Kamis, 04 Juni 2009

Andrological Disorder

ANDROLOGICAL DISORDER
(http://bhattacharyyad.blogspot.com/search/label/ANDROLOGICAL%20DISORDER)

ANDROLOGY : The Science of Dysfunctions of the Male Reproductive System

Ask any ten year old school kid with an average GK (general knowledge) who a gynecologist is or what gynecology is, and pat will often come the right answer. For some obscure reason, the Greek root 'gynaik', which means 'woman', seems to be very well known to many.

Yet 'andrology', with its exactly identical and obvious Greek roots, is something that even most doctors haven't heard of. What's worse is that many respectable dictionaries don't mention it either..

Confusing the issue further is the fact that, except in a few countries, andrology remains a sub-specialty area within urology. This is probably because, unlike in the female, the same organ (penis) is used for both urination and copulation in the male, and hence the territorial encompassment - and confusion.

And then there are the 'laboratory' andrologists. Many of these people are not physician doctors, but scientists whose specialty fields include biochemistry, animal science, molecular & cell biology, and reproductive technologies. These are non - clinical fields. Their use of the terms 'andrology' and 'andrologist' probably derives from the fact that many of these workers are spermatologists, i.e. scientists who study spermatozoa. Technically speaking, one has to admit that sperms are quintessentially masculine, and hence 'andro'. Yet, this is somewhat akin to calling a scientist who examines urine under the microscope, an 'urologist'.

It is quite obvious therefore, that there's a lot of confusion here and that this nomenclature needs to be reviewed.

Hardly surprising then, that so much ambiguity and ignorance surround not only the term 'andrology', but also many andrological conditions and disorders.

Take impotence or erectile dysfunction (ED). For centuries, impotence has been presumed to be the result of mental (or psychogenic) causes, and countless millions of patients have either undergone ineffective psychiatric treatment, or worse - fallen prey to aphrodisiacs and other thoroughly useless forms of 'medication' dispensed by quacks.

Research has now conclusively shown that impotence has a physical (or physiological) cause in nearly 90% of cases. And like most other physiological problems, impotence is often eminently curable. It is quite deplorable that sometimes the blame for this is put on the woman and she is labeled 'frigid' instead of the man addressing his problem!

It's the same with male infertility, another very common andrological condition. Even though it is the man who is responsible for nearly 50 % of all childlessness among couples, in many parts of the world it is still the 'barren' woman who is usually blamed.
In more than cases, male reproductive disorders have an organic (bodily) cause which can be diagnosed and treated successfully.


Today it is perfectly natural for a lady with a complaint referable to her reproductive system to seek the services of a gynecologist. The lady visits her gynecologist with little or no embarrassment and is quite often accompanied by her husband, parents or other friends/relatives.

Female reproductive anatomy and physiology have been well researched over the centuries and great strides have been made in the treatment of female reproductive disorders.

This is the era of super-specialisation. Today, for example, even among gynaecologists there is diversification into areas like gynaecological oncology (cancers), female infertility, gynaecological endocrinology etc.

Specialty centers have sprung up everywhere which do not have either the inclination or the time to dabble in routine day-to-day gynaecological disorders.

It is ironic that despite such rapid advancement in other branches of medicine, the male reproductive system has remained woefully neglected.

The male afflicted with a genital problem still does not know whom to consult (whereas most women have their own personal gynecologists). For want of a separate discipline, urologists, skin & VD specialists, endocrinologists, `sex specialists', psychiatrists and quacks have been treating these problems - frequently unsuccessfully and quite often, disastrously. Fortunately, it need not be so any more.

THE BIRTH OF ANDROLOGY

Tremendous progress in basic and clinical research over the past few years has led to a great improvement in our understanding of male reproductive function. Andrology, the branch of medicine that deals exclusively with disorders of the male reproductive system, is the outcome of this research.

Thus, andrology is to the male what gynecology is to the female.


DETERRENTS TO PROGRESS

Among the deterrents to progress in this field are myth and superstition, male chauvinism and psychology. The prevalent belief, world-wide, that sex is something sinful and shameful is one of the main factors responsible for the delayed birth of andrology.

Unfortunately, in many cultures, such misconceptions continue to flourish even today.

Some Common Andrological Disorders

1.Impotence(erectile disfunction)

2 Infertility(child lessness)

3 Intersex disorders and transsexuality

4 Ejaculatory disturbances

5 Peyronie's disease

6 Penile curvature

7 Priapism

8 Sperm conducting system defects (epididymis, vas, ejaculatory duct)

9 Andrologic cancers (penis, testes, scrotum)

10 Hypospadias

11 Epispadias

12 Cryptochdism

13 Swellings of scrotum and intra-scrotal contents

14 Venereal disease in males

15 Groin swelling (including hernias)

16 Delayed puberty in boys

17 Penile torsion


This was further compounded by male chauvinism. In a male-dominated society, our menfolk could not accept the fact that something could actually be wrong with their `symbols of manhood' - the male reproductive organs. Research was therefore, laggardly. It is ironic that it is these very men who discovered gynecology and saw it progress so rapidly.

The Freudian era made progress even more difficult. Sigmund Freud taught (to put it very simply), that everything was linked to human sexuality. This led people to erroneously conclude that reproductive disorders in men were largely psychological in origin.

The birth of every new branch in medicine begins with biology i.e. a study of the anatomy (structure) and physiology (function) of the part. When either of these is deranged, pathology (disease) ensues. Unfortunately for andrology, the study of male sexuality began with psychology rather than biology. This has caused a gross misunderstanding of the subject.

Not only that, the seeds of misconception sown so many decades ago are still firmly entrenched in people's minds, and most people - including several doctors - even today continue to think that impotence is largely a psychological disorder.

This explains why most people know that it takes a complex series of neuromuscular phenomena to lift a little finger but fail to realise that equally complex phenomena are required to lift the penis. Most imagine that all that is needed for the latter event to occur is a naughty thought.

IT IS NOT PSYCHOLOGICAL

In more than 90% of cases, male reproductive disorders have an organic (bodily) cause which can be diagnosed and treated successfully - sometimes with medication, at other times with external devices or with surgery.

Sex therapy, in contradistinction to andrology, treats only the remaining minority with purely psychological problems. The earlier tendency to label most male reproductive problems psychological was the outcome of ignorance within the medical profession itself.

It may be pertinent to mention here at this juncture that at the famed Masters and Johnson Institute for psycho-sexual therapy, no patient is taken up for treatment today until he has gone through the entire gamut of andrological tests to eliminate organic disease first. The same Masters and Johnson had publicly proclaimed in the seventies that more than 90% of impotence is psychological. But all that is rewritten history now


.FEMINISM - THE DAWN OF A NEW ERA

With the gradual erosion of male chauvinism and the emergence of the self-assertive, economically-independent modern woman, it was becoming more and more difficult for fraudulent quacks and sex specialists to provide tangible results using hazy `techniques' and men themselves were forced to seek more scientific methods to cure their condition. Today's woman will insist that the husband be investigated for their childlessness. She also justifiably demands sexual gratification and will not be a silent suffering spectator to her partner's sexual inadequacies

.THE END OF THE QUACK ERA

In the earlier days, the cure for male reproductive problems began and ended with the quacks. A stealthy visit to a 'doctor', often in a remote city, was followed by the inevitable - exorbitant fees and dubious medicines but no cures.

Today, millions of men the world over walk into andrological clinics without embarrassment and often walk out completely cured


.PREVALENCE OF ANDROLOGICAL DISORDERS

Most andrological disorders are seldom discussed socially for reasons of shyness, guilt or embarrassment. The true magnitude of these problems is therefore not known to many. Here are some eye-opening statistics.

In 50% of childless couples it is a male factor (the husband) that is responsible for the infertility. Upto 15% of all couples are childless i.e. 7.5% of all cohabiting men are infertile. In a country of 980 million people that should leave little to the imagination!

Impotence, which is different from infertility and suggests an inability to perform sexually because of poor erections rather than an inability to father children, is likewise very common.

It affects a staggering percentage of the sexually active adult male population. Contrary to popular belief, impotence is more often partial than complete and does not affect the elderly alone. Young and old alike are affected - sometimes from birth.

Clinical States associated with Impotence

1.Primary
Impotent since birth

2.Secondary
Impotence sets in after years of normal sex

Causes of Secondary Impotence:

1 Diabetes mellitus

2 Hypertension (high blood pressure)

3 Atherosclerosis

4 Renal (kidney) failure

5 Heart disease

6 Neurological disorders - multiple sclerosis, stroke, paraplegia, spinal cord lesions, Parkinsonism, etc.

7 Injuries - sudden - e.g. pelvic and perineal

8 Injuries - gradual - as in bicycle-riders etc.

9 Surgery-operations on bowel, rectum, bladder, retroperitoneum, spine, urethra, prostate etc.

10 Local e.g. Peyronie's disease

Medication e.g. drugs administered for duodenal ulcer, hypertension, mental disease etc.

