Male Reproductive System

Erectile Dysfunction+-

This is a common problem that affects over a 150 Million men worldwide, affecting 50% of men between the ages of 40 and 70. However only a small proportion seek help, as there are often barriers such as fear of attending the doctor, difficulty in discussing the subject, or occasionally lack of interest by medical professionals. It is also often accepted as a ‘normal’ part of ageing. Either way it is possible to get help from your GP or an interested specialist.

There are a number of risk factors eg diabetes, obesity, smoking, and elevated cholesterol, and a number of studies have now shown that it can a warning sign for heart disease later in life. In addition, there are a number of other physical and psychological causes such as previous pelvic / prostate surgery, radiotherapy, Peyronie’s disease, hormone disorders, psychological factors or occasionally abnormalities of the veins of the penis.

Assessment includes a full history and examination, as well as blood tests to exclude diabetes, a high cholesterol or a low testosterone. It may also be necessary to check the Prostate Specific Antigen (PSA) if there are symptoms or signs of prostate disease.

Treatments for erectile dysfunction+-

There are a range of treatments for this condition, all of which are available at this clinic. They are:

  1. Tablets – ie Sildenafil (Viagra), Vardenafil (Levitra) or Tadalafil (Cialis). Approximately 80% of men with ED will get a good response to these medications.
  2. Intra-cavernosal injection therapy: Following a test-dose and demonstration, this is a self-administered injection that is highly effective in patients who do not respond to tablet therapy.
  3. Vacuum erection device therapy: A minimally invasive and successful method of treatment in those happy to use this advice. Better for those in stable relationships.
  4. Surgery: The mainstay of surgical treatment for this condition is the penile implant, or prosthesis. Typically these are inserted for men in whom all other modalities of treatment have failed or are unsuitable. These include Peyronie’s disease, following radical prostatectomy / pelvic surgery, vascular problems or priapism.
  5. Either an inflatable or flexible device is inserted under anaesthetic, and these devices lead to a reliable erection and high patient satisfaction rates. Devices have improved in recent years and infection rates are down to 2-5%. The operation involves an overnight stay and a catheter overnight.

Penile Implant

Penile implants (or prostheses) are devices used as a last-resort treatment option for men with end-stage erectile dysfunction, where other treatments have failed. Such severe ED can be associated with diabetes, Peyronie’s disease, following radical prostatectomy or other pelvic surgery, pelvic fracture or priapism.

The use of penile prostheses has increased since the advent of PDE5 inhibitors, presumably due to increased awareness of the disease and treatment options, but also due to recent technical advances improved reliability of devices. They are a highly effective form of treatment for the motivated patient (and partner) who has failed, or is not suitable for other forms of therapy.

The results of surgery at high-volume centres are excellent (93% 5 year survival of devices), and satisfaction rates high among patients (up to 89%) Infection rates have fallen to around 2%, and there have been no infections or implants removed in Winchester over the last 3 years. Despite this, relatively few patients in the UK are offered this treatment option by the NHS, and statistically men in other European countries and North America are significantly (X1000) more likely to be receive such treatment when required.

Penile prostheses are available as malleable or inflatable devices, and the choice of implant depends on a number of factors – such as patient preference, other medical conditions, the presence of scarring and cost. Malleable implants are simpler devices, easier and quicker to insert, and have a lower risk of mechanical complications. On the other hand, inflatable devices offer a more natural and concelable result, and are generally more popular as a result.
Patients are carefully counselled beforehand to ensure suitability for the procedure, and undergo thorough pre-assessment to exclude other urological problems, urinary infection etc. The operation takes between one and two hours, requires a tube in the bladder (catheter) overnight, and involves a one-night stay in hospital. Patients do not find the procedure particularly painful, and barring any problems complete healing will have occured by around 6 weeks.
Figure 5: A 3-piece inflatable penile prosthesis showing cylinders (penis), reservoir (pelvis) and pump (scrotum) (courtesy of AMS)

Penile deformity - Peyronies disease+-

First described by Francois de la Peyronie in 1743, Peyronie’s disease affects up to 9% of men during their lifetime, and is sometimes linked to ‘vascular’ risk factors such as diabetes, high blood pressure and high cholesterol. Mr Rees is referred > 100 new patients a year with Peyronie’s disease, and all evidence-based treatment options are available via the clinic.

Peyronie’s is essentially abnormal scarring in the inner lining of the penis, and may manifest itself by a lump, curvature on erection, erectile dysfunction, penile shortening or deformity. Its cause is unclear.

