The implantation of a penile prosthesis is indicated in all the forms of erectile dysfunction that do not respond to other therapeutic aids, in cases in which drug treatments are contraindicated or might have led to the occurrence of relevant side effects. A penile prosthesis is the best surgical option for the treatment of men with erectile dysfunction. Some regard it as the “last resort” for men suffering from impotence; however, we do not opine that.
A penile implantation can be performed on any patient suffering from organic Erectile Dysfunction (ED), as most of these problems fail to resolve spontaneously with non-surgical treatments. A long hesitation in undergoing this option might cause a significant and irreversible shortening of the penis because of the poor oxygenation of the corpora cavernosa. Which is worse in the patients suffering from Induratio Penis Plastica.
The prostheses can be both non-hydraulic (malleable) and hydraulic (three-component). They consist of two cylinders that are placed in the two natural cylinders of the penis: the “corpora cavernosa”. The non-hydraulic is the simplest: constituted by two cylinders of constant consistency which stimulate erection with the rigidity requested for penetration, also allowing adequate bending of the penis so that it can comfortably get placed immediately after. They represent the model of first choice when patients have limited manual ability or there are cost related issues. It is important to notice that, if on one hand the stiffness conferred to the penis allows the penetration, perennial turgidity of the rod could cause significant lifestyle changes: for example, it is difficult to camouflage under tight-fitting clothing, which could be a problem, for example, while working out or practicing sports. Moreover, the state of high pressure on the cavernous tissue can reduce the tropism and consequently increase the chances of perforation and extrusion of the prosthesis. These prosthesis are, therefore, suggested only in cases where there are limitations of manual ability of the patient or there are issues related to the high costs of implant.
The hydraulic models are instead made up of two cylinders, a control device inside the scrotum and a reservoir of liquid placed near the bladder. It creates a closed loop system, where the liquid gets transferred to the two cylinders to achieve erection, the procedure is manually operated wherein the liquid is again transferred back to the reservoir to obtain flaccidity. The hydraulic prosthesis allows obtaining an erection in solidity with absolutely no distinguishment from a natural erection. The hydraulic models thus allow, on command, erections of optimum rigidity, with the same sensitivity as was present before the surgery, and with the same ability to ejaculate and orgasm, without any significant noticeable feature on the outside; in fact, all the elements of the prosthesis are present within the body.
The great advantage of hydraulic implants is that the penile rigidity is obtained only during the culmination of the sexual activity. This allows the patient to hide the erection during social moments. Thus, in most of the cases, the choice of the prosthesis should rest on a hydraulic device, in order to make the erection and the flaccid states resemble the natural ones. However, in reality, noticeable conditions will make the choice according to National Healthcare system due to the different costs that the public facilities have to endure for the type of prosthesis.
In most of the cases, the selection of the patients eligible for prosthesis implant is based on the exclusion criteria. In other words, patients are considered candidates for prosthetic implant when they are affected by erectile dysfunction on a prevailingly organic cause, cases where the therapeutic path of oral treatment and intracavernous injection of vasoactive drugs with minimal invasiveness prove to be ineffective or the improvement is unacceptable.
In some cases, instead, the prosthesis may be preferable in case of severe curvature secondary to the induratio penis plastica, when the small size of the penis and/or the co-existence of a pre-operative erectile dysfunction does not allow a successful conservative surgery based on the simple straightening or on the excision of the plate and the grafting of an autologous material or heterologous replacement. However, in certain rare cases where, despite the presence of a normal responsiveness to pharmacological treatments, sometimes it may be the Patient himself to request for the prosthetic implant, as the choice of treatment. In this case, like in the rest of the prosthetic surgeries, correct preoperative information is particularly important.
The phases of the surgery include skin incision, exposure of the corpora cavernosa, choice and positioning of the prosthesis components and, in case of hydraulic prosthesis, filling and emptying of the prosthesis.The surgery is usually performed under the loco-regional anesthesia and involves the placement of two expandable cylinders at the corpora cavernosa level of the penis, a reservoir at the paravesical space level and a pump in the scrotum. The three components are connected by the thin connecting tubes that run on the subcutaneous level.
The most significant complication is represented by the infection that generally requires another surgical operation for the removal of the prosthesis. The mechanical reliability and the technical characteristics of the models currently available in the market guarantee excellent results in aesthetic and functional terms; however, some precautions are necessary to avoid cases of postoperative dissatisfaction.
The preoperative interview is very important to understand the expectations of the patient, the surgical results and the aspects of sexuality post-implantation enables one to choose the most appropriate prosthesis. In cases where the preoperative interviews are useful to make the correct treatment choice, the results in terms of sexual rehabilitation of the patient and its favourable effects on the couple become extremely flattering. The patient must be made aware of the irreversibility of the surgical procedure and the specific risks related to it; these, being the mechanical functional problems reduced to a minimum, are mainly represented by the infection of the prosthesis with the highest values, especially in groups at risk with poor immune reactivity, such as diabetes, kidney disease, or immunocompromised.
The correct preoperative information should take into consideration some basic elements: the size of the penis post surgery, in both the erection and flaccid state may differ from the sizes found prior to the operation and this event will be in the long term, this disparity will be found in case of the use of malleable prosthesis as well. Cases of infection of the prosthesis have been described and the consequent need to provide for its removal have been well explained, especially in cases where the need for replanting has been deferred (resulting in at least six months); as with any surgery, infection is an inevitable possibility.
The probability of incurring an infection following our treatment is less than 1%. This percentage may be higher if there is a spinal cord injury or diabetes involved. Men who need surgery to revise or replace an implant are at a higher risk of infection than they were during the first operation. The risk of infection can be significantly reduced if the patient follows the instructions provided in pre and post operative stages. Infections are treated with the immediate removal of the prosthesis. The prosthesis implant does neither directly affect the levels of desire nor the intensity of orgasm.
Difficulty in reaching orgasm may persist only for a short period of time post surgery; in this case, the patient should be encouraged to increase the frequency of intercourse and duration of erotic foreplay. Similarly, the use of the prosthesis does not automatically improve your relational skills, even considering it can play a key role in the recovery of self-esteem, nor will it resolve conflicts between the couple that stem due to erectile dysfunction.
When the penis is erect, the prosthesis makes the penis harder and it appears like a natural erection. A penile prosthesis does not change the sensitivity of the penis or a man’s ability to achieve orgasm. The ejaculation is not affected. Sometimes the patients report “loss of penile length”. The perceived loss of penile length is not due to the positioning of the penile prosthesis: the positioning of the implant stops the process of atrophy and, with proper rehabilitation the patient can recover some of his lost penis length.
“I feel the tubes around my cylinders”. We do everything that is possible to hide the tubes but some anatomies require installation of the cylinder where the tubes can be felt under the skin.
“The head of the penis is not hard.” This is a possible situation. The implant does not give adequate bulge to the Glans. Our surgical technique limits the possibility of achieving flaccid penis. Viagra and/or intraurethral creams can be used for the treatment of this problem.
How does one live with inflatable penile prosthesis? No physical activity or other sports activity will be denied after the implantation of the prosthesis. Our patients, once healed, live a normal active lifestyle.
How effective are the implants? About 90% – 95% of the implants of inflatable prosthesis produce erections suitable for intercourse. Satisfaction rates with the prosthesis are very high, and typically 80% – 90% of men are satisfied with the results and choose to opt for the surgery again.
It should be emphasized that the operation of penile prosthesis implantation must be performed by specialists dedicated to the medical branch of Andrology and in proper facilities.
Dual Implantation of Artificial Urinary Sphincter and Penile Prosthesis
Erectile dysfunction and urinary incontinence due to sphincter deficiency are relatively common conditions after radical prostatectomy. They both impact greatly on quality of life domains and have been associated with poor performance outcomes in the past. When there are not any other options, these conditions are easily fixable with the implantation of prosthetic devices. Both, the artificial urinary sphincter and the penile prosthesis, are gold standard treatments with proven efficacy, satisfaction and durability. Recently, it was advised to have both operations simultaneously.