It especially affects diabetics (more than 50% of whom are impotent), hypertensives, smokers, alcoholics, patients with liver, kidney and heart disease, men who are on medication for unrelated disorders such as hypertension, peptic ulcer or depression (more than 250 drugs are known to cause impotence) etc..

Injuries to the pelvis and genital regions and many operations in that area performed for other unrelated disorders can also cause impotence by damaging the delicate arteries, veins and nerves to the penis.

Most of these are completely curable with modern andrological methods.


WHAT CAN MODERN ANDROLOGY OFFER ?

Modern andrology has revolutionised the treatment of male reproductive disorders.

An entirely new set of investigative modalities has made diagnosis not only much simpler but more accurate and comprehensive.

Inflatable penile prostheses restore excellent erections surgically, and offer new hope for the impotent. (The model shown here )

Today, for instance, it is possible for us to measure with great accuracy the exact amount of blood entering the penis. A block in the artery to the penis (similar to a coronary artery block) can be localised.

Sperms can be counted and studied on a computer screen.

Microsurgery can use magnifications of upto 40 times to visualise structures invisible to the naked eye and to operate on them with great precision.


The reproductive laboratory has opened up new avenues in semen-handling. IVF and ICSI have become everyday procedures.

Bypass operations are being performed under the microscope for impotence and infertility.

Vacuum devices cure impotence with 90% efficacy. Prosthetic implants are being inserted surgically to cure impotence. And a lot more awaits us in the future.

• What every Adult needs to know about Impotence.
• Ejaculatory Disturbances.
• The Male Factor in Infertility.
• Andropause (Male Menopause) - Does it really exist ?
• Curves, Bends, and Peyronie's Disease.
• Penis Lengthening and Girth Enhancement
• Why some Women want to become Men (and vice versa).
• Are You at Risk of turning Impotent ?
• Male Impotence - A Woman's Perspective.
• Non-surgical Solutions for Impotence.


What every Adult need to know about Impotence

Though ejaculation often occurs normally and is an intensely pleasurable sensation for most men, it is an extremely complex phenomenon that is regulated by many different systems. Hence, things often can, and do go wrong.


Before the advent of andrology, it was both thought and taught that impotence was psychological in origin. Epoch-making andrologic research in the past decade has shattered this myth and today it is known that in 80-90% of such cases, there is a physical (organic) cause rather than a purely psychological (functional) one.

Not many people are aware that in most cases physical rather than psychological causes are responsible for impotence, and it is very often eminently curable.

Sexual impotence isperhaps the most poorly understood and mismanaged of all medical disorders. Two factors are responsible for this unfortunate state of affairs.
Ignorance, myths, superstition, guilt and the stigma and taboo attached to anything sexual in the minds of the laity.

Abysmal sexual ignorance among most doctors who continue to believe that impotence is something that is largely psychological in origin.

These two factors account for the fact that most cases of impotence do not come to light and the few that do are grossly mismanaged by ignorant doctors. It is not surprising, therefore, that the general impression is that impotence is something largely psychological and incurable.

This is indeed unfortunate because not only are most cases of impotence NOT psychological in origin but most are eminently curable as well.

Impotence or erectile dysfunction as andrologists prefer to call it, has always been and continues to remain an extremely common disorder. It is said to afflict as much as 10 percent of the male population. Despite this staggering incidence, few cases come to light.

Contrary to popular belief, impotence is almost never an "all or none" phenomenon. Most laymen (and several doctors) believe that a man can either have an erection of very good quality or not at all. Nothing can be farther from the truth. Most men with erectile dysfunction have normal desire and can obtain an erection, only the erection is not hard enough. Hence the term erectile dysfunction (which suggests partial loss) is preferred to impotence (which suggests a total loss). Not many are aware that in most cases organic rather than psychological causes are responsible.

In as many as 80-90 percent of cases of chronic impotence, the cause is not in the mind but in the body.

However, the trend is slowly but definitely changing. This is largely due to tremendous advances in andrological research over the past few years which have conclusively established that in as many as 80-90 percent of cases of chronic impotence, the cause is not in the mind but in the body. These causes can be identified using modern andrological investigative modalities, quantified and often successfully treated using totally non-psychological methods.

In an era where so many advances have been made in nearly all other branches of medicine, it is surprising that male reproductive system research has remained so woefully neglected and backward. For instance, the branch of obstetrics and gynecology (the female analogue of andrology) which deals with disorders of the female reproductive system has been with us for several decades now and is a well recognised specialty. In fact, so advanced in the understanding of the subject that today in most countries gynecologists restrict themselves to sub-specialty areas within their subject such as gynecological oncology, high-risk pregnancies, female infertility etc. because it is so difficult to keep pace with all the developments in the subject.

The masculine ego would not admit that there could be something wrong with the male reproductive organs - that would be demeaning to 'manhood'.

It may be of interest to our readers to deliberate in passing on the reasons for this laggardness in andrological research.

Clinical States associated with impotence

Primary
Impotent since birth

Secondary
Impotence sets in after years of normal sex

Two factors are predominant. The first of these is male chauvinism. Throughout human history, most of our societies have been patriarchal and male-dominated. The masculine ego would not admit that there could be something wrong with the male reproductive organs - that would be demeaning to `manhood'. Ironically, it is these very men who researched the female reproductive system and helped evolve the branch of gynecology and obstetrics. But they refused to look into themselves.

The second is the misinterpretation of the teachings of Sigmund Freud. This led to the erroneous conclusion that most male sexual problems had their roots in the mind.

Whereas most branches of medicine have taken their roots from biology - the study beginning with an understanding of the anatomy and physiology of that part and proceeding to then figure out what happens when anatomy or physiology goes wrong thus causing disease, the male reproductive system alone took its roots from psychology, thus causing tremendous damage.

This explains why most people know that it takes a complex series of neuromuscular phenomena to lift a little finger but fail to realise that equally complex phenomena are needed to lift the penis!! Most think that all that is needed for the latter event to occur is a naughty thought.

What then causes impotence ? Although impotence can afflict anyone from 13 to 90 plus and is associated with a wide variety of clinical conditions and disease states (see box), the basic mechanisms causing impotence are only a few. All of these can be accurately identified using modern andrological investigative techniques.

TYPES OF IMPOTENCE

Impotence can be of several types :

Arteriogenic

Where the arteries supplying blood to the penis do not bring in enough blood to cause an erection. This can occur because of a narrowing of the arteries such as occurs in the elderly, diabetics and those with high blood pressure or because of injury to the genital region which causes a block in the artery to the penis. The last is very common in the young. The injury can be major and sudden as after a vehicular accident causing a fracture of the pelvis or pubic bones, or low grade and gradual. This is very common in bicycle and other riders and occurs because sustained friction in that region causes a clot-like substance (thrombus) to develop in the artery. This clot gradually grows and ultimately blocks the artery completely.

CASE STUDY:

College student S.V.S., 23, became totally impotent following a vehicular accident in which he sustained a fracture of the pelvis and a rupture of the urethra. This involved hospitalisation for nearly a month and an operation.

Before the accident, he had had a normal sex life with his fiance. When he went back to the doctors who treated the primary problem, he was told that his was a purely psychological problem and that everything would be all right in a couple of months. A year later, there was still no improvement and he wanted to break his engagement because he "did not want to spoil a girl's life". An article in a magazine brought him to an Andrologist. A phalloarteriogram showed that the main artery to the penis was blocked. Today, 7 years after a microsurgical bypass operation, the patient is very happy.

of ignorance of the causative conditions Arteriogenic impotence resulting from injuries is very common but often unsuspected because. Many such patients are to be found in orthopedic and urology wards. The impotence is often discovered much later, after the more obvious wounds and fractures have healed. Ironically, it is most often discovered by the patient himself and not by the doctor.


Venogenic

Where the veins of the penis leak blood and prevent the development of a rigid erection. In a normal man during full erection the veins close down almost completely and practically no blood flows out from the penis. This allows blood to accumulate in the sinuses of the penis, thus raising pressure and allowing for the development of rigidity or hardness.

Venogenic impotence is extremely common. It is said to account for as much as 30-70 percent of all impotence. Some men have venogenic impotence from birth (primary). Such men have never had a rigid erection all their lives. Others develop venogenic impotence suddenly after years of normal sexuality (secondary).



Neurogenic

The nerve supply to the penis is very delicate and complicated. A proper conduction of impulses along these is basic for the initiation and maintenance of an erection. It is these nerves that activate the arteries and the veins and alter the dynamics of blood flow within them.

Many things can go wrong with the nerve supply to the penis. Injuries to the back, especially if they involve the vertebral column and the spinal cord can cause impotence. So also can injury to other nerves supplying the penis such as occurs after pelvic or perineal trauma. A wide variety of operations performed for other conditions can cause incidental injury to the nerves of the penis and cause impotence. These include operations on the rectum, prostate, urethra, spine, retroperitoneum, urinary bladder etc..

Of course, disorders of the nervous system such as multiple sclerosis, myelitis, tumour etc. are wont to cause impotence if they involve the nerve supply to the penis.

