Urinary Incontinence- You Are Not Alone and You Don’t Have To Suffer In Silence

October 22, 2014

I am writing this blog to let you know that incontinence is common in middle aged and older women. One in four women struggle at least occasionally with incontinence. One in five people over 40 deal with an overactive bladder or inability to control the urge and reach the toilet in a timely fashion. One in three women over 80 are incontinent.

Unfortunately many doctors don’t raise the issue with patients during visits, and many patients are uncomfortable of bringing up the subject with their healthcare provider.

The critical valves in a woman’s pelvis seem to become a problem as we age. As women age they get leaky valves in the colon, heart, and the lower urinary tract. The quality of the supporting tissues and structures fail as women get older. It fails as women have other types of treatments. Neurologically, things can fail. In this country, one of the problems we have is morbid obesity and that certainly increases the risk of urinary incontinence, leakage.

For most women with urinary incontinence there are almost always conservative options that don’t involve surgery.

Often very simple lifestyle changes can help patients tremendously, without any invasive therapy, without any medication, without any surgeries.

It begins with the diet. There are certain foods that are irritative to the lower urinary tract. The most common culprits are alcohol, caffeine, spicy food, acidic food.

Next are exercises: Doing pelvic floor exercises, Kegel exercises, for both men and women, can be helpful.

Are there medical and surgical options and when do those come into play?  Yes, there are medications for treating overactive bladder.

Surgical options are something that are considred after they’ve failed conservative therapies.

The most important thing in this population is improving quality of life, and in order to get at that, your doctor needs to look at the entire person. Patients need to understand that they need to get involved in long-term exercise routines and dietary modification will be helpful.

Most of incontinence is not life-threatening, but if people leak and they can’t see, and they’re up in the middle of the night and they fall, the mortality rates are high.

Bottom Line:  Urinary incontinence is a common condition that impacts the quality of life of millions of American women.  Help is available and often conservative treatments will control the problem.  For more information consult with your gynecologist or your urologist.

What if I think my medicine is affecting my sex life?

October 22, 2014

In the previous blog I discussed the relationship between medications and sexual performance. This blog will make suggestions on how to approach your doctor and what are some of the options when drugs\medications impact your sexual performance.  If you are at all worried that your medicine may be affecting your ability to have sex, consult with your physician who prescribed the medication.

Do not stop taking your medicine without first talking to your doctor.

Do not be put off seeking help. Your quality of life is important, particularly if you are being treated for something like high blood pressure, which often has no symptoms and can require lifelong treatment.

Treatment of high blood pressure

  • Impotence seems to be less of a problem with ACE inhibitors such as enalapril.
  • Calcium channel blockers and alpha-blockers cause fewer sexual problems than diuretics (water tablets) or beta-blockers.
  • Loop diuretics such as furosemide have a lower risk of impotence than thiazide diuretics.

Treatment of depression

  • SSRIs cause the highest frequency of sexual dysfunction, followed by MAOIs (monoamine oxidase inhibitors) and then tricyclic antidepressants.

Treatment of high cholesterol levels

  • Not all statins are associated with sexual problems. Even in those that are, the risk of developing such problems is very low.
  • Statins may be less likely to cause impotence than fibrates.

Bottom Line: Your doctor may switch you to another medicine in the same class, i.e., that acts in a similar way, in the hope that the new one will not cause the same side effects.

Alternatively, your doctor may try a different type (class) of medicine altogether, providing it is suitable for you to take.

Your doctor may also adjust the dosage and prescribe a lower dose which may have the desired effect on your blood pressure or your depression and not have the unwanted side effects of ED or lowering the testosterone level. The real bottom line is to speak to your physician to help with your medications and preserve your sexual performance.

Medicines and Your Performance In the Bedroom

October 22, 2014

There are hundreds of medicines, some commonly used drugs, that can affect a man’s sex life and sexual performance.  Many of these drugs are necessary for treatment of depression and hypertension and shouldn’t be stopped.  This blog will discuss the causes of medications and deterioration of sex drive and sexual performance.

How can medicines affect sexual function?

The mechanism of sexual function involves a complex coordination of hormones, chemical messengers in the brain (neurotransmitters such as dopamine and serotonin) and the sexual organs. In general:

  • dopamine increases sexual function
  • serotonin inhibits sexual function
  • the hormone testosterone is important, as are the blood vessels supplying the penis are also involved in producing an erection.

A medicine can therefore affect sexual function in several ways.