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Plasma cells enriched for Erectile Dysfunction
Increased feelings of pleasure with improved sexual performance and a drastic reduction in penile curvature in case of deformity. These are the results achieved from the procedure with PRP (Platelet Rich Plasma), used for the treatment of erectile dysfunction and plastic induratio, which was developed in the US and now arrives in Italy.
“The PRP therapy gives strength to all those people who, for various reasons, no longer respond to treatment with inhibitors of phosphodiesterase type 5: the famous love pills. Some patients have also reported an increase in length and circumference of the penis and of the sexual desire“ says Gabriele Antonini, urologist-andrologist of Rome, who collaborated with colleagues Joseph Banno in Chicago and Paul Perito in Miami. The PRP has been successfully used for several years in orthopedics and sports medicine and has quickly became one of the most effective methods of treatment for erectile dysfunction and penis plastic induratio or Peyronie’s disease in the United States.
“The human body has a remarkable ability to heal itself. The regeneration of a fabric is obtained with the natural production of stem cells – recalls Antonini – The PRP provides for the application of concentrated platelets rich in bioactive proteins that release growth factors to stimulate cell regeneration and accelerate tissue repair. “
The treatment starts with a simple blood sample placed in a centrifuge which separates plasma and platelets from the rest of the blood. “The plasma, enriched with highly concentrated platelets, is collected in small syringes and injected into damaged tissue again. The Priapus shot is a procedure performed on an outpatient basis by locally applying a simple anesthetic cream before injection, without any discomfort during the treatment.“ says the urologist.
“In the United States, more than 60,000 PRP procedures were performed with no side effects or complications. In Italy, it was approved by the Ministry of Health,” he continues. “The growth factors stimulate the regeneration of new tissue in the corpora cavernosa, the growth of new blood vessels and, therefore, improving circulation within the penis – said Antonini – The results consist in stronger erections, increased feelings of pleasure. Many of these benefits are immediate after the injection. This treatment is hypoallergenic and free of side effects – he concludes – because it uses and reinfonde the plasma of the same person”.
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Penile aesthetic surgery
What is Phimosis?
It is the narrowing of the foreskin that makes it difficult or impossible for a complete and easier uncovering of the glans; the foreskin is thus the skin covering the glans. Phimosis can occur only in erection (mild cases) or it can also be present in flaccid penis.
The causes can be: – Congenital: the foreskin, which is normally abundant and tight in children, also remains tight during pubertal development rather than widening; – Acquired: the causes which intervene after the normal pubertal development; they are generally linked to infectious factors, infections of the glans and foreskin (balanoposthitis) which post healing result into the processes of cicatricial retraction of the foreskin until it reaches phimosis.
Problems and Consequences of Phimosis
The inability to retract the foreskin in whole or in part is variable depending on the severity of the disorder: 1. Mild Phimosis: the glans is seen with difficulty only during the erection, it can be annoying during the intercourse when the foreskin is retracted downwards, however, the condition does not lead to hygiene problems; 2. Medium Phimosis: it can even be verified in the flaccid penis, the glans is seen only in part, in such cases, besides facing problems in the sexual phase, there may be problems of hygiene: cleaning of the glans becomes difficult and this may cause infectious complications that may worsen the phimosis; 3. Severe Phimosis: the glans cannot be seen, the hygiene factor is compromised, there are frequent infectious complications and, in more advanced cases, it could be difficult even to urinate.
How to recognize it?
The diagnosis of phimosis is very simple and is often done by the patient himself. During the examination, the foreskin looks tight and, therefore, the diagnosis becomes easy to conduct. In milder forms where phimosis manifests itself only during erection, the outcome of the examination gets a little doubtful, in such cases the interview with the patient clarifies the situation.
How is it treated?
The treatment of phimosis includes: 1. Medical treatment 2. Surgical treatments
Medical treatments of Phimosis
The medical treatments are reserved to those cases in which the phimosis is either supported by infection or inflammation, while it is not indicated in cases of congenital phimosis. Medical treatments for the same include: 1. Anti-infective treatments targeted to the causative agent of balanoposthitis, generally bacterial or fungal which, depending on the situation, can be dosed exclusively locally: aureomycin, gentamicin ointments etc. or antifungal ointments; in the more severe cases, however, it may be necessary to employ a systemic treatment comprehending antibiotics or oral antifungals such as; 2. Anti-inflammatory treatments: these are primarily corticosteroids based on local treatments; these drugs can be employed in the infectious phase in combination with the drugs mentioned above, and in the subsequent post-infectious inflammatory phase to prevent a stabilized cicatricial retraction; where a phimosis might be supported by recent inflammatory factors and thus becomes reversible, these treatments can be lead to unprecedented benefits and treat the forms of phimosis that may initially hint towards surgical interventions for an untrained eye; in such cases, it gets possible to avoid surgery.
Surgical treatments of Phimosis
The surgical treatments of Phimosis include Circumcision and Partial Postectomy. 1. Circumcision: is one of the most commonly used operations. It is done under local anesthesia and performed at the base of the penis circumferentially. The procedure includes the removal of the entire foreskin; after surgery, the glans remains completely uncovered; the treatment has the advantage to be decisive in almost all cases but has the disadvantage of leaving the glans completely uncovered; 2. Partial Postectomy: is, as its name implies, the operation of partial removal of the foreskin; this surgery is recommended when there is a formation of narrow preputial ring while the rest of the foreskin remains spacious. In the treatment, only the narrow part of the foreskin gets removed. The advantage of surgery is that a part of the foreskin remains retained and thus the glans remain partially covered; however, sometimes it could not solve the phimosis which could reappear.
Recovery after Surgery
After-surgery stitches are absorbable and do not require removal, the wound heals in about two weeks, normal sexual activity takes around 3-4 weeks to resume, although at the beginning of the recovery the scar still remains sensitive and can give some discomfort. However, the use of the ointments consisting of anti-inflammatory substances can help to accelerate recovery. The glans that remains uncovered in whole or in part becomes extremely sensitive because it comes in direct contact with the external environment; this sensitivity is however completely transitional because it rapidly forms a keratinized (corneum) coating, like the one found on the lips, which helps reduce the sensitivity.
Phimosis is a benign disease that can become a source of problems, especially when it hinders the normal course of the life of the subject, it is easily detected in just one examination; it is easily treated; the treatment is not only surgical in nature but in its early inflammatory forms, it can also be treated very well with medical pharmaceutical options; surgery, when needed, is decisive; in addition to the complete removal of the foreskin performed in the circumcision surgery, one can perform partial removal as well (Partial Postectomy).
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Scratch Technique for Peyronie’s disease
Peyronie’s disease, also known as Induratio Penis Plastica or chronic inflammation of the tunica albuginea of the corpus cavernosum, it’s a disease involving the formation of calcified fibrous plaques within the penis. It affects 5% of men.
The pathology can cause pain, penile deformity, an hourglass effect and abnormal curvature of the erect penis due to chronic inflammation of the tunica albuginea. A commonly held erroneous belief is that Peyronie’s disease always leads to curvature of the penis. The scar tissue often leads to deformities or shortening rather than curvature. The condition can also make sexual intercourse painful and difficult until the disease process leads to atrophy. Almost 25% of patients seeking a penile prosthetic implant have a form of Induratio Penis Plastica. The average patient age is 58.
10% have a mild form of the condition, 10% moderate and 80% have a severe form of Peyronie’s disease. It is more common than people think. It is, beyond any reasonable doubt, related to diabetes, which causes endothelial damage and thus fibrosis of the corpus cavernosum, but it is also associated with “vigorous” sexual activity.
Early diagnosis is extremely important: a matter of days can make all the difference. The use of integrators as part of the treatment plan for Peyronie’s disease can be of help but does not resolve the problem.