Another disease affecting the nerves to the penis is diabetes mellitus. Impotence is extremely common among diabetics. In fact, as many as 50 per cent of all diabetics are impotent. Impotence in diabetics is almost always organic in origin. Appropriate therapy for diabetes can never restore erectile function because the basic diabetic process can never be reversed. Only the blood sugar levels and the complications of diabetes can be controlled. Modern andrology, however, can offer a cure to nearly all patients with diabetes-related impotence. This is another fact that is, unfortunately, not known to most people.

CASE STUDY

R.K., 35, a senior corporate executive married happily for 6 years with a son, complained of declining erections. Over the preceding six months, his erections had become so weak that he could not penetrate. He stopped trying three months ago.

He thought that this was due to his highly stressful lifestyle and pressures at the workplace. He even took a vacation with his wife hoping that this would improve matters. It only made them worse. His wife, at first very co-operative, eventually began to feel rejected and there was a palpable friction in their marriage.

When first seen at the andrology center, R.K. was defensive. "How can this happen to a guy like me doc ? I could do it all night, several times a night, night after night. My family doctor says that this kind of thing is quite common these days and it's probably the stress".

It turned out that R.K. was a diabetic of 4 years' standing. He also had high blood pressure for which he was on beta blockers. He was obese (209 lbs - 175 cm) and smoked 40 cigarettes a day. He partied 7 days a week and drank quite heavily. He had never exercised in his life. Sadly, his family doctor had never connected any of these to his sexual problem.

Andrologic tests at the author's center revealed that his overall rigidity levels were well below normal and that he had problems both with his arteries and his veins. He was eventually cured with an inflatable penile prosthesis.

Many drugs also cause neurogenic impotence by affecting the neurotransmitters at the nerve endings. Notable among these are anti-hypertensives and psychotropics although the list is very large. Often, it is not known that the medicine (which is prescribed for some unrelated disease, such as duodenal ulcer) is the culprit.

Endocrinologic (or hormonal)

This occurs when there is an imbalance or insufficiency of sex hormones in the blood stream. It accounts for about 5 to 10 per cent of all organic impotence. Generally, hormonal changes affect the libido (or sex drive) rather than the quality of the erection. A variety of disease conditions can cause these changes.

Mixed

Sometimes, more than one factor can be operative in the same patient. Such patients generally have systemic disease. Notable examples are diabetes, kidney failure and liver failure.

Another group where mixed factors operate is where long standing impotence has led to secondary psychiatric disorders such as depression etc.. Here, the basic causative factor is organic but being unrecognised and untreated (or maltreated) it eventually takes its toll on the mind, often because the patient thinks or has been led to believe that the condition is incurable and that it's all in this mind.

Psychogenic

When there is no organic factor and the problem lies purely in the mind, it is labeled a case of psychogenic impotence. But before such hasty and convenient labeling it is necessary to prove by andrological investigation that no organic or bodily cause exists.

Only then can treatment proceed in a scientific and systematic manner.

CURRENT TREATMENT OPTIONS FOR IMPOTENCE

There are several treatment options for impotence. This is a very brief discussion on some of the options.
Sexual Counselling
Counseling and sex therapy are sometimes effective in helping patients with sexual problems, especially when caused by psychogenic reasons. Sex therapy promotes education and relief of symptoms of sexual dysfunction. Marital and personal counseling is targeted on interpersonal and relationship issues which contribute to resolving a couple's or an individual's psychological and emotional dysfunction.

Oral Medication

Yohimbine therapy frequently improves libido or sexual desire, and 30-40% of patients report improved erections, particularly when the cause of impotence is psychological or undetermined. Effectiveness may be enhanced when used with trazodone. Side effects include mild dizziness, nausea, nervousness, and headaches.

Trazadone, an antidepressant, has recently been found to be helpful in treating some patients with psychogenic symptoms. This drug is most effective when combined with yohimbine. Recently, sildenafil, oral phentolamine and a few other drugs have shown promise as oral agents.

Hormone Replacement Therapy

Testosterone is the major male hormone that gives men their sexual characteristics (deep voice, beard, chest hair). As men age, their level of testosterone decreases and this may have an adverse effect on sexual performance. Injections or oral prescriptions of testosterone may enhance potency and improve sex drive. Only a small percentage of men respond to this treatment and serious side effects may occur, which may affect the liver, prostate and heart.

External Vacuum Devices

Vacuum therapy has the highest documented rate of success, the least reported injuries, and is the least expensive. It involves the use of an external vacuum device, and one or more tension rings. This therapy is effective for over 90% of the men who use it. In fact, most can technically master its use in one day, and can use it to maintain erections for up to 30 minutes, even after ejaculation and/or orgasm.

CASE STUDY

K.M., 65, decided to remarry 8 years after his wife's death. He married a lady considerably younger and though he was not totally impotent, there was a major libido mismatch and he felt that he was not being fair to his wife. A vacuum device solved his problem. He has been using it satisfactorily for more than 2 years.

Side effects, though minimal, may include petechiae (reddish, pinpoint-size dots) and ecchymoses (bruising). These conditions are not painful or serious and generally occur only during an initial learning period. Penile temperature may decrease 1-2 degrees during use.

Penile Injections

Papaverine, phentolamine, prostaglandin E1, and combinations of these drugs may be self-injected into the penis with a fine, small gauge hypodermic needle. Men must first be taught the procedure in the physician's office. These drugss produce erections of good quality for about 75-85% of patients who select this option. Some patients combine this method with the use of an external vacuum device with excellent results.

A Self-Injection Kit from Owen Mumford

Erections obtained by injection usually last 30-60 minutes and may not subside when a man has an orgasm or ejaculates, and may interfere with the patient's social/business agenda. An overdose can cause a prolonged and painful erection that may require medical or surgical intervention. Frequent use may lead to the build-up of scar tissue in the penis, further complicating the process of erection.

Penile Implants

A penile prosthesis (implant) is a fixed or mechanical device surgically implanted within the two corpora cavernosa of the penis, allowing erection as often as desired. Most implants are successful. However, some may require surgical repair or removal due to infection, erosion or mechanical failure.

The semi-rigid, malleable rod-type prosthesis is the simplest prosthesis, but may be difficult to conceal. Self-contained mechanical implants are made of a series of interlocking plastic blocks with a spring-loaded cable passing through them. They are easy to operate, but mechanical failure can occur.

Inflatable prostheses include :

A multi-component prosthesis consisting of a fluid pump located in the scrotum, a reservoir in the lower abdomen, and two inflatable cylinders, and
A self-contained inflatable prosthesis composed of two sealed cylinders, each containing fluid, a pumping mechanism, and a release valve.

How the Inflatable Penile Prosthesis works

A discrete squeeze of the pump produces an instant erection, that is maintained till such time as the release valve is similarly squeezed.

Microsurgery
Penile revascularisation and venous ligation are microsurgical procedures similar in technical complexity to a heart by-pass operation although they clearly do not carry anywhere near the same risk to the life of the patient.

EjaculatoryDisturbances

How much of a risk do you face ?

Sex is man's second strongest instinct. An instinct that is second only to the survival instinct. This means that if a man's life is not immediately imperilled, the next thing he will automatically think of is sex.

Though ejaculation often occurs normally and is an intensely pleasurable sensation for most men, it is an extremely complex phenomenon that is regulated by many different systems. Hence, things often can, and do go wrong.

an has forever been obsessed with semen and everything associated with it (seminal matters ?!). This includes, among others, its color, consistency, odor, quantity, loss and force of ejaculation.

For some strange reason, miraculous properties have been ascribed to this rather ordinary body fluid by nearly every culture in human history. The total quantity of a man's semen was assumed to be a valuable lifetime constant from which all release had to be very frugally rationed. Though this hypothetical quantity was never determined and the quotas for rationed release never specified, loss of semen was nonetheless associated with `weakness'. Even now, it is quite common to see educated, well-placed men complaining of `weakness' from head to toe, ostensibly because of their belief that they have lost more semen than was good for them.

It is interesting to note that human spermatozoa were first seen under the microscope by Leeuwenhoek only in 1674 and that scientific proof that the sperm fertilizes the ovum to produce pregnancy was first available only in 1779 (Spallanzani). Yet, theories about the `vital fluid' abounded centuries ago, especially the one equating one drop of semen to forty drops of blood !! Quacks and `sexologists' help considerably in perpetrating these beliefs across all strata of society even today.

The act of seminal ejaculation, likewise, is poorly understood by most. Erotic films and literature depicting `bucketfuls of cum squirted several feet' don't help matters and tend to confuse even the well - informed. Though ejaculation often occurs normally and is an intensely pleasurable sensation for most men, it is an extremely complex phenomenon that is regulated by many different systems. Hence, things often can, and do go wrong.

Let's take a look at some of the common ejaculatory disturbances. (It must be emphasized that a detailed classification and discussion of these is outside the scope of this article.)

