Archive for Urology

What is Benign Prostatic Hypertrophy?

benign prostatic hypertrophy

Benign Prostatic Hypertrophy (BPH) is the presence of an enlarged prostate gland, a condition which is more prevalent in older men. Men who suffer from BPH experience many of the same symptoms as prostate cancer; however, BPH is non-cancerous and the presence of this condition does not mean that a man is more likely to develop prostate cancer in the future.

What is Benign Prostatic Hypertrophy (BPH)?

Although BPH is common in older men, many may still ask “What is BPH (benign prostatic hypertrophy)?”

BPH is the inflammation or enlargement of the prostate gland. The risk for developing BPH increases with age, because as men get older, their prostate enlarges. The reason behind this is attributed to changes in hormone levels. As men get older, the amount of active testosterone in the blood drops, resulting in a higher proportion of estrogen, which is suggested to promote cell growth in the prostate gland and lead to prostate enlargement.

According to the National Institutes of Health (NIH), BPH is prevalent in more than 50% of men over age 60 years and in around 90% of men over the age of 70 years.

Location of Prostate Glands and Relationship to BPH Symptoms

The prostate gland is located behind the rectum and below the bladder. This gland surrounds the urethra, which is the thin tube that carries blood from the bladder to the outside of the body. The main function of the prostate gland is to help produce semen, which is also transported from the body during ejaculation via the urethra in men.

When the prostate gland is enlarged by a condition, such as BPH, it impinges on the bodily functions in that region. As such, BPH symptoms include many urinary-related symptoms that are also often seen in men who have prostate cancer.

BPH Symptoms and Warning Signs of Enlarged Prostate

The most common BPH symptoms are problems associated with urinating, as the enlarged prostate pushes on the urethra and bladder. BPH symptoms include the following:

  • difficultly beginning to urinate
  • a feeling of incomplete emptying of the bladder
  • waking up multiple times in the night in order to urinate
  • the sudden urge to urinate
  • frequent urination
  • pain when urinating

If the bladder does not completely empty, a urinary tract infection can occur. Some men may also experience blood in their urine, which occurs becuase blood vessel are broken on the inner surface of the enlarged prostate or a sudden streching of the bladder.

How to Distinguish BPH Symptoms from Prostate Cancer

While men who suffer from BPH experience many of the same symptoms as prostate cancer, BPH is non-cancerous and the presence of this condition does not mean that a man is more likely to develop prostate cancer in the future. However, a man who is experiencing BPH symptoms must first undergo some screening tests, such as a PSA test and DRE (digital rectal examination), in order to rule out the presence of prostate cancer. As such, any man who experiences BPH should seek help from their doctor.

While one-third of all mild cases of BPH can be resolved without any treatment at all, when a man in inconvenienced by his BPH symptoms or the condition is posing a problem to his health, pharmacological drug therapy can be employed, with surgery reserved for more severe BPH cases.

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Estrogen-Containing Foods & Male Function

Q. Can eating foods containing phytoestrogens lower a man’s testosterone ratio, thus leading to erection dysfunction?

A. Estrogen supplements can lower testosterone, and in fact some of the early forms of treatment for prostate cancer were estrogen therapies to lower testosterone production. However, I am unaware of any study with phytoestrogens that has been shown to affect testosterone levels.

In urology, the most famous phytoestrogen is an herb called saw palmetto. This substance has been investigated extensively, and it is commonly used for enlarged prostates. Some studies have shown that it can affect prostate growth without affecting sex drive or testosterone production.

If you are concerned about your hormone levels, you could simply ask your doctor to check blood levels of testosterone. If your hormone levels are low, you should see an endocrinologist who specializes in such problems to get it corrected.

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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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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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Antidepressants & Ejaculation Problems

Q. I am 59, and my wife and I have experienced very good sex for 40 years. A few months ago, I experienced an extreme attack of acid reflux and passed out. Our family doctor gave me Paxil and Prevacid. Now I have no erection. The doctor gave me Viagra, and it works, but I have not experienced ejaculation since I started the Paxil and Prevacid. We need help. My wife is beginning to feel that she no longer can satisfy me. I’m glad I “last” longer, but an hour (or all night) is too much! What can I do to ejaculate?

A. Your situation is not uncommon. The medication Paxil, typically prescribed for depression or anxiety, has been known to cause inability to ejaculate. As an antidepressant, it changes chemical activity in the central nervous system, which is the key center controlling ejaculation. That means your penis will stay hard longer and you will be sexually aroused and full of pleasure, but you will not be able to have an orgasm. When I have a patient with similar complaints on Paxil, I suggest asking the prescribing physician to change the Paxil.