Iontophoresis, low frequency shock waves and laser therapy can help in selected cases. The Vacuum device is very useful both as a preventive measure as well as for the purposes of maintaining the post-operative result. The Vacuum device is a mechanical device using a vacuum created by a pump to stretch penile structures (smooth muscle and tunica albuginea) and to draw blood into the corpus cavernosum, also for the purpose of inducing an erection. The device essentially consists in a large silicone cylinder with an appropriate adaptor, into which the patient’s flaccid penis is inserted and a pump (manual or electric) connected to the cylinder so as to aspirate air, creating negative pressure of up to 450 mmHg. Maintenance time and vacuum management will be suggested in the recovery phase based on the specific pathology. The Vacuum device can be used to treat forms of erectile dysfunction as an alternative to first-line therapies.
There are other pathological conditions which can be treated using the Vacuum device: these include situations in which the penis may undergo retraction or shortening such as, for example, the one of the penis, which may be observed following a radical prostatectomy. In such cases, the penile stretching associated with the oxygenation of the corpus cavernosum can prevent the retraction connected to the loss of erectile function, before the insertion of a prosthetic penile implant. According to the same principle, in cases of shortening due to Induratio Penis Plastica, the use of the Vacuum device can help to slow down the retraction-related shortening of the albuginea characteristic of the disease.
In our practice, men aged over 50 with any degree of erectile dysfunction are candidates for the implantation of a penile prosthesis.
Correcting the curvature alone will not guarantee an improvement in erectile function. As a matter of fact, such patients will need to undergo another procedure. However, a long wait can lead to a permanent shortening of the penis: carrying out the surgical procedure as soon as possible will avoid further length loss. When the penile prosthesis is inserted, we use a new approach to correct the curvature and defects of the tunica albuginea, called “Scratch” technique. Concretely, the fibrosis is broken from within and the shaft is re-modelled prior to implanting the prosthesis.
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Green Light for the treatment of prostatic hypertrophy
Benign Prostatic Hyperplasia (BPH) can cause severe trouble in urinating with age. About 50% of men will experience a radical change in urinating during their lives because of this benign growth. Surgical treatment of benign prostatic hyperplasia (BPH), a treatment method being used for the past 20 years, is based on transurethral resection of the prostate (TURP). The treatment is undergoing revolution in terms of its nature with the advent of laser technology. In fact, the non-negligible percentage of post-operative complications related to TURP (persistent microhematuria, post-TURP syndrome, anemia), has resulted in the industry’s ever increasing interest in search of the ideal method for resolving the obstruction of prostatic hyperplasia, a system whose main features should be minimal invasiveness, absence in the problems of intraoperative reabsorption of liquids, absence of bleeding, possibility of the total removal of the prostatic adenoma, shorter duration of stay in the hospital and the reproducibility of the results. The application of the laser technology to prostate surgery is itself a sign of significant improvement in the ideal surgical approach used in the last decade. The new standard for the surgical treatment of Benign Prostatic Hyperplasia is the photoselective vaporization of the prostate using the GREEN LASER, more commonly called “GreenLight laser prostatectomy”. It is a minimally invasive procedure that results in significant improvements in the urinary symptoms. A thin fiber is inserted into the urethra through a cystoscope, an instrument that allows the doctor to examine the bladder and the prostate. The fiber delivers green laser energy that quickly evaporates and removes the prostate tissue. The urologist is able to view and check safely the area of treatment, by adapting to one’s anatomy and needs. Since the prostate tissue is vaporized and removed, it creates a wide channel: as a result, the flow of urine is immediately restored and all the urinary symptoms should be treated. The green laser light used in the vaporization has a wavelength that gets easily absorbed by the hemoglobin present in the red blood cells. Because of this, the tissue which has blood in it (such as the prostate) gets selectively vaporized. Once the capsule of the prostate is reached, vaporization ceases completing the procedure: by being fibrous, the prostatic capsule has no hemoglobin and is therefore protected from the laser. The ADVANTAGE of this procedure in comparison to TURP is that, in this procedure, the prostate tissue gets vaporized selectively rather than cut-off. When the prostate tissue gets cut off in the TURP procedure, the prostate bleeds abundantly while, during the photoselective vaporization, this tissue does not bleed at all. The GreenLight laser exploits the capability of the tissue vaporization by lithium triborate crystals with the consequent advantage of an operation which is mini-invasive, bloodless, without any possibility to cause problems in the resorption of fluid and requires a short stay in the hospital.
The advantages of GREENLIGHT XPS 180 watt manufactured by American Medical Systems, Inc. are numerous.
With the use of intraoperative saline, the BPH treatment has become more successful (risk of resorption of liquid is minimal or absent).
Because of the great coagulation capacity of GREENLIGHT XPS that allows the removal of the urinary catheter and the secretion of the discharge to flow in the first or the second day, the number of days required for hospitalization for availing the treatment has reduced significantly.
Absence of intra and postoperative bleeding complications which can result into re-operations.
Possibility of treating anticoagulated patients, without suspension of the same (non-insignificant advantage in an era of an ever increasing use of antiplatelet therapies related to cardiovascular events).
Elimination of problems connected to blood transfusions.
Possibility of the treatment of the patients with pacemakers, since no electric energy is used.
Quicker functional recovery of the patient. The results are equivalent to those of TURP with fewer side effects and complications.
Rapid and significant improvement in urinary flow.
Treatment given to patients with varying severity in symptoms.
Further studies support the use of GreenLight on the large sized glands, on anticoagulant and high-risk patients.
One Day Surgery Procedure (one night of hospitalization). Much lower risk compared to TURP; no significant risk of TURP syndrome.
Much lower risk compared to TURP; no significant risk of TURP syndrome.
Catheterization of the average duration of 72 hours.
Mild irritative symptoms that last for short duration only.
Quick resume of normal activities.
The safety and effectiveness of photoselective vaporization with GREEN LASER has seeped in a revolution in the traditional treatment of Benign Prostatic Hyperplasia (BPH).
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Artificial urinary sphincter for male urinary incontinence
Urinary incontinence refers to the involuntary loss of urine at inappropriate times or places causing hygiene or social problems. In males, this kind of incontinence is rare and generally caused by trauma and/or surgical interventions to the urinary sphincter. Neurological conditions that compromise the innervation of the bladder and urethra might as well be a cause. In other cases, the person experiences a sudden urge to urinate and has to hurry to the toilet, but may “wet himself” before he gets there. The urinary flow ranges from a few drops to full micturition and are both frequent and unpredictable. In this case, we refer to urgency urinary incontinence. In most cases, the disorder is associated with frequent, involuntary and unstoppable contractions of the bladder muscle. Its causes included neurological disease, urinary tract infections, calculi and bladder tumors. This type of incontinence is frequently seen in the elders, particularly in those with cerebral disease (arteriosclerosis, Parkinson’s disease, etc.) and is aggravated by gait and balance disorders, as well as mental confusion. The AMS 800 device is used to treat urinary incontinence due to resistance to urinary flow in the urethra/bladder (intrinsic sphincteric deficiency) in male, female and pediatric patients. The AMS 800 sphincter is a reliable device for the treatment of incontinence in appropriately selected patients. The artificial sphincter is currently the best treatment for incontinence due to a sphincteric deficiency subsequent to radical prostatectomy. The positioning of an artificial sphincter for sphincter insufficiency produces satisfactory continence in 80-90% of cases. It simulates a healthy sphincter insofar as it maintains the urethra closed until urination is desired. The artificial urinary sphincter is a small, surgically implanted device which aims to restore the natural micturition control process. When the natural sphincter (the muscle responsible for controlling the micturition) does not function correctly, as may occur after a prostatectomy, it results in uncontrollable urine loss. In cases of severe incontinence, where rehabilitation techniques and pelvic floor physiotherapy are insufficient to restore continence mechanisms, the use of an artificial sphincter may be a solution to the problem. It is made up of three components: a cuff, which surrounds and closes the urethra, a pump located in the scrotum to deflate the cuff and a reservoir balloon. These components are connected together with flexible tubes.