1 Premature ejaculation
2 Delayed (Retarded) ejaculation
3 Retrograde ejaculation
4 Anejaculation


PREMATURE EJACULATION

Premature ejaculation is an extremely common condition. Kinsey, in his landmark report, had stated that it affects as many as 75% of all men. In today's context, premature ejaculation (PE) becomes especially relevant because of the increasing emphasis on female sexual gratification. Today's woman will not take anything lying down unless it is good enough (pun intended, of course). However, premature ejaculation seems to be nature's original design. The Kama Sutra has classified PE as one among many normal ejaculatory patterns.

From the standpoint of procreation of the species, prematurity of ejaculation seems to confer an evolutionary advantage. Early man lived in dangerous environs and had to finish mating in a hurry. He therefore had very little time in which to deposit his semen in the female's vagina and ensure propagation of the species. The continuation of this primitive PE streak in humans perhaps explains the preponderance of the condition in modern man.

PE is hard to define because its spectrum is so vast. Some men ejaculate at the mere thought of coitus. Others seem to be able to last long enough by average standards but are yet unable to gratify their partners. Hence, attempts have been made to quantify PE objectively on the basis of timing of intercourse up to the point of ejaculation, the number of pelvic thrusts until ejaculation, partner satisfaction, etc.. Researchers have actually placed stop-watches and thrustometers in patients' bedrooms.

None of these methods, however, is ideal. The current working definition of PE is the one published in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders - the DSM-IV. Briefly, the DSM-IV defines PE as "persistent or recurrent ejaculation with minimal stimulation before, during or shortly after penetration and before the person wishes it". Even this hasn't been standardized. Many additional parameters need to be looked at, and the importance of physical factors (increasingly incriminated in PE) needs to be incorporated (see Table below).

PHYSICAL (NON-PSYCHOLOGICAL) CAUSES

Injury to sympathetic nervous system (e.g. following surgery for abdominal aortic aneurysm)

Pelvic fractures

Prostatic hypertrophy and prostatitis

Urethritis

Diabetes

Arteriosclerosis

Cardiovascular disease

Local genitourinary disease

Local sensory impairment

Polycythemia

Polyneuritis

Definitions notwithstanding, PE, despite many claims to the contrary, is a difficult condition to treat. Since PE has been a human concern for centuries, every system of medicine and every culture boasts its own unique `cures' for the condition. Many of these have acquired a reputation for efficaciousness because of their strong placebo effect. Since PE is often a psychological disorder, even substances without any real pharmacological effect on the ejaculatory apparatus can work by the power of suggestion (placebo).

Some decades ago, psychosexual methods of treatment gained tremendously in popularity. One such was the `start-stop' method, which was propounded by Semans and then popularized by Helen Singer Kaplan. The other was the `squeeze' technique described by Masters and Johnson. These techniques held sway for many decades, largely because of the unavailability of other treatment methods. However, it soon became clear that the initial success rates claimed with these were not sustainable and that, over time the success rates had dwindled to 25%. Besides, these techniques are very tedious to employ and unsuitable for today's space age. Today, research is centered on understanding the central and peripheral neurological control of the ejaculatory process and regulating it with drugs.

The various treatment options for PE are summarised in the Table below. The current treatment of choice seems to be medication with the SSRI (Selective Serotonin Reuptake Inhibitors) and allied groups of drugs.

TREATMENT OF PREMATURE EJACULATION

Pharmacological therapy
dopamine antagonists
antidepressants
anxiolytics
others
Topical anesthetics
Microsurgery
Psychological treatment
Miscellaneous agents

DELAYED (RETARDED) EJACULATION

Delayed or retarded ejaculation is a condition which is, in many ways the exact opposite of premature ejaculation. It is defined as a persistent difficulty in achieving ejaculation despite the presence of adequate sexual desire, erection and stimulation. On the face of it, this might seem to be a good condition to suffer from because it carries connotations of great staying power. This may be true sometimes, especially if the female partner also requires a long time to reach orgasm. Often, however, it is more a cause for worry than for rejoicing. The male often goes on for a half hour or more with little sexual pleasure, and constantly worries about when he is going to finish. The female partner usually has already attained orgasm and waits eagerly for the man to finish. She stops lubricating shortly after she has attained orgasm and the remainder of the sex act is a painful formality. Situations such as these can lead to a lot of relationship problems between the partners.

In its most severe manifestation, delayed ejaculation takes the form of ejaculatory incompetence, a condition where the man can never ejaculate inside the vagina. This poses additional problems when the couple wants to have a baby (see under Anejaculation - vide infra).

Positive reinforcement of operative conditioning associated with masturbation might play a central role in the development of delayed ejaculation.

A very common reason for delayed ejaculation is this: most men have their first orgasm through masturbation. Many men go on to have quite a few more orgasms by continuing to `take matters into their own hands'. And, many men exert much more pressure with their hands than they are likely to experience during intercourse. In doing so, they essentially train themselves to sexually respond to lots of pressure. One reason young males use strong pressure during masturbation is they're often rushing to finish so they don't get caught. Then, as adults, they mistakenly think they need that same pressure to reach orgasm. Many men can learn to reach orgasm with a partner if they practice self-stimulation slowly and with much less pressure than usual. This can be done at any time, whether with a partner or not. Of course, self-stimulation just before one is likely to be sexual with another person must be avoided.

`Working' at sex seldom works well - whether one is doing the working or being worked on. At the root of this approach to sex is the belief that there is a formula for how sex is supposed to go. This belief is one of the main reasons why people get into sexual difficulties. Formulae are necessary for creating chemical reactions, but they nearly always stymie sexual reactions. Working to follow a formula requires people to ignore both their own physical sensations as well as the signs of their partner's pleasure. It obstructs spontaneity and dictates a script that makes partners deny one another's uniqueness. Some men get into the habit of thinking about how difficult it's been in the past to reach orgasm when they're having sex with a partner. This slows down arousal and makes orgasm that much more elusive.

So what do you do if you suffer from delayed ejaculation ?

Focus on things that are sexy to you. It can be some aspect of your partner's personality or body, a hoped-for experience or an embellishment of the situation you're currently in. The brain has an amazing way of propelling sexual arousal forward even when the physical stimulation is different or less intense than usual. Teach your partner how to stimulate you by hand or orally in the way you like best. Many women think that all men like more or less the same things. While there tend to be some common characteristics, good sex can become great sex if subtle nuances and personal preferences and kinks are part of it. This means that you'll want to be in a state of mind that welcomes the sexual sensations your partner is offering you. Set aside concerns about how you look as you become aroused. Luxuriate in the physical gifts you're getting moment by moment. Check whether you are focusing excessively on giving your partner pleasure. Sex with a partner is not about giving only; it is also as much about receiving. Decide to really be comfortable receiving pleasure. You'll feel better and so will your partner.

There's another common approach to sex that slows things down - often intercourse is begun too soon in the sexual encounter. Many men with delayed ejaculation have the idea that they'd better start working at it early on because they fear that their partner will tire out if the whole experience takes what the partner considers `too long'.

This leads to missing many an erotic experience that builds the arousal level - not to mention missing out on a lot of fun. Rushing to intercourse, in essence, short-circuits things. Many people feel that going straight to intense genital stimulation numbs what could have been intense pleasure if only one's partner had built it up in graded fashion.

Give up watching the clock with an arbitrary time limit in mind. Unless your partner has made specific complaints, let go of that pressure on yourself. Many people enjoy a man's taking his time while moving through his sexual responses. Keep in mind that you can `take matters into your own hands' while in bed with a partner. Many men and women bring themselves to orgasm while a partner adds extra caresses or kisses. You might be underestimating how arousing it could be to your partner to see you stimulate yourself.

Take a look at how you feel emotionally during sex. Are you angry? Anxious? Afraid? Depressed? These emotions activate the sympathetic nervous system, which in turn blocks the arousal needed to reach orgasm.

Other factors that can be contributory to delayed ejaculation include obsessive-compulsive disorders, marital conflict and chronic substance abuse (alcohol and drugs). Delayed ejaculation is often related to anger or resentment towards women and an oppressive upbringing. It could also result from lack of emotional involvement with the partner and fear of commitment.

Many organic (physical) causes too can contribute to delayed ejaculation. These include many neurological and endocrine illnesses, diabetes, cancer, prostate problems, drugs such as those employed for the treatment of psychiatric illnesses and high blood pressure, and surgical intervention that can affect the ejaculatory apparatus. Physical and psychological factors often co-exist. All these conditions will require specialist intervention.

RETROGRADE EJACULATION

Retrograde ejaculation (which can also present as Anejaculation - vide infra), as its name implies, is a condition where the seminal fluid is ejaculated backward (retrograde) into the urinary bladder instead of forward (antegrade), as is the norm. (I once had a patient in my consulting chamber who asked me, "Dr. Krishnamurti, are you trying to tell me that instead of coming, I go ?". ) This usually occurs because the neck of the urinary bladder, which normally closes to block such retrograde flow, is unable to do so. Such inability usually results from neurological or physical damage to the bladder neck, which in turn can result from a variety of clinical conditions.


