CONSULTATION WITH AN EXPERIENCED UROLOGIST-ANDROLOGIST

Any disorders of erection are termed erectile dysfunction (impotence being an obsolete term).

The disease occurs in almost 16% of men and its frequency is seriously higher with age.

The causes of erection disorders can be very different, from psychogenic (15%) to organic (85%), associated with damage to the vessels and nerves of the penis, hormonal imbalance, concomitant diseases, as well as medications taken and undergone oncological surgeries on the pelvic organs (radical prostatectomy, radical cystectomy, etc.).

Modern diagnostics of erectile dysfunction involves collection of the information using special questionnaires, finding out history of the disease, performing laboratory blood tests for certain hormonal and biochemical parameters, as well as the use of special methods that evaluate blood circulation in the penis (penile Doppler ultrasonography, cavernosography, etc.).

Effective treatment of 90% of erectile dysfunction is based on a stepwise principle, starting with the elimination of avoidable risk factors before prescribing drugs, more often in the form of tablets, less often in the form of injections. In 10% of cases, to restore potency, a penile implant surgery is required, the effectiveness of which exceeds 98%. In rare situations, it is possible to perform surgical intervention on the vessels of the penis.

Penile prosthetic surgery – prosthesis implantation in penis for the treatment of severe erectile dysfunction. In this case, the penile implant substitute cavernous bodies without visible signs of the intervention. It's like replacing a tube in a flat tire, but the tire itself stays the same.

There are semi-rigid and inflatable (hydraulic) penile implants. The latter are the most convenient in everyday life, create a more natural erection and are completely invisible.

To achieve an erection with a semi-rigid penile prosthesis, it simply necessary to straighten the penis. Deactivation of the implant is carried out by bending the organ parallel to the scrotum

To achieve an erection with a inflatable penile prosthesis, you need to press several times on the lower part of the pump, which is hidden in the scrotum behind the testicles. The transfer of the implant to an inactive state is carried out by pressing the button in the upper part of the same pump.

Implantation of modern penile prostheses can be done through 3 different skin incisions: on the scrotum, on the pubis or behind the head of the penis. Each method is preferred in specific situations, depending on concomitant diseases. In this regard, it is desirable that the operation is performed by a surgeon who knows all the methods of penile prosthetic surgery, so that the optimal option for a particular patient is applied.

The resource of modern hydraulic penile prostheses exceeds 20 years of service and they are covered by a lifetime warranty against breakage. Semi-rigid implants function on average for about 10 years.

Congenital penile curvature occurs in about 15% of men and occurs due to the uneven growth of this organ.

The disease is manifested by curvature of the penis during erection, which is usually noticed at the time of puberty.

To confirm the curvature of the penis, a man is asked to provide photographs of the erected organ to the consultation. The congenital nature of the deformity is established on the basis of finding out the history of the disease. Unlike Peyronie's disease (acquired curvature of the penis), palpation of this organ does not reveal any tissue indurations.

Only severe (>15°) curvature of the penis can be treated. Deformity correction is performed surgically. The most common is the imposition of non-absorbable sutures, shortening the penis along the convex side.

Surgical penile straightening is a complex plastic surgery, the results of which depend on the experience of the operating urologist.

Peyronie's disease is an acquired curvature of the penis, which occurs due to the growth of fibrous plaques in one of the deep membranes of this organ.

The disease is associated with a genetic predisposition and increases the risk of erectile dysfunction by 3 times.

Peyronie's disease has acute and chronic stages. The curvature of the penis occurs in 90% of cases in the chronic phase and it is ascertained according to the photographs of the erect organ taken by the patient. When palpating, deep tissue seals (plaques) are revealed. In the acute stage, there is pain in the penis during erection.

Treatment of the acute phase of Peyronie's disease is carried out with the help of drugs (pentoxifylline, coenzyme Q10, etc.), which accelerate its transition to the chronic stage.

Curvature of the penis is corrected in case if it has a pronounced character (> 15 °) and only in the chronic stage of the disease.

With normal erection and acceptable size of the penis, its straightening is achieved by applying non-absorbable sutures that shorten the organ along the convex side.

In the case of a preserved erection and small size of the penis, in order to avoid its shortening, the plaque is replaced along the concave side with normal tissues of the patient himself or with those of the donor.

In case of impaired erection, combined with a pronounced curvature of the penis, a penile prosthetic surgery is performed, which resolves both problems.