Where is the device implanted? Balloon (reservoir): positioned close to the bladder. Tubes: connect the different parts of the device, allowing the movement of liquid within. Cuff: positioned around the urethra. Deactivation valve: a small button on the stiff part of the pump. Pump: positioned within the scrotum such that it can be felt through the skin. The lower part is soft and distensible. The liquid-filled cuff applies gentle pressure to keep the urethra closed and thus hold the urine in the bladder. In order to urinate, the patient presses the pump several times. The liquid is thus transferred into the reservoir and the cuff remains open. Once emptied, the cuff no longer exerts pressure on the urethra and urine is able to flow out of the bladder. A few minutes after micturition, the liquid automatically returns to the cuff’s balloon, which fills up to close the urethra, restoring continence. The surgical procedure for the implantation of the artificial urinary sphincter can be carried out as a Day Surgery, involving a single 3 cm incision below the scrotum. It is necessary to wait 30 days after the procedure before starting to use the device.
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Minimally invasive varicocele treatment
There are many different surgical techniques available for varicocele. The common approach is that of closing the pathological venous circuit allowing for the subsequent development of collateral circuits through the circuits of the deferential vein and the external gonadal vein.
Surgical techniques can be classified into 3 groups:
Inguinal and subinguinal techniques
These techniques involve the ligature of the gonadal vein within the abdomen and thus require opening of the abdomen by either open abdominal or laparoscopic means. They are generally carried out under general or spinal anesthesia. They are somewhat invasive techniques (opening of the abdomen, general or spinal anesthesia) and subject to complications, such as hydrocele (collection of liquid around the testicle) in 8-10% of cases, requiring a second surgical intervention.
Inguinal and subinguinal techniques:
These techniques involve the closure of veins upstream of the gonadal vein, the pampiniform plexus veins. Access is via incision of the skin of the inguinal, sub-inguinal (external ring) or high scrotal regions.
Radiologically guided techniques:
These techniques involve closure of the gonadal vein via the insertion of catheters (thin tubes) into a vein in the arm. The advantage of these techniques is that they do not entail any incision. We carry out retrograde sclerosis, preferably via a vein in the fold of the arm. This technical modification offers the advantage of being less invasive than the transfemoral approach and offers easier access to the renal-spermatic region not only on the left, but also on the right, because the catheter advances from the top down. A small quantity of local anesthetic at the puncture site through which the catheter is inserted is enough for the entire procedure. Once the spermatic vein is reached, under radioscopic guidance, the sclerosing substance is injected. During the same session, if the varicocele is bilateral, it is possible to treat both the right and left sides. The patient is allowed to rest for a few hours and is discharged the same day.
Following local anesthesia of the inguinal region, an incision of about 1 cm is made at the root of the scrotum and one of the veins forming the varicocele is isolated and cannulated. After radiological guidance showing the course of the vein, the sclerosing substance is injected. The vein is then tied and the small wound is sutured with absorbable sutures. The patient is discharged as a day case. Again, in this case, we have introduced a few technical modifications, which make this procedure preferable in pre-pubertal or early-pubertal boys.
Local Anesthesia: applied between the external inguinal ring and the root of the scrotum around the spermatic cord using a thin insulin needle.
Cutaneous incision: around 2.5cm to the upper part of the scrotum.
Exteriorization of spermatic cord: the cord is the structure that allows the passage of the testicular blood vessels and nerves in addition to the vas deferens (the seminal canal).
Exposure of the external spermatic fascia: the external spermatic fascia is then incised to reach the veins.
The different elements of the spermatic cord are explored: the vas deferens and the 3 venous plexus of the testicle are identified:
The pampiniform plexus
The deferential plexus
The cremasteric plexus
A dilated vein from the pampiniform plexus is isolated.
Gonadal phlebography is performed: phlebography allows the continuity with the gonadal vein to be confirmed.
The sclerosing liquid is injected:
The liquid will cause fibrotic retraction, leading to closure of the lumen of the cannulated vein, the collateral branches of the pampiniform plexus and the gonadal vein downstream.
The incised structures are then closed, that is, the spermatic fascia, subcutis and cutis.
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650 Men, and counting Got their lives back Since 2004, more than 650 men have decided to have a Penile Implant to win their battle against Erectile Dysfunction. Where normally psychological causes are part of E.D. and, in most cases, a pharmacological intervention is enough to return to a normal quality sex life, when there is a mechanical reason for which the Erection can’t be obtained anymore, the Penile Implant is the only efficient way to get back to a functioning male genitalia. Start your FREE consult
Male Genitalia that look and feel 100% Natural 100% efficient and satisfying erection Restored sexual function and performance No waiting lines, and short recovery time
Who we work with
Gabriele Antonini MD PhD
Researcher and Associate Professor at La Sapienza University of Rome. For more than 10 years he has been the urologist who successfully implanted the largest number of hydraulic penile prostheses in Italy.
He is the first and only in Europe to carry out the minimally invasive technique of a three-component hydraulic penile prosthesis developed by his American colleague Dr. Paul Perito with whom he has a continuous collaboration in the United States of America.
First Surgeon in the World, he is the only one authorized by the Government to carry out and teach the Penis Prosthesis implant in Cuba, where he created a center of sexual medicine of reference for all of South America. Member of the International Board of the 20 leading world experts in penile prosthetic implantology.
“The erectile deficit does not take years away from life. It takes life away from the years“
Erectile dysfunction (ED) is defined as the inability to achieve and / or maintain an erection that represents a satisfactory sexual intercourse. The term erectile dysfunction is better than the term “impotence” because it defines more precisely the nature of this sexual dysfunction. Numerous physical and psychological factors are involved in normal erectile function, including neurological factors, vascular, hormonal and cavernosa.
Alterations of one or more of these factors can cause Erectile Dysfunction. For simplicity, Erectile Dysfunction is frequently classified as: – organic, due to vascular, hormonal or cavernosus alterations as well as neurological injuries; – psychogenic, due to an inhibition of the central mechanisms of erection in the absence of a detectable organic cause; – mixed organic-psychogenic, due to a combination of organic and psychogenic factors.
In the majority of patients with Erectile Dysfunction, it is a combination of organic and psychogenic factors. According to an analysis of data from six clinical trials conducted over the past 10 years, in about 78% of men with Erectile Dysfunction, organic factors were detected independently from the presence of psychogenic factors. It is still important to note that the etiological classifications are relatively simplistic. In fact, the presence of organic alteration in the case of Erectile Dysfunction does not exclude concomitant psychological causes. For, again, the failure relief of an organic cause by itself does not confirm the exclusively psychogenic origin of Erectile Dysfunction. The relaxation of the smooth muscles of the cavernous body and the penis erection depend on a delicate balance between the effects of vasoconstrictor and vasodilator factors.
To bring the flaccid penis, tonically contract, to the state of erection it is necessary that the relaxation of the smooth muscle of the corpus cavernosum exceeds a certain threshold level. Studies show that the basic defect in patients with Erectile Dysfunction may be, regardless of aetiology, an imbalance between the contraction and the capacity of the relaxation of the smooth musculature of the corpus cavernosum. If the base tone of the corpus cavernosum smooth musculature is too high, the maximum relaxation level may not be sufficient to allow the increase of blood flow required for a normal erection. If you reach or maintain the threshold level of smooth muscle relaxation, resistance to venous outflow will be insufficient.
Because of this, a person can have erections with different degrees of rigidity.
It could happen to anybody, at some point in life, not to be able to achieve an erection but, the persistent erectile dysfunction, is an infrequent problem under 40 years of age. From this age, however, the incidence rapidly increases to the point that 65% of men aged 70 presents problems of sexual potency. This increase is mainly due to vascular disease and occurs with about 10 years earlier in diabetic men.