Libido or sex drive

Sex drive is influenced by reproductive hormones, particularly testosterone, which is required for sexual arousal.

Medicines that reduce the testosterone level or block its effects are likely to reduce sex drive.

Libido is also affected by your general emotional and physical health. Medicines that affect any of these aspects, even indirectly by causing drowsiness, lethargy, weight gain or confusion, have the potential to reduce your sex drive.

An erection is the result of coordination between nerves, hormones, blood vessels and psychological factors. This means there are many areas where things can go wrong.

Medicines that have a physical effect on the blood vessels in the penis, those drugs that act on the brain or interfere with hormone levels (particularly testosterone) or affect the transmission of nerve messages, can all cause impotence.

Ejaculation is a complex reflex process that involves the activation of alpha receptors in the prostate gland and seminal vesicles.

Medicines that block alpha-receptors can interfere with ejaculation.

During ejaculation, increased alpha-receptor activation closes the bladder neck, facilitating the normal flow of semen out of the penis.

If this mechanism is disrupted, it results in retrograde ejaculation, with semen flowing along the path of least resistance from the urethra up into the bladder.

Various chemicals in the brain are also involved in orgasm and ejaculation, and medicines that affect these chemicals can also cause ejaculatory disturbances.

The most widely prescribed centrally acting agents that affect ejaculation are selective serotonin re-uptake inhibitor (SSRI) antidepressants.

Antidepressants are the medicines most frequently implicated in causing sexual dysfunction. This is because they work by altering levels of chemicals in the brain. In particular, SSRIs increase serotonin levels, which inhibits sexual function.

Blood pressure lowering (antihypertensive) medicines are also implicated, although the mechanism by which they cause sexual problems will vary from medicine to medicine.

The table of medicines below lists the sexual side effects that some people have reported during their use.

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Antidepressants Main use Possible effect on sexual function
MAOI antidepressants (eg moclobemide, phenelzine) Depression Decreased sex drive, impotence, delayed orgasm, ejaculatory disturbances
SSRI antidepressants (eg fluoxetine) Depression Decreased sex drive, impotence, delayed or absent orgasm, ejaculatory disturbances
Tricyclic antidepressants (eg amitryptiline) Depression Decreased sex drive, impotence, delayed or absent orgasm, ejaculatory disturbances
Antiepileptics Main use Possible effect on sexual function
Carbamazepine Epilepsy Impotence
Antihypertensives Main use Possible effect on sexual function
ACE inhibitors (eg enalapril, lisinopril) High blood pressure, heart failure Impotence
Alpha-blockers (eg prazosin, doxazosin) High blood pressure, enlarged prostate Impotence, ejaculatory disturbances
Beta-blockers (eg atenolol, propranolol and including timolol eye drops) High blood pressure, angina, glaucoma Impotence
Calcium channel blockers (eg verapamil, nifedipine) High blood pressure, angina Impotence
Clonidine High blood pressure Impotence, decreased sex drive, delayed or failure of ejaculation
Methyldopa High blood pressure Impotence, decreased sex drive, ejaculatory failure
Thiazide diuretics (eg bendroflumethiazide) High blood pressure Impotence
Antipsychotics Main use Possible effect on sexual function
Phenothiazines (eg chlorpromazine, thioridazine) Psychotic illness Ejaculatory disturbances, decreased sex drive, impotence
Risperidone Psychotic illness Impotence, ejaculatory disturbances
Cholesterol lowering medicines Main use Possible effect on sexual function
Fibrates (eg clofibrate, gemfibrozil) High cholesterol Impotence
Statins (eg simvastatin) High cholesterol Impotence
Other Main use Possible effect on sexual function
Benzodiazepines Anxiety and insomnia Decreased sex drive
Cimetidine Peptic ulcers, acid reflux disease Decreased sex drive, impotence
Cyproterone acetate Prostate cancer Decreased libido, impotence, reduced volume of ejaculation
Disulfiram Alcohol withdrawal Decreased sex drive
Finasteride Enlarged prostate Impotence, decreased sex drive, ejaculation disorders, reduced volume of ejaculation
Metoclopramide Nausea and vomiting Decreased sex drive, impotence
Omeprazole Peptic ulcers, acid reflux disease Impotence
Opioid painkillers (eg morphine) Severe pain Decreased sex drive, impotence
Prochlorperazine Nausea and vomiting Impotence
Propantheline Gut spasm Impotence
Spironolactone Heart failure, fluid retention Impotence, decreased sex drive

Bottom Line: This blog makes the connection between medications and sexual performance.  The next blog will discuss how to

approach your physician and what options are available for men who have sexual side effects from medications.

