Archive for January 31, 2016

Urinating Blood After Sex

Q. After my husband and I have sex, the next two or three times he urinates, he passes blood clots and has very bloody urine. He has seen a urologist three times, but they can’t find anything wrong. His PSA was good. The cystoscopy found nothing. They checked his kidneys and did a full-body scan with dye. Still no answers! There is no pain associated with the passing of this blood. I know it has something to do with his erection, because it will happen if he has a wet dream, or even if he just becomes aroused and we don’t have sex. It is worst after full sexual intercourse. Why is this happening, what should we do?

A. I realize how frustrating and scary it can be to see blood without knowing the cause. As far as I can guess without examining your husband in person, I believe your hunch is right — the blood is a result of his erection. The penis is a very vascular organ, meaning it has many blood vessels. When erect, it is full of blood under high pressure. In fact, the pressures in the penis during intercourse are two to three times higher than anywhere in the body. Such high pressure can cause blood vessels in the prostate or urethra (urine tube) to rupture, causing profuse bleeding.

I have had several patients with visible blood in the urine in whom we were unable to find the site of the bleeding. So, we simulated an erection by injecting a medication into the penis to produce an erection. During the erection, we performed a flexible cystoscopy, a procedure that involves passing a narrow tube with a viewing device into the penis. In two patients, the bleeding was obviously coming from the penile urethra during the erection. In a third patient, after the penis was no longer erect, blood was seen coming from the prostate.

Such bleeding can be cauterized. Another treatment for bleeding prostates in men over 50 is a medication called Proscar (finasteride). This medication works by blocking the growth of blood vessels in the prostate. In addition, it shrinks the prostate, which tends to enlarge with age.

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Unsafe, Unnecessary Viagra Use

Q. If a man takes Viagra that is not prescribed to him, can it hurt him? If the man has no sexual problems with having a erection and takes the Viagra, can it cause him to go impotent? My brother-in-law is doing this because he thinks it will enhance his sex life. My sister is trying to get pregnant, and I’m worried about her.

A. First, no one should ever share prescriptions. Viagra has been associated with deaths in some circumstances. If someone with certain heart problems takes it, that person could have a heart attack and die. In fact, I ask many of my patients to see a heart doctor before giving them the OK to start Viagra.

Second, if a person is already having normal erections, Viagra will not make a better or longer-lasting erection. The medication is designed for people who have weak erections due to poor blood flow into the penis. The medication causes more blood to go into the penis, resulting a more rigid erection. If the person already a rigid erection, Viagra offers no benefit. There is no evidence, however, to suggest that Viagra causes impotency.

Lastly, Viagra is not approved for pregnant women. If the man ejaculates his semen into her while taking Viagra, there may be detectable levels of Viagra in the semen. Once in her womb, it may be absorbed into her body, which may put any fetus at risk.

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Vacuum Pump for Erection Problems

Q. My friend has erectile dysfunction and was given injections of papaverine. These were painful, so he discontinued. Now he is using a vacuum pump device. Is it safe to use such a device? How long can one use it in one session? Are there any side effects to prolonged use?

A. Vacuum devices to improve erections have been used for years. In fact, the U.S. Patent Office issued its first patent for such a device in 1917. The devices have undergone many changes since then, and today they are FDA- approved for erectile dysfunction.

The vacuum erection device works by creating the vacuum around the penis, causing blood to rush into it. Once the penis is full and erect, a constriction band is placed at the base of the penis. The constriction band is the key to a successful safe erection. The band should not be so tight that it causes pain, yet it must be tight enough to trap the blood in the penis and maintain the erection.

To answer your first question, yes, the device is generally very safe to use, although there have been some serious complications reported. One problem reported was gangrene of the penile skin in a paraplegic man who used a constriction band for three days. Another reported complaint was scarring in the penis related to tension from the ring. Other than these isolated incidents, the usual complaints are minor; they include bruising, pain, coolness of the penis and occasionally pain on ejaculation.