Aging in itself does not cause erectile dysfunction, although it certainly involves physiological changes. Many men need greater stimulation of the penis, the erection becomes less stiff and any distraction can result in loss of erection, often difficult to achieve again. The frequency of sex is reduced even though sexual activity remains satisfactory and represents an important element for the sense of well-being.
It is important to emphasize the importance of smoking, hypertension and other cardiovascular problems, diabetes and alcohol abuse.
Erectile dysfunction (ED) is defined as the inability to achieve and / or maintain an erection for a satisfactory sexual intercourse. The term erectile dysfunction is better than the term “impotence” because it more precisely defines the nature of this sexual dysfunction.
Can prostate diseases cause Erectile dysfunction?
It generally is inflammations of the prostate (but also of the rectum) that cause a venous-lymphatic pelvic congestion with possible alterations of erectile capacity.
Correcting imbalances of blood sugar in diabetic patient can make Erectile dysfunction reversible?
Many of the effects of diabetes on erectile function are determined by chronic alterations caused by persistent hyperglycemia on the tissues and blood vessels and, therefore, they are not fully reversible. However improving glycemic control is critical to stop or slow the progression of tissue damage.
The Erectile dysfunction can be the alarm bell of other diseases?
Erectile Dysfunction and cardiovascular disease share common risk factors and the prevalence of Erectile Dysfunction in patients with coronary artery disease, myocardial infarction or stroke is very high. It is therefore considered that, in some patients, the onset of Erectile Dysfunction can be the first sign of a cardiovascular condition and that therefore the patient with Erectile Dysfunction should be evaluated for the presence of this condition as well.
Prostate surgeries always cause Erectile Dysfunction?
The radical removal of the prostate (radical prostatectomy), which is performed to treat prostate cancer, is often associated with DE determined by lesion of the cavernous nerves. This, in selected cases, can be avoided by using a technique that allows to preserve nervous structures (technique called “nerve sparing”).
Is it true that the penis is a muscle?
NO. The penis is a complex organ: modifications of its volume and its shape are not associated to the contraction of voluntary muscles, but to variations in the incoming and blood flow in its interior.
Is it true that Erectile Dysfunction increases with age?
YES. Age is the main risk factor for Erectile Dysfunction, but is not itself cause of Erectile Dysfunction.
Is it true that, if I had a heart attack, I can not use inhibitors of type 5 phosphodiesterase?
NO. These drugs are contraindicated if a patient is already taking nitrates, used to treat angina and, often, by patients who have suffered a heart attack, or if the heart attack led to a decrease in cardiac function as well accentuated by making dangerous physical activity connected with sexual function.
Is it true that cigarette smoking impairs erection?
YES. Recent studies show that many components of smoking, including nicotine itself, contrast the erectile activity on the short or long term. Some of these effects may be rapidly reversible after smoking cessation, others are permanent.
Is it true that a penile prosthesis does not allow pleasure?
NO. Penile implants, which are applied within the corpora cavernosa, can play the mechanism of erection, but do not affect other aspects of sexuality such as the sensitivity of the penis or orgasm.
Is it true that Erectile Dysfunction is always associated with deficiency of testosterone?
NO. In fact only a small share of Erectile Dysfunction (less than 5%) are associated with deficiencies of sex hormones; The most frequent causes are those related to vascular diseases or chronic diseases such as diabetes or kidney failure.
Andropause and testosterone
Andropause is the male equivalent of menopause and it usually manifests through the reduction in the production of testosterone; unlike female menopause, the man maintains his reproductive capacity. More formally, we refer to it as PADAM (Partial Androgen Deficiency of Aging Male) or ADAM (Androgen Deficiency of Aging Male).
Andropause does not start at a precisely defined age, though natural aging represents a factor itself: the production of testosterone in a man usually start decreasing at around age 30 and continues throughout his whole life course. It is ordinarily found in men over 60 and, this extreme decline in the production of testosterone can be enhanced by other factors like being overweight, physical inactivity or the natural psychological decline, smoking also has a huge influence. Being overweight, however, is one of the main causes as the body will produce a significantly lower level of testosterone and, therefore, could cause this hormonal condition. This notion has led experts to define every occurrence of the symptoms with the general term androgen deficiency syndrome in old age, rather than andropause.
As we said, the symptoms of andropause are correlated with the production of testosterone. The reduction of the testicles due to age and the lower capacity of Leydig cells to produce this hormone affect the severity of the symptoms. The symptoms are quite varied because testosterone does not act only on the sexual level in men, but has direct influence on the metabolic, cardiovascular, locomotor, mental, behavioral and social dynamics of the individual.
This means that among the verifiable symptoms we also find some irritability, a natural decline in cognitive function and fragility of the bones. Yet it is possible to encounter weakness, loss of muscle strength, fatigue, decreased muscle mass, hair loss, abdominal obesity, depression and anxiety with erectile problems following a decreased libido.
These symptoms manifest in very different ways throughout a long period of time so, unfortunately, a simple test on the level of testosterone in the blood is often not enough for a precise diagnosis of andropause.
A healthy lifestyle, characterized by moderate exercise and a balanced diet, can be very useful for the prevention and treatment of this hormonal condition.
In these cases, a substitutive treatment with testosterone for a short period of time may be useful. Testosterone is the primary male hormone, essential for the development of sexual characteristics and the genitalia. Very often, this hormone is involved in the metabolism and it is used to cure genital as well as hormonal pathologies.
Testosterone is available in capsules, ampoules for intramuscular injection, gel and transdermal delivery patches. Each one of these methods have been tested and work well but, of course, they have pros and cons: the capsules do not guarantee a steady concentration in the blood, the patches are considered the most simple way to take the hormone, but they are more expensive. The testosterone gel formulation would seem to better reproduce the natural circadian rhythm of testosterone secretion.
During the first year of testosterone therapy, patients under treatment should undergo medical check-ups every three months. The clinical examination should include the evaluation of the prostate. These options, however, are contraindicated in cases of suspected or ascertained prostate cancer and male breast cancer.
A sexual disorder of the orgasmic phase so widespread that some consider it to be a variant of normal male sexuality. It is the condition in which a man is unable to exert voluntary control over his ejaculatory reflex, so that, once sexually excited, he reaches orgasm before his partner in most cases of coitus, with any partner and any type of sexual activity; It can occur even before penetration: (ante-portas) or immediately after (post-portas).
It can present as a permanent (“lifelong”) or acquired condition characterized by ejaculation which always or nearly always occurs before or within 1 minute after vaginal penetration, and inability to delay ejaculation.
