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Symptoms and Treatments

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia, or BPH, is the enlargement of the prostate gland in men. The prostate is a gland which produces part of the semen, and is located beneath the bladder and surrounding part of the urethra in men only. Enlargement of this gland occurs slowly as men age, and the amount of enlargement varies from man to man. As the gland enlarges, it may compress the urethra and bladder neck, leading to obstruction to the flow of urine.

Common symptoms of BPH include slow urine stream, frequent urination (daytime or nighttime, or both), interrupted stream, and the feeling of not emptying the bladder. Diagnosis of BPH usually involves a digital rectal exam, urinalysis, urine flow test and measurement for residual urine in the bladder, PSA blood test to rule out prostate cancer, and cystoscopy (looking inside the urethra with a telescope).

Treatments vary depending on the size and configuration of the prostate, the severity of the symptoms and the age and health of the patient. Treatment options include:

    1. Herbs such as Saw Palmetto
    2. Prescription drugs (Hytrin, Flomax, Proscar)
    3. Microwave treatment
    4. Laser or radiofrequency treatment (Indigo laser or TUNA)
    5. Transurethral incision of the prostate (TUIP)
    6. Transurethral resection of the prostate (TURP, "roto rooter job")
    7. Open surgical removal of the prostate
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Vasectomy

Vasectomy is a safe and effective method of permanent contraception employed by nearly 7% of all married couples and performed on approximately one-half million men per year. Vasectomy is less expensive and associated with much less in the way of complications than tubal ligation ("tubes tied"). Vasectomy is performed in the office under local anesthesia and ordinarily takes approximately 15 minutes. Our preferred method is the 'No-scalpel' vasectomy as popularized in China by Li in 1976.

The majority of patients do extremely well after their procedure, only having to limit major strenuous activity for several days. They are given pain pills afterwards and asked to follow up in the office the following week for a postoperative exam. Minor complications can occur, but are very rare. They would include bleeding and infection. Patients are asked to obtain two semen analyses around six and eight weeks from the time of their procedure to assure complete sterility.

Any patient interested in this procedure is encouraged to make an appointment for a consultation with one of our nurses. He can, with or without his significant other, view a videotape discussing the procedure and receive current literature outlining the benefits and potential risks.

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Urinary Lithiasis (kidney stone disease)

Diagnosis and Management

Neprolithiasis (kidney stone disease) today represents a common medical problem which Urologists deal with on a daily basis. The prevalence in the American population is approximately 2-3%. The symptoms of nephrolithiasis usually appear in an acute episode, the most prominent symptom being renal colic.

Typically, renal colic occurs during the early mornings or evenings. It is acute in onset and the patient will experience a crescendo of flank, lower abdominal or groin pain. Often times this will be associated with nausea and vomiting and sometimes fevers or chills. In other patients, kidney stones may be asymptomatic.

A diagnosis of kidney stones begins with a detailed history and physical examination. Laboratory testing follows, the backbone of which is the urinalysis, which may show red blood cells, white blood cells or bacteria. Today, the radiologic diagnosis of kidney stones is performed with the intravenous urogram or a noncontrast spiral CT scan. Ultrasound scanning may also be used to demonstrate stones in the kidneys or when X-ray testing is medically undesirable, such as during pregnancy. Hippocrates once stated in the Hippocratic Oath, "I will not cut, even for the stone, but leave such procedures to the practitioners of the craft".

Today, there are numerous surgical and nonsurgical techniques for the treatment of kidney stones. These include pain control with spontaneous passage, ureteroscopy, extra-corporal shock wave lithotripsy, percutaneous renal surgeries and finally open surgical extraction. With the excellent fiber-optic scopes available today as well as newer techniques such as percutaneous surgery and shock wave therapies, open stone surgery is now a treatment of the past. In general, if the stone is small and near to the bladder it can often be reached with fiber-optic scope and fragmented with a laser beam.

For larger stones in the kidneys, shock-wave therapy or percutaneous surgery is often effective. Prior to the 1980's, kidney stones were a serious medical problem,often leading to loss of the kidney and at times more serious complications. Today with our newer and less invasive techniques, we can often accomplish complete removal of kidney stone with minimal patient morbidity.

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Male Infertility

Infertility is generally defined as an inability to conceive a viable pregnancy after appropriately timed intercourse. Generally, a workup for infertility is instituted after a 12-month period of time. Although oftentimes, especially in older couples, if the intercourse has been appropriately timed, the workup can begin after only six months of failure to conceive.