Patients with retrograde ejaculation usually achieve orgasm normally and feel the sensation of having ejaculated. However, little or no seminal fluid emerges from the penis. Instead, the patient often notices that the post-ejaculatory urine, i.e. the urine passed after sexual intercourse, is cloudy with semen.

Diabetes is an extremely common cause of retrograde ejaculation (also a very common cause of impotence). This occurs because diabetic neuropathy impairs the sympathetic autonomic nerve supply to the bladder neck. Nearly 32% of diabetics will have some degree of retrograde ejaculation (50% will suffer impotence). Other causes of retrograde ejaculation are spinal cord lesions and injuries, operations on the spine, retroperitoneum or pelvic organs, surgery on the bladder neck and prostate and again, many, many drugs that affect the neurological control of the bladder neck.

Retrograde ejaculation is again a difficult condition to treat. Drugs that are normally used to treat this condition, such as imipramine, ephedrine and phenylpropanolamine are not always effective. Many patients reconcile themselves to the condition and learn to live with it. Many lead otherwise normal sex lives.

For men who want to father children, however, retrograde ejaculation becomes a serious matter since these men cannot deposit their semen inside the vagina. These men can be treated by retrieval of sperms from the urinary bladder followed by assisted reproduction - with good results.

ANEJACULATION

Anejaculation, as its name implies, is a condition characterized by the absence of ejaculation. The causes can be psychological and physical. Psychological anejaculation is usually anorgasmic i.e. unaccompanied by orgasm. This again, can be situational or total. Situational anejaculation means that a man can ejaculate in some situations but not in others. For instance, a man may be able to ejaculate and attain orgasm with one partner but not with another. This usually occurs when there is a psychological conflict or a relationship difficulty with one partner. Or he may be able to ejaculate quite normally during masturbation but not during intercourse. It can also occur in stressful situations, as when a man is asked to collect a sample of semen in the laboratory for infertility treatment. In total anejaculation, the man is never able to ejaculate when awake. Deep-rooted psychological conflicts are usually the cause. Such men, however, usually have normal nocturnal (night) sleep emissions.

Physical (organic) anejaculation, which includes retrograde ejaculation (vide supra), can occur due to neurogenic and obstructive causes. Many of the neurogenic causes are similar to those outlined earlier. It must be reiterated that diabetes is an important cause.

Treatment
Treatment depends on the cause and includes psychosexual counselling, drugs such as ephedrine and imipramine, vibrator therapy and electroejaculation. The last is a procedure in which an electrical current is applied to the ejaculatory organs to stimulate ejaculation. Success rates are nearly 100 %. Obstructions to the ejaculatory pathway will, of course, need surgery.


The Multicept Vibro-ejaculator & the Seager Electro-ejaculator

We have seen how even `normal' men are obsessed with seminal matters. It is easy to imagine, therefore, how crippling a real ejaculatory dysfunction can be. Yet, it is not uncommon in clinical practice for a physician to dismiss a patient's complaints as trivial and ask him not to make much ado of it. The complexity of ejaculatory disturbances necessitates treatment only by experts with a special interest and experience in treating these conditions. Despite this, some cases might be refractory to treatment.


Penile torsion

This was further compounded by male chauvinism. In a male-dominated society, our menfolk could not accept the fact that something could actually be wrong with their `symbols of manhood' - the male reproductive organs. Research was therefore, laggardly. It is ironic that it is these very men who discovered gynecology and saw it progress so rapidly.

The Freudian era made progress even more difficult. Sigmund Freud taught (to put it very simply), that everything was linked to human sexuality. This led people to erroneously conclude that reproductive disorders in men were largely psychological in origin.

The birth of every new branch in medicine begins with biology i.e. a study of the anatomy (structure) and physiology (function) of the part. When either of these is deranged, pathology (disease) ensues. Unfortunately for andrology, the study of male sexuality began with psychology rather than biology. This has caused a gross misunderstanding of the subject.

Not only that, the seeds of misconception sown so many decades ago are still firmly entrenched in people's minds, and most people - including several doctors - even today continue to think that impotence is largely a psychological disorder.

This explains why most people know that it takes a complex series of neuromuscular phenomena to lift a little finger but fail to realise that equally complex phenomena are required to lift the penis. Most imagine that all that is needed for the latter event to occur is a naughty thought.


When women can go in for breast implants, face lifts, and liposuction to enhance their self esteem, why can't men undergo surgery for penis enlargement ?

here is no doubt about the fact that penis enhancement surgery can be of immense value to certain men. But present techniques are woefully inadequate, produce dubious results, and are often of short-lived value.


WHO WILL BENEFIT ?

Surgical sculpting of the penis will help three sets of people.

THE NEEDY
These people are penile cripples. They usually suffer from malformations or deformities of the penis. On account of these deformities, the penis is cosmetically and aesthetically unsightly. Besides, in many of these cases, the patient is incapable of normal erectile ability and copulation.

Such people can have a normal sex life if the new phalloplasty technique proves useful.

THE GREEDY
The second group of men are those with normal penises but who desire a longer or thicker penis to either bolster their own sagging self-esteem or to satisfy their sexual partners' unrealistic expectations of penis size.

AND TRANSSEXUALS
The third group, where this technique will help is female transsexuals who desire a female-to-male sex change (gender reassignment) operation.

WHY IT IS NECESSARY ?

A busy Andrologist may have as many as two or three requests for penis enlargement daily. Many men have a penis fixation just as women have a breast fixation.

We all know that breast size isn't really important, but still no amount of explanation or reasoning will satisfy some women who will insist on breast augmentation through implants. And if this is not done they are unhappy indeed.

If the size of the penis means so much to a man why not give him a penis that will make him happy ?

The same analogy holds true for men. Even though their concept of penis size may be unrealistic, they will still insist on a longer and thicker penis. If a penis means so much to a man why not give him a penis that will make him happy ?

Especially if refusal to do so might ruin both his self-esteem and his sex life. What's important is that the technique should provide a real (rather than apparent) increase in both length and girth, in both flaccid and erect states, without causing any significant complications.

THE PRESENT TECHNIQUES

Penis enlargement is being practised in many parts of the world, though the currently employed techniques are highly controversial. Practitioners of these have come in for a lot of flak both from colleagues within the medical profession as well as the laity.

The currently available techniques for penis lengthening and girth-enhancement have many drawbacks

STRUCTURE OF PENIS

Broadly, a penis comprises of three cylindrical tubes - the paired corpora cavernosa above, and the urethra (the urine tube, that's anatomically contiguous with the glans penis) below.

The paired corpora (erectile bodies) are attached to the pubic bone by a suspensory ligament that gives the penis stability during erection. In the currently available lengthening procedure, this ligament is cut. This produces a purely illusory and apparent increase in penile length due to gravitational traction - and that too only in the flaccid state.

This means that the penis will not really be much longer in the erect state. Not only that, the patient also loses the important stabilising support of the suspensory ligament which keeps the erect penis steady during the vigorous movements accompanying sexual intercourse.

Likewise, in the currently offered girth-enhancement operation, fat from the lower abdominal wall is drawn out through liposuction and injected beneath the loose skin of the penile shaft to create an illusion of thickening.

Fat injection produces only a temporary illusion of thickening

This is actually quite ridiculous. You are putting fat into an area that nature has intentionally kept bereft of fat. It must be remembered that the subcutaneous (below skin) tissue in the penis does not have a fat layer. There is a purpose to this. Injecting fat there defeats this purpose completely.

Besides, this kind of fat injection produces only a temporary illusion of thickening. With the passage of time, the injected fat, which is avascular i.e. without blood supply, only dies - a phenomenon known as fat necrosis. This necrosis will sooner or later cause the penis to return to its original pre-operative girth. And, in the process of necrosis, it leaves behind scars, fibrous nodules and a cosmetically disfigured, uneven, lumpy penile contour .

What the old techniques offer the patient is a few days' opportunity to fool their friends in the swimming pool locker room. However, they won't be able to fool their sexual partners

What's even worse is that even this temporary, complication-fraught girth-enhancement is only an apparent, rather than real one. When the penis gets erect, all the fat is compressed and flattened against the skin of the penile shaft (which also has limitations to its elasticity) and the penis is no thicker in the erect state than it was before operation. And it is this thicker erect penis that most patients and their partners want.

So at most, what these techniques will offer the patient is a few days' opportunity to fool their friends in the swimming pool locker room. However, they won't be able to fool their sexual partners. What's even worse is that they will have down-the-line problems of explaining to the same friends why their organ has begun to suddenly shrivel !

FOR TRANSSEXUALS

The phalloplasty technique hopes to be able to provide a new operation for transsexual patients.

The goals of surgery for female-to-male gender reassignment are manifold. In the first place, it is required to create a penis that looks like a penis and not just a skin tube. Secondly, the glans penis has to be simulated. Next, the organ should be capable of perceiving erogenous sensations to the point of orgasm and should be capable of erection and vaginal penetration. Testes have to be re-created. The new man must be able to use a gents' loo without any hassles. And all this plus more without too many complications.

