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Geriatric Urology
Many elderly patients suffer from urologic conditions particular to their age group. Often times physicians are unfamiliar with the treatment of such conditions. Furthermore, many urologists are unfamiliar with the side effects in the elderly of commonly used urologic medications. Dr. Tomas Griebling focuses on urologic problems in the elderly, their diagnosis and their treatment. Having completed a fellowship to address urologic problems in the elderly, Dr. Griebling is a nationally recognized leader in the field of Geriatric Urology. In addition, he is the only urologist in the state of Kansas with such specialized training.
Sexual Dysfunction
Sexual dysfunction is an extremely common problem affecting over 50% of men between the ages of 40 and 70. With newer treatments available, public awareness of the problem has increased greatly. Impotence, or erectile dysfunction (ED), as with many disease processes, has a spectrum of severity. The most frequent symptom that we see is the inability to achieve any penile erection at all. Commonly, however, one may experience partial erection with either incomplete rigidity or loss of rigidity before ejaculation. In the past physicians often attributed ED to psychological causes. However, we now know that psychogenic impotence is responsible for less than 10% of cases of serious erectile dysfunction. Common causes of ED include medications for other conditions, arterial blockage due to atherosclerosis, peripheral nerve damage due to diabetes, pelvic fracture, and spinal cord injury. Fortunately, determining the specific cause of erectile dysfunction is usually not necessary as treatment is fairly standard.
Often times, ED can be treated easily with prescription oral medications. The physicians at the University of Kansas Hospital will evaluate your erectile dysfunction and select the best medication for you. If one of these medications is not effective, our physicians are equipped with a wide range of options to treat erectile dysfunction including intercavernosal injections, vacuum erection devices, intraurethral therapy, and surgical placement of a penile prosthesis.
In the event that surgery is needed for your erectile dysfunction, Dr. Ajay Nangia and Dr. Joshua Broghammer are currently one of the few physicians in the Kansas City area who are placing penile protheses and doing complex protheses for the treatment of erectile dysfunction. This procedure which uses an artificial device to provide erections has been reported to result in satisfaction rates greater than 90%. With extensive experience in these techniques, they offer the latest approaches for this surgical correction of impotence.
Watch the Multimedia Webcast: Sexual Dysfunction In The American Male as presented at the American Urological Association national meeting in 2009.
SATISFYING SOLUTIONS Effective Treatments for Erectile Dysfunction
The University of Kansas Department of Urology specializes in the latest treatment options for erectile dysfunction (ED) – the persistent inability to maintain an erection that is firm enough or lasts long enough to have sexual intercourse. This common problem is often caused by physical conditions, including prostate cancer, diabetes and cardiovascular disease.
ED can limit your intimacy, affect your self-esteem and impact your most important relationships. But the good news is that nearly every case is treatable today…You don’t have to simply live with it.
Treatment Options
• Oral Medications (Viagra®, Levitra®, Cialis®)
• Vacuum Erection Devices
• Injections
• Intraurethral Suppositories
• Penile Prostheses
The Satisfying Solution
The Department of Urology at KUMed has extensive experience with penile prosthetic surgery. Penile prostheses have been in use for over 30 years, and offer a satisfying long-term solution for ED. In a study comparing ED treatment options, patients reported a 93% satisfaction rate with penile prostheses – which far surpasses satisfaction with other treatment options.
Benefits & Risks of a Penile Prosthesis
Benefits
• Long-term solution
• Have an erection anytime you choose
• Allows for spontaneity – have sex when the mood strikes
• Maintain erection as long as you desire
• No ongoing costs for pills or shots
• Feels natural during intercourse
• Doesn’t interfere with ejaculation or orgasm
Risks
• Will make latent natural or spontaneous erections as well as other interventional treatment options impossible
• If an infection occurs, the prosthesis may have to be removed
• May cause the penis to become shorter, curved or scarred
• May cause lasting pain
• There may be mechanical failure of the prosthesis
A penile implant is entirely concealed within the body and is designed to be simple and discrete to operate. It may offer a permanent, long-term solution to ED, and can help you return to an active, satisfying sex life.