The usual amount of time the construction device can stay on is 20 minutes. However, I have had many patients leave it on for longer amounts of time without any problems. Certainly, though, I would never go beyond an hour, to avoid the possibility that the penis would suffer and scar internally.

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Uses for Yohimbe Root

Q. What are the properties of yohimbe root? What is it supposed to aid in?

A. Yohimbe is an herbal supplement made from the bark of the Pausinystalia yohimbe tree. Until Viagra, the alkaloid yohimbine from yohimbe was the only FDA-approved oral medication for the treatment of impotence. So, yohimbe is available both as an herbal extract and a prescription medication. It does help to increase libido, but its primary action is to increase blood flow to erectile tissue like the penis. It does not affect testosterone levels.

By itself, yohimbe has been shown to be effective in about 40 percent of impotence cases. Its main problem is side effects. Yohimbe can cause elevated blood pressure and heart rate, dizziness, headache, skin flushing, anxiety, panic attacks and hallucinations. It should not be taken by anyone with heart disease, kidney disease or anxiety.

While yohimbe is available as an over-the-counter herbal extract, I would strongly recommend using it only with a doctor’s supervision. If you choose to use an over-the-counter product, be sure to pick one that states the yohimbine content per dose. Most products available in health food stores were found to contain little or no yohimbine when tested.

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Cannot Reach Orgasm or Ejaculate

Q. I am 39 and just got married. My problem is I am having difficulty ejaculating or reaching an orgasm. I really would like to impregnate my wife, but I just cannot. Do you have any suggestions?

A. Problems with impotence include difficulty with erection, failure to maintain the erection, difficulty achieving orgasm, or ejaculatory disturbances. Each of these problems can stem from a variety of causes. Your doctor can help you determine just what is happening in your case.

Difficulty achieving erection can reflect problems with either the nervous system or the blood vessels. This can be due to diabetes, lumbar-sacral disk disease, multiple sclerosis or certain types of prostate or bowel surgery. After an evaluation, your physician may prescribe Viagra to help you achieve and maintain an erection.

Psychologic factors may also come into play. If you have no difficulty achieving an erection and orgasm with masturbation, the problem may be psychological, and you should consider counseling.

Failure to ejaculate can indicate retrograde ejaculation, caused by a weakness of the muscles that close off the opening to the bladder during ejaculation. When this muscle sphincter fails, the semen take the wrong path; they enter the bladder rather than escaping through the urethra. This is best treated by a procedure to recover sperm from the bladder. The sperm can be used for insemination or IVF and ICSI (sperm injection). For more information on this condition, see my previous column, No Semen Comes Out during Intercourse.

If an irreversible neurologic cause is identified, sperm can be retrieved by a procedure called electroejaculation. While the patient is under anesthesia, his prostate is stimulated with an electrical current and a semen specimen retrieved for insemination. Alternatively, sperm can be retrieved directly from the testicle and used for ICSI during an IVF procedure.

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Cannot Ejaculate

Q. I am 18 and am unable to ejaculate. I can get and maintain an erection, but I cannot achieve orgasm by either masturbation or sexual intercourse with my partner. I have spoken about this with my doctor, but he does not consider it to be a serious problem at this stage. I do get “wet dreams” where semen is released in bed at night, so my GP says that my problem is likely to be psychological rather than physical. If this is the case, what can I do about it? Please help.

A.
You are describing a condition called anejaculation This condition is usually diagnosed on the basis of the patient’s description of the problem. Men with anejaculation suffer total anorgasmia, an inability to climax and ejaculate during sexual activity. Some men with this condition are able to ejaculate with masturbation, but most are unable to reach climax under any circumstances while awake. Typically nocturnal emissions are present, as you have noticed.

As your GP has suggested, the cause can be somewhat complex and may be psychological. The best approach for you would be to see a urologist for a detailed history, physical examination, and if necessary nerve stimulation testing to correctly identify the cause. Some medical conditions that cause nerve damage (such as diabetes) may lead to anejaculation.

If you are diagnosed with a psychological basis for anejaculation, don’t worry. The results of behavioral modification therapy and counseling are excellent. Ask your urologist to refer you to a therapist experienced in this area.

