
Definition: Urethral stricture is an uncommon condition which results in blockage of the urethra or “peeing tube”. Stricture formation results in a narrow circular ring of scar which restricts the flow of urine.
Signs and symptoms: Most men will experience obstructive symptoms such as slow stream, frequent urination, feelings of incomplete emptying, recurrent infections, and straining to void. In severe cases, urinary retention may prevent individuals from urinating and may require emergency intervention. In severely injured patients, blood in the urine may also be seen.
Causes: The cause for the majority of urethral strictures is unknown. The most common cause results from trauma of being struck in the area between the legs known as the perineum. Other causes include: inflammatory diseases, i.e. lichen sclerosis (LS) and balanitis xerotica obliterans (BXO); infections, i.e.sexually transmitted disease; congenital abnormalities; instrumentation, i.e. surgery, catheter placement, or pelvic fracture.
Diagnosis: Patient evaluation starts with a thorough history and physical. The majority of patients will require a retrograde urethrogram (RUG). This is an outpatient x-ray test which shows the location, density, and length of the urethral stricture and is required for planning a repair. Other additional tests can include insertion of a camera into the bladder called cystoscopy.
Treatment: The treatment for urethral stricture is customized to fit each individual patient. The Kansas University Department of Urology is a unique in that it has multiple fellowship trained surgeons specializing in urethroplasty surgery including Drs. Joshua Broghammer, Priya Padmanabahn, and J Brantley Thrasher. Most of urethroplasties are performed with an overnight stay in the hospital. The types of treatments offered are below:
For an evaluation or treatment of urethral stricture disease please contact the Kansas University Medical Center Department of Urology to schedule an appointment.
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