STATUS OF NEW TECHNIQUE

We are only now going from the conceptual stage and cadaver dissection stage to the clinical trial stage. And we have to begin with the `needy' group of penile cripples where a poor result will at worst only return the patient to his status quo and where a small complication or two will not be of real consequence. Only then can it be tried on the `greedy' and the transsexual group. One cannot experiment on human beings. Research methodology has to be thorough and fool-proof.

Of course ultimate acceptance and sanction for the technique will come from the scientific community, especially the peer review group of specialists and publications involved in similar work, and the gratified patient population. But meanwhile, work must go on.

Curves, Bends,and Peyronie's Disease

The most important symptoms of Peyronie's Disease are pain, lump formation, deformity of the penis on erection, and impotence. The latter two will sometimes warrant surgical treatment.

Peyronie’s disease a condition characterised by the development of fibrous plaques or nodules in the substance of the penis.

The disease is named after an eighteenth century French surgeon, Francois Gigot de La Peyronie and afflicts about 1 percent of the adult male population.

A study of the cross section of the penis in the human male shows that the organ has many layers. Peyronie's disease affects the tunica albuginea layer of the penis. It is commonest between ages 40 and 70 though no age is exempt. Even boys in their teens with Peyronie's disease have been described. The exact cause of this disease is not known and many theories abound about the probable mechanism of occurrence of this condition.

CLINICAL PRESENTATION

Most patients will present one or more of the following complaints:
The noticing of a lump in the substance of the penis
Development of pain in the penis, especially on erection
Bending or deformity of the erect organ
Loss of erection
Difficulty in vaginal penetration

Pain accompanies the lump in approximately two-thirds of all patients but is often self-limiting and disappears after the disease has run its full course.

The lump (or plaque or nodule) is generally about a centimeter in size and is usually located on the upper midline. Sometimes, it may be much larger in size and in diffuse or multiple form.

In many cases, genital examination is conducted perfunctorily and, in the absence of pain, a lump may be missed

The lump may also be located at other areas on the penile shaft. The dorsal and ventral midlines are the common sites. The most important symptoms from the patient's and the clinician's standpoint are deformity on erection and impotence. Both these are common, and will require treatment.

It is important for the examining clinician to be aware of the possibility of dealing with Peyronie's disease when he first sees the patient. Often, genital examination is conducted very perfunctorily and, in the absence of pain, a lump may be missed.

It is also necessary to examine the penis in the erect position after the administration of a vasodilator drug like papaverine, phentolamine prostaglandin E1, or a combination of these. This allows accurate and objective measurement of the true extent of deformity and the degree of rigidity. Of course, all lumps on the penis are not secondary to Peyronie's disease.

Additional investigations may include a 2 or 3 night computerised Rigiscan study for rigidity, a plain X-ray, and a flaccid penis ultrasound. Sometimes, it might be necessary to perform vascular studies (e.g. DICC, post-injection ultrasound), an MRI, etc..

The Rigiscan study gives a non-invasive and objective measurement of the patient's erection. Some people with Peyronie's disease may have impotence that is psychological in origin, rather than due to a true organic impairment. In such situations, the Rigiscan is invaluable for differentiating between the two. Shown below is a normal Rigiscan graph.

Besides, the Rigiscan also helps to detect disparity in penile base and tip rigidity which can occur because of the constricting effect of the lump.

A plain soft tissue X-ray of the penis is useful in detecting the presence of calcific lesions. Approximately one-thirds of all patients with Peyronie's disease will develop calcific changes in the fibrous tissue of the lump.

Calcification (deposition of calcium) generally denotes end-stage disease i.e. that the disease has run its full course and deformity and erection are not going to worsen further. This is useful in planning treatment.

An ultrasound examination helps to demarcate the entire extent of the plaque (lump) - in all three dimensions. This is of great value if the Andrologist is contemplating operative intervention since a decision can be made about the type of operation suitable for employment in a given patient. The ultrasound examination can be further coupled with injections of vaso-active substances to study the arteries of the penis.

TREATMENT

The aims of treatment are:
Relief of pain and arrest of progression of disease.
Straightening of the penis - if deformity is severe. Milder degrees of deformity may be left untreated because some patients may nevertheless be able to function sexually.
Cure of impotence.

Several treatment modalities have been employed in the past to reduce pain and arrest the progression of the fibrotic process. These include several oral medications, X-ray therapy, topical applications, electrical therapy, ultrasonic treatment and locally injectable agents.

None has so far proved conclusively superior to others, and benefits derived are probably sympathetic, placebo (psychological) or because of the self-limiting nature of the illness in some cases.

In some cases, after the disease has run its course, it may be possible for a patient to rehabilitate himself sexually

It must be remembered that, in some cases, Peyronie's disease runs quite a benign and self-limiting course. Such patients are fortunate and will require little or no therapeutic interference.

In fact, needless administration (especially of intra-penile steroid injections, which are commonly used) can be damaging. After the disease has run its course it may even be possible for the patient, with his minimal penile deformity to rehabilitate himself quite well sexually.

On the other end of the spectrum, of course, we have the much less fortunate patient, who not only has severe deformity (greater than 30 degrees) but also has severe impotence and just cannot perform sexually. Superimposed on these is always the element of depression. Such patients will require surgery especially if 12 to 18 months have elapsed since the first symptom appeared, and all other treatment forms have failed.

SURGERY

Many operations are available for the surgical treatment of this condition. The choice of operation in a given case will depend on the location of the lump, the extent of the lump and the degree of deformity caused, the presence or absence of superimposed organic impotence and the preferences of the operating Andrologist.

Plication Procedures:
attempt to straighten the penis by trying to shorten the longer side to match the shorter side. Though simple and effective, some authorities are against this approach since the penile shortening that ensues is unacceptable to most patients.

Excision-Grafting Procedures:
involve the incising of the lump in the tunica albuginea layer and straightening of the penis followed by reconstruction of the resultant defect using graft material. A variety of graft sources are available. Most currently available / described grafts give seemingly satisfactory results on the operating table. Sooner or later, however, patients experience shortening or return of deformity and sometimes even impotence.

This is a drawback inherent in all free grafts because these are known to contract. Besides, foreign grafts (synthetic and animal) will also stimulate the formation of fibrous tissue and contraction.

The only way to minimise these problems, i.e. to avoid contraction and impotence, is to use a FLAP (with its own blood supply) rather than a graft..

Step-wise Photographic Representation of the Penile Dermal Flap.

Prosthetic Implantation Procedures:
involve the placement of hollow (inflatable) or semi-rigid silastic cylinders into the corpora cavernosa of the penis. These are generally employed when severe organic (non-psychological) impotence coexists. Sometimes, semi-rigid prostheses alone are employed to straighten the penis and correct minor degrees of curvature.

Generally speaking, operations for Peyronie's disease should be performed with prudence and only by the experienced. Premature and inadequate surgery can be disastrous and can have a high recurrence/failure rate. Though the results of surgery are, by and large, satisfactory, the re-operation rate in patients operated upon improperly, is quite high. "Wait and watch : operate only when all else fails or disability is severe", seems a good maxim.

Peyronie's disease is not uncommon and can sometimes be a crippling disease of the penis. Presenting usually as a lump in the midline shaft, it can cause deformity on erection and impotence. It especially affects the middle-aged and elderly. The exact cause of the condition is not known. The disease is sometimes self-limiting and disability is minimal. More severe deformity and impotence will require treatment, sometimes surgical. Surgery should be performed as a last resort and only by those especially experienced in dealing with this condition.


OTHER CAUSES OF PENILE DEFORMITY

Apart from Peyronie's Disease, there are other causes of penile curvature and deformity. Many of these are congenital (present from birth). Some are associated with conditions of the urethra. Some are not.

In the latter situation, the penis appears absolutely normal in the flaccid (non-erect) state. Most patients have no impairment of rigidity and are capable of good erections. However, sometimes the deformity is severe enough to preclude peno-vaginal penetration and can also cause serious psychosexual disturbances. Both these situations will warrant surgical intervention. Surgery is simple, safe and gives very good results with complete straightening of the penis.

Contrary to popular belief, impotence is almost never an "all or none" phenomenon. Most laymen (and several doctors) believe that a man can either have an erection of very good quality or none at all. Nothing can be farther from the truth. Most men with erectile dysfunction have normal desire and can obtain an erection, only the erection is not hard enough or doesn't last long enough, Hence the term erectile dysfunction (which suggests partial loss) is preferred to impotence (which suggests a total loss). Not many are aware that in most cases organic rather than psychological causes are responsible.
In as many as 80-90 percent of cases of chronic impotence, the cause is not in the mind but in the body.


However, the trend is slowly but definitely changing. This is largely due to tremendous advances in andrological research over the past few years which have conclusively established that in as many as 80-90 percent of cases of chronic impotence, the cause is not in the mind but in the body. These causes can be identified using modern andrological investigative modalities, quantified and often successfully treated using totally non-psychological methods.