There is no established medical / tablet therapy that can reverse the process, and treatment essentially aims at allieviating symptoms, correcting the deformity and restoring sexual function.

Typically there is an intital painful, inflammatory phase which can be helped with tablet therapy such as Vitamin E or Pentoxyifylline, but while they improve pain, these treatments do not alter the natural history or progression of the disease, or the extent of curvature.

There is emerging evidence for the benefit of vacuum therapy device exercises, and a trial is currently underway to study this in more detail. The inital results are promising, and if you would like to find out more then please do get in touch via the link above.

The use of collagenase is being investigated as a potential injectable treatment for Peyronie’s disease with some promising initial data, but this is not yet approved or in routine use.

The most effective treatment for penile curvature and Peyronie’s disease remains surgical treatment. The three main surgical options are listed below. All are carried out regularly by Mr Rees.

Nesbit procedure: shortening the longer side to produce symmetry and a straight erection
Incision and Grafting (Lue) procedure: to lengthen the scarred (shorter) side, using a piece of vein from the leg or synthetic material.
Penile prosthesis: The best option for men with complex deformities or a combination of significant penile curvature and erectile dysfunction

Peyronie’s Surgery+-

Surgery remains the mainstay of treatment for congenital and acquired forms of penile curvature. The type of operation depends mainly on the severity of the deformity, as well as the quality of erectile function. It is standard practise to allow the disease to stabilise for approximately a year before considering surgery.

One of the most important aspects of Peyronie’s disease is to have realistic expectations of what treatment can achieve. The psychological effects of a penile deformity must not be underestimated, and is important for patients to realise that the underlying disease process cannot be reversed or cured.

The three broad categories of surgery for Peyronie’s disease are

  • To shorten the long / healthy side eg Nesbit procedure
  • To lengthen the short side – ie the Lue (or Incision and Grafting procedure)
  • Penile prostheses – for patients with significant erectile dysfunction or complex deformities

Nesbit procedure

The Nesbit procedure is by far the most commonly performed procedure, where an elliptical area of tissue is removed from the healthy (longer) side of the penis to restore symmetry – thus straightening the erection.

A cut is made in the skin around the top of the penis, and occasionally a circumcision is also required. The skin is pulled back, and after an injection to create an artificial erection, the point of curvature as well as the area to be removed on the opposite side is marked out. This tissue layer, which contains blood during erection, is called the tunica albuginea, and is the layer that is affected by scarring in Peyronie’s disease. The width of tissue removed is proportional to the degree of penile curvature.

The defect is then closed with slowly-absorbing stitches, and the correction checked. The skin is then returned to position, and absorbable stitches placed in the skin.

The above procedure will take a little over an hour to carry out, and the vast majority of patients are day-cases. An anaesthetic block is injected at the end of the penis, and a dressing is placed around the penis that can be removed the next day. Patients can expect some minor bruising and swelling for a week or so, but there are usually no problems with urination or healing. Patients are reviewed at 6 weeks in the outpatients to ensure all is well.

The success rate in terms of satisfaction and durability is high (~ 85% over 15 years1). One has to remember that Peyronie’s disease will progress in a small proportion of men, even if no operation is carried out.

The main drawback of the Nesbit procedure is that of penile shortening, though in 90% of patients this is 1cm or less. Some patients also experience a reduction in sensation, which may be temporary, and others are aware of being able to feel the stitches. However due to the type of slowly-absorbing sutures used, this problem tends to resolve with time. If a circumcision is not carried out, a small proportion may develop tightening of the foreskin subsequently.

Approximately 10% of men undergoing Nesbit procedure will subsequently report weaker erections, and may go on to require medication such as Viagra / Cialis / Levitra. Again, it should be bourne in mind that even without surgery, a proportion of men will develop such problems with time – either as a function of ageing, or as a consequence of the Peyronie’s disease process.

Incision and Grafting – The Lue procedure

The incision is similar to that of the Nesbit procedure, but in this operation, the nerves and blood vessels are carefully moved away from the scarred area of penile tissue, and a cut made into the scarred layer (tunica albuginea). The penis is then straightened and a gap therefore created. A graft is then stitched into this gap to allow lengthening of the scarred side of the penis. The commonest graft type is a piece of vein from the groin (saphenous vein), but artificial materials can also be used.

Satisfaction rates are again high 2, and erectile dysfunction is the main complication (up to 20%). Therefore good pre-operative erectile function is required to undergo this procedure. It is indicated where the penile curvature is greater than 60 degrees, and is popular with men anxious about their penile length.

The procedure can also sometimes be used to treat other deformities of the penis due to scarring, such as indentations or areas of instability.

Penile Prostheses

When a penile curvature is associated with difficulties in maintaining erection, then penile straightening surgery alone may not restore sexual function.

If drugs such as Viagra / Cialis / Levitra are effective, it may be possible carry out a Nesbit procedure and use these medications post-operatively. However where these drugs are not helping, it may be advisable to consider a penile prosthesis from the outset. This device (see penile prosthesis section) will treat both the erectile dysfunction and the curvature. In a large study of American men, 90% of patients with severe Peyronie’s disease undergoing penile prosthesis insertion were successfully using their prostheses 3 years later 3.

References

  1. Ralph DJ, al-Akraa M, Pryor JP. The Nesbit operation for Peyronie’s disease: 16-year experience. J Urol. 1995 Oct;154(4):1362-3.
  2. El-Sakka AI, Rashwan HM, Lue TF. Venous patch graft for Peyronie’s disease. Part II: outcome analysis. J Urol. 1998 Dec;160(6 Pt 1):2050-3.
  3. Wilson SK, Delk JR 2nd. A new treatment for Peyronie’s disease: modeling the penis over an inflatable penile prosthesis. J Urol. 1994 Oct;152(4):1121-3.

Penile skin lesions+-

Abnormalities of the skin of the head or shaft of the penis are common, and most often are due to infection or inflammation. Very rarely, they may represent cancerous or pre-cancerous changes.

Infections of the penis can be fungal or bacterial, and your GP may be able to start you on the necessary treatment, often cream-based. If there is tightening of the foreskin (phimosis), infections of the head of the penis (balanitis) may be recurrent and difficult to clear. In which case, discussion about a circumcision may be necessary.

A fairly common cause of redness, pain +/- white scarring of the penis is lichen sclerosus (or Balanitis Xerotica Obliterans – BXO). This is not an infection, and the cause is not well understood. However it is commoner in diabetic and overweight men.

BXO may start as a red or painful area of the foreskin or head of penis (glans), which does not respond to antibiotic or anti-fungal creams. It can progress to white scarring or pale areas on the head of the penis, eventually causing tightness of the foreskin. In the early phase of the problem, a short course of steroid cream may be useful in reversing the inflammatory changes, but once scar tissue has formed, creams are less useful.

The vast majority of men with foreskin problems associated with BXO are cured by a circumcision, but a small proportion will develop further scarring requiring more extensive surgery such as skin grafts. There is a very small risk of cancerous changes in men with untreated persistent / severe BXO, and it is therefore best to have it treated in the early phase.

Occasionally a penile lesion may have some suspicious features, such as aggressive-looking red areas, raised red areas, ulceration, hardness etc), and these may prompt the Urologist to advise a biopsy. If so, this can often be done with a local anaesthetic (injection), and the results will determine what happens next.

Thankfully penile cancer is very rare in the UK, but if there is an early type of penile cancer, a limited procedure to remove the skin of the head of the penis may be possible (glans resurfacing), and the skin replaced with a skin graft. In larger tumours, it may be necessary to remove part or all of the penis (penectomy), in which case the water-pipe (urethra) can be brought out to the surface beneath the scrotum (penineal urethrostomy). This necessitates passing urine in the sitting position.

Low Testosterone+-

A number of terms have been used to describe the reduction in testosterone that many men experience as they get older – Andropause, Male Menopause. Testosterone Deficiency Syndrome (TDS), Late Onset Hypogonadism (LOH) etc. They all refer to the same condition.

Symptoms include reduced sex drive, erectile dysfunction, fatigue, depressed mood, loss of muscle strength and mass, and increased fat, especially in the abdomen. Low Testosterone can also cause reduced bone density in men, which in more advanced cases can cause osteoporosis and an increased risk of fractures.

A number of studies also show that a low Testosterone can be associated with an increased risk of diabetes or cardiovascular disease, and that treatment can be effective in restoring sexual function, improving mood and energy. Men who are treated will also often experience an increase in muscle, a decrease in fat mass, and improved bone density.

Treatment to restore the Testosterone to normal levels may be considered in men who are both symptomatic and have a significantly lowered Testosterone level. A number of checks need to be done before starting treatment, including prostate specific antigen (PSA), liver enzymes and haemoglobin levels.

Treatment options include gels, patches, and injections, and close monitoring is required in the initial phase. If beneficial, the treatment can be continued in the long-term, and there is some evidence that a normal Testosterone is good for the general health of the ageing male.

The symptoms of testosterone deficiency can be quite non-specific, but a validated questionnaire on the Andropause Society website could help you decide whether you need to medical help:

http://www.andropausesociety.org/self-test-questionnaire

Male infertility+-

Infertility, or Subfertility is defined as failure of conception after 12 months of regular unprotected intercourse. Fertility problems affect approximately 1 in 6 couples trying to conceive, and a male factor is implicated in around half of these couples. Therefore in total, 10% or so of males trying to conceive suffer from infertility.
Perhaps surprisingly, over half of male fertility problems are treatable, but this can often be overlooked.

Causes of Male Infertility

Aetiology

Varicocoele (~40%) – Varicocoeles are due to incompetent valves in the gonadal vein, are present in ~ 35% of men seen in a fertility clinic, and are commoner on the left (90%). The medical literature suggests that repairing varicocoeles improves sperm parameters significantly. Some good-quality studies have shown significant improvements in pregnancy rates, but others have not, and therefore this area remains controversial.

Genetic factors

Cryptorchidism (Undescended testes)

Klinefelter syndrome (XXY) , Kallmann syndrome: (Low pituitary production of LH and FSH), Kartagener syndrome (primary ciliarydyskinesia)

Congenital bilateral absence of the vas deferens (CBAVD)

Changes in the gene responsible for cystic fibrosis cause the vas deferens on both sides to be absent. The inability to palpate either vas in the presence of azoospermia points to this diagnosis.

Congenital Androgen Insensitivity Syndrome (CAIS)

The receptor that binds to testosterone is altered

5-a-reductase deficiency

The enzyme that converts testosterone to the more active form dihydrotestosterone is altered

Persistent Müllerian duct syndrome

Female organs develop in the male embryo

Changes in the Azoospermia Factor (AZF) gene has been demonstrated to;

  • Drugs and Toxins
  • Environmental (Smoking, Marijuana, Alcohol, phyto-oestrogens, general debility)
  • Anti-spermatogenic agents (Cytotoxic chemotherapies, colchicine, sulphasalazine, Nitrofurantoin, Amiodarone)
  • Anti-motility drugs (Propranolol, Chlorpromazine, Quinine)
  • Anti-androgens: anabolic steroids (including testosterone replacement therapy), Spironolactone, Cimetidine, Cyproterone,
  • Testis injury: Post-pubertal bilateral mumps orchitis, torsion, radiotherapy, trauma
  • Obstruction: Chlamydia / Gonorrhoea infection, previous groin or scrotal surgery, congenital absence of vas deferens or ejaculatory system (Wolffian duct abnormality), previous vasectomy, prostate cysts.
  • Ejaculatory disorders: Absence of, or low ejaculate volume may not necessarily be due to obstruction, and can result from retrograde (backward) ejaculation into the bladder, pelvic nerve injury or diabetes.

Investigation

Infertility, or Subfertility is defined as failure of conception after 12 months of regular unprotected intercourse. Fertility problems affect approximately 1 in 6 couples trying to conceive, and a male factor is implicated in around half of these couples. Therefore in total, 10% or so of males trying to conceive suffer from infertility.
Perhaps surprisingly, over half of male fertility problems are treatable, but this can often be overlooked.
Hormone Tests

Men with severely low sperm count should undergo hormonal evaluation (Testosterone, FSH and LH). This will help explain the cause of the problem, and thus determine treatment and outcome. It also examine the other function of the testes – Testosterone production.

Genetic evaluation

Karyotype: Again severely low sperm count or complete absence of sperm in the ejaculate warrants a genetic analysis, as the incidence of chromosomal abnormalities is approximately 5% .
Y-microdeletions: Around 7% of all infertile males, and 23% of those with azoospermia have deletions in an area of the long arm of the Y chromosome – termed the Azoospermia Factor (AZF. This is the area responsible for sperm production, and is divided into AZF a, b and c.

Lifestyle Advice

Patients with mild abnormalities in their semen analysis may well benefit from adjustments in lifestyle to optimise sperm parameters. These include stopping smoking and any recreational drugs, limiting caffeine (1-2 cups / day) and alcohol intake, engaging in moderate (but not excessive) exercise, having a healthy diet including fresh fruit, vegetables and fish, limiting animal fat intake, avoiding excessive heat and limiting emotional stress. Some authorities also recommend nutritional supplements (Vitamin C and E, Selenium, Zinc, Folic acid and CoQ10). Commercially available combined preparations of the above are available. The use of lubricants during sexual intercourse should be avoided.

Andropause & Testosterone deficiency+-

Scrotal problems+-

Vasectomy+-

Vasectomy is one of the most effective and popular methods of contraception, and takes around 20 minutes to perform under a local anaesthetic. If there is difficulty feeling the tubes (vas deferens) or there has been previous scrotal surgery, sometimes a general anaesthetic is preferred.

Vasectomy should be regarded as a permanent method of contraception, and although the vast majority of patients are pleased with the procedure, there is a small risk of complications to be aware of – including bleeding, infection, failure and long-term discomfort in the scrotum in a small number of men.

For a comprehensive patient-information sheet, please refer to the Vasectomy guide on the British Association of Urological Surgeons website – , following links to ‘Patients’ and ‘Fertility or Infertility procedures’.

Vasectomy reversal+-

Vasectomy reversal is performed for around 4% of men who have previously undergone vasectomy. World-wide studies show that the best results are achieved when surgery is carried out with the aid of an operating microscope – achieveing patency rates of up to 97% (and pregnancy rates of 76%) when the interval since vasectomy is < 3yrs. These figures reduce to 79% and 45% respectively when the interval is between 9 and 14 years.

Hence vasectomy reversal carries a higher success rate than a single cycle of IVF (which also necessitates surgical sperm retrieval), and is also considerably cheaper. Other advantages of vasectomy reversal are that it allows for a natural conception, and further children. Furthermore, the success rates of IVF fall dramatically in females over the age of 35, and a successful vasectomy reversal allows for limitless attempts at conception.

Mr Rees carries out micro-surgical vasectomy reversal, and since starting consultant practise has achieved patency in every patient tested to date. Micro-surgical vasectomy reversal allows repair in most situations, including joining the vas to the tubes draining the testis (an operation called epididymo-vasostomy) if the vasectomy was carried out too low to be reversed by a conventional vasectomy reversal . This maximises the success rate, combined with the precise placement of extremely fine sutures.

Mr Rees also works closely with colleagues at the Wessex Fertility centre to offer simultaneous sperm freezing for anyone undergoing vasectomy reversal. This is particularly recommended for those with long obstructive intervals, and removes the need for further testicular surgery to harvest sperm if IVF were required in the future.

The Operation

Initially a consultation to discuss the pros and cons of all the options available, to review the general medical history, and a clinical examination are required, prior to deciding on the best way forward. During this consultation both general and specific risks of surgery are discussed.

The procedure takes approximately 2 hours, and is carried out under general anaesthetic. Two cuts are made in the scrotum, one on either side, and dissolvable stitches are used. It can result in some bruising and discomfort in the scrotum, and patients are advised to rest for 48 hrs after surgery. The operation is most often done as a daycase procedure, though some patients opt to stay overnight.
For a comprehansive information sheet about vascectomy reversal, please go to the British Assocation of Urological Surgeons website and follow links to ‘Patients’, ‘Fertility procedures’ and ‘Vasectomy reversal’.

Circumcision & Foreskin problems+-

Circumcision (surgical removal of the foreskin) is a common and usually straightforward operation that can be carried out under local or general anaesthetic.

The commonest reason for medical circumcision is a tight foreskin (phimosis), which may be causing pain, difficulty passing urine or difficulty with sexual intercourse. Other indications are recurrent infections, inflammatory conditions such as lichen sclerosus (also termed BXO – Balanitis Xerotica Obliterans), and more rarely – penile cancer or pre-cancer. It is also carried out for religious reasons.

The operation takes around 25 minutes, and is carried out as a daycase procedure using special cauterising scisssors and dissolvable stitches. A small dressing is placed over the suture-line, which can be removed later that day. Long-acting local anaesthetic is placed beneath the skin which minimises pain in the post-operative period.

General day-to-day activities can be resumed soon after circumcision, but you are advised to refrain from sexual activity for 4 weeks or so. It is common to get some swelling post-operatively, and uncommon complications include bleeding, infection, reduced sensation and cosmetic dissatisfaction.

For more detailed information about circumcision, please follow the link below to the patient information section of the British Association of Urological Surgeons website:
http://www.baus.org.uk/Resources/BAUS/Documents/PDF%20Documents/Patient%20information/Circumcision.pdf

Frenuplasty

Occasionally the band of skin linking the underneath of the head of the penis to the penile skin (frenulum) is tight or becomes tight after tearing / injury, and the remainder of the foreskin is unaffected and normal. In this case it may be reasonable to cut the frenulum under a local or general anaesthetic, and stitch it in such a way as to elongate it and get rid of the tightness. This appeals to many as it avoids removal of the foreskin, but in approximately 50% of patients undergoing frenuloplasty, there are further problems with the foreskin requiring subsequent circumcision.