Testosterone and Its Impact On the Heart-Here’s the Good News

October 22, 2014

I am frequently queried by my patients about the safety of using testosterone and the risk of developing heart disease or a stroke. I would like to give you the evidence from the medical literature, and then help you make an informed decision if testosterone replacement is right for you.

Men have more than twice the risk of dying from coronary disease than women. It has been assumed that testosterone is deleterious to the male cardiovascular system and contributes to the risk of heart disease. In fact, there is little evidence that testosterone produced in body by the testicles is an adverse risk factor but the role of testosterone status and replacement therapy on male health is controversial.

High doses of anabolic steroids often used by body builders and athletes are undoubtedly associated with cardiac disease but these are doses much higher than what the body normally produces. Testosterone levels within the normal range do not appear to be harmful. Indeed, low rather than high testosterone levels in men are associated with several cardiovascular risk factors including an atherosclerosis or hardening of the arteries, insulin resistance, and obesity.

Let me give you information first from animal studies where the scientists can control the variables. Studies in male animals have shown that castration or induced hypogonadism increases atherosclerosis and testosterone replacement prevents this. In addition, testosterone has beneficial effects in men with cardiac disease. Testosterone is a potent coronary artery vasodilator. Testosterone therapy reduces total cholesterol, fat mass, waist circumference and pro-inflammatory cytokines associated with atherosclerosis, diabetes and the metabolic syndrome. Testosterone also improves functional capacity of the heart and insulin resistance in men with heart failure.

In an ageing male population low serumotal testosterone is common and has a prevalence of 30% in men over the age of 60 years. Testosterone deficiency may cause undesirable effects such as loss of bone and lean body mass, increased adiposity, low energy and impaired physical and sexual function. Until recently, these effects were viewed as the natural physiology of aging; however, four recent major studies have found low testosterone to be associated with increased all-cause mortality after controlling for baseline morbidity and age.

The effect of testosterone on mortality has demonstrated an increased risk of death due to cardiovascular diseases in men with low testosterone. One report found that mortality due to any cause and cardiovascular mortality was increased with a reduction in serum testosterone. Low testosterone status is therefore associated with mortality and vascular mortality, yet no study has specifically examined patients with established cardiovascular disease. This is important because men with manifest coronary artery disease are at a higher risk of cardiovascular mortality and represent a patient population prone to testosterone deficiency. In addition, those men with angina, chronic heart failure or diabetes may derive particular symptomatic benefit from androgen replacement therapy.

This study had two aims: first to assess the impact of testosterone status on life expectancy in men with pre-existing coronary disease, and second to identify the prevalence of biochemical testosterone deficiency in men with coronary disease. Our hypothesis was that low serum testosterone would be associated with an adverse survival.

One excellent study that was peer reviewed showed that the prevalence of testosterone deficiency is common in men with coronary disease and is present in 25% of the men. The data have confirmed that low T is related to all-cause and vascular mortality in a coronary disease population. Therefore, the study also concluded that borderline low levels of T may also have an adverse impact on survival.

This study is entirely consistent with previous studies of low testosterone as a cause of decreased life expectancy.

What is the pathophysiology of low testosterone status and the apparent increased mortality of atherosclerotic disease? Animal data show that testosterone deficiency accelerates atheroma or atherosclerosis and replacement with testosterone prevents this. Human studies have shown an increased progression of atheroma in men with lower testosterone. These data therefore suggest that testosterone deficiency is associated with progressive atherosclerosis and replacement, in animals at least, prevents this progression of the heart disease.

We have demonstrated that testosterone deficiency is associated with premature death in male patients with vascular disease; many of these patients died and will continue to die from cardiovascular disease. There is scientific evidence and several documented trials showing benefit in terms of risk factor modification and symptoms. If androgen deficiency is part of the underlying pathophysiology of atherosclerotic disease in men, then the serum testosterone level could be viewed as a modifiable risk factor as men can increase the T level by testosterone replacement therapy. Physiological testosterone replacement is an inexpensive and well-tolerated therapy but does require careful monitoring.