Andrologic tests at Andromeda Andrology Center revealed that his overall rigidity levels were well below normal and that he had problems both with his arteries and his veins. He was eventually cured with an inflatable penile prosthesis.


Many drugs also cause neurogenic impotence by affecting the neurotransmitters at the nerve endings. Notable among these are anti-hypertensives (BP lowering) and psychotropics although the list is very large. Often, it is not known that the medicine (which is prescribed for some unrelated disease, such as duodenal ulcer) is the culprit.
Endocrinologic (or hormonal)

This occurs when there is an imbalance or insufficiency of sex hormones in the blood stream. It accounts for about 5 to 10 per cent of all organic impotence. Generally, hormonal changes affect the libido (or sex drive) rather than the quality of the erection per se. A variety of disease conditions can cause these changes.
Mixed

Sometimes, more than one factor can be operative in the same patient. Such patients generally have systemic disease. Notable examples are diabetes, kidney failure and liver failure.

Another group where mixed factors operate is where long standing impotence has led to secondary psychiatric disorders such as depression etc.. Here, the basic causative factor is organic but being unrecognised and untreated (or maltreated) it eventually takes its toll on the mind, often because the patient thinks or has been led to believe that the condition is incurable and that it's all in this mind.
Psychogenic

When there is no organic factor and the problem lies purely in the mind, it is labeled a case of psychogenic impotence. But before such hasty and convenient labeling it is necessary to prove by andrological investigation that no organic or bodily cause exists.

Only then can treatment proceed in a scientific and systematic manner.


CURRENT TREATMENT OPTIONS FOR IMPOTENCE


There are several treatment options for impotence. This is a very brief discussion on some of the options.Sexual Counselling

Counseling and sex therapy are sometimes effective in helping patients with sexual problems, especially when caused by psychogenic reasons. Sex therapy promotes education and relief of symptoms of sexual dysfunction. Marital and personal counseling is targeted on interpersonal and relationship issues which contribute to resolving a couple's or an Oral Medication

individual's psychological and emotional dysfunction. Oral Medication
The introduction of Viagra by
Pfizer in March, 1998,, marked the beginning of a revolution in the oral medical management of erectile dysfunction (ED, E.D., impotence). The launch of Viagra was soon followed by that of Levitra and Cialis. Other (even better) drugs are in the pipeline.

Effective oral medication has re-written the management of ED and is effective in nearly 70 - 75 % of cases. Several internet resources are available for more detailed information about these drugs.Hormone Replacement Therapy

Testosterone is the major male hormone that gives men their sexual characteristics (deep voice, beard, chest hair). As men age, their level of testosterone decreases (andropause) and this may have an adverse effect on sexual performance. In proven cases of andropause, testosterone preparations may enhance potency and improve sex drive. However, this therapy must be only offered under expert medical External Vacuum Devices

supervision because many side effects can occur. External Vacuum Devices
Vacuum therapy involves the use
of an external vacuum device, and one or more tension rings. This therapy is purported to be effective for over 90% of the men who use it. In fact, most can technically master its use in one day, and can use it to maintain erections for up to 30 minutes, even after ejaculation and/or orgasm.



Side effects, include petechiae (reddish, pinpoint-size dots) and ecchymoses (bruising). These conditions are not painful or serious and generally occur only during an initial learning period. Penile temperature may decrease 1-2 degrees during use. Vacuum devices are generally favoured by elderly patients with erectile dysfunction (ED, E.D.).Penile Injections

Penile Injections The need for the use of injections has declined enormously since the advent of orally effective drugs like Viagra for ED. Papaverine, phentolamine, prostaglandin E1, and combinations of these drugs may be self-injected into the penis with a fine, small gauge hypodermic needle. Men must first be taught the procedure in the physician's office. These drugs produce erections of good quality for about 75-85% of patients who select this option. Some patients combine this method with the use of an external vacuum device. Not too many injections are used nowadays.


A Self-Injection Kit


Erections obtained by injection usually last 30-60 minutes and may not subside when a man has an orgasm or ejaculates, and may interfere with the patient's social/business agenda. An overdose can cause a prolonged and painful erection that may require medical or surgical intervention. Frequent use may lead to the build-up of scar tissue in the penis, further complicating the process of erection.Penile Implants

A penile prosthesis (implant) is a fixed or mechanical device surgically implanted within the two corpora cavernosa of the penis, allowing erection as often as desired. Most implants are successful. However, some may require surgical repair or removal due to infection, erosion or mechanical failure. The incidence of these complications at centers of excellence is very low, however.

The semi-rigid, malleable rod-type prosthesis is the simplest prosthesis, but may be difficult to conceal. Self-contained mechanical implants are made of a series of interlocking plastic blocks with a spring-loaded cable passing through them. They are easy to operate, but mechanical failure can occur.

Inflatable prostheses include :
A multi-component prosthesis consisting of a fluid pump located in the scrotum, a reservoir in the lower abdomen, and two inflatable cylinders, and
A self-contained inflatable prosthesis composed of two sealed cylinders, each containing fluid, a pumping mechanism, and a release valve.
.


1.Varicocele

2 Infections :
a. acute : smallpox, mumps, other viral infections
b. chronic : TB, leprosy, prostatitis

3.Sexually transmitted diseases

4.Idiopathic - cause unknown

5.Injury
a. direct : testicular or pelvic trauma, heat, irradiation
b. indirect : radiotherapy, chemotherapy, environmental toxins, drugs, marijuana, tobacco, alcohol

6.Undescended testes (cryptorchidism)

7.Previous surgery : inguinal, scrotal, retroperitoneal, bladder neck, vasectomy

8.Obstructions : congenital (aplasia), vasectomy, post-infective

9.Systemic illnesses esp. hepatic, renal

10.Immunologic : infection, obstruction

11.Ejaculatory disturbances

12.Spinal cord lesions

13.Genetic, endocrine & familial disorders : Klinefelter's syndrome, Young's syndrome, cystic fibrosis, adrenal hyperplasia

14.Sexual dysfunctions


Sometimes, in spite of the most meticulous search, no obvious cause can be found for the infertility. This group, known as the idiopathic infertility group, constitutes a large percentage.

EVALUATION OF MALE INFERTILITY

The first test in the evaluation of the infertile male is the semen analysis. This test is inexpensive, easy to perform and gives valuable information.

A perfectly normal semen analysis report generally precludes a significant male factor component and investigation and treatment should be more appropriately targeted at the wife. In fact, in many countries, the first test in the evaluation of an infertile couple is the semen analysis. This is generally performed before any tests are conducted on the wife.

Often, in the case of male infertility, the semen analysis is abnormal. Either the count is low (oligospermia) or sperms are altogether absent in the ejaculate (azoospermia).

Sometimes, sperm motility is seriously affected (asthenospermia) and sometimes the sperms are totally immobile or dead (necrospermia). There are many other anomalies that one may find on semen analysis.

When one finds anomalies in the semen analysis, the next step is to try and find a cause for it. To do this, one must perform additional investigations. Some of the other tests that may need to be performed are a semen culture, anti-sperm antibody estimation, scrotal ultrasound, hormonal assays, karyotyping, vasography etc..

TREATMENT

Treatment of male infertility is difficult and sometimes frustrating. Immediate results are hard to produce and persistence with therapy is required.

The following modalities of treatment are generally employed.
1. Medical treatment

This consists of the administration of certain drugs to improve seminal quality. Clomiphene citrate, mesterolone, tamoxifen, gonadotropin injections, antibiotics, steroids etc. are commonly used.
2. Surgical treatment

Obstructions in the sperm conduction pathway, varicoceles, undescended testes etc. can be treated by operation.

Modern microsurgical techniques are of great help. Even patients who have undergone a vasectomy in the past can have their vasectomy reversed and the tubes recanalised successfully using microsurgery.
3. Assisted reproduction

In many cases, neither medicines nor operations are of help. In such cases, an attempt is made in the reproductive laboratory to improve semen quality and facilitate the penetration of the sperm into the ovum. This includes sperm washing/capacitation, intra-uterine insemination (IUI), gamete intra-fallopian transfer (GIFT), in vitro fertilisation (IVF), and micro-manipulation (ICSI).

Microsurgery and assisted reproduction require considerable training, skill and infrastructure.

Despite the availability of so many treatment modalities, some patients remain incurable and no treatment, cheap or expensive, can improve their fertility prospects. One then has no alternative but to recommend an AID (donor insemination) or adoption.

Awareness of the magnitude and importance of the male factor in infertility is relatively recent. Tremendous advances have been made in andrological research over the past few years. If not today, one can envisage in the conceivable future, a situation where all males (and females) with infertility can be completely cured.

The most important symptoms of Peyronie's Disease are pain, lump formation, deformity of the penis on erection, and impotence. The latter two will sometimes warrant surgical treatment.
Peyronie's disease is a condition characterised by the development of fibrous plaques or nodules in the substance of the penis.

