Holmium Laser Enucleation Of The Prostate
Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and an anaesthetic. A catheter (a tube which drains the bladder) is also needed for 1-2 days until the urine clears. Patients are advised to take life quietly and to avoid straining or heavy lifting for four weeks after the surgery.
Who is it suitable for?
HoLEP can be performed on men of any age with urinary outflow obstruction caused by an enlarged prostate. It is particularly indicated in men with large prostates (over 60mls in size) and men on medications to thin the blood such as warfarin, aspirin or clopidogrel.
What are the advantages of HoLEP
There is no upper size limit of prostate that can be dis-obstructed – traditionally men with prostates over 100ml in size needed major open surgery
- There is often less bleeding than after a TURP
- Discharge is often quicker than after TURP at 1-2 days
- The chance of recurrence requiring further surgery is very low
- Unlike greenlight laser operations, large quantities of prostate tissue are sent for pathological analysis
- The PSA generally drops to very low levels after HoLEP operations
How does it work?
The aim of HoLEP is to relieve pressure on the tube through which the urine drains (urethra) by anatomically enucleating the majority of excess benign prostate tissue. This is done under a general anaesthetic with the help of a telescopic camera inserted through the penis. The three lobes of the prostate that are cored out intact are pushed into the bladder before being sucked up (morcellated) by a special instrument inserted through the telescopic camera. The pieces are sent for laboratory analysis just in case they might be found to be cancerous. A catheter is placed into the bladder to drain the urine while the raw surface heals, then left in place for around 24 hours before being removed on the day of discharge from hospital. Sterile saline fluid is also irrigated into the bladder through the catheter to dilute any blood in the urine and prevent clots from forming.
It is normal to have some blood in the urine after this operation, so it is advisable to drink plenty of water for a few days while it clears. Clots are sometimes passed 10-14 days afterwards; again, this is part of the healing process.
Apart from this and the risk of infection that accompanies any operation or invasive procedure, the only significant side-effect is the near certainty that normal ejaculation will cease. This is because the contraction that occurs during orgasm may not completely block the entrance to the bladder once some tissue has been removed, and the semen will flow back into the bladder (“retrograde” or “dry” ejaculation) rather than out through the penis. This is not harmful, but it does mean that future fertility is greatly reduced. The procedure does not generally affect erectile function or continence, although the urinary symptoms may take a few weeks to settle down afterwards.
Credit: The Prostate Centre
Transurethral Resection of the Prostate (TURP)
What is a transurethral resection of the prostate or TURP?
A transurethral resection of the prostate (TURP) is a surgical procedure that removes portions of the prostate gland through the penis. A TURP requires no external incision.
The surgeon reaches the prostate by inserting an instrument through the urethra (the narrow channel through which urine passes from the bladder out of the body). This instrument, called a resectoscope, is about 12 inches long and one-half inch in diameter. It contains a light, valves that control irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels. It’s inserted through the penis and the wire loop is guided by the surgeon so it can remove the obstructing tissue one piece at a time. The pieces of tissue are carried by fluid into the bladder and flushed out at the end of the procedure.
Many common problems are associated with the prostate gland. These problems may occur in men of all ages and include:
- Benign prostatic hyperplasia (BPH). An age-related enlargement of the prostate that isn’t malignant. BPH is the most common noncancerous prostate problem, occurring in most men by the time they reach their 60s. Symptoms are slow, interrupted, or weak urinary stream; urgency with leaking or dribbling; and frequent urination, especially at night. Although it isn’t cancer, BPH symptoms are often similar to those of prostate cancer.
- Prostatism. This involves decreased urinary force due to obstruction of flow through the prostate gland. The most common cause of prostatism is BPH.
- Prostatitis. Prostatitis is inflammation or infection of the prostate gland characterized by discomfort, pain, frequent or infrequent urination, and sometimes fever.
- Prostatalgia. This involves pain in the prostate gland, also called prostatodynia. It’s frequently a symptom of prostatitis.
Cancer of the prostate is a common and serious health concern. According to the American Cancer Society, prostate cancer is the most common form of cancer in men older than age 50, and the third leading cause of death from cancer.
There are different ways to achieve the goal of removing the prostate gland. Methods of performing prostatectomy include:
- Surgical removal includes a radical prostatectomy (RP), with either a retropubic or perineal approach. This is used to treat cancer. Radical prostatectomy is the removal of the entire prostate gland. Nerve-sparing surgical removal is important to preserve as much function as possible.
- Transurethral resection of the prostate, or TURP, which also involves removal of part of the prostate gland, is an approach performed through the penis with an endoscope (small, flexible tube with a light and a lens on the end).
- Cryosurgery is a less invasive procedure than surgical removal of the prostate gland. Treatment is administered using probe-like needles that are inserted in the skin between the scrotum and anus. The urologist can also use microwaves.
- Laparoscopic surgery, done manually or by robot, is another method of removal of the prostate gland.
Credit : Hopkins Medicine
TURis Plasma Vaporization
Where and what is the Prostate Gland?
The Prostate gland is at the base of the Bladder and surrounds the urinary passage (urethra). The normal function of the gland is to produce some of the seminal fluid, which is expressed with ejaculation.
How does the gland cause trouble?
With increasing age, the prostate gland enlarges slowly due to the stimulation by the male sex hormone (testosterone). Testosterone is produced by the testicles and therefore the first enlargement of the prostate gland begins at puberty. Slow growth continues in most men as they get older but only causes trouble if it narrows the urinary passage.
What does a prostate operation do?
The latest technique is the removal of the Prostate Gland is with Bi Polar resection and vapourisation in saline. The operation removes the gland and thus allows free passage of urine from the bladder.
The operation is done under anesthesia using a special instrument called a Resectoscope and the Bi Polar button and loop electrode which is passed down the urinary passage. Because there is no cut in the skin, healing after the operation is quicker. It may still be necessary however, to leave a catheter to drain the bladder for 1-2 days. The procedure is done as a Day Case or overnight stay in Hospital unless other concomitant ailments dictate a longer stay.