Intra-vaginal ejaculatory latency time (IELT) is defined as the time from vaginal penetration to ejaculation. The causes can be organic or mental; in organic cases it is linked to inflammation of the urogenital tract, neurological diseases, or use of drugs, and in these cases the therapy is aimed at removing the causal factors. With regard to psychological causes, individuals affected by this disorder are probably united by an attempt to defend themselves from the anxiety generated by sexuality and, in particular, by the intense erotic sensations that precede orgasm, and are therefore unable to control it. However, there are also organic causes that, although not frequently, induce these symptom:Intra-vaginal ejaculatory latency time (IELT) is defined as the time from vaginal penetration to ejaculation. The causes can be organic or mental; in organic cases it is linked to inflammation of the urogenital tract, neurological diseases, or use of drugs, and in these cases the therapy is aimed at removing the causal factors. With regard to psychological causes, individuals affected by this disorder are probably united by an attempt to defend themselves from the anxiety generated by sexuality and, in particular, by the intense erotic sensations that precede orgasm, and are therefore unable to control it. However, there are also organic causes that, although not frequently, induce these symptom:1. Pathologies of the glans
– Short frenulum – acute or chronic inflammatory conditions 2. Pathologies of the urinary tract
– Urethritis – vasculitis – prostatitis 3. Neurological pathologies
– Multiple sclerosis – medullary tumors – spina bifida 4. Other pathophysiological situations – stress – hyperthyroidism 5. Drugs – sympathomimetics – antidepressants, MAO inhibitors These conditions and, in particular, those related to pathologies of the genitourinary tract, should be carefully considered before initiating a psychological treatment of the subject. The first examination to detect and study the effective presence of premature ejaculation is the Viricare or phallic vibration test: a microinjection is made into the penis of vasodilator drugs that induce an erection, after which the penis is placed on a small vibrating platform which records the number of vibrations necessary to induce ejaculation (Viri-care test). When ejaculation occurs in very few minutes the cause is probably organic. Another test to be made is the desensitization test: this test must be performed at home and involves the use of a penile topical numbing cream. About 30 minutes before relations, the man, unbeknown to his partner (so as not to alter their usual way of performing the coitus), spreads it on the glans and the penis. The anesthetic cream will reduce sensitivity. If during the subsequent relations, equally premature ejaculation occurs, it very likely that the cause of the problem is purely of a psychological nature and not caused by excessive sensitivity of the penis. If, however, ejaculation occurs after a significantly greater amount of time than usual, it is very likely that the cause is a hyperexcitability of the penis that is often secondary to the presence of highly sensitive foreskin (cutis) covering the glans.
If the cause is psychological, sex or psychological therapy should be suggested.
If the causes are organic, in addition to therapies based on local desensitizing creams, we offer surgical therapy: a safe procedure to eliminate the exaggerated sensitivity of the penis without acting on the large nerve bundles, in a way that avoids the loss of normal penile sensitivity. It is a simple and painless operation which is performed under local anesthesia and takes about 50 minutes: after the penis is anesthetized, a part of the foreskin is removed (circumcision), and the subglans peripheral ramifications of the dorsal nerve of the penis are incised – those that end under the glans, which are responsible for the hyper excitability.
The frenulum of the penis is the thin flap of skin that joins the glans to the foreskin. This tissue is very sensitive and rich in blood vessels and pleasure receptors, and when particularly solicited during sex it may be partially torn, resulting in conspicuous bleeding. In some individuals, even after puberty, the frenulum remains short and does not allow the foreskin to retract from the glans, or causes discomfort during erection, in such cases it is possible to perform a frenulotomy, an operation that consists in an incision of the frenulum under local anesthesia, which heals over the course of a week or two.
The shortness of the foreskin frenulum represents a further source of anxiety for the adult man due to its frequent organic implication with regards premature ejaculation, as linked to a hyperstimulation of the richly innervated area, which is under constant tension during sex. The solution, technically simple, is of surgical pertinence – a procedure under local anesthesia called frenuloplasty. Frenuloplasty is a surgical practice that consists in a transverse incision across the foreskin frenulum, and suturing it longitudinally. It is particularly recommended for those suffering from a short frenulum, a pathology that impedes the proper “action” of the foreskin. It is also widely used to attain an effect of penis enlargement.
There are more and more men, young and old, who, not satisfied with their own size, are seeking for help with surgery to increase not only the length, but also the width of the penis.
Now, thanks to a groundbreaking technique developed by two surgeons, one Italian and the other American, it can be done in a safe and lasting way, with the use of laboratory-obtained cross-linked hyaluronic acid. The preliminary data, presented today at the world premiere of the Aesthetic Show 2015 in Las Vegas, out of 1500 patients (between the ages of 28 and 55) treated in the past 3 years show an increase of the circumference of the penis from 4 to 8 centimeters, up to 10 cm in selected cases.
“90% of the patients are satisfied, and at 20 months have not seen a reabsorption of the injected material, while 10% want a ‘refill’ but are still satisfied. What we have developed is an outpatient procedure, lasting about 15 minutes, with no side effects.” To explain to Adnkronos Salute is Gabriele Antonini, urologist/andrologist of the U. Bracci Department of Urology at Umberto I – Sapienza University of Rome – the co-author of the technique along with Paul Perito, an American surgeon at Coral Gables Hospital (Florida).
“Penis enlargement is something that many people require; in Italy about 15% of males between 25 and 55 years make their first andrological visit for this reason, ” Professor Antonini underlines, “Within the EU, there are similar percentages in Spain, Portugal, France and Switzerland. In the US it is especially Latin Americans and Hispanics who request this type of procedure.” Why are so many men seeking ‘oversized’ dimensions? “It happens,” answers the surgeon, “when a man is embarrassed to be living with an organ that is too slim or narrow, even if the length is average.”
“So far,” the expert warns, “the centrifuged fat taken from the patient himself, chemically treated dermal matrix and, finally, silicon infiltration have all been used improperly. Methods that bring enormous aesthetic damage: with bulges and adhesions, which can also block the penis. While with our process there is no allergic reaction, because hyaluronic acid is already physiologically present in the dermis; the penis appears perfectly natural, soft with an homogenous distribution of hyaluronic acid without blemishes or deformities.”
“There are,” Antonini emphasizes, “two types of hyaluronic acid – linear and cross-linked: the first, which is very well known, is used as a filler in anti-aging therapies, for example, to remove wrinkles in the forehead. The second is prepared in a laboratory and has t+c, benefitting the natural expansion of the tissues. It is also long-lasting, with a duration of up to 24 months. This is also because the penis is subjected little to continuous movements, as occurs in the muscles of the face. ”
“During experimentation,” the urologist surgeon recalls, “we used the technique of hydrodissection of the dartos, and then proceeded to the infiltration of cross-linked hyaluronic acid above Buck’s fascia. It starts with the injection of 1 ml, and ends with 10 ml. This way, the penis has undergone an enlargement of 4 to 8 cm, and in some cases 10. Now, after the presentation at the most important meeting of aesthetic medicine in Las Vegas, we will publish the results of our studies.”
The Peyronie’s disease is characterized by the chronic inflammation of the Tunica Albuginea, a membrane that covers the corpus cavernosum of the penis. The Tunica Albuginea is usually elastic and allows an elongation of approximately 30% of the length of the penis’ size when erect. In Induratio penis plastica, the penis becomes thickened, inelastic and sometimes hard and calcified. In the initial phase, the hardening of the tissues is limited to small nodules, in later stages the nodules can multiply and extend to the majority of the penis.
This disease has the highest incidence on males between 50 and 65 years of age, but can also appear at an earlier age. Quite frequently, it is accompanied by diabetes, gout, hypertension and atherosclerosis. It can also be triggered by past events of traumas or microtraumas occurred to the penis; sometimes it can be triggered by injuries occurred during sexual activity. The disease is most frequently found in concurrence with other connective tissue diseases (e.g.: Dupuytren’s disease or handheld fibrosis, ear cartilage fibrosis, tympanosclerosis, arthritis etc.). The key element of the disease is the appearance of the hardening zone(“plaque”) on the tunica albuginea (sheath) of the corpus cavernosum, ranging from a few mm to 2-3 cm. This causes some local tenderness that is accentuated during erection, during the touching, masturbation or sexual intercourse.
Quite promptly, it results into a bending of the penis at an angle of the curvature in correspondence to the plaque. The bending can be moderate, but in some cases, can be so severe that it makes the penetration difficult or impossible. Hardening of the area is indeed a cause of alarm for the patient (the main concern is to have a tumor), secondly, pain in the area is also a matter of concern as it can prevent sexual activities and subsequently cause aesthetic and functional problems. The most reliable pathogenetic hypothesis traces the beginning of the disease to a microtrauma of albuginea with a small fracture of the sheath.