Bottom Line: Testosterone deficiency is common in middle aged and older men. Low testosterone levels appear to cause men to be at an increased risk of cardiovascular disease and even increased risk of death. Hormone replacement therapy for men who are symptomatic may be protective of heart disease but these men require close follow up consisting of a PSA test, a digital rectal exam, and a blood count to check that there is not an increased production of red blood cells.

Are Statins Responsible For Placing Your Sex Drive In the Tank?

October 22, 2014

Statin therapy prescribed to lower cholesterol also appears to lower testosterone, according to a new study that evaluated nearly 3,500 men who had erectile dysfunction or ED.

Current statin therapy is associated with a twofold increased prevalence of hypogonadism or low T a condition in which men don’t produce enough testosterone.

About one of six adults in the U.S. has high cholesterol, according to the CDC. The number of people using a statin (such as Lipitor or Zocor) rose from 15.8 million people in 2000 to 29.7 million in 2005.

The Italian study evaluated 3,484 men with complaints of sexual dysfunction between January 2002 and August 2009.

Of that total, 244, or 7%, were being treated with statins for their high cholesterol. Most often the statin was simvastatin (Zocor) or atorvastatin (Lipitor).

The researchers calculated the men’s total testosterone as well as free testosterone, the amount of unbound testosterone in the bloodstream.

When they compared men on statins to those not, the men on statins were twice as likely to have low testosterone.

The researchers emphasize they have found a link between statins and lower testosterone.

One possibility is that low testosterone levels and the need for statin treatment share some common causes.

Some researchers also have looked at the possibility that the statins’ inhibition of cholesterol synthesis may interfere with the production of testosterone, which depends on a supply of cholesterol. The statins may disrupt the body’s feedback mechanism to instruct it to make more testosterone.

Bottom Line: There appears to be documented study that links statin use to low testosterone. If you have symptoms of low T, lethargy, decreased sex drive, or erectile dysfunction and are using a statin, speak to your doctor. He will likely order a testosterone level and suggest hormone replacement therapy if the T level is low or provide you with suggestions to lower your cholesterol that don’t require the use of statins.

Urinary Incontinence-Common Problem With Good Solutions

October 22, 2014

Millions of American women suffer from loss of urine or urinary incontinence. The problem is a source of embarrassment and lead to social isolation and even depression. This blog will discuss the three types of incontinence and offer some suggestions for solving the problem.

Some women with incontinence have only occasional leakage such as when they have a respiratory tract infection and have a severe coughing spell, while others may have a great deal of leakage on a daily basis. This can result in various limitations on activities, and can seriously impact quality of life. Bladder control issues are not a normal part of aging and they are not something you should have to live with.

Urologists and gynecologists are physicians with training in the evaluation, diagnosis, and treatment of conditions that include urinary incontinence.

There are three common categories of urinary incontinence.

  1. Stress incontinence is loss of urine that occurs with activities that increase abdominal pressure (such as sneezing, coughing, laughing, and exercising). This rise in pressure within the abdomen is transmitted to the pelvic organs including the bladder which can result in urine leaking through the urethra, the tube from the bladder to the outside of the body. This is usually due to weakness of the muscle that controls urination and support structures, often related to hormone (estrogen) deficiency which is common after menopause and prior vaginal delivery.
  1. Urge incontinence, which is also often referred to as overactive bladder, describes loss of urine with a sense of urgency or inability to hold urine long enough to reach a bathroom. This is usually due to over-activity of the bladder. Often women with urge incontinence report leaking with specific triggers such as running water or putting a key in the lock. Other associated symptoms often include frequent daytime and nighttime voids.
  1. Mixed incontinence is the common situation when women have components of both stress and urge incontinence.

Risk factors for the development of urinary incontinence include pregnancy, vaginal delivery, pelvic surgery, and pelvic radiation. Other potential risk factors include obesity, smoking, caffeine intake, chronic constipation leading to excessive straining, repetitive heavy lifting and neurological diseases such as multiple sclerosis. Certain basic interventions can reduce the risk of developing incontinence or even the severity of leakage.

For instance, maintaining a normal weight, or losing weight if overweight, can be extremely helpful. In fact, studies show that as little as a 10 percent loss in body weight can improve leakage symptoms by up to 50 percent. In addition, avoiding chronic straining which occurs with chronic constipation can prevent injury to the muscles and nerves of the pelvic floor. A diet with plenty of fiber and fluids, as well as good lifting technique, is key.

Next, if you are a smoker, strongly consider kicking the smoking habit. Besides improving your bladder health, there are countless other benefits to your overall well-being if you can quit. Also, avoid significant caffeine intake as it may be a major bladder irritant in some women.