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Bloody or Colored Semen

Q. When I ejaculate, sometimes the color is a pale yellow, sometimes dark brown, and sometimes red. There is no pain associated with ejaculation. I have been to a urologist, and he said that there was no sign of infection or anything else that he thought could cause it. He did say he thought it could be a burst blood vessel. I notice that when I am on a exercise regimen, it slowly returns to a “normal” color. What might be causing this, and how would I find out for sure?

A. Your symptoms are suggestive of hematospermia — that is, the presence of blood in the seminal fluid. It most commonly results from nonspecific inflammation of the urethra, prostate and/or seminal vesicles. Most men with hematospermia are young (average age 37). Hematospermia typically resolves spontaneously, usually within several weeks. Most urologists feel that if you are in this age group and the hematospermia goes away on its own within three to four weeks, a full evaluation is not necessary.

However, if the symptoms persist, you will need a complete evaluation. This should include a blood pressure measurement, a genital and rectal exam, a serum PSA test, urine culture, urine cytology and a transrectal ultrasound of the prostate. If everything checks out OK and problem still persists, your doctor may perform a cystoscopy. This procedure involves inserting a small viewing device into the urethra.

Hematospermia may be associated with infections like tuberculosis, cytomegalovirus and schistosomiasis. It may also be a sign of calculi (stones) in the prostate, cysts of the prostate and/or seminal vesicles, and — rarely — a malignancy like bladder or prostate cancer. Your doctor will know more about your risk for these problems. Let me emphasize, though, that hematospermia almost always resolves on its own and is rarely associated with any significant disease.

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Blockage in Ejaculation Duct?

Q. My husband was just told he has stones in his ejaculation duct. We had noticed a problem when we were unable to conceive because no semen came out. He had an ultrasound, and the urologist found the stones. We were told some of them were embedded and therefore cannot be removed. We are trying to get a second opinion before we proceed with surgery. Can stones like this be removed? Will we have a better chance of conceiving after surgery?

A. It sounds like your doctor told your husband that no semen comes out because stones are blocking his ejaculatory duct. This is possible, though not common. Even if obstruction is present, stones in the ejaculatory duct are far less likely to be the cause. In a 1992 study by Larry Lishultz, an expert in male fertility at Baylor University in Texas, only two of 20 men with ejaculatory duct obstruction were found to have calcifications (they were not well-defined enough to identify as stones, so he called them “concretions”) in the ejaculatory duct. More common causes of ejaculatory duct obstructions are growths or malformations within the duct. These are easily identified by transrectal ultrasound and can be treated.

There are other, more common reasons for no semen coming out. The most common is a problem called retrograde ejaculation, which means that when your husband has an orgasm, the semen goes backwards into the bladder. Your doctor can test for this easily by checking your husband’s urine for sperm after an ejaculation.

The next most common cause is obstruction, but not necessarily in the ejaculatory duct. To check for obstruction, a transrectal ultrasound is used. Signs to look for are dilated ejaculatory ducts and dilated seminal vesicles, not stones. Although stones are usually not found in the ejaculatory duct, they are common in the prostate, and they don’t cause problems there unless perhaps they get infected. If your husband’s stones are in the prostate, it makes sense that your doctor cannot get all of them out, because most stones in the prostate are deep, and no one can remove them all without taking the entire prostate out.

The only true way to check for obstruction is to perform a vasogram. This is done by putting a special fluid into the ejaculatory duct and at the same time taking X-rays. The ejaculatory duct is a hollow tube, so the doctor can see exactly where the blockage is — if there is a blockage. Before your doctor does this or any other surgery, find out his qualifications. There are many good urologists who are not experienced in vasography. I am concerned about your husband; I think if you have any doubt after reading this, a second opinion might be in order.

As for your fertility, you will obviously need to deal with the problem of the absence of semen. However, there are many other factors involved in fertility of a couple. Once you have addressed the ejaculation problem, you might ask your doctors (including your own gynecologist) whether you should consider a more complete fertility workup, starting with a semen analysis for your husband.

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