The process of tissue repair involves the production of fibrous substance by specialized cells (fibroblasts) to “close the fracture”. This process does not stop and the production of the fibrous tissue continues determining the appearance of a plaque that is rigid, inextensible and perceptible to touch. Many therapies have been proposed but with little results. The only substance that can stop the disease seems to be Vitamin E. However, the therapy of Iontophoresis with verapamil and corticosteroids is helpful. At an early stage of the disease, the patient experiences a feeling of moderate penile pain accentuated by the erection. An area of localized hardening (plaque, nodule) appears and the penis tends to curve in correspondence of the plaque. The pain spontaneously tends to subside, the size of the plaque stabilizes and the bending halts; but this is only an apparent spontaneous improvement. Actually, with the involvement of the lateral wall of the cavernous, the penis can reach out to straighten but will lose some of its length, it is often accompanied narrowing or by the formation of new nodules. The capacity of obtaining an erection is gradually reduced until the stage of impotency, which may also become absolute; this is because the changes faced by the tunic coating of the corpora cavernosa interferes with the mechanism of seizure of the blood within them (erectile dysfunction “venous leak”). Over time, the plaque tends to calcify and the penis becomes shorter and thinner. These modifications occur with a devious trend, generally in the space of several months, sometimes even slower; but they may also occur at a rapid pace and with acute progression. Inevitably, deep psychological problems occur due to the progression of the disease, erection difficulties or even out of self-developed “shame” in showing a deformed penis to the sexual partner; the psychological distress can further amplify the problem of sexual functioning.
An examination performed by a specialist is the essential tool to detect this disease. Besides recognizing the plaque, the visit allows to estimate the elasticity index of the penis, that is, the ratio between its length while in erection and in the flaccid state. This ratio gives us information about the extension of induratio itself.
Ultrasound, however, has its own importance but is employed in order to get precise indications only, namely the test tells us whether there are calcifications inside a plaque and, above all, if it is associated with a drug-erection test (a pharmacologically induced erection conducted by injecting substances such as alprostadil into the penis) allows us to study the arterial and venous vascular system: the blood flow ending in the penis through the cavernous arteries and the flows of the outbound blood, also called the veno-occlusive mechanism. This investigation is of particular importance when planning a surgical treatment, as it lets the patient know if there are any risk factors for the decline in erection.
The induratio penis plastica is a benign non-tumoral lesion and may never become a tumor.
Surgery is reserved for cases where there is a penile curvature that makes relationships difficult.
Varicocele: Causes, Symptoms, Diagnosis, and Treatment
Varicocele is a disorder characterized by an alteration of the venous testicular circulation that involves damage to the testicular function. It is a very common disease that affects approximately 15 to 20% of males. This disorder bears great social significance because of its frequency and its consequences: it is the leading cause of infertility, not only for men, but also for the entire couple (adding together the causes of male and female infertility). The varicocele is treated only after analyzing the symptoms in detail, starting from the general information, the initial symptoms, signs of recognition, relationship with the couple’s infertility, possible effects of varicocele on the decline of testosterone hormones and on the erection disorders and the surgical methods for varicocele. Antegrade Scrotal Sclerotherapy and Microsurgical Ligation are described in details, using photos of the actual conduct of surgical operations. The point is explained with the help of guidelines, international bibliographical references and personal studies of Dr. Maio recently published in national and international conferences.
The testicular or spermatic veins have a long course upwards, up to the vicinity of the kidneys and are provided with one-way valve mechanisms that prevent the blood, little by little until stagnate at the bottom, around the testicle. If there are any predisposing conditions (like absence of valves, course, and/or abnormal outlet of the veins, multiplicity or increased length of the same in young long-limbed persons), one can determine a reflux (reverse flow) within the venous system. Anatomical Diversity facilitates the formation of varicocele on the left; it rarely manifests itself on the right, it is bilateral by approximately 15%.
The wearing out of the veins involves a pooling of blood around the testicle, an increase in temperature and a slowdown in metabolisms of the gonad itself which, in the long run, causes irreversible changes resulting in the possible infertility.
The treatment of varicocele is the interruption of the mentioned reflux. There are several surgical methods of refluxing veins ligation at the sub-groin level, groin level or, further up, in retroperitoneum (laparoscopically), each with its own advantages and disadvantages. It is important to keep in mind that, like with any type of medical treatment, failures are also possible. In the past 15 years, sclerotherapy techniques have been developed with the advantage of being less invasive, executable under local anesthesia and, thus, in Day Hospital. These methods have been perfected and integrated according to the need, in order to obtain a customized treatment with the best results and minimal invasiveness.
The varicocele is a major cause of male infertility and appears at the onset of puberty. It is a very common situation, since about 15-20% of all the children aged 14-15 years and above are the possible carriers.
Having a varicocele does not necessarily mean to be undergoing surgery. About 60% of all Varicoceles which are highlighted at school screenings are not so important as to undergo treatment, at least during adolescence.
Since the incidences of varicocele is very high, exceeding that of male infertility (there are many men with varicocele who have children), and since the age of 18 is not justified to perform the examination of the seminal fluid (Sperm analysis) to evaluate fertility, just those cases where some major forms have been developed are treated during adolescence and are therefore more at risk of developing future infertility. The rest are monitored in time and treated just in case the condition worsens.
How can you realize that you have varicocele?
Cases of Varicocele bearing particular relevance are visible and palpable like it happens with varicose veins of the legs. In this case, the situation becomes much more evident if one stands-up. By palpating funicular-like structures over the testicle while standing and by exercising an abdominal contraction, the expansion in the volume of these veins becomes clear. This is evidence of reflux in the spermatic vein system which is clearer in the standing position and during the abdominal contraction. The subjective relief of a situation of this kind is, almost always, an expression of the presence of a varicocele. However, in the most modest forms it may also not be noticed during medical examination, so much that, in case of suspicious pain or infertility, further investigation is recommended with instruments such the Doppler or eco-color-doppler.
As for those in which surgery is required, please note that currently we have alternative methods to the classic surgery that are equally valid but much less invasive: treatable under local anesthesia where the patient gets discharged after a few hours.
What constitutes an andrological visit?
It is a simple examination of the genital apparatus that is typically performed either by standing position or by lying down, lasts for a few minutes and is completely painless. The youth tends not to go to an andrological visit, because they are not experiencing any trouble or merely because they feel embarrassed. It must be stressed that, at least in young men, the symptoms such as pain in the testicle, feeling of heaviness or discomfort associated with the Varicoceles are quite rare and the discovery of this disorder usually happens during a visit performed by a general physician, a sports doctor or during a a called-up visit.
At least 90% of young people suffering from Varicoceles were examined with the disease during a school screening, while they were completely unaware of carrying the disease. Moreover, we must remember that the testicle has two functions: one is to produce hormones (Testosterone) which serve for the purpose of sexual development and sexual desire, the other is to produce spermatozoa (spermatogenesis), the cells necessary for fertilization. The alterations that occur in the Varicoceles are mainly concerned with the spermatogenesis. This means that a man can have no complaint in terms of sexual performance but, quite unaware, he may have a reduced reproductive capacity. Finally, it should be added that, if the shame could be considered as normal among the teenagers, the same attitude is also expected from older people. In both the cases, making an andrological visit proves to be useful to clear any doubts or concerns about their genital apparatus. In fact, if Varicoceles is one of the most frequently encountered andrological problem, visits to the medical experts during adolescence gives accurate information on the changes of the genital apparatus during the development of puberty.
Benign Prostatic Hyperplasia (enlarged prostate)
The prostate is a male genital gland situated below the bladder, around the urethra- the tube from which the urine flows out. The prostate produces a secretion (prostatic fluid) which participates in the formation of the seminal fluid. At birth, the prostate is of the size of an almond.
During puberty, the volume of this gland increases because of the presence of the male hormones (androgens) acting as a stimulant.
Around the age of 50, among the majority of men, the volume of the prostate continues to increase while squeezing the urethra, which causes numerous urinary problems.
A common pathology, present in 50% of men over 50 years and 88% of men with more than 80 years.
The irritation in the bladder that follows the failure to discharge provokes disorders very frequently.