About 70% of men are not satisfied with the size of the penis, which leads to the popularity of penis enlargement surgery.

Pulling therapy with an extender increases the length of the penis for a short time. However, after lengthening surgery, it is desirable to wear an penile extender to achieve the best lengthening results.

In order to increase the length of the penis, you can use the intersection of the ligament that fixes this organ to the pubic bone. This operation can be performed through an incision in the pubis (more effectively) or on the scrotum (more imperceptible).

It is possible to increase the thickness of the shaft of the penis or its glans by implanting hyaluronic acid gel under the skin of this organ.

In case of severe erectile dysfunction you can simultaneous enlarge the penis with the help of penile prosthesis according to a special sliding technique.

The maximum possible increase in the penis length is no more than 4 cm.

Varicocele is an enlargement of the veins of the testis, more often noted on the left side, and is the most common cause of male infertility.

Most often, varicocele is manifested by pain and discomfort in the scrotum during physical exertion, an increase in the scrotum on the side of the disease and a possible lack of fertility.

Diagnosis of varicocele is based on palpation of the dilated veins of the scrotum in a vertical position. The final diagnosis is confirmed by ultrasound. Semen analysis (spermogram) is mandatory for varicocele.

Varicocele is subject to treatment if it is palpable and abnormalities are detected in the spermogram. An operation is performed to ligate the dilated testicular veins. The highest efficiency was noted with the use of microsurgical technology of surgical interventions (Marmar technique, Goldstein’s technique).

Microsurgical treatment of varicocele requires an expensive surgical microscope, special microinstrumentation and a rare qualification of a urologist in the field of microsurgery. It is safest to carry out such operations with the additional use of Doppler ultrasound during the intervention to ensure the detection and preservation of testicular arteries, to prevent the death of the operated testicle.

Approximately 15% of married couples suffer from infertility, while in half of the cases the man is “to blame”.

Many factors lead to male infertility. In most cases, the cause of the disease remains unknown (idiopathic infertility). The most common known factors include: varicocele, infectious lesions of the genital organs, hormonal disorders, genetic abnormalities, etc.

The most severe but rare manifestation of male infertility is azoospermia (absence of spermatozoa in semen). At the same time, non-obstructive azoospermia associated with impaired sperm production in the testicles is detected more often (80-85%). There is also obstructive azoospermia (15-20%) due to obstruction of the seminal ducts, most often in the epididymis.

Mandatory research method for suspected male infertility is the study of sperm (spermogram) after 3 days of sexual abstinence. With a normal result of 1 analysis, the diagnosis of infertility is refuted. If there are deviations in the semen analysis, another examination of the semen is necessary.

Hormonal, genetic tests and investigations to detect infections in the organs of the reproductive system are used in the presence of appropriate deviations in the spermogram (decrease in the number and mobility of spermatozoa as well as deterioration of their structure, increase in the count of leukocytes in semen, etc.).

In recent years, research on sperm DNA fragmentation has become popular. If this indicator is exceeded, the probability of conception is significantly reduced.

Treatment of male infertility when a causative factor is identified is to eliminate it (treatment of varicocele, hormonal disorders, infectious processes, etc.).

In cases of unidentified male infertility, the optimal result is achieved by treatment with antioxidants.

In case of non-obstructive azoospermia, microsurgical methods of spermatozoa extraction (MicroTESE) are used for their application in different variants of artificial insemination.

In obstructive azoospermia, microsurgical repair of patency of seminal ducts can be performed (vasovasostomy or vasoepididymostomy). It is also possible to perform extraction of sermatozoa from the epididymis through the skin (PESA) or the preferred microsurgical method (MESA).

In the absence of spermatozoa in the semen due to a disturbance of their formation (obstructive azoospermia), microsurgical testicular biopsy (MicroTESE) is used. The essence of the procedure is to search for the thickest seminiferous tubules, which often contain male germ cells with the aim of their further use in various types of artificial insemination.

Efficiency of MicroTESE in terms of detecting spermatozoa reaches 40%, which is several times more effective than conventional testicular biopsy.

In the absence of spermatozoa in semen due to obstruction of the seminiferous tubules (obstructive azoospermia), it is possible to extract spermatozoa from the epididymis either through the skin of the scrotum or microsurgically.

Percutaneous epididymal sperm retrieval (PESA) is performed using a needle that is passed into the tissue through the skin.