Interestingly, Paxil and related drugs are sometimes used to treat premature ejaculation. Men with this common problem ejaculate very quickly with minimal genital stimulation. In such a case, the antidepressant’s side effects can be a benefit.

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Abundant Ejaculation from Genital Massage

Q. My husband and I are both 28. We were both virgins when we married three years ago. He has always experienced delayed ejaculation even after prolonged foreplay and intercourse, which has frustrated him. Recently, I have been giving him “hand jobs” with startling results — instead of the usual one or two teaspoonfuls of ejaculate, copious amounts of a translucent liquid come out, and I am also able to give him multiple ejaculations. This surprise discharge ONLY occurs after prolonged lovemaking, followed by my hand job with lubricant. However, my husband is worried that he’s urinating on me during these awesome orgasms, and this has tempered his enjoyment. I say he’s ejaculating semen, but he says he has trouble believing this because of the great volume of discharge. Could you please calm his fears? These genital massages are a delicious tool in our lovemaking.

A. I can assure you men do not urinate during orgasms. Neurologically, the pathways for urination and ejaculation are different. The nerves that control ejaculation cause the bladder to relax and the bladder outlet (bladder neck) to stay closed. Therefore men do not have to worry about urinating while they have an erection — physiologically it is not possible.

Commonly couples have this concern about the pre-ejaculate fluid, which is clear and watery. It usually precedes the orgasm and semen ejaculation. Normally a man produces varying amounts of this fluid from secretions in the seminal vesicles and periurethral glands. This is normal, and it may contain sperm. During the ejaculation itself, about 3-5 milliliters (about a teaspoon) of semen is projected.

Large amounts of ejaculate can be collected from men depending on the nature of the orgasm. The natural process might occur as follows. First, there is stimulation of the erect penis, which starts production and secretion of fluid from the periurethral glands and prostate. This fluid accumulates in the prostatic urethra, which can hold up to 75 milliliters (15 teaspoons) of this fluid. Only a small amount of the fluid leaks out before the man reaches orgasm. The amount of fluid produced depends on the amount of stimulation and the time to orgasm. For instance, most men reach climax in 90 seconds, so only a small amount is produced. However, when there is prolonged intense stimulation, there is prolonged secretion. Then, when the man reaches climax and all the fluid is ejected out of the prostate and seminal vesicles, there can be large amounts of watery ejaculate.

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Will Sex Supplement Harm Prostate?

Q. I am 53 and have the general symptoms of benign prostate enlargement. A year ago my PSA was less than 4. I have been taking an over-the-counter herbal prostate pill twice a day for about two years, with no side effects. I’d like to know if it’s safe to also take a testosterone-precursor type of herbal supplement. I see several products advertised for increasing libido, but I have not seen any discussion as to the effect on the prostate. I am hesitant to consider such a pill at my age, due to my concern with prostate enlargement.

A. I can assure you, you are not alone. You see, as a man ages, his prostate continues to grow, due a variety of hormonal changes in the prostate gland itself. Most experts agree that increasing the amount of testosterone in the gland will cause an increase in growth of the gland and a worsening of the urinary problems that often occur with prostate enlargement. A form of testosterone called dihydrotestosterone (DHT), which is made in the prostate, is particularly thought to cause such growth. To complicate things further, prostate cancer grows in the presence of testosterone. Any man taking testosterone supplements needs to be aware of the risk of promoting and spreading prostate cancer.

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Overcoming Premature Ejaculation

Q. I’m a 34-year-old man. I’m in good shape, and I watch my diet. However, I’ve always had a problem of early ejaculation. I used to think it was because I was young, but it has gotten so bad that I am sometimes afraid of having sex because I may not “do the job well.” I don’t talk about it because I sometimes feel it’s just petty, but it has obviously been bothering me for some time. Do you have any suggestions?

A. Let me congratulate you for sharing such a difficult situation with me. You are going to be fine, since you just took the first step — talking about it.

In fact, many men have this problem. It’s called premature ejaculation, and there are many good treatments available. The best treatment starts with telling someone who cares about you. Keeping it a secret only adds to your frustration and stress, generating fear of failure or performance anxiety that only makes the problem worse. On top of that, your own ego is hurt, which can cause embarrassment and guilt. Your partner, on the other hand, may not know what happened and take the blame personally. All of that can be avoided.

Traditionally, premature ejaculation has been seen as a psychological problem — a learned response in which the ejaculatory reflex is activated sooner than desired. It has therefore been treated with a variety of behavioral techniques to help your body learn new patterns.