The disease is named after an eighteenth century French surgeon, Francois Gigot de La Peyronie and afflicts about 1 percent of the adult male population.

A study of the cross section of the penis in the human male shows that the organ has many layers. Peyronie's disease affects the tunica albuginea layer of the penis. It is commonest between ages 40 and 70 though no age is exempt. Even boys in their teens with Peyronie's disease have been described. The exact cause of this disease is not known and many theories abound about the probable mechanism of occurrence of this condition.

Discussion:

On scrotal ultrasonography the prevalence of scrotal abnormalities in mountain bikers was 96%, which is unexpectedly high. By comparison, scrotal abnormalities are found in 29% of asymptomatic young men and in 40% of andrological patients undergoing routine scrotal ultrasonography (17,18). In the group of mountain bikers only 49% presented with symptoms on clinical examination.
The most common sonographic findings were scrotoliths, which were seen in 84% of cases. Scrotoliths may result from hematomas, inflammation of the tunica vaginalis or from torsion of the appendix testis or epididymis (20). These benign calcifications often present as painful free-floating or dependent scrotal masses. They may be detected on palpation by the bikers themselves and may raise concerns about testicular tumour, as the prevalence of this malignancy in the age group between 20 and 35 years is high (21). On ultrasonography calcifications are typically depicted as posterior acoustic shadowing, which allows for accurate diagnosis (22). Furthermore, calcifications of the epididymis and testis, which were related to previous trauma, inflammation and/or degeneration, were seen in up to 44% of bikers only.
Testicular microlithiasis has been reported to be a sign of testicular tumour (22). We found testicular microlithiasis in one biker (2%), but testicular biopsy revealed no evidence of tumour. The reported incidence of testicular microlithiasis is approximately 2%. Hence, extreme mountain biking does not seem to increase the risk of developing testicular microlithiasis.
The high prevalence of extratesticular and testicular calcifications caused us to believe that these pathological changes of the scrotal contents result primarily from chronic, repeated microtrauma. Vuong et al. reported perineal nodular indurations in cyclists--also referred to as ²accessory testicles²--to result from microtrauma to the perineum secondary to saddle vibration (8).
Our findings also included spermatoceles, which were found in 44% of bikers and 16% of volunteers. These pathological changes were symptomatic in 31% of bikers, whereas in the volunteer group all spermatoceles were asymptomatic. Hydroceles were observed in 38% and varicoceles in 9% of mountain bikers. Only one of the four bikers presenting with varicoceles on ultrasonography had positive findings on palpation, which is the routine screening test for varicocele, the most common abnormality in infertile men. According to Pierik et al. (24) nonpalpable scrotal abnormalities are frequently detected on scrotal ultrasonography in infertile men. They concluded that the relatively high prevalence of testicular abnormalities emphasizes the importance of routine scrotal ultrasonography.
Bilateral pudendal nerve injury secondary to excessive biking has been reported to be a saddle-related condition, and if the blood supply to the penis is compromised male erectile dysfunction may develop (10). We assume that the abnormalities of the scrotal contents we have detected are basically also a saddle-related problem. The mechanical component responsible for these scrotal changes may be reduced by improving the padding of the seat or shorts, adjusting the saddle angle to either horizontal or downward in front, adjusting the saddle height, using an ergonomically designed saddle and by taking frequent pauses during each ride. Furthermore, new shock-absorbent saddles and full suspension bikes may help reduce saddle vibration and thus the amount of microtrauma.
In summary, we found a significantly higher prevalence of abnormalities of the scrotal contents in mountain bikers compared to non-biking healthy volunteers (p-value <0.001). The most common findings were scrotal calcifications, which were seen in up to 84% of cases. However, only 49% of bikers presented with clinical symptoms. Such saddle-related problems result from a higher rate of microtrauma to the scrotal contents than previously assumed. The high prevalence of testicular and extratesticular disorders in mountain bikers emphasizes the need of improved saddle and bike suspension systems to make sure that mountain biking remains a relatively safe and healthy sport.

Table 1: Ultrasonographic finding Volunteers Mountain Bikers
Scrotolith 38 (84%)
Spermatocele 5 (16%) 22 (49%)
Epididymal calcification 20 (44%)
Testicular calcification - 17 (38%)
Hydrocele - 17 (38%)
Varicocele - 4 (9%)
Testicular microlithiasis - 1 (2%)




Subclinical Microtraumatization of the Scrotal Contents in Excessive Mountain Bikers


Patients and Methods:

Study Population
Between March and July 2006 forty-five enthusiastic amateur mountain bikers aged between 16 and 44 years (26 ± 9.3 years) were entered into this study. All of them reported a minimum of 2 hours per day, 6 days a week of off-road biking. Furthermore, they had all covered a distance of more than 5000 km with their mountain bikes annually.
All athletes underwent clinical assessment at the Department of Urology, including a history of pain, discomfort, and scrotal trauma or inflammation as well as scrotal inspection and palpation for swelling, induration or other abnormalities.
Furthermore, 31 healthy volunteers between 15 and 42 years (24 ± 8.3 years) of age who had no history of bicycling underwent clinical and sonographic examination. Written informed consent was obtained from the mountain bikers and the healthy volunteers.

Ultrasonographic Examination

High-resolution ultrasonography was jointly performed and interpreted by two radiologists with extensive experience in genitourinary ultrasonography (F.F., A.K.).
For the investigations a Sequoia 512 unit (Acuson, MountainView, Cal.) fitted with a linear-array transducer operating at a frequency of 8.0 MHz was used. Colour Doppler ultrasonography was performed to identify varicoceles, which were diagnosed on the basis of a venous diameter of 3 mm or more with the diameter increasing during the Valsalva manoeuvre or when changing from the supine to the upright position. The findings were documented on video tapes and printouts.
Ultrasonography was performed to identify abnormalities of the scrotal contents. The findings obtained in mountain bikers were compared to those in healthy volunteers. The data were analysed using StatView software (version 4.02; Abacus Concepts, Berkeley, Cal.). Differences between bikers and healthy volunteers were evaluated using the Student t test. A P-value of less than .05 was considered statistically significant (19).

Healthy Non-bikers

On ultrasonography 5 of the 31 non-biking volunteers (16%) showed pathological changes in the scrotum. In all 5 cases spermatoceles up to 1.3 cm in diameter were detected. On clinical examination they were all asymptomatic.
Table 1 shows a comparison of the sonographic findings obtained in volunteers and mountain bikers. The prevalence of testicular and extratesticular disorders in the group of mountain bikers was significantly higher (p-value <0.001).





Subclinical Microtraumatization of the Scrotal Contents in Excessive Mountain Bikers


Information:

1. Scrotum:
contains the testicle, epididymis and the intrascrotal portion of the spermatic cord. The cremastic artery (a branch of the inferior epigastric artery), and the testicular artery are located in the spermatic cord. Furthermore the spermatic cord contains the pampiniform plexus of veins.

2. Scrotoliths:
are benign calcifications in the potential space of the tunica vaginalis or in the sinus of the epididymis. They may occur either free-floating or dependent.
Why is it bad?

Scrotoliths may often present as painful scrotal masses, often after repeated palpation by the biker. Furthermore scrotoliths may mimic scrotal tumors by palpation.

3. Spermatocele:

by definition, spermatoceles contain sperm and are the epididymal equivalent of a berry aneurysm. The lesion may occure anywhere in the epididymis but is more common in the caput region. They are relatively common, increasing in frequency with age, and identified incidentally in up to 30% of men undergoing scrotal ultrasound.
Why is it bad?
Interventions (spermatocelectomy) are indicated when the spermatocele is associated with unremitting pain or when it has grown to an uncomfortable large size or when it has got infected. Stagnant sperm within a spermatocele occasionally leads to antisperm antibody formation, and excision may eleminate these antibodies.

4. Calcifications of the epididymis:

calcifications may occur anywhere in the epididymis. They are associated with microtraumatization or can occur after inflammatory diseases of the epididymis.
Why is it bad?
Calcifications can cause pain, and very large calcifications may obstruct the epididymal tubule and may therefore cause epididymal obstruction

5. Repercussions:
in our opinion we think the major reason for the pathological findings in the scrotum are multiple subclinical microtraumas caused by mountain biking. Therefore this seems to be in first line a saddle related problem. At the moment we don´t have fertility issues of the bikers, but maybe these changes may result in fertility problems. Another saddle related problem is male impotence. Damage to peripheral nerves and vessels seems to be the major reason; the pathological changes in the scrotum do not contribute to the development of impotence. We believe that the extent of microtraumas can be reduced with the development of new saddles and improvement of bike- and especially saddle-suspension systems.

6. Fertility issues:

at the moment we don´t have fertility issues from the bikers, but we will perform such issues in the near future.

7. Other repercussions:

96% of the bikers showed pathological findings in the extratesticular space, but only about 50% demonstrated clinical symptoms. That means that the pathological findings are associated with symptoms in half of the bikers. The major clinical symptom was tenderness. Furthermore some bikers presented with suspicion of a scrotal mass, which was identified sonographic

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