THE MAIN SYMPTOMS ARE: – Increased frequency of urination – Weak urinary stream – Hesitancy while urinating – Dribbling after urination – Necessity of efforts while urinating – Burning sensation – Painful urination
Diagnosing Benign Prostatic Hyperplasia
The medical examination in this case involves the performance of a physical abdominal examination, especially in the abdominal rectal area, which gives an idea about the volume of the prostate gland and highlights the presence of suspicious nodules; the patient will also fill a questionnaire, called I-PSS, to analyze the severity of the symptoms.
After that, some further investigation is necessary: a urine test with eventual urine culture, PSA measurement (prostate-specific antigen), kidney function tests and a Uroflowmetry (test that measures the speed of the urinary stream during urination, simply performed by urinating into a special instrument called a flow meter). After that, depending on the clinical and therapeutic needs, a transrectal prostate ultrasound, abdominal ultrasound, urodynamic examination with a pressure-flow relationship curve may also be requested.
Among the most common complications of Benign Prostatic Hyperplasia we can observe an increased risk of urinary tract infections due to retention of urine in the bladder. There are two types of treatments: the medical and the surgical. The Medical treatment employs drugs to alleviate the symptoms, such as alpha-blockers. These drugs relax the prostate and bladder neck thus increasing the flow of urine flow.
Besides the alpha-blockers, the 5-alpha-reductase inhibitors are used as well. The therapy of association between alpha-blockers and 5-alpha-reductase inhibitors has proven successful in drastically reducing the volume of the prostate. In case of failure of medical treatment a surgical treatment may become necessary. This involves the resection of the portion of the prostate through urethra. It is important not to overlook the first signs of a possible urinary tract disturbance, and if any persistence of symptoms is found, it is appropriate to undergo a medical examination. Ascertaining the cause of the problems at an early stage allows one to take prompt action in order to prevent or at least slow down the progression of the disease into a more serious condition, which could have an impact on the personal and social life of the patient.
Benign Prostatic Hyperplasia is neither cancer, nor an early stage of cancer.
Urinary incontinence: Causes, Symptoms and Risks
Urinary incontinence is the inability to control and hold urine. It can manifest with different levels of severity, from minimal losses (one or a few drops) to the complete loss of bladder content. Urinary leaking, even when slight, constitutes a hygienic problem and is a cause of social discomfort that may significantly compromise quality of life. Urinary incontinence most frequently affects females, but it is estimated that between 2-10% of the male population presents urinary leaking. Fortunately, there are different solutions in accordance with the causes of the incontinence itself.
Urinary incontinence is not a health hazard, except in the most severe cases, when it is associated with immobility and poor personal hygiene or when accompanied by serious urinary retention problems as in overflow incontinence or neurological diseases.
Urinary incontinence can contribute to the aggravation of skin lesions, so-called bedsores, which increasingly compromise the health of the subject with reduced mobility. In most cases, however, urinary incontinence is a problem that “merely” diminishes the quality of everyday life. The inability to control urine leakage, in addition to hygiene problems, causes physical and psychological discomfort, eliciting feelings of embarrassment and shame. Those affected by urinary incontinence increasingly tend to avoid embarrassing situations: social contact becomes very difficult from the workplace to their sex lives.
This constitutes a vicious circle, in which the difficulty of communicating their disorder can aggravate the sense of frustration.
Roughly, the severity of urinary incontinence can be described in four different degrees:
Minimal, when the incontinent person does not make use of diapers and social activities are not compromised.
Modest, when the use of various absorbent aids is occasional, but social and work relationships are not substantially compromised.
Moderate, when the use of absorbent aids is practically constant and meeting social interactions become problematic.
Severe, when diapers or condom catheters (an external container connected to a bag) are a constant companion, social activities and work suffer heavy restrictions, and it is necessary to enlist the help of other people.
What are the causes of incontinence?
The bladder is the sac-shaped organ designated to contain urine. The urethra is the tube connected to the bladder that leads outside of the body. This channel is kept closed by a sphincter mechanism. Incontinence may be caused by a malfunctioning of the bladder, urethra, or both. The bladder may contract and push out the urine when it should be at rest, or may not expand from the urine that it stores. The urethra, however, may not close sufficiently to ensure the sealing of the urine when the pressure in the bladder increases, for example, when standing up, coughing, walking, exerting effort, squatting or, in more severe cases, even at rest. The closing of the urethra may also be too strong due to an obstruction, so much that it fails when emptying of the bladder, with consequent overdistension and loss of urine.
But why might the bladder and/or urethra malfunction in this way?
Here is a list of some possible causes:
Surgical operations Operations on the prostate, especially total prostate removal (radical prostatectomy) as it happens when there is a tumor, may make the sphincter unable to perform its sealing function.
Certain operations performed on the urethra or bladder neck can compromise the sealing mechanisms as well.
Overactive bladder syndrome There are some situations in which the filling of the bladder does not take place in a gradual manner, but is interrupted by irregular contractions with muscular spasms of the bladder (overactive bladder). Sometimes this situation is correlated with difficulty urinating due to an obstruction (for example from hypertrophy of the prostate), and sometimes there is an underlying neurological problem, but there is often a true identifiable cause of the dysfunction. Overactive bladder syndrome is characterized by an urgent need to urinate, often with an increase in the frequency of the urge, and inconsistently with incontinence.
Chronic urinary retention A chronic obstruction in emptying (the most frequent non-neurological cause is benign prostatic obstructive hypertrophy), which results in abundant residual urine in the bladder (almost correspondent to its capacity) after completion of urination, which may cause distension of the reservoir and urinary leakage due to an inability of the bladder to fill up any further.
Aging The bladder and urethra age and, consequently, may function less effectively. The presence of other health problems that reduce the ability of movement, manual dexterity, attention, and memory may additionally contribute in damaging the bladder-sphincter system. – Urinary infections can irritate the bladder and cause involuntary contractions. – Incidental trauma to the urethra involving the pelvis and causing a rupture of the sphincter urethra, even if properly treated, may also compromise the mechanisms of continence. – Acquired and congenital neurological causes: Many neurological diseases, of both the central and peripheral nervous system, may result in an alteration of the regulatory mechanisms of vesicoureteral function.
Congenital conditions Certain severe congenital malformations (epispadias, exstrophy) can cause incontinence due to alterations of the structure and, consequently, the function of the bladder and urethra.
How does incontinence manifest?
Urinary incontinence in men may manifest with a variety of characteristics. These are the situations or types of incontinence that may occur:
loss of urine associated with exertion of effort, or stress, such as coughing, sneezing, and lifting objects from the ground, but also when changing posture: for example, standing up from a sitting or lying position or even walking or squatting. In this case we refer to stress urinary incontinence;
loss of urine associated with a very strong, compelling, and uncontrollable urinary urge, not allowing one to make it to the bathroom. In this case we refer to it as urge incontinence;
continuous loss of urine, drop by drop, defined as continuous urinary incontinence;
loss of urine in drops that appears after having finished urinating, called post-void dribbling;
loss of urine in both of the above circumstances, defined as mixed urinary incontinence;
involuntary loss of urine during sleep, called nocturnal enuresis.
In certain cases, incontinence arises as a red flag for situations where the bladder does not empty completely during voluntary urination: the residual urine that accumulates in the bladder can lead to losses, caused by an overfilled bladder. In this case it is referred to as overflow incontinence, which is particularly important to differentiate from other forms of incontinence. In fact, in this case therapy consists of helping the person to completely empty the bladder and does not involve the direct treatment of the incontinence. Moreover, this situation, if left untreated, could potentially cause renal complications.
Urinary incontinence in men, besides being of different types, may be of varying severity. It is possible to have urinary leakage with characteristics ranging from the loss of only a few drops, to a more significant stream or quantity, to the entire loss of the contents of the bladder.
The frequency of loss can also be highly variable: some people are affected by a rare incontinence, of a frequency of less than once a week or month, while others lose urine many times a day or, in extreme cases, continuously.
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