Microsurgical epididymal sperm extraction (MESA) is performed using an operating microscope and requires a rare qualification in microsurgery from the operating urologist.

The effectiveness of MESA in terms of obtaining valuable sperm for subsequent artificial insemination is 2 times higher than in the percutaneous technique (PESA).

In the case where a man has completed his reproductive tasks and wants to protect himself from unwanted pregnancies with a partner, a small surgery can be performed to eliminate his fertility by ligating the vas deferens in the scrotum.

The described surgery is male surgical sterilization or vasectomy.

Carrying out a vasectomy is possible in the classical way through a 3-4 cm long incision in the skin of the scrotum under local anesthesia. The disadvantage of this method is significant swelling of the surgery area and a long period of rehabilitation.

A new method of male sterilization is the no-scalpel vasectomy. In this case, the ligation of the vas deferens is carried out through a puncture of the skin of the scrotum up to 3 millimeters long under local anesthesia. The patient can leave the clinic just after 30 minutes since the procedure is finished.

In the absence of spermatozoa in the semen, associated with obstruction of the seminiferous tubules (obstructive azoospermia), it is possible to restore their patency microsurgery.

The term reverse vasectomy comes from the United States, where surgical sterilization of men (vasectomy) was the most popular method to avoid unwanted pregnancy in a partner. But in 20% of cases, situations demanded to restore the fertility of a man through a reverse vasectomy.

Reverse vasectomy is a complex reconstructive surgery performed on the seminal ducts, which is carried out exclusively using microsurgical methods.

There are two types of reverse vasectomy: vasovasostomy, which connects the passable parts of the vas deferens, and vasoepididymostomy, in which a tubule of the epididymis and the vas deferens are sutured.

Complexity of these microsurgical methods of reverse vasectomy lies in the fact that tubules less than 1 mm in diameter have to be sutured.

Among urologists trained in male reproductive microsurgery, the success rate of reverse vasectomy is over 90%. Thus, most of the men who undergo this operation are able to conceive naturally.

In the absence of one or both testicles, a man often experiences psychological discomfort due to the presence of a visible cosmetic defect.

To restore the natural appearance of the scrotum and create the illusion of the presence of the testicles, it is possible to carry out prosthetics of one or both testicles.

High-quality testicular implants fully correspond in size and density to normal organs and relieve a man from psychological discomfort.

Testicular prosthesis surgery takes about 30 minutes and is most often performed under local anesthesia, the patient can leave the clinic in one hour after the surgery.

A short frenulum of the penis is an anomaly in the development of this organ in which the skin cord along the lower surface of the glance is insufficient in length and can be strongly stretched and damaged during intercourse.

The disease is manifested by pain during intercourse and ruptures of the frenulum of the penis, accompanied by severe bleeding. Sometimes men with this anomaly may also have premature ejaculation.

During the treatment of a short frenulum of the penis, which had not been injured, a small plastic surgery is performed, which allows lengthening the frenulum due to transverse dissection and longitudinal stitching of the tissues.

In the event that the frenulum of the penis was injured and unsuccessfully healed, it is necessary to carry out its complex z-shaped plasty.

An ejaculation is termed premature ejaculation if it occurs in less than 2 minutes after intercourse or before it begins. At the same time, there is a lack of control over ejaculation, partner's dissatisfaction and interpersonal conflicts in a couple.

There are primary (congenital) and secondary (acquired) forms of the disease.

Causes of primary premature ejaculation: lack of an important substance, serotonin in the brain, high sensitivity of the glans penis due to excess nerve supply, short frenulum of the penis.

Causes of secondary premature ejaculation: erectile dysfunction, chronic prostatitis, increased thyroid function.

Diagnosis of premature ejaculation is based on information obtained my means of special questionnaires, ascertaining the history of the disease, measuring the duration of sexual intercourse and assessing the sensitivity of the glans penis. Secondary premature ejaculation is searched for erectile dysfunction, chronic prostatitis, and elevated thyroid function.

Treatment of the primary form of the disease can be medical and surgical. First of all, tablet medications are used that allow you to increase the concentration of serotonin in the brain. Local anesthetics may also be effective. For a stable therapeutic effect, in most cases it is necessary to carry out a microsurgical operation to destroy the extra nerves of the penis. In the case of a short frenulum of this organ, plastic surgery to lengthen it can be effective.

The treatment of secondary premature ejaculation consists in treating the causative diseases (erectile dysfunction, chronic prostatitis and overactive thyroid gland).