The two most common approaches are the stop-start technique and the squeeze technique. In the stop-start technique, you and your partner work together to delay ejaculation. Every time you feel like ejaculating, both of you stop; when the sensation subsides, you restart. You can try this on your own or with the help of a behavioral therapist. The squeeze method involves using your hand to squeeze either the head of the penis or the base of the penis anytime you get the urge to ejaculate. Or you can use a constriction band, sold through most pharmacies, called the Actis ring. This squeezes the base of the penis for a more prolonged erection.

Studies have shown a 60-90 percent success rate in overcoming premature ejaculation using such behavioral techniques. However, you must be patient, as these methods may take up to six months to work completely. More important, you can take advantage of this time to develop new approaches to making love and to learn to satisfy your partner in many ways.

The use of medication to treat premature ejaculation is relatively new, but it can provide excellent, immediate responses with minimal side effects. These agents alter the metabolism of serotonin and other neurotransmitters in the brain to inhibit the ejaculatory reflex.

One such medication is clomipramine (Anafranil), an antidepressant. Urologists at Case Western Reserve University found good response to this drug in a carefully selected group of men — specifically, patients who were in stable relationships and who had a lifelong history of premature ejaculation, no evidence of erectile dysfunction, and no evidence of psychological disorders. The researchers noted some side effects, including hot flashes, headaches or nausea. Still, 79 percent of the men in the study were able to tolerate the drug. Later studies found that 25mg of clomipramine, given daily, increased time to ejaculation by 249 percent, and higher doses produced an increase of 517 percent. Because of side effects at those dosages, most doctors advise using the drug less frequently or only in anticipation of intercourse.

Men with a history of psychiatric disorders or who are taking other antidepressants should not be given clomipramine, as it may interact with other medications. One study demonstrated changes in sperm, perhaps affecting fertility, that may reflect such interaction.

Another group of antidepressant medications, the selective serotonin re-uptake inhibitors (SSRIs) also work well, with infrequent side effects (such as loss of appetite and headache). I have prescribed the SSRI sertraline (Trazdone, Zoloft) with excellent results, but only after a careful examination and a medical/social history to make sure the patient really has premature ejaculation; otherwise, the drug might cause priapism (prolonged erection). Two other SSRIs — paroxetine (Paxil) and fluoxetine (Prozac) — are now under investigation for this use.

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No Semen Comes Out During Intercourse

Q. I have no problem with erection, but no semen comes out from either masturbation or even intercourse. A doctor has checked for prostate problems and it is negative. I used to be able to produce semen. I am diabetic.

A. You probably have a common condition called retrograde ejaculation, which is frequently seen in people with diabetes. The semen enters the penis via the ejaculatory ducts, which pass through the prostate. At the time of ejaculation, a muscle at the opening to the bladder squeezes shut. With each muscle contraction, the semen is propelled down the urethra and out the opening of the penis. However, if there is nerve damage due to diabetes, the muscle at the opening to the bladder will not close off properly, and the semen enters the bladder instead of shooting out the end of the penis.

Your urologist can diagnose this condition easily by checking your urine for semen after ejaculation. If this is the problem, you may try medication to strengthen the function of the muscle that closes the bladder. Or you may have sperm collected from the bladder to use for insemination or for in vitro fertilization.

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No Ejaculation, Just Prolonged Oozing

Q. When I am fortunate enough to have an orgasm, very little ejaculate comes out. The problem is that after an orgasm, the ejaculate oozes out over the next five to 10 minutes. Without the discharge of semen, this reduces the intensity of the orgasm as well. I know that jumping up and urinating will solve most of the problem, but on occasion it will continue to ooze even after urination (though not in the same quantity). Can you offer any advice?

A. I have only seen one patient with the problem of orgasm without ejaculation (squirting of semen), followed by a slow release of semen. In that case, the man had a blockage, called a stricture, in the urethra (the tube in the penis that carries urine and semen out of the body). The semen was released, but it couldn’t get out of the penis during orgasm. Instead, it would slowly drip out afterward.

Such a stricture may also cause difficulty in urinating. The stream would be weak and may require straining to get started. In addition, my patient had urinary frequency (the need to urinate often) and a lot of dribbling.

Diagnosis of a stricture can be made either with an X-ray exam called a urethrogram or with a cystoscopy. The urethrogram consists of putting a tube in the opening in the tip of the penis and slowly filling the urethra up with a special fluid while taking X-rays of the penis. Cystoscopy involves putting a miniature viewing device into the opening and advancing it up the urethra looking for the blockage. If this is done in the operating room, then once the blockage is found it can be treated at the same time.

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