Although most couples will conceive within one year, anywhere from 10% to 15% of couples who are otherwise normal, will have difficulty doing so. In approximately 50% of the cases, a male factor will be responsible for the infertility. The mainstay of the investigation from Allen Fertility is based on a thorough history and physical examination. This focuses on the male genitalia and sexual function. The laboratory backbone for male infertility workup is the semen analysis. Oftentimes, other blood tests will be necessary, such as a testosterone level or further hormonal testing.

While the causes of male infertility are varied, many such causes are easily reversed through treatment. These include simple infections of the urinary tract or testicles. One common cause of male factor infertility is the varicocele. The varicocele is a dilated vein in the spermatic cord leading to the testicle. They are more commonly found on the left side than on the right and oftentimes varicoceles may have a detrimental affect on the semen quality and absolute number of sperm.

Correction is easily done through an outpatient surgery where the veins are tied off, thus repairing the varicocele. Oftentimes in patients who have either obstruction of the vas deferens, or who have had a previous vasectomy, the vas deferens may be surgically reconnected in a procedure called a vasovasostomy.

Ultimately, if medications or simple surgical procedures fail, today there are a large variety of assisted reproductive technologies which may allow even the most severely affected patient to conceive a viable pregnancy. These include in vitro fertilization, where the female's egg and sperm are brought together in a test tube setting, and the newest treatment available called ICSI.

ICSI, or intracytoplasmic sperm injection is a new technique through the use of microscopic manipulation, a single sperm may be injected directly into the egg in order to conceive a pregnancy. This has greatly revolutionized the treatments of severe infertility and has led to greater hope for many couples faced with severe infertility.

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Impotence

Erectile Dysfunction (ED) affects over 20 million men in America. With the publicity of Viagra and other treatments, most men are now seeking treatment. The mechanisms involve either organic or psychologic etiologies. The most common organic disease would include hypertension or other heart related diseases, diabetes, and many of the numerous neurogenic disorders (Parkinsonism, multiple sclerosis, stroke, spinal cord injury, etc.).

The patient with ED presenting to our office would get a routine history and physical examination along with pertinent laboratory examinations. Further testing may include Doppler penile vascular testing and nocturnal erection monitoring. Doppler evaluation is performed to assess the patency of the main penile arteries that are very important for normal erectile activity. The Rigiscan nocturnal monitor is used to detect any erections that occur during the normal sleep cycle. This becomes extremely important to diagnose possible psychologic interferences to normal sexual function.

Currently, treatment recommendations would include Viagra, penile injections, vacuum erection devices, and penile prosthetic implantation. Viagra has success rates approximating 75%. For patients in whom Viagra isn't successful or for those with medical contraindications, injections and pumps have also been successful. If a patient either desires surgery or where other treatments have failed, we would then recommend implantation of any one of a number of penile prosthetics ranging from articulating semi-rigid implants to fully inflatable devices. The operative time is approximately one to two hours, depending on the complexity of the implant, while the hospital stay is only one day, mainly for analgesia and intravenous antibiotics for infection prophylaxis.

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Bladder Cancer

Bladder cancer is the abnormal and uncontrolled growth of cells in the urinary bladder. The most common type of bladder cancer is called transitional cell carcinoma (TCC). This is a cancer of the cells which line the inside of the bladder (called the mucosa). Other, more rare types of bladder cancer include adenocarcinoma and squamous cell cacinoma.

Common signs and symptoms of bladder cancer include blood in the urine, burning during urination, frequency of urination, and difficulty urinating. However, these signs are not specific for cancer and may occur with other less serious conditions. Risk factors for bladder cancer include exposure to certain dyes and chemicals, family history and especially cigarette smoking!

Diagnosis of bladder cancer includes testing the urine for infection and for abnormal cells, checking the urinary tract with xrays and looking inside the bladder with a telescope. If a suspicious area is seen in the bladder, biopsy is performed through a telescope while the patient is under anesthesia.

Treatment depends on the stage and grade of the cancer. Stage refers to how advanced a cancer is, or in the case of bladder cancer, how deep into the bladder wall the cancer extends and whether the cancer has spread outside of the bladder. Grade refers to how aggressive the cancer appears to the pathologist. Treatments range from removal through the telescope followed by routine surveillance only, to instillation of medications into the bladder, all the way to complete bladder removal and replacement.

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