Plastic surgery of the foreskin of the penis may be associated with its removal or restoration.

Removal of the foreskin is called circumcision. This surgery can be performed for medical, religious or aesthetic reasons. There are more than 5 ways to carry out this operation. The best aesthetic result was shown by the plastic method of circumcision, performed on the basis of geometric principles.

Sometimes we yield a situation when it is necessary to restore the removed foreskin. For this, plastic surgery is usually used using a skin graft from the scrotum. Methods of non-surgical traction of the skin of the penis to restore the foreskin are usually ineffective.

In the presence of the excess skin of the scrotum, which is called the scrotal sail, it looks unaesthetic and visually reduces the size of the penis.

To treat the scrotal sail, plastic surgery is performed to remove excess skin, which favorably affects the appearance of the genitals.

A stricture is a narrowing of the urethra due to scarring of the mucosa layer.

Most often, urethral stricture is associated with previous medical operations and manipulations, less often with trauma and contracted gonorrhea.

Diagnosis of urethral stricture is based on its X-ray examination. In some cases, it may be necessary to additionally examine the urethra with a special flexible endoscope.

Effective treatment of urethral strictures is possible only with surgery. Bougienage of the narrowing and cutting it from the inside improves the situation only for a short time, leading to more growth of scar tissue and additional narrowing of the urethra.

Plastic surgery for urethral stricture is called urethroplasty. If the stricture is short, then the narrowed area can be removed and the normal sections of the urethra can be sutured. For long strictures, it is necessary to build up the urethral mucosa by means of its transplantation from the oral cavity.

Plastic surgery of the urethra requires significant experience from the urologist in performing such operations.

Urinary incontinence, manifested by its uncontrolled leakage, occurs in men most often as a result of surgery on the prostate gland (radical prostatectomy, transurethral resection of the bladder).

Most often, this disorder resolves on its own within 1 year after surgery.

In 8-10% of cases, urinary incontinence persists and requires special treatment.

WFor minor leaks, there can effectively be used pads, penis clamps and special urocondoms.

In case of severe urinary incontinence, a surgery is necessary, implying to implant a special prosthesis - an artificial sphincter of the bladder, which completely restores urinary retention and the man feels healthy again.

Penis fracture is a rupture of the tunica albuginea that surrounds the cavernous bodies of this organ, usually occurring during rough intercourse or masturbation.

A typical sign of this injury is a sharp pain in the penis, a loud crunch, instant fading of the erection and the accumulation of a large amount of blood under his skin, which makes the organ look like an eggplant.

In about 20% of cases, a penile fracture is combined with damage to the urethra, which can be dangerous.

Treatment of rupture of the tunica albuginea consists in its urgent suturing. This allows you to seriously reduce in the future risks of developing erectile dysfunction or curvature of the penis.

Priapism is an abnormally long erection that lasts more than 4 hours.

Priapism is manifested by pain in the erect penis and flaccidity of its head.

The most accurate diagnosis of this disease is carried out after the collection of anamnesis, analysis of the gas composition of blood obtained from the penis, and according to data obtained by Doppler ultrasound investigation, which evaluates blood flow in this organ.

In the absence of timely treatment, severe erectile dysfunction develops, which requires a penile prosthesis .

Treatment of priapism consists of the urgent elimination of erection. For this, first of all, washing of the cavernous bodies of the penis and the introduction of vasoconstrictor drugs into them are used. If these measures are ineffective, different methods of surgical bypass of this organ are used. If priapism lasts more than 24 hours, a penile implant surgery is performed to preserve the function and size of the penis.

Testosterone is the main sex hormone in men that regulates almost all processes in a man's body.

Lack of testosterone is the cause of not only sexual and reproductive disorders, but also the cause of reduced performance, obesity, diabetes, as well as other diseases that significantly reduce a man's life expectancy.

Testosterone usually starts to decline in men after 35 years of age. It reaches a critically low level after 45-50 years. At the same time, this hormonal disorder can sometimes occur at a young age.

Diagnosis of testosterone deficiency is based on the measurement of the content of this hormone in blood in the morning, on an empty stomach, and on assessment of the general symptoms of a reduced content of this hormone using special questionnaires.

Testosterone insufficiency is treated with lifelong prescription of drugs containing this hormone, if the man has no reproductive plans. With there is planned to conceive of a child, an increase in testosterone levels is achieved by indirect stimulation of the testicles by one of the pituitary hormones.