If the prostate gland is very large, it may be necessary to remove the gland by a cutting operation in the lower abdomen. If this method is preferred, our surgeon will explain the details.
What is TURIS?
The word TURIS emanates from Trans Urethral Resection in Saline. Here the resection of the obstructing part of the prostate gland is removed by Bi-Polar current using cutting and vapourisation in Saline.
What are the advantages of Laser over Standard TURP Operation?
TURIS affords the following advantages:
- Greatly reduced bleeding in most cases resulting in less strain physiologically on your body, reduction in transfusion rate and early discharge from the hospital.
- The irrigation fluid used is Normal Saline and not Glycine which is 10 times more expensive volume for volume.
- This in turn results in diminishing the complication of the TUR Syndrome or Water intoxication and a reduction in cost.
- Post-operative irrigation is not required.
- Retrograde Ejaculation, which is very common after a standard TURP, is almost non-existent in TURIS.
- All the above factors result in cost savings without any compromise whatsoever in the results of surgery!
Further, the cost savings are transmitted to you as we are not charging you more for this procedure. It is estimated that you will on average save Ksh. 40,000 – 60,000.
What are the disadvantages of TURIS?
The disadvantage is that it takes slightly longer to perform the surgery.
After the operation
There is usually some bleeding from the prostate cavity and this causes a red discoloration of the fluid coming from the catheter. This usually stops after a day or two. It helps to drink plenty of fluids after the operation to get a good wash-through of the bladder.
A common fear is that there will be leakage of urine after the operation, but serious leakage is rare. There may be minor leakage for a day or two after the catheter is removed, but this soon stops. There may also be feeling of urgency resulting in the need to pass urine frequently. Both the minor leakage and the urgency occur because there is a raw area inside which has to heal up. If there has been long-standing blockage of the bladder, the bladder itself may be damaged and the need to pass urine frequently may continue for several weeks.
Sometimes blood may appear again in the urine some 10-14 days after the operation. This is caused by the internal healing process and may be aggravated by constipation. This bleeding usually clears up quickly and it helps to drink plenty. In order to minimize this bleeding, we recommend that constipation should be avoided, and it may be necessary to take a mild laxative.
How soon will the urinary stream Improve?
Following the operation there is usually an immediate improvement in the urinary stream and further improvement may continue for up to 6 months. You may find that the frequency of urination does not completely settle down for 2-3 months.
Will the operation affect my sex life?
Sexual intercourse often becomes less frequent with increasing age but there is no reason for the prostate operation to end sex life. Removing the prostate gland does not alter erections of the penis or the sensation of orgasm. Once the operation has healed having sex will not cause damage, but it is best to wait 3-4 weeks.
How long before I can go back to work and become fully active?
This depends on how fit you were before the operation. However most of our patients are advised to go back to work even for half days in a couple of days.
Credit: Laserstone Surgery
Blood in the semen (haematospermia)
What should I do if I have blood in my semen?
If you see blood in your semen, you should contact your GP for further advice although it is unlikely that there is a worrying underlying cause
Your GP will normally provide reassurance about blood in the semen. Most GPs will perform some simple, baseline tests. You may be commenced on antibiotics or anti-inflammatory drugs to treat presumed infection/inflammation. It is not normally necessary for you to be referred for more detailed investigations unless your prostate gland feels abnormal, there is associated blood in the urine or your PSA blood test is abnormal.
What are the facts about blood in the semen?
The commonest cause of blood in the semen is low-grade infection or inflammation in the seminal tract (particularly in the prostate gland)
- Although possible, it is unlikely to be caused by sexually-transmissible infection
- Rarely, it can be due to cancer of the testis or the prostate gland
- If it is associated with blood in the urine, whether visible or non-visible (found on a urine test), it should always be investigated fully
- If it is associated with an abnormal prostate gland on rectal examination or a raised PSA blood test, you will normally be referred to your local urology department on the “fast-track” (2-week wait) system
- Blood in the semen usually resolves spontaneously or with the help of anti-inflammatory drugs
- Recurrence over a long period of time is common
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for patients with blood in the semen. This will normally include some or all of the following:
1. A full history
Your GP will ask you questions about any recent symptoms (especially pelvic pain), any associated matters (including any drugs you are taking) and will enquire about smoking habits. You should inform your GP if you are taking blood-thinning drugs (warfarin, dicoumarin) or if you take anti-platelet treatment (aspirin, dipyridamole, clopidogrel). If the blood in the semen is painful or associated with blood in the urine, it is likely that he/she will arrange referral to a urologist.
2. A physical examination
A general physical examination will be performed, together with a rectal examination and assessment of your testicles. Your blood pressure may be measured as part of this examination.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion but it is common to measure kidney function, clotting factors, prostate-specific antigen (PSA) and to check the blood cells for anaemia or other problems.
b. Urine testing
A urine test will normally be sent for infection. Your GP may commence you on antibiotics whilst awaiting the result of this test. If there is blood in your urine, fresh urine may be sent to the laboratory for microscopic examination, to look for cancerous cells.
Testing the semen for infection is not normally performed because harmless bacteria are often found in semen and are not the cause of any infection.
c. Other specific tests
Your GP may arrange an ultrasound scan of your kidneys and bladder, pictured right. This is more likely to be arranged by the urology department who may also request a rectal ultrasound scan of your prostate gland and seminal vesicles.
What could have caused the blood in my semen?
Most patients with blood in the semen have low-grade prostate, urethral or seminal vesicle inflammation which requires no specific treatment and often resolves spontaneously.
Although there are many potential causes for blood in the semen, it is often difficult to identify a clear cause. Those most often found are:
- Low-grade seminal tract infection (± urinary tract infection)
- Blood disorders (e.g. sickle cell disease, clotting disorders, anticoagulant and anti-platelet drugs)
- Recent urological surgery (e.g. cystoscopy, prostatic biopsy, vasectomy, vasectomy reversal
- Testicular or prostate cancer (very rare)
- Other causes, including less common infections (e,g. TB, schistosomiasis)
What happens next?
It is very unusual for men with blood in the semen to require urological referral
Your GP will reassure you that the condition usually improves by itself. If the blood in the semen persists, your GP will normally prescribe a 6-8 week course of antibiotics or anti-inflammatory drugs. Urological referral may be considered if:
- your prostate feels abnormal on rectal examination and/or your PSA blood test is abnormal
- examination or ultrasound reveals an abnormal testicle
- there is blood in your urine (visible or invisible)
- you have persistent blood in the semen, despite adequate treatment, especially if you are over the age of 45 years
This will involve an outpatient appointment when some or all of the following assessments will be performed:
- Detailed questioning about your urinary tract and any related symptoms
- A physical examination (including rectal & scrotal examination)
- Blood tests (if not already performed by your GP)
- Examination of the urine for cancer cells (if not already performed by your GP)
- X-rays or scans
This may involve one or more of the following:
- CT scan
- ultrasound scan of kidneys & bladder
- rectal ultrasound scan of the prostate
- ultrasound of the scrotum
A flexible cystoscopy (if you have persistent blood in the urine)
this is a telescopic check of the bladder. It is performed under antibiotic cover & local anaesthetic using a small, flexible telescope which allows the clinic doctor to see inside your bladder (pictured). If you have concerns about this or have experienced problems with local anaesthetic in the past, you should ask about having your examination under a brief general anaesthetic (i.e. whilst you are asleep). When your tests have been completed, the medical staff will advise you on what to do next:
If an abnormality requiring further treatment is detected, the medical staff will advise you on what treatment is necessary. If no specific abnormality is found, you should keep a careful eye on your symptoms and report any further bleeding to your GP who will be informed of the result of your assessment.
Erectile Dysfunction (impotence)
What should I do if I have problems with impotence?
Your GP will normally wish to review both you & your partner together and several visits may be needed before a full picture of the problem can be obtained. Following initial discussions, it is not unusual for some couples to decide not to pursue any further investigations or treatment for impotence (erectile dysfunction).
What are the facts about impotence?
- Impotence becomes commoner with increasing age and is seen in 50-55% of men between 40 and 70 years old
- It is often associated with the so-called “deadly quartet” of obesity, high blood pressure, high cholesterol & diabetes which are all significant risks to health
- Investigation is only indicated if both partners wish to pursue treatment
- Most treatable causes can be identified by a clinical history, physical examination and routine blood tests
- If there is no treatable cause, treatment with tablets is the first option for most men
- Other methods of treatment are only indicated if tablets prove ineffective, cause side-effects or cannot be used because of specific medical conditions
What should I expect when I visit my GP?
1. A full history
Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption). He/she will take a detailed sexual history to determine why your erections are failing and under what circumstances you are having sexual difficulties. It is also normal to ask about your sex drive (libido), whether you still get night-time or early-morning erections and whether your partner is also concerned about your difficulties.
It is important to tell your GP if you have premature ejaculation (uncontrolled ejaculation before or immediately after penetration) or symptoms of prostatic obstruction because they are often associated with impotence (erectile dsyfunction).
Your GP may help you to complete a symptom questionnaire (the International Index of Erectile Function) as an aid to further assessment and discussion of treatment options. This will allow your GP to:
- identify your needs & expectations
- help you & your partner share in decision-making
- decide whether psychosexual counselling might be helpful.
2. A physical examination
A general physical examination will be performed to assess the development of your male sexual characteristics and to detect any abnormality of your penis or genitals. Your blood pressure will normally be measured as part of this examination. The pulses in your legs will normally be assessed and the nerve reflexes involving your legs and your penis or anus (back passage). Rectal examination (pictured) is normally performed to assess the tone of your anal muscles and to feel your prostate gland.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function, liver function, cholesterol & prostate-specific antigen (PSA) as well as checking your blood cells for anaemia or other problems. A blood sugar measurement will be performed to exclude diabetes.
b. Routine urine tests
Your urine will normally be assessed by stick-testing to see whether it contains sugar which might indicate diabetes.
c. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured.
d. Other specific tests
Other tests, if indicated, are normally arranged by the urology clinic. Your GP may be able to arrange measurement of blood flow in your penis by ultrasound, formal nerve conduction tests and even a trial injection of a drug called prostglandin E1 (Caverject®) into your penis. A good erection after the injection means that the arterial blood flow to your penis is likely to be normal.
What could have caused my impotence?
Although a psychological component, often called “performance anxiety”, is common in men with impotence, a purely psychological problem is seen in only 10%.
Of the 90% of men who have an underlying physical cause, the main abnormalities found are:
- Vascular disease in 40%
- Diabetes in 33%
- Hormone problems (e.g. high prolactin or low testosterone levels) & drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%
- Neurological disorders in 10%
- Pelvic surgery or trauma in 3-5%
- Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie’s disease, inflammation, penile curvature)
What treatments are available for this problem?
Initial treatment will usually involve:
- treatment of any anatomical abnormality (e.g. circumcision, frenuloplasty, penile straightening)
- treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your the levels are normal)
- lifestyle modification (e.g. reduce stress, stop smoking & drinking, stop all drugs)
- weight loss & increased exercise (which may reduce the risk of impotence by up to 70%)
- specific support for psychological problems
If these fail to help, your GP will issue a prescription for Viagra®, Cialis® or Levitra®. These drugs require sexual stimulation to be effective and will not produce an erection without it. They will have no effect on your sex drive. There is no evidence that these drugs are dangerous if you have underlying heart disease. However, they should not be taken if you are taking nitrates (e.g. GTN, isosorbide for angina).
You should only take Viagra, Cialis or Levitra by getting a prescription from your GP & you should have a detailed discussion about the risks & benefits before starting treatment.
1. Penile injections to produce erections
Self-administered injections of prostaglandin E1 (Caverject®) provide a simple means of obtaining a natural erection. You will be taught how to administer the injections (pictured) and told what to do in the event of problems such as an erection which will not go down.
2. Medicated urethral system for erection (MUSE)
Insertion of a prostaglandin pellet in the urethra (water pipe) is no longer widely used because of its poor success rates and significant side-effects.
3. Vacuum erection assistance devices (VEDs)
VEDs provide a simple way of obtaining an erection for 30-45 minutes by sucking blood into the penis and holding it in place with a constriction (pictured). Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects. Unfortunately, most patients have to purchase VEDs themselves.
4. Vascular surgery/angioplasty
If you have blockage of the large blood vessels to the legs and the pelvis, it may be possible to undergo reconstruction of the arteries or angioplasty to re-establish erections. Re-vascularisation for small artery blockage is rarely successful.
5. Penile prostheses
Insertion of artificial penile implants (pictured) is highly effective. It is reserved as a last resort when all other forms of treatment have failed. It involves major surgery with a significant risk of complications. You will need to undergo long-term follow-up in a specialist andrology unit for many years after the surgery.
Fertility problems
What should I do if I have fertility problems?
If you have been trying unsuccessfully to produce a pregnancy for 1-2 years, without using any form of contraception, you should contact your GP for further advice.
Your GP will normally wish to review both of you initially. Further investigations may reveal that only one partner has a problem contributing to the infertility. As a general rule, most urologists only deal with problems affecting the male partner. Investigations in the female partner are not considered on this website.
What are the facts about male infertility?infer
- 10% – 15% of couples in Kenya are unable to have a child.
- In 60% of these couples, the problem lies wholly or partly with the male partner
- Urological investigation may reveal a reversible underlying cause for male-factor subfertility and full assessment by a urologist is recommended
- In many cases, no underlying cause is found, in which case assisted conception may offer the best chance of pregnancy
- Infertile couples are often assessed in gynaecology gepartments and, therefore, subfertile men may wish to seek a urology assessment from a urologist specialising in andrology
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for men with infertility. This will normally include some or all of the following:
1. A full history
Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption) as well as asking whether you have previously fathered children. Your past medical history may also be relevant in identifying a reason for your infertility, especially if you have had previous testicular infections or operations. You will be asked about when you have been having sexual intercourse. Ideally, this should be timed to coincide with your partner’s ovulation (approximately 7-10 days before the next menstrual period).
2. A physical examination
A general physical examination will be performed, paying particular attention to the development of your male sexual characteristics. Your blood pressure will normally be measured as part of this examination.
Special attention is paid to your genitals – shape, size and consistency of your testicles, and the presence or absence of all the structures which attach to the testicles and carry sperms. Your GP will also look for evidence of enlarged, varicose veins (a varicocele) in your scrotum, usually above the left testicle but, very occasionally, on the right.
3. Additional tests
The usual tests performed are:
a. Sperm counts
You will need to provide at least two semen specimens for analysis. Click here for information on how to do these specimens (opens a PDF file in a new browser window). A sperm count of more than 15 million normal, motile (active) sperms per ml should be sufficient to allow pregnancy by natural means
b. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function & liver function and to check the blood cells for anaemia or other problems
c. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured. Anti-sperm antibodies are not routinely measured during assessment of male infertility
d. Other specific tests
Other tests, usually performed by specialists, may include chromosomal studies, ultrasound of the scrotum and, possibly, the prostate area.
What could have caused my infertility?
In 75% of infertile men, the cause remains unexplained (this is termed “idiopathic infertility”). It may, however, still be possible for couples to conceive naturally, provided some sperms are present.
Physical abnormalities
Absence or blockage of the tubes that carry sperms (vas deferens) is uncommon but may be treatable. The best-known cause of blockage is, of course, vasectomy which, like scarring due to infection, may be treatable surgically by reconstruction or bypass.
A Varicocele is seen in 20% of infertile men (and in 10% of the normal male population). Surgical treatment has little effect on natural pregnancy rates and is usually reserved for those with symptoms (aching discomfort) or to improve semen quality in couples undergoing assisted conception.
Childhood surgery, especially for undescended testicles or hernias, may be associated with reduced fertility in later life.
Genetic causes
10% of infertile men have an underlying genetic problem. Typically they have very poor sperm counts or no sperms at all. In men with no sperms, hormone measurements help to determine whether this is genetic (primary testicular failure) or associated with obstruction. The former is untreatable whilst the latter can usually be treated successfully.
Other factors
All of the following can have harmful effects on sperms:
- smoking
- excess alcohol consumption
- tight-fitting clothing
- prolonged sitting
- drugs, both prescribed (e.g. steroids) and recreational (e.g. cannabis, cocaine)
What treatments are available for this problem?
Many couples produce a pregnancy whilst undergoing investigations or treatment for infertility (85% within the first year) but, for those who do not, a number of treatments are available
General Measures
If you have poor sperm counts, you should wear loose-fitting trousers and boxer shorts. You should stop smoking, reduce your drug consumption and endeavour to adopt a “healthy” lifestyle. Spraying or splashing the scrotum with cold water 2-3 times a day may also be beneficial.
Drug treatment
Many drugs have been used to improve sperm counts. None has been found to be beneficial although steroids may be useful if you have anti-sperm antibodies after vasectomy reversal.
Surgery
Surgical bypass may be possible for obstruction caused by infection or surgical injury. There is, however, an increasing tendency to avoid surgery in this situation and to use sperm retrieval with assisted conception.
Vasectomy reversal is 75-90% successful in restoring sperm production. Unfortunately, restoration of sperms does not guarantee a pregnancy if your sperm count is low or if your sperms are of poor quality.
Intrauterine insemination (IUI)
Selecting out the most motile sperms and injecting them directly through the cervix at the time of ovulation, whilst employing drug-induced ovarian stimulation in the female partner, results in a 7-8% pregnancy rate for each cycle of treatment.
Intracytoplasmic insemination (ICSI)
In this type of in vitro fertilisation (IVF) a single sperm is injected directly into an egg to fertilise it. It is useful if you have a very low sperm count. It may be necessary to extract useful sperms directly from the testicle or from the epididymis (sperm-carrying mechanism). The procedure carries risks for the female partner and has a pregnancy rate of 20-30% per cycle.
Donor insemination (DI)
Donor semen is carefully screened for infections and a donor selected to have similar attributes to you. This is the only viable option if you have no sperms at all and you do not have obstruction which can be relieved surgically.
Adoption
If you are unfortunate and do not to have any success with other treatments, you may wish to consider adopting a child. Your GP and local / national adoption agencies can help with this process.
Testicular lump
What should I do if I have a testicular lump?
If you find a lump inside the scrotum, not arising from the skin of the scrotum itself, you should contact your GP immediately for further advice. To feel for testicular lumps, it is best to examine yourself when you are warm and relaxed (e.g. after a bath or shower). Stand in front of a mirror and hold each testicle in turn between your fingers. Feel the body of the testicle and all the structures attached to it.
testicular lump
If your GP is concerned that you could have testicular cancer, you may be referred urgently to the urology department using the fast-track (2-week wait) referral system.
What are the facts about testicular lumps?
- The vast majority of swellings in the scrotum are benign and should not give cause for concern
- Benign swellings in the scrotum only require surgical treatment if they cause significant symptoms (e.g. aching, cosmetic embarrassment)
- A simple ultrasound scan will usually differentiate between benign and cancerous swellings
- If the lump is attached to the surface of the testicle, it is probably benign
- If a lump is within the body of the testis itself, there is a 90% chance that it is a testicular cancer
- Testicular cancer is the commonest malignant tumour in men between 20 and 50 years old
- Whilst testicular cancer is rare in men over the age of 50, certain forms do occur and you should always seek advice from your GP
- Testicular cancer is commoner in abnormal testicles e.g. previously undescended testicles, testicles which have been injured or infected and soft, atrophic testicles (sometimes seen in infertile men)
- Early diagnosis and treatment mean that more than 95% of men can be cured of testicular cancer, even if it has spread beyond the testicle itself
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for patients with a scrotal swelling. This will normally include some or all of the following:
1. A full history
Your GP will take a full history, paying particular attention to any possible trauma or infection of the testicles in the past. You should mention any previous operations on your testicles to your GP, especially surgery for an undescended testicle. Please tell your GP if you have had a vasectomy in the past.
2. A physical examination
A full physical examination will be performed, including examination of your scrotum, your abdomen and your lymph glands. Your blood pressure will normally be measured as part of this examination.
3. Additional tests
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function & liver function, and to check the blood cells for anaemia or other problems.
b. Tumour markers
If your GP suspects testicular cancer, he/she may arrange some specific blood tests to measure tumour markers (alpha-fetoprotein, beta-human chorionic gonadotrophin, lactate dehydrogenase).
c. Other specific tests
An ultrasound scan (pictured, showing a testicular tumour) will normally be arranged to assess exactly where the swelling is in relation to your testicle. Depending on the findings of the ultrasound scan, a CT scan of your abdomen & chest may also be arranged. This is normally fixed through the urology unit.
What could have caused my testicular lump?
Swellings of the scrotum are usually cystic (fluid-filled), inflammatory or solid. Clinical examination and ultrasound scanning can usually differentiate between the possible causes.
Cystic (fluid-filled) swellings
These are the commonest swellings and are usually caused by a hydrocele (fluid around the testicle, pictured), a cyst in the epididymis (sperm-carrying mechanism) or varicose veins above the testicle (a varicocele). They are all benign and only require treatment if they cause significant symptoms.
Inflammatory swellings
Infection of the epididymis (sexually-acquired or secondary to a urinary infection), twisting of the testicle (torsion, usually in children) or infection of the testicle itself (e.g. due to mumps) are the commonest causes of inflammation.
Solid swellings
Solid swellings include tuberculosis & syphilis (both very rare nowadays), a sperm granuloma or nodule (usually following a previous vasectomy), chronic inflammation of the epididymis. If the lump is within the testicle itself, it may be a testicular tumour.
Hernias
A hernia arising in the groin can extend down towards the testicle but simple examination will reveal that the swelling does not arise from the scrotum itself. Urologists do not treat hernias and your GP may recommend referral to a hernia surgeon.
What treatments are available for this problem?
Cystic (fluid-filled) swellings
Hydrocele repair, excision of an epididymal cyst (pictured) and open surgery, laparoscopic surgery or radiological embolisation may be needed for significant symptoms from the swelling. Otherwise, no treatment is necessary.
Inflammatory swellings
Antibiotics are used for infection of the epididymis. Your GP may refer you to a urologist (if you are over 50 or have a urinary infection) or to a genitomedical clinic (if you are young or your infection may be sexually-acquired). Testicular involvement with mumps usually requires no specific treatment apart from painkillers. Suspected torsion of the testis requires emergency admission and immediate surgery.
Testicular cancer
If you are found to have testicular cancer, you will be referred urgently to the urology clinic. Following further investigations (see above), you will normally be advised to have the testicle removed as soon as possible. An artificial testicle can be inserted at the same time or at a later date. The need for further treatment (radiotherapy or chemotherapy) is determined by the pathology results, the results of your tumour marker blood tests & the findings on a CT scan. Once surgery has been arranged, you will referred to an oncologist for any further treatment and for long-term follow-up.
Other solid swellings
Tuberculosis and syphilis are rarely seen nowadays but are treated with appropriate antibiotics. Sperm granulomas in the epididymis may be removed if they are uncomfortable but they rarely require treatment.
Raised PSA
What should I do if I have a raised PSA?
If you have a raised PSA or you have been told that your prostate feels abnormal, you should contact your GP or your urologist for further advice.
PSA (prostate-specific antigen) is a small protein molecule which is released from the prostate gland into the bloodstream. As you get older, your prostate slowly enlarges and your PSA gradually increases. The larger your prostate, the higher the PSA.
Prostate cancer (pictured) also becomes commoner with increasing age. By the age of 90 years, almost all men will have microscopic areas of tumour in the prostate. This does not mean that they have active prostate cancer. Many elderly men live a normal lifespan without the need to treat these “incidental” tumours.
Only detailed urological investigation can determine whether a prostate cancer is “incidental” (requiring no treatment) or “significant” (requiring active treatment).
What are the facts about a raised PSA?
- PSA is not a specific test for prostate cancer. Raised levels may also be caused by inflammation, benign enlargement or previous surgery.
- With PSA levels between 3 and 10, only 20% of men have prostate cancer on biopsy.
- Higher levels of PSA make prostate cancer more likely (50% chance with a PSA greater than 10) If your PSA is raised, you will probably have a further blood test to measure the free/total PSA ratio (FTR). An FTR of less than 17% makes prostate cancer more likely. Levels greater than 22% usually mean that the prostate is benign.
- If there is a high suspicion of prostate cancer on the basis of the blood tests, you will normally be advised to have biopsy samples taken from your prostate gland.
- Even negative biopsies do not always rule out prostate cancer. Further biopsies may be needed if your PSA remains raised or increases with time.
- If prostate cancer is present, the best way of treating early prostate cancer is still not known with any certainty.
What should I expect when I seek further advice?
1. History, examination & additional tests
Your GP will normally assess your general health, examine your prostate (by rectal examination, pictured) and ask about any prostate symptoms you may have. A further blood test, to measure the free/total PSA ratio, may also be arranged. You will normally have tests of kidney function, bone function, liver function and your GP may check your blood cells for anaemia or other abnormalities. Newer tests for prostate cancer, which are thought to be more specific (e.g. the PCA3 urine test), are not available to GPs and are only performed by a few urologists because they are still under assessment.
2. Risk calculation
Click here to see the prostate risk indicator for prostate cancer. This opens in a new browser window and takes account of a number of factors to produce an approximate risk of prostate cancer.
This should not be used as a substitute for a full discussion of risks with your urologist.
3. Initial treatment from your GP
If your PSA is greater than 100, your GP may start you immediately on hormone treatment (before you are seen in the urology clinic). This PSA level means it is likely that prostate cancer is present and that it is no longer confined to the prostate gland. Your GP may also arrange a bone scintigram (bone scan) if he/she is able to do this.
What happens next?
If your PSA remains raised, if the free/total ratio is low or if your GP suspects that your prostate feels abnormal, a referral will be arranged for you to see a urologist using the fast-track (2-week wait) system.
In a urology clinic, you will be assessed carefully by a urologist or a urology nurse specialist. Based on this assessment, it is likely that you will be advised to have transrectal ultra-sound guided biopsies of your prostate. This procedure may be performed at the first visit or at a later stage, and you should read the information leaflet before the procedure is performed.
Click here to see a calculation of the risk of biopsy-detectable prostate cancer
It may take up to a week before you get the final results of your prostate biopsies. The biopsies are analysed under a microscope (pictured right) to determine whether prostate cancer is present. If it is, the tissue is examined in more detail to determine the grade of cancer (the Gleason grade). This is done by looking at the characteristics of individual groups of cancerous cells. Once the biopsies have been examined carefully, the results will be discussed in a multi-disciplinary meeting where a number of specialists will consider them in detail.
If your prostate biopsies are negative for prostate cancer
You will normally be advised about treatment of any prostate symptoms you may have and your urologist will arrange for you to have regular (6-monthly) blood tests to check your PSA. If the PSA level remains raised or increases with time, you may be advised to have repeat biopsies or to have biopsies performed under a general anaesthetic (saturation biopsies). The latter allows more extensive sampling and is more likely to detect prostate cancer if it is present. More accurate still is a technique where your ultrasound scan is superimposed on an MRI scan. This technique is probably more sensitive in detecting prostate cancer but is still under assessment.
If your prostate biopsies are positive for prostate cancer
Your urologist will then discuss the following:
Staging investigations
To find out the extent of your prostate cancer, your urologist may arrange a CT scan, an MRI scan or a bone scintigram (or bone scan). Together with the Gleason grade found on the biopsies, these will determine what treatment is needed. Not all patients will require staging investigations before treatment.
Treatment options
Once the results of all the tests are available, your urologist will discuss what treatment options are available and what is best for you. This will take into account your age, general health, PSA level, Gleason grade and stage of the tumour.
Your urologist will help you decide whether treatment by surgery, hormones, chemotherapy or radiotherapy is best for you. It may be more appropriate for your cancer to be monitored closely and treated only of there are signs of progression (active monitoring).
Prostate Symptoms
What does the prostate gland do?
The prostate gland lies just beneath the bladder and is normally about the size of a chestnut. The urethra (water pipe) runs through the middle of the prostate. The main function of the prostate is during your reproductive life. It produces fluid containing chemicals which nourish sperms to help with fertilisation.
What should I do if I have prostate symptoms?
If you have difficulty starting or stopping your urine flow, a weak stream, a feeling that you do not empty your bladder completely, increased frequency and urgency of urine passage by day or night and a tendency to dribble after you have finished, you should contact your GP for further advice.
Your GP will normally review you initially and may supply you with a symptom questionnaire and/or a voiding diary to complete before your appointment. Referral to a urologist is only indicated if:
- your symptoms are severe
- your urine flow is very poor
- your blood tests (e.g. PSA) are abnormal
- there are any complications of the condition (e.g. chronic retention, urinary infection, bladder stones).
What are the facts about prostate symptoms?
- By the age of 65 years, 50% of men will experience benign enlargement of the prostate. At the age of 90, 90% of men have prostatic enlargement
- An enlarged prostate alone does not always cause symptoms
- The severity of the symptoms is not related to the size of the prostate
- 1 in 3 men will suffer prostatic symptoms during their life
- 1 in 10 men will require surgical treatment for their symptoms
- Not all urinary symptoms in men are due to an enlarged prostate – incontinence, pain or blood in the urine may be due to other conditions
- The risk of prostate cancer is not increased by having benign enlargement of the prostate. You are no more likely to develop prostate cancer than a man without benign prostatic enlargement
- 30-40% of men with prostatic symptoms do not experience worsening of their condition with time and may not require any treatment
- If treatment is indicated, this usually involves with drugs which relax the muscle in and around the prostate and/or drugs which shrink the glandular component of the prostate
- If symptoms are severe, if there is no response to medical treatment or if there are complications of prostatic enlargement, surgical treatment may be indicated
- The risk of acute, painful retention of urine is small (approximately 1 in 100) and it is not always preceded by prostatic symptoms. Acute retention usually requires surgical treatment
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for men with prostatic symptoms. This will normally include some or all of the following:
1. A full history
Your GP will take a general history and a more detailed urological history. Using the symptom score and voiding dairy (see above), this will allow him/her to understand the severity of your symptoms and, in particular, how much they affect your daily activities. You may also be asked about your erections because reduced erections and prostatic symptoms often go together.
Some drugs can affect your bladder function and it is important that your GP is aware of all the drugs you are taking.
In younger men (less than 45), “prostatic” symptoms may be due to other problems such as a stricture in the urethra (water pipe); Your GP will ask about previous injuries, diseases or operations in this area which may cause a stricture to develop.
2. A physical examination
A full physical examination is normally performed, including measurement of your blood pressure. Your GP will perform a rectal examination to assess the size and texture of the prostate gland. Your abdomen may also be examined to feel for an enlarged bladder. Your reflexes will normally be tested to ensure that your symptoms are not due to a neurological problem.
3. Additional tests a. General blood tests
The actual blood tests performed will be left your your GP’s discretion. It is essential to measure kidney function and to check the blood cells for anaemia or other problems.
b. PSA (prostate-specific antigen) measurement
It is usual to measure PSA levels in the blood in men with prostatic symptoms. If you are concerned about this, you should read the leaflet on PSA measurement and discuss the test with your GP. If your PSA is measured and is found to be raised above normal levels, or if your prostate feels abnormal on rectal examination, your GP will normally refer you urgently to see a urologist with a view to further tests to exclude prostate cancer.
Having a raised PSA does not mean you have prostate cancer. 50-60% of men with benign enlargement of the prostate have a raised PSA level. The only way to exclude prostate cancer is to see a urologist for further tests.
c. Urine tests
Your urine will be tested for any abnormality. A sample will normally be sent to the laboratory to exclude infection.
d. Other specific tests
Other tests are not always necessary at this stage but your GP may wish to have a more detailed assessment by arranging:
- an abdominal X-ray (to look for stones)
- an ultrasound scan to see how much is left behind in your bladder after you pass urine (residual urine)
- a measurement of how fast you are able to pass urine (a voiding flow rate, see picture).
- These tests will normally be performed in the urology clinic if your GP feels that a referral is needed.
What could have caused my prostate to enlarge?
In general terms, we know very little about why the prostate gland enlarges with increasing age but hormone imbalance within the gland itself probably plays a part as well as certain genetic factors.
There is some evidence that hormones and certain growth factors may work together to cause the prostate gland to enlarge. There also seems to be an inherited tendency in approximately 10% of men (1 in 10).
What treatments are available for this problem?
No treatment is likely to clear all your symptoms completely but they can be greatly improved so that the degree of “bother” is minimal; your symptoms can then be monitored regularly to see whether changes in treatment are needed
Treatment options include:
General measures (“watchful waiting”)
If you and your GP decide treatment is not necessary initially, some simple measures can improve your quality of life:
- limit your fluid intake when you know you will be out of the house
- try emptying your bladder twice each time by returning to the toilet after a few minutes for another attempt at emptying
- reduce your caffeine, alcohol & nicotine intake which all cause you to make more urine
- if you suffer from urgency, try distraction techniques (e.g. breathing exercises or counting) to take your mind off the urge to pass urine
- if your stream is slow to start, try relaxation measures when standing to pass urine
- try “holding on” as long as possible to improve your bladder capacity
Your symptoms may improve significantly with these measures. If they progress, you should go back to see your GP and get further advice.
Drugs
Alpha-blockers (e.g. tamsulosin, terazosin, alfuzosin, doxazosin) will normally be the first type of drug your GP prescribes. They relax the muscles in and around the prostate/bladder neck area to make the passage of urine easier. They may cause low blood pressure, a stuffy nose, skin rashes and impaired ejaculation.
Alpha-blockers should not be taken if you are due to undergo cataract surgery because they cause floppiness of the iris. This can result in complications after cataract surgery.
5-alpha-reductase inhibitors (e.g. finasteride, dutasteride) shrink large prostate glands (>40 grams) and may be used together with alpha-blockers if your PSA is more than 1.5 (an indication that your prostate is significantly enlarged). They can cause ejaculatory problems They take at least 6 months to have maximum effect and do not work well if your prostate is small. They also reduce your PSA level by up to 50%.
With larger prostates, a combination of both types of drug has been shown to be better than either type used alone, to reduce the risk of complications (especially retention) and to reduce the need for surgery.
Herbal Remedies
Some herbal & plant extracts (e.g. saw palmetto, pictured right) are effective in relieving symptoms without the risk of side-effects. They probably work because the extracts contain plant hormones which alter the abnormal hormone balance within the prostate. These extracts are not usually available on prescription from your GP.
Surgery
Surgical treatment is usually recommended if symptoms are severe, medical treatment has failed or if there are complications (e.g. a large residual urine,. retention of urine, infection, bladder stones).
Open surgery on the prostate is rarely performed nowadays but may be necessary if the prostate is very large.
Conventional telescopic surgery involves resecting the central part of the prostate using a telescope passed into the bladder through the penis (transurethral resection or TURP). There are risks to this procedure (outlined in the information leaflet) so, other techniques such as electrical vaporisation and laser surgery have been developed which also give good results with less risk.
Courtesy of PreOp.com Video Patient Education
Video Courtesy of of Mr TF Aho
Sometimes, when the prostate is small, the muscle at the neck of the bladder can be cut telescopically without actually removing the prostate (bladder neck incision or prostatotomy); normally, the surgeon can only decide if this is appropriate after looking inside the bladder.
Less invasive alternatives to surgery
Microwave heat treatment, stretching with a balloon, radio-frequency needle ablation and freezing (cryotherapy) have all been tried. They are less effective than conventional surgery and often not long-lasting. Prostate stents, an indwelling catheter or intermittent self-catheterisation relieve symptoms but should be regarded as temporary measures.
Video summary
This video was prepared by Mr Mark Speakman, Consultant Urological Surgeon in Taunton, and it summarises the current thinking about how lower urinary tract symptoms (LUTS) due to benign prostatic enlargement should be investigated and managed.
Courtesy of TRENDSUROLOGY
Premature ejaculation
What should I do if I have premature ejaculation?
If your ejaculation is earlier than desired (before or soon after penetration) with minimal stimulation and you have little control over it, you should consider seeking further advice from your GP.
What are the facts about premature ejaculation?
- Premature ejaculation is usually lifelong (i.e. it usually dates back to the first sexual experience)
- Rarely, premature ejaculation may develop in later life when it is often progressive
- We do not know accurately how common it is but between 1 in 3 & 1 in 5 men (20-30%) are thought to have premature ejaculation
- Less than a quarter of men with premature ejaculation actually seek medical advice for their condition
- Premature ejaculation is often associated with erectile dysfunction (impotence) and with rapid loss of erection after ejaculation
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for men with troublesome premature ejaculation. This will normally include one or all of the following:
1. A full history
Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption and will take a detailed sexual history.
Your GP may also ask you to complete a premature ejaculation symptom questionnaire as an aid to further assessment and discussion of treatment options. This will allow your GP to:
- identify your needs & expectations
- help you & your partner share in decision-making
- decide whether psychosexual counselling might be helpful
2. A physical examination
A general physical examination will be performed to assess the development of your male sexual characteristics and to detect any abnormality of your penis or genitals. Your blood pressure will normally be measured as part of this examination. The pulses in your legs will normally be assessed. The nerve reflexes involving your legs, penis and anus (back passage) are also tested. Rectal examination (pictured) is normally performed to assess the tone of your anal muscles and to feel your prostate gland.
3. Additional tests
Specific tests are not usually needed but the following may be performed:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function, liver function and cholesterol as well as checking your blood cells for anaemia or other problems. A blood sugar measurement may be performed to exclude diabetes
b. Routine urine tests
Your urine will normally be assessed by stick-testing to see whether it contains sugar which might indicate diabetes
c. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones may be measured if you also have erectile dysfunction (impotence).
d. Other specific tests
Your GP may ask you to time the interval between penetration and ejaculation (the intravaginal ejaculation latency time, IELT) using a stopwatch. A latency time of less than 1 minute is regarded as abnormal.
What could have caused by premature ejaculation?
The cause of premature ejaculation is unknown; it appears unrelated to performance anxiety, hypersensitivity of the penis or nerve receptor sensitivity.
Premature ejaculation may, however, have a genetic tendency and is also associated with prostate inflammation (prostatitis), thyroid disorders, emotional disorders and previous traumatic sexual experiences.
What treatments are available?
Psychosexual counselling may help men with less troublesome premature ejaculation but, in most men, the mainstay of long-term treatment is with drugs.
Most patients can be managed in general practice without the need for urological referral. If you have troublesome erectile dysfuncton (impotence) as well, your GP may ask you to consult a urologist.
Drugs
Selective serotonin uptake inhibitors (SSRIs) are powerful antidepressants but they also have a beneficial effect on premature ejaculation. They are used as first-line treatment for this condition and their effectiveness is often maintained for several years. Dapoxetine (Priligy®, pictured) is the only SSRI licensed for use in premature ejaculation. It is not available on the NHS and requires a private prescription, allowing purchase of the drug at cost price. This can prove expensive, so your GP may recommend another SSRI (e.g. paroxetine, fluoxetine, fluvoxamine, sertraline, clomipramine). Dapoxetine is, however, the only drug which can be taken “on demand” (i.e. when needed) Common side-effects of SSRIs include fatigue, drowsiness, nausea, dry mouth, diarrhoea & excessive perspiration. These are often mild and usually settle after 2-3 weeks.
SSRIs are powerful drugs. You should only take them by getting a prescription from your GP & you should have a detailed discussion about the risks & benefits before starting treatment.
Other drugs which delay ejaculation (e.g. tramodol, terazosin, alfuzosin) have been used but their role is unclear and, at the moment, they are not recommended for clinical use in premature ejaculation.
Viagra®, Cialis® or Levitra® and self-administered penile injections have also been used to help premature ejaculation but their exact role is uncertain. They do, however, improve sexual confidence and reduce performance anxiety by producing better erections (if this is a problem).
Topical treatment
Local anaesthetic cream (lignocaine + prilocaine or SS-cream), applied 20 – 60 minutes before intercourse, can be useful but may numb the vagina unless used with a condom. It can occasionally cause irritation of the penile skin.
“Long love” condoms, containing the local anaesthetic benzocaine, are also available commercially and have proved useful in some patients.
Psychosexual counselling
Behavioural strategies, listed below, are all effective.
- the “stop-start” technique (developed by Semans)
- the “squeeze” technique (developed by Masters & Johnson)
- the Kegel technique (learning to control the ejaculatory muscles)
Improvements are seen in 50-60% of patients but may not be maintained in the long term. These techniques are best learnt under the supervision of a psychosexual counsellor. They can be used alone in acquired premature ejaculation and when symptoms are mild. When problems are severe or lifelong, they are best used in conjunction with drugs.
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