Finally, make sure to keep your pelvic floor muscles nice and strong — this requires learning how to do Kegel exercises. (For more information on Kegel exercises, please go to my website, http://www.neilbaum.com)

Unfortunately, sometimes these basic interventions are not as successful as we would like. Luckily, a significant percentage of women who seek help for urinary incontinence will experience significant improvement in their leakage.

For this reason, women with bothersome leakage should always feel comfortable raising this issue with their physicians. A wide range of treatment options exist, ranging from physical therapy to surgery, and are being used every day to help women with leakage improve their quality of life. If your leakage is bothersome, get evaluated and learn about your treatment options.

Knowledge is power, and the more you know, the more confident you will be in directing your treatment.

Bottom Line: You don’t have to suffer the consequences of urinary incontinence. Help is available; you don’t have to depend on Depends!

ED or Impotence May Be Sending A Message To Your Heart and Brain

October 22, 2014

Having trouble with your erections? You are not alone as nearly 30 million American men suffer from this problem. That’s the bad news. The good news is that erectile dysfunction or ED may be harbinger of something more ominous that may affect your health and well-being. This blog will discuss the connection between ED and heart disease.

No man wants to be diagnosed with erectile dysfunction (ED), but believe it or not, it could save your life. In many cases, ED is a precursor to cardiovascular disease and when diagnosed properly could reduce the chance of having a heart attack or stroke.

ED is the inability to obtain or sustain an erection. It is extremely common, affecting more than half of men over 60. Given our rising rates of obesity and sedentary lifestyles, there is a good chance that performance in the bedroom is not about emotional issues or the male anatomy itself. It may sound strange but the penis is the barometer of a man’s overall health.

You can imagine how a heart artery gets clogged in a person with high blood pressure, high cholesterol or diabetes. When that coronary artery, which measures around 1\8 inch, gets obstructed that little to no blood flows through it, that man is going to experience chest pain (angina) or a heart attack. The same holds true for the carotid arteries, which measure 1\2 inch and take blood up to the brain. When the carotid artery gets blocked, that man will experience symptoms of a stroke. Now imagine the tiny penile artery, measuring only 1\16 inch. Its smaller diameter makes it ultra-sensitive to blockages, resulting in erectile dysfunction the penile artery becomes blocked.

Our entire vascular system is connected and the same things that harm our big blood vessels to our heart and brain will affect our smallest ones as well. The common cause of all this is what’s called atherosclerosis. As the same systemic process takes place throughout our vascular system, it’s these small arteries in the penis that will feel the effects earlier and manifest the symptoms of ED before other organs such as a man’s heart or brain start to suffer.

A lack of erections or difficulty holding an erection may be one of the earliest signs of impending heart disease or a stroke. When a man experiences ED this should an alarm should for men, their partners and their doctors. It’s important to realize that ED and cardiovascular disease have the same risk factors. These include high blood pressure, diabetes, high cholesterol, smoking and excess weight. Realize, too, that all these risk factors are modifiable, meaning you can actually improve them to reverse or halt the damage that is being done.

The message is: the recognition of ED as a warning sign of silent vascular disease has led to the concept that a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proven otherwise. Studies show that men presenting with only mild ED have a significant amount of undiagnosed high blood pressure, high blood sugar and high cholesterol, among other things. This is why men with mild ED, particularly if they are younger than 50, need to be screened for cardiovascular risk factors and have those risks treated aggressively. This means a visit to a doctor, having an EKG, and a stress test to see if there any decrease in blood supply to the heart.

We’ve come a long way since the days when ED was something men kept to themselves, too embarrassed to discuss with their friends or doctor. The introduction of pills (Viagra, Cialis, Levitra) to treat ED over 15 years ago opened the door for conversations about the condition.

The good news that lifestyle changes to modify risk factors, such as high blood pressure, elevated cholesterol level, obesity, and diabetes, that will provide the greatest benefit to a man’s overall health, not just his penis.

Bottom Line: ED can be a harbinger of impending heart disease or stroke. Don’t dismiss difficulty getting or holding an erection as this may indicate a future heart attack or stroke. See you doctor or urologist.

Issues To Consider Regarding Vasectomy

October 12, 2014

Men who consider a vasectomy often ask questions about the risks involved. This blog will discuss the risks and the consequences of vasectomy and what every man needs to know before proceeding with the procedure.