How Penile Prostheses Work
Choosing the penile prosthesis that is best for you is a very personal decision. Because each type of prosthesis offers unique features, you will want to discuss the choices with your doctor in order to choose the option that is right for you.
One-Piece Positionable Prosthesis (Malleable)
One-piece positionable prostheses are the simplest types of penile prostheses. The prosthesis consists of a pair of cylinders that are surgically inserted into the penis. The prosthesis is positioned up for intercourse or down for everyday activities.
Advantages
• Totally concealed in body
• Easy for you and your partner to use
• Good option for men with limited dexterity
• Generally the simplest surgical procedure
• Simply bend prosthesis to conceal
• 91% patient satisfaction rate
Disadvantages
• Remains firm when not being used
• Less appropriate for patients requiring repeated cystoscopy
Two-Piece Inflatable Prosthesis
The two-piece inflatable prosthesis consists of a fluid-filled pair of cylinders implanted in the penis and a small pump implanted in the scrotum. To get an erection, you simply squeeze and release the pump several times. When the fluid is pumped into the cylinders, it creates an erection that provides rigidity.
Advantages
• Totally concealed in body
• Simple to use
• One-step deflation
• Device is inflated to provide rigidity and deflated for concealment
• 90% of partners would recommend it to other couples
Disadvantages
• Requires some manual dexterity
• Cylinders remain partially filled with fluid when deflated
Three-Piece Inflatable Prosthesis
The three-piece, fluid-filled inflatable prosthesis features a pair of cylinders implanted in the penis, a pump implanted in the scrotum, and a reservoir implanted in the lower abdomen. When the fluid is pumped into the cylinders, it creates an erection that provides rigidity and girth expansion.
Advantages
• Totally concealed in body
• Like a natural erection
• Device is inflated to provide rigidity and deflated for concealment
• Expands in girth (all AMS 700® cylinders) and length (AMS 700 LGX® and Ultrex® cylinders)
• When deflated, the cylinders are soft and flaccid
• AMS 700 with InhibiZone® is the only inflatable penile prosthesis with clinical evidence showing a significant reduction in the rate of revision due to infection.
• Parylene coating increases durability
• 92% patient satisfaction rate
Disadvantages
• Requires some manual dexterity
The AMS 700 LGX may not be appropriate for all patients, please consult with your physician to determine if it is right for you.
Finding the Right Treatment for You
Of course, a surgical solution is generally not the first course of action. Many men with ED benefit from other therapies like oral medications, injections or vacuum devices. But for those men who are not satisfied with those treatments – or not getting the results they desire – a penile prosthesis may provide a permanent, satisfying option.
Make an Appointment to Learn More
If you suffer from ED and are interested in reclaiming your sex life, make an appointment to discuss your options and learn more about today’s satisfying solutions.
As with any medical procedure, there are risks involved and not all patients are candidates for a penile implant. Discuss the risks and benefits of this procedure in more detail with your doctor.
Summary of Warnings, Precautions and Contraindications for Penile Prostheses
• Implantation of the device will make latent natural or spontaneous erections as well as other interventional treatment options impossible and may result in penile shortening, curvature or scarring.
• This device contains solid silicone elastomer. The risks and benefits of implanting this device in patients with documented sensitivity to silicone should be carefully considered.
• The implantation of this device is contraindicated in patients who have active urogenital infections or active skin infections in the region of surgery.
• The implantation of the InhibiZone® version of this device is contraindicated in patients with known allergy or sensitivity to rifampin (rifampicin) or to minocycline or other tetracyclines.
For a complete list of indications, contraindications and precautions, please contact us today.
Penile Curvature
Penile curvature also known as Peyronie’s disease is one of the most challenging problems facing urologists today. Our understanding of the disease is currently a topic of much research, but remains largely unknown. However, the physicians in the Department of Urology are providing state of the art care, using the latest treatments available.
For those with a recent onset of Peyronie’s disease, treatments provided in the office might be successful. However, patients who have a long history of penile curvature often require surgical intervention. Whatever your needs, the Department of Urology at KU provides all of the options available.
Male Infertility
Infertility is a common problem affecting up to 15% of couples. In over 50% of cases a male factor is solely responsible or is contributing to the problem. Many causes of male infertility exist ranging from hormonal, blockages, genetic, environmental/lifestyle, medications or unexplained to name a few. Certain potentially life-threatening medical conditions may present for the first time as the inability to achieve a pregnancy and lower sperm counts, such as testicular tumors and some brain tumors. They are uncommon, and the reason why male patients should be evaluated in couples that have infertility.
The evaluation should involve a thorough history and physical and evaluate some of the risk factors that are known to cause male infertility e.g. some childhood disorders that do not become a concern until later in life e/g undescended testicle(s); infections; smoking, alcohol and drug use; certain issues with heat (not boxers or briefs – a myth); cancer treatments; spinal cord injury and other medical conditions. Blockages of the reproductive tract can sometimes be the cause and possible reconstruction using microsurgery can be performed to reverse this and avoid assisted reproduction techniques (ART) and have children naturally. Unfortunately these blockages sometimes cannot be corrected and sperm retrieval techniques and sperm freezing are required for in vitro fertilization (IVF) with intracytoplasmic injection (ICSI) – one sperm injected into an egg outside the body.
Correction of men with low counts and/or motility can also be corrected with a full evaluation, correcting any treatable causes e.g. manipulation of hormones, and correction of certain conditions such as varicoceles – dilated veins in the scrotum that are thought to increase scrotal temperature and affect sperm production. Up to 40% of men who present with infertility have a varicocele on exam. Treatment for this requires careful patient selection and can result in 40-70% improvement in sperm production and up to 40% improvement in pregnancy rates. Even some men with no sperm in their semen who have a varicocele may get return of sperm (approx 17%). It is important to know that the number of sperm is usually not enough for natural conception in these cases and would require ART with IVF. Correction of the varicocele is a same day surgery as an outpatient but is in the operating room and requires an operating microscope to tie off the veins accurately and completely without causing damage to the blood supply to the testicle. Embolization of the veins can also be performed.
Dr. Ajay Nangia along with a large group of scientists at the University of Kansas Medical Center are advancing the treatment of men with male infertility with better insight into the reasons for the infertility problem. They hope to correct the problems that men have with their fertility and achieve a pregnancy and allow couples to achieve a pregnancy without need for assisted reproduction if possible or to make the quality and function of the sperm better to more likely achieve a pregnancy if assisted reproduction is needed. Dr. Nangia is a leading member in the field of male infertility on a regional and national level and will be able to advise couples on all the latest information in the filed of male infertility and best advise couples of options and alternatives. He recently was a member of the Best Practice Statement in Male Infertility prepared by the American Urological Association and will be happy to discuss current standards of care in the field of male reproduction and infertility, along with new testing techniques and their limitations. Treatment options need to be determined after thorough evaluation of both the history and also careful examination.
One important feature is the issue of decline of testosterone in the reproductive years. Male patients should not be placed on testosterone - this will shut down sperm production. Correction of the testosterone level has limited success for male fertility but is becoming more and more recognized as a potential health concern for later heart disease, insulin resistance and diabetes. Dr Nangia has a special interest and expertise in this field and will be able to discuss this with you and how it relates to male reproductive and post reproductive health.
Recently, the WHO (World Health Organization) updated their guidelines for normal semen analysis to define fertility. The methodology, study and findings can be viewed by clicking here.
Vasectomy Reversal
Vasectomy is a common procedure for permanent birth control in the US with over 520,000 performed a year. This is a form of secondary infertility. Six percent of men who have undergone a vasectomy desire a reversal with 12 times higher desire for reversal if the vasectomy was performed under the age of 30. Options for men who wish to have more children either with the same or new partner include vasectomy reversal, sperm aspiration (not undoing the vasectomy) with IVF-ICSI, donor sperm insemination, adoption or doing nothing. The decision to follow a particular option is determined on a case-by-case basis and depends on important factors such as length of time from vasectomy, experience and training of the surgeon and use of an operating microscope; age of the female partner; gynecological history of the female partner; and economic/financial issues since post vasectomy fertility management is most often not covered by insurance. A common myth is that men over 10 years should not have a vasectomy reversal – this is not correct, with the decision making based on the whole evaluation including examination and couples desires and time line as well as issues of views on family planning hopes of the couple. Vasectomy reversal is performed either as an end to end connection – removing the area of vasectomy and reconnecting, and this is called a vasovasostomy. The other type of reversal is a connection between the vas and the back of the testicle (the epididymis) called a vasoepididymostomy. The decision to perform one or the other of these operations depends on the fluid seen at the vasectomy site at the time of the vas reversal. The vasoepididymostomy is a very specialized microsurgery operation that requires significant training. Dr Nangiais trained in this operation. Vasectomy reversal is an outpatient surgery and then semen analysis checked 4 weeks after surgery and periodically there after until pregnancy occurs. Success rates are approximately 75% pregnancy if the vasectomy was performed under 3-5 years prior to approximately 30% if vasectomy was 15 or more years previously.
Sperm aspiration/retrieval techniques for use with IVF-ICSI can be performed in many ways (MESA, TESA, TESE, microTESE) depending on the situation for each patient/couple – ranging from men who have had a vasectomy to men who do not have sperm in the ejaculated semen, known as azoospermia. The reason men have no sperm in the semen and who do not have a blockage (known as non obstructive azoospermia) can be genetic, hormonal or unknown. In up to 10% of cases the genetic reason is felt to be due to missing a piece of the Y chromosome (the male chromosome), known as the AZF region. Some men may also have pieces of one chromosome on another (translocation) or too many X chromosomes. These can be checked by performing blood work. Azoospermia is not the end of the road for having biological children. Even though a man may not have sperm in the semen, there may still be pockets of sperm in the testicles that are not getting out and can be retrieved in up to 60% of cases. This does require a special type of sperm retrieval called micro TESE – which is an extensive biopsy using an operating microscope. This does have to be performed in the operating room. The number of sperm can only be used with IVF-ICSI. Genetic counseling of a couple is sometimes needed especially if a known genetic problem is found.
Another group of patients may develop infertility – those who receive chemotherapy or radiation for cancer. In these cases men should try to freeze sperm prior to treatment for later use if their counts are too low or zero. Hope is not lost in those who did not freeze and may require micro TESE or use of ART. Spinal cord injury in a young man is another reason for problems with fertility – mainly because of ejaculatory issues. In this situation special methods are required to retrieve sperm for couples to have children. Sometimes men have retrograde ejaculation – sperm going into the bladder e.g diabetics, spinal cord injuries, neurological issues, urological/prostate surgery and medications. Retrieval of the sperm from the bladder can be performed to use with assisted reproduction. Sometimes medications can be used to reverse retrograde ejaculation.
At the University of Kansas Medical Center, we have a comprehensive male infertility center that includes an andrology laboratory capable of semen analysis, cryopreservation, and other sophisticated sperm testing. Dr. Ajay Nangia works closely with the reproductive endocrinologists at KU and in the community when couples desire to pursue assisted reproduction – insemination or in vitro fertilization (IVF). Dr. Nangia is fellowship trained from the Cleveland Clinic in male infertility and microsurgery and specializes in vas and epididymis reconstruction, sophisticated sperm retrieval techniques, as well as problems of fertility following cancer and other illnesses including spinal cord injury. Dr. Nangia is a national leader in this field, as well as issues of male contraception.
Vasectomy
Vasectomy is a common urological procedure to result in permanent birth control. Over 520, 000 are performed a year in the USA. It is an outpatient procedure that is done in the clinic/office. It takes about half an hour. A piece of the vas is removed and either clips or ties are applied and some urologists turn the vas back or place the two ends in different levels. Ice pack, rest and pain medication are recommended after the surgery. Protected intercourse is needed until no sperm in the semen is confirmed. This is checked after a certain number of ejaculations (e.g. 15-20) or based on time frame (6 weeks or more after vasectomy). The patient is NOT CLEARED FOR UNPROTECTED INTERCOURSE until the follow up semen analysis shows no sperm. Certain questions often asked are listed below:
Will a man have normal erections after vasectomy?
Answer: yes – any affect on erections may be psychological – there are no changes hormonally that cause a problem. Some residual discomfort may play a role possibly.
Will a man still produce fluid?
Answer: yes – the main fluid a man produces is “down stream” from the vasectomy.
Will a man still reach climax?
Answer: yes….no further explanation needed
Will a man still have normal libido (sex drive)?
Answer: yes. Again the problem may be psychological or if he still has some pain may lead to less desire.
Can a vasectomy increase the chance of testicular cancer?
Answer: no. There is no connection between the two. Also there is no connection with prostate cancer or any other cancers.
Are there any diseases that a vasectomy can lead to?
Answer: no. There have been some associations made that a vasectomy can lead to an increased risk of heart disease, and Alzheimer’s disease. These have not been supported by adequate studies.
Can a vasectomy reverse itself spontaneously?
Answer: This is called “recanalization” and unfortunately the answer is yes but rarely and the statistics range from 1 in a 1000 to 1 in 10,000 chance. The reason for this is that there is a sort of “honey combing effect” that the body manages to do in some cases. This however may be very much related to the technique of vasectomy performed and to the man being compliant with the instructions to get his semen checked to make sure there are no sperm. Under 50% of men get checked to make sure that they have no sperm. It is recommended that the analysis not be performed until at least 15-20 ejaculations have occurred. Some doctors recommend a time line e.g. analysis after 6 weeks. The exact time line is not completely clear.
Can a vasectomy be reversed deliberately?
Answer; yes. Of the 520,000 or more men who have a vasectomy in the USA per year, approximately 6% feel that they have made a mistake or a change in their life situation has occurred to consider reversing this permanent means of contraception. It is important to also know that if a man is under 30 years of age, he has a 12 times higher chance of wanting a reversal. See male infertility section.
What is the no scalpel vasectomy?
Answer: this isn’t quite what everyone thinks. No scalpel does not mean “no pain” or miraculously the surgery is performed like something out of Star Trek. No scalpel unfortunately doesn’t really mean it is any less anxiety provoking, nor any less of a procedure. The main issue is exactly what the name suggests. In place of a scalpel is an instrument that stretches the skin to open it up…..still requires local anesthetic. The main issue is that most times no stitch in the skin is required and the hole is small. Recovery may be better but I have not noticed any difference.
As a patient some time should be taken thinking about the options. It is an important milestone so it is important to get it right the first time. If a patient is unsure, vasectomy may not be the right option. For more information on vasectomies, procedures and follow-up protocols, please click here to read the review article by Lee Warner, PhD, MPH; Denise Jamieson, MD, MPH; Ajay Nangia, MBBS, FACS.
Benign Prostate Hypertrophy (BPH)
One of the most common problems in Urology is difficulty with urination. Since Greek times, physicians have employed different methods to relieve problems associated with urinary obstruction due to an enlarging prostate gland. The Urology department at Kansas University Medical Centers offers a comprehensive array of diagnostic and treatment options for the enlarged prostate. These include oral medications, minimally invasive techniques, and transurethral resection of the prostate. We are the only major medical facility in this area offering the transurethral needle ablation (TUNA) of the prostate which involves the use of radiofrequency to heat the prostate and shrink it over a 3-6 week period. In addition, we are now offering transurethral microwave therapy (TUMT), which uses microwave therapy to help shrink the prostