Peyronie's Disease
Peyronie’s Disease, also called penile fibrosis, is a fibrous scar (plaque) involving the outer sheath (tunica albuginea of the corpus cavernosum) that surrounds the spongy erectile tissue of the penis. Peyronie’s disease causes curved and often painful erections that result in foreshortening of the penile shaft length. As the normal soft tissue of the penis expands during an erection, the Peyronie’s plaque remains inelastic causing the erect penis to deviate toward the side of the scar. Plaque that extends around the circumference of the shaft or involving both sides of the penis can create an “hourglass” appearance of the erect shaft. Severe cases can result in erectile dysfunction, as sufficient expansion of the penis is prohibited for a normal or comfortable erection.
Incidence and Prevalence
Peyronie’s disease is relatively common, affecting more than 200,000 American men annually. Diagnosis is made by physical examination rather than blood tests or biopsy. The condition is often diagnosed before it has completed its clinical course, meaning that changes to the plaque and, consequently, to the appearance of the erect penis may occur for several months following identification. In a minority of cases, the plaque will soften and resolve spontaneously; however, usually they either remain stable or worsen for 6-12 months later and be expected to persist indefinitely unless treated. Treatment involving injections or surgery should, therefore, be reserved until the clinical course has declared itself.
Signs and Symptoms
Although each patient is unique, the most common symptoms of Peyronie's disease are:
- Plaque on the top of the shaft that causes the penis to bend upward
- Plaque on the side of the shaft that causes the penis to bend toward that side
- Plaque on both top and bottom that causes indentation and shortening of the penis
- Painful erections
Treatment
Treatment involves some combination of oral medication, intra-lesional (plaque) injection or surgery. While brand-name medication (Xiaflex-Boston Scientific) is available, its expense doesn’t justify its use over Verapamil, a common anti-hypertensive medication that works to soften and shrink the fibrous scar. In our practice, approximately 2/3 of men will see a greater than 50% reduction in both penile curvature and plaque length and density. These results often require multiple injections over a several week course.
It is common to treat with every-other weekly injections for a total of 6 injections. The regimen can be adjusted, however, to suit each individual condition and response to therapy. As a specialty prosthetic surgical practice, we often will incorporate penile Verapamil injection with or without vacuum erection device use in preparation for penile prosthesis placement. This often permits larger implant selection and minimizes additional penile surgery at the time of penile implantation.
Surgical Correction
For those cases where erectile dysfunction is not involved and less invasive measures have failed, specific surgical procedures are available to either incise and relax the scar and permit straightening of the erect shaft or excise the plaque entirely and replace with a more elastic soft tissue patch. Excision with patch grafting, regardless of the graft material chosen, is expected to reduce the eventual erect shaft length at least the distance of the excised plaque. Larger excisions or those occurring along the dorsum (top side) of the penile shaft may result in reduced penile sensation and even in complete erectile dysfunction and should be performed only by a urologist experienced in such maneuvers.
Hypogonadism
Hypogonadism is a condition of testicular hormone (testosterone) underproduction, also known as low testosterone or Low T. Testosterone is commonly known as the male hormone, responsible for male sexual development, libido and instrumental in the cascade of events that produce a normal erection. Testosterone is produced by specific cells of the testis, called Leydig cells. Testosterone produced here is critical to proper sperm production by the Sertoli cells of the testis.
Hypogonadism can have broad-ranging effects that include poor libido, fatigue, muscle loss, increased abdominal fat, impaired sleep, difficulty concentrating and memory loss, depression, irritability, early diabetes and heart disease, as well as infertility, erectile dysfunction, loss of bone mass, hot flashes, and potentially reduced life expectancy after age 50.
Free testosterone levels decline by slightly over 1% each year in men over 45 years of age. This gradual decline is often undiagnosed, but exists in nearly 40% of middle-aged men. A simple blood test of total testosterone is used to establish a diagnosis, with normal levels ranging between 300 - 1,000 ng/dl.
Hypogonadism may be the result of andropause, or male menopause, where the testicles over time fail to produce adequate levels of testosterone. Adropause represents primary hypogonadism, where the problem exists with the testicles themselves failing to produce adequate hormone levels. Other causes of primary hypogonadism are varicocele, where dilation of scrotal veins leads to testicular atrophy and/or abnormal sperm production, and specific endocrinologic conditions like Klinefelter Syndrome. Mumps infection after puberty can also lead to testicular failure and primary hypogonadism within several months to several years after infection.
Hypogonadism can also result from abnormalities with hormone production necessary for adequate testicular function. Deficient production of hypothalamic or anterior pituitary hormones necessary to stimulate testicular hormone production is termed secondary or central hypogonadism, as the underlying disorder exists outside the testicle in the brain. Measurement of pituitary hormones LH and FSH are used to distinguish primary from secondary hypogonadism. Exogenous steroid use (usually anabolic steroid abuse) is another cause of secondary hypogonadism. In this condition, the administered anabolic steroid is detected by the hypothalamus and anterior pituitary in the brain, leading to reduced levels of stimulatory hormones produced by these glands, thereby turning off testicular hormone production and causing testicular atrophy.
Treatment of hypogonadism is accomplished by safely replacing the deficient hormone. Testosterone replacement therapies (TRT) include daily transdermal patches, gels or creams and can be administered by once- or twice-monthly testosterone injection. TRT does not cause prostate cancer; however, because the progression of existing prostate cancer is usually testosterone-dependent, prostate cancer screening with PSA measurement and digital rectal examination every 6 months instead of annually is recommended during TRT.
Varicocele Repair
Varicocele is an abnormal enlargement of the network of veins draining the testicle. It is usually caused by failure of valves in these veins to accommodate the back pressure of blood within the venous column that spans the distance from the testicle to the inferior vena cava and renal vein in the upper torso. Compression of the veins by a nearby structure can also cause a varicocele. Dilatation of these scrotal veins greater than 2 mm represents a varicocele. The increased temperature surrounding the testicle caused by this pooling of venous blood is thought to disrupt normal sperm production and sperm maturation and can lead to male infertility. In over 90% of male infertility cases, bilateral varicoceles can be identified.
Varicocele is a condition of young men, presenting usually between the ages of 15-25 years, and rarely after the age of 40. 98% of varicoceles caused simply by incompetence of venous valves (primary varicocele) occur on the left side, as the insertion of the left gonadal vein into the left renal vein creates a longer and straighter column of venous blood leading to greater vascular back pressure. Isolated right sided varicoceles are rare and should prompt an evaluation for a source of extrinsic compression (secondary varicocele).
Symptoms of a varicocele may include a dull aching within the scrotum, feeling of heaviness in the testicle, shrinkage (atrophy) of the testicle or visible or palpable enlargement of scrotal veins, likened to feeling "a bag of worms". Varicoceles are reliably diagnosed with scrotal ultrasound, documenting dilatation of the scrotal vessels greater than 2 mm and/or reversal of blood flow within the scrotal vessels during an increase in abdominal pressure.
Surgical correction of a varicocele is termed varicocelectomy. This procedure is performed in the operating room as an out-patient procedure through a small inguinal (groin) incision resembling that of an inguinal hernia repair. The procedure is performed with the assistance of optical loupes or under a microscope, permitting identification of the small scrotal veins within the spermatic cord. Intra-operative ultrasound is also performed permitting identification and preservation of the testicular artery carrying blood to the testicle. The individual enlarged veins are simply looped with silk suture and occluded, preventing pooling of venous blood below the suture and allowing the arterial blood flowing to the testicle to cool before reaching the testicle.
Approximately 70% of men diagnosed with abnormal sperm production or maturation who undergo varicocelectomy will respond with improvement in their semen analysis. 50% of these men will go on to father a pregnancy, assuming the female evaluation is normal.
Possible complications of this procedure include bleeding, infection and injury to the testicular artery, which can lead to testicular damage or loss. These complications are uncommon.
Epididymitis
What is Epididymitis?
The epididymis is a long tubular organ that lies above and behind each testicle. It collects and stores sperm made by the testicles prior to ejaculation and is the site of sperm maturation. Inflammation and infection of the epididymis is called epididymitis.
What Causes Epididymitis?
Epididymitis is most common in young men, ages 19 - 35, and is usually caused by the spread of a bacterial infection from the urinary tract. This condition is usually not caused by sexual transmission nor is it considered contagious.
Epididymitis Risk Factors
The following are risk factors for epididymitis:
- Recent instrumentation of the urinary tract
- History of lower urinary tract obstruction (urethral stricture or BPH)
- Being uncircumcised
- Regular use of a urethral catheter
Symptoms of Epididymitis
Epididymitis may begin with a low-grade fever, chills, and a heavy sensation in the scrotum. The area increasingly becomes sensitive to pressure as inflammation mounts and/or the infection progresses.
Other Epididymitis symptoms include:
- Blood in the semen
- Discomfort in the lower abdomen or pelvis
- Pain or burning during urination
- Pain during ejaculation
- Groin pain
- Painful scrotal swelling (epididymis is enlarged)
Diagnosing Epididymitis
Physical examination shows exquisitely tender, and often firm, swelling of the affected side of the scrotum. There may be enlarged lymph nodes in the groin area (inguinal nodes), or a discharge from the penile urethra. A rectal examination may show an enlarged or tender prostate.
These tests may be performed:
- Urinalysis and Urine culture
- Scrotal Ultrasound
- Complete blood count (CBC)
- Urinary test for urethritis
Treatment of Epididymitis
The mainstay of medical treatment includes broad-spectrum oral antibiotics, scheduled oral anti-inflammatories (NSAIDS) and scrotal support (jock strap).
Bed rest, with scrotal elevation and ice pack application, is recommended. It is very important to have a follow-up visit to ensure the infection has not progressed to scrotal abscess or that systemic infection has not developed.
If not treated, or in some, the condition can become long-term (chronic). In chronic cases, there is usually no swelling, but there is often pain associated with epididymal firmness. Chronic epididymitis most commonly relates to the effects of epididymal infection and/or inflammation and is more akin to soft tissue scarring than an active infectious process. Chronic epididymitis is treated with intermittent anti-inflammatory and scrotal support palliative measures, as complete eradication is often only possible with surgical removal of the epididymitis.
Testicular Cancer
Testicular cancer typically develops in young men, but may occur in older men as well. It is a highly treatable and usually curable type of cancer.
What is Testicular Cancer?
The testicles are made up of several kinds of cells and each may develop into one or more types of cancer. It is important to know from which cell type the tumor originated, as each type of testis cancer is treated differently and carry different prognoses.
- Germ cell tumors are the most common type of testicular tumors. Germ cell tumors start in the cells that make sperm
- Stromal tumors start in the cells that make hormones and the cells that support the cells that make sperm
- Secondary testicular tumors are from cancer that has spread to the testicles from other parts of the body
- Lymphoma arises most commonly in elderly men as a form of testis cancer, arising from blood cells.
Risk Factors for Testicular Cancer
- Undescended testicle (cryptorchidism)
- Family history of testicular cancer
- HIV infection
- Testicular CIS (carcinoma in situ)
- Cancer of the other testicle
- Age 20 to 34, but can affect males of any age
- Caucasion Americans
- Tall men
Signs and Symptoms of Testicular Cancer
In most cases of testicular cancer, a noticeable lump or the feeling of heaviness is felt in the affected testicle, usually with little pain. Men with testicular cancer may also notice a feeling of heaviness or aching in the lower belly or scrotum in general.
Rarely, men with germ cell testis cancer notice their breasts are sore or have enlarged. This happens because some germ cell tumors produce high levels of a hormone called human chorionic gonadotropin (HCG), which causes the breasts to grow. Blood tests can measure HCG levels. These tests are important in identifying, staging, and monitoring of some testicular cancers.
Some stromal tumors can also make hormones. If the tumor makes male hormones (androgens), it can cause the growth of facial and body hair at an early age in boys. The extra androgens are not likely to cause any symptoms in older, post-pubertal men. Some stromal tumors make female hormones (estrogens) that can cause breast enlargement or loss of libido.
How is Testicular Cancer Treated?
After the cancer is diagnosed and staged by surgical removal of the testis and with serum tumor markers and radiographic imaging studies, Dr. Cornell will talk to you about your treatment choices. You should take time to consider each treatment option, often in consultation with a medical oncologist.
The three main methods of treatment for testicular cancer are:
- Surgery to remove lymph nodes that serve as common sites of testis tumor spread
- Radiation therapy to these areas outside the scrotum and pelvis
- Chemotherapy
- Surveillance following primary testis removal
The relative effectiveness of each treatment option will depend on the specific cell type of the original testis tumor, the stage of the disease, your age and overall health and your willingness or ability to participate in regular surveillance protocols. Regardless of your particular diagnosis, however, a lifetime of tumor surveillance with Dr. Cornell and / or your medical or radiation oncologist will be necessary.