There are three main concerns regarding the long-term consequences or general health hazards of vasectomy. These concerns have arisen mainly from isolated studies over the past 50 years. Remember that it is important to show that several things be true when trying to link two medical conditions: a) that the link makes physiological sense and that this is shown in either animal models or in humans, and b) there should be excellent evidence of this link in populations of humans.

Heart Disease Risk

In 1979 a study was published that suggested that atherosclerosis or coronary artery disease might occur prematurely after vasectomy in monkeys. In this small study, monkeys fed high cholesterol diets were found to have what appeared to be increased amounts of atherosclerosis following vasectomy. Subsequent animal studies did not agree with these initial findings, and large epidemiological studies, including an extensive study of U.S physicians followed for 259,000 person-years have concluded that neither early atherosclerosis nor heart attacks or strokes occur more frequently in men who have had vasectomies compared to men who have not.

It is true is that after vasectomy, approximately 60-70% of men develop a form of allergy to their sperm in the form of antisperm antibodies. The body, either during the vasectomy or after, is exposed to sperm proteins that it commonly does not see and antibodies against these proteins can be observed in some patients. However, it has not been shown conclusively that the presence of these antibodies has any significant effect on other organs.

Prostate Cancer Risk

There has been much discussion over the past 15 years about whether vasectomy is associated with the development of prostate cancer later in life. The Journal of the American Medical Association published 2 reports suggesting that men who have had a vasectomy may be at risk for developing prostate cancer. Both studies were coauthored by Dr. Edward Giovannucci. One study evaluated men married to female nurses: men with vasectomies were compared to men without. The second study evaluated men in the health professions (veterinarians, pharmacists etc) who had had a vasectomy, and, again compared them with other male health professionals who had not had vasectomies. In both studies, there appeared to be an increased risk of developing prostate cancer in men who had a vasectomy more than 20-22 years before. On the contrary, several other studies, including several in the U.S showed no statistically significant increase in the risk of prostate cancer following vasectomy. Indeed, it was suggested in the same JAMA issues that a true cause-and-effect relationship could occur by chance alone, or because of biases (selectivity) or other unaccounted variables in these two studies.

Concerns raised from these studies include the fact that the men in the study might not represent the larger population of all men who get vasectomies. This means that the study cannot be used with certainty to predict a similar occurrence in the general population. It is also possible that the men who had had vasectomies in these studies would be more likely to see a urologist rather than an internist or family practice physician for later evaluation of a urologic problem than the men who had not had vasectomies. Urologists are better at finding prostate abnormalities than other kinds of physicians and therefore cancer might have been detected earlier than it would have otherwise. This is called “detection bias.” It has also been suggested this study design makes it impossible to identify all of the factors that might contribute to this end result with two events (vasectomy and cancer) occurring several decades apart. A prospective study is really necessary here to answer the question. A prospective study evaluates groups of patients at the time they have the vasectomy and follows them regularly for years to see, if indeed, cancers do occur. This is the most powerful way to study this relationship, but was not used in the Giovannucci papers. In addition, no study has ever established that there is an increased risk of death after prostate cancer following vasectomy.

Because the question of a relationship between vasectomy and prostate cancer was raised, the American Urological Association first recommended that men who had a vasectomy more than 20 years ago or who were > 40 years of age at the time of vasectomy have an annual examination of their prostates as well as a blood test for prostate cancer (serum Prostate Specific Antigen or PSA). However, given the recent lack of support for this relationship between vasectomy and prostate cancer, this recommendation has been revoked. Finally, no mechanism is known, nor is there any animal model proof of the plausibility of the link between these conditions.

Dementia Risk

There is a recent, single, small paper that has linked vasectomy to the later development of a rare form of Alzheimer’s disease. The issue is that a researcher found that, among a group of patients suffering a form of dementia called primary progressive aphasia (PPA) that is often confused for Alzheimer’s disease, the men had a higher percentage of vasectomy than was thought normal. The study found that 40% of 47 men with PPA had had a vasectomy, while among another 57 men from the community without PPA there was a vasectomy rate of 16%. What this means is simply that the rate of vasectomy among PPA patients is a little over 2 fold higher than in otherwise healthy patients. This study did not find an increased rate of vasectomy in patients with Alzheimer’s.

The most common form of dementia caused by brain deterioration in individuals over age 65 is Alzheimer’s disease. A very unusual form of Alzheimer’s disease is called primary progressive aphasia. This condition robs people of their ability to speak and understand language, but they are still able to maintain their hobbies and perform other complicated tasks for a long time. By contrast, Alzheimer’s patients lose their memory, interest in hobbies, family life and become idle.

A “mechanism” for the association between PPA and vasectomy was also proposed in the study. It involves the fact that men can have antibodies form to sperm after having a vasectomy (see above risks) and these antibodies may somehow cross-react with the brain and cause PPA. There is no animal model data to support this theory, however.

Problems with this study are similar to that described for prostate cancer risk and vasectomy. How unique were these patients that they gathered from all over the US twice annually to participate in a support group with such rare disease? We really need a prospective study to show this relationship as retrospective studies have too much “bias” or too many uncontrolled issues that could produce the same result. In addition, the study groups were very small: fewer than 20 PPA patients had a vasectomy and fewer than 10 healthy patients had a vasectomy. It is hard to generalize at all from so few patients in a study. Also, the study methods were faulty in that the vasectomy condition should have been confirmed by reviewing the medical charts on the PPA patients, since their disease alters their ability to understand, hear and remember what has happened to them! Indeed, like the issue of prostate cancer and vasectomy, this issue will take at least a decade or two to confirm or disprove.

Bottom Line: Vasectomy remains an effective method of sterilization. Certainly there are risks with any procedure and the risks of prostate cancer, dementia, and heart disease need to be considered by every man who wishes to proceed with the vasectomy.

The Safety of Vasectomy Using No Scalpel, No-Needle Technique

October 12, 2014

Vasectomy remains one of the most effective and safest methods of contraception. The only technique that would be cheaper is the diaphragm and abstinence. Both of which have a high failure rate. The next few blogs will discuss the safety of vasectomy.

Besides the fact that a vasectomy is very popular, one must remember that there is no form of fertility control, except abstinence, which is completely free of potential complications. In all, vasectomy remains one of the safest and best forms of permanent contraception, provided that the patient is aware of and understands the potential risks associated with the procedure. The side effects and complications of vasectomy are divided into “early” and “late” categories, depending on when they occur. The risks and complications of the procedure, including potential vasectomy pain, are examined below in greater detail.

Vasectomy and Pain

Men worry about pain and discomfort during and after the procedure. In my practice less than 5% of respondents said they had pain, much lower than the well-recognized and commonly published rate. In addition, seldom do any of the men require post operative pain medication. I suggest bed rest and ice over the scrotum the day of the procedure and non-steroidal anti-inflammatory medication such as Tylenol or Aleve for post operative pain.

Early Complications

Shortly after the procedure there may be mild discomfort, and most men are able to return to work in 1-2 days. A small amount of oozing (light bleeding, less than the size of a quarter) and swelling in the area of the tiny opening are not unusual. This should subside within 72 hours. Occasionally, the skin of the scrotum and base of the penis turn black and blue. This is not painful, lasts only a few days, and goes away without treatment. For a period of 7 days following the vasectomy, sex should be avoided. Strenuous exercise (for example climbing, riding motorcycles or bicycles, playing tennis or racquetball) should also be avoided for 7 days, and nothing heavier than 8-10 pounds should be lifted after the procedure until day 7 when all activities including heavy lifting can begin.

Rarely (less than 1%), a small blood vessel may bleed into the scrotum and continue to bleed and form a clot of blood (hematoma). A small clot will be reabsorbed by the body with time, but a large one usually requires drainage through a surgical procedure.

Importantly, the vasectomy procedure is not always 100% effective in preventing pregnancy because, on rare occasions, the cut ends of the vas may rejoin. This occurs very infrequently; the published rate is about 1 in every 600 vasectomies. My vasectomy failure rate, defined as either persistent motile sperm in the ejaculate or a pregnancy after the procedure, is less than 1/1000 cases.

Since sperm can survive for several months in the vas deferens above the point where they were interrupted, it is very important that another form of contraceptive is used until sterility is assured. To determine whether the ejaculate is devoid of sperm, an ejaculate must be brought in for formal microscopic examination after the procedure. Since “clearing the tubes” through ejaculation is a relatively inefficient process, it make take 15 ejaculations to empty the system entirely of sperm. In terms of time after the procedure, roughly 90% of men will have no sperm in the ejaculate 3 months later. This is the reason we ask men to provide us with a semen sample after 15 ejaculations or 3 months after the vasectomy. Occasionally, it may take 6 months or longer after the procedure to flush out all the sperm. The semen specimen must demonstrate no sperm before unprotected intercourse is permitted.

Bottom Line: Vasectomy is a safe form of sterilization and there are few complications.  Each man who considers proceeding with a vasectomy needs to weigh the benefits vs. the risks and complications associated with the procedure.  Most men will find that the procedure is the best way to proceed with contraception.

Benign Prostate Enlargement (BPH) – Help Is Available

October 10, 2014

Millions of middle age men suffer from non-cancerous prostate gland enlargement. The cause is not known but is probably related to hormonal changes that occur normally in men after age 50.

The symptoms are going to the bathroom frequently, urgency of urination, poor stream, dribbling after urination. However, the most bothersome symptom that impacts a man’s quality of life is getting up multiple times during the night to go to the restroom.

Though the prostate continues to grow during most of a man’s life, the enlargement doesn’t usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties, and as many as 90% in their seventies and eighties, have some symptoms of BPH. Moreover, because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than conventional surgery.

Thus, BPH is an age-related condition like many others, such as memory deficiency, reduced bones density and muscles flexibility.

As for natural treatment options, it has been noted Saw palmetto, a popular herbal therapy among men with prostate symptoms, is not effective and more and more scientific studies are showing that saw palmetto has no benefits in the treatment of BPH.

There are oral medications such as alpha-blockers such as Flomax and Rapaflo that relax the muscles in the prostate and make it easier for the bladder to empty the contents from the bladder. There are also medications that reduce the size of the prostate gland. These drugs, Proscar and Advodart, actually help decrease the size of the prostate thus decreasing the resistance to the flow of urine from the bladder to the outside of the body. Unfortunately, these drugs have mild side effects and since so many Americans are polymedicated, and alternative solutions are often more attractive to active middle aged men.

Minimally invasive treatments

Men with enlarged prostate glands have symptoms of going to the bathroom frequently, dribbling after urination, and getting up at night to go to the bathroom. The problem is usually caused by a benign enlargement of the prostate gland, which blocks the flow of urine from the bladder to the outside of the body. The cause of the benign enlargement is not known but is probably related to alternations in the hormones, testosterone, of middle aged and older men. Treatment usually consists of medications, alpha-blockers and medications to actually relax the muscles in the prostate gland but these are often ineffective especially if used for long period of time. The other options include minimally invasive procedures such as microwaves that can actually shrink the prostate gland. Now there’s a new treatment option that can be done in the doctor’s office under a local anesthetic.

What are some of the minimally invasive treatments available for BPH?

Laser vaporization: Anesthesia is usually required for this procedure, but patients can usually go home the same day. The technology involves placing a “cystoscope” (metal tube through which the visual lens and laser can be passed). A laser is used to burn and vaporize the obstructing or blocking prostatic tissue. Studies to date have shown limited long-term benefits.

Microwave thermotherapy of the prostate (TUMT): This is an office-based procedure performed with topical and oral pain medication and does not require a general anesthesia. Computer-regulated microwaves are sent through a catheter to heat portions of the prostate. A cooling system is required in some types for better tolerance. Traditionally, the best use of this procedure has been for patients who have too many medical problems for more invasive surgery or for patients who truly wish to avoid any type of anesthesia. Benefits are that there is no need for anesthesia and there is no blood loss or fluid absorption (these would be significant benefits in a person with a weak heart). Patients usually go home the same day. Men may need a catheter for one or two days after the procedure.

The UroLift system, made by NeoTract Inc. of Pleasanton, Calif., is the first permanent implant to relieve low or blocked urine flow in men age 50 and older with an enlarged prostate.

By pulling back prostate tissue that presses on the urethra, the system allows more natural urine flow.   This procedure is compared to pulling back the curtains with a sash. The procedure can be done in the doctor’s office under a local anesthetic and will actually open up the urethra to allow the flow of urine and reduce the urinary symptoms of frequency of urination, improve the force and caliber of the urine stream, and decrease the number of times a man needs to get up at night to empty his bladder.

Of course with any procedure there may be side effects and complications. Some b patients reported pain or burning during urination, increased urgency, decreased urine flow, incomplete bladder emptying, and blood in the urine. Most of these symptoms and side effects were temporary and resolved a few days or weeks after the UroLift was performed.

Bottom Line: Millions of American men suffer from symptoms as a result of an enlarged prostate gland. Certainly medications are a first line treatment option. However, the UroLift may be a permanent solution to this common problem and help men get a good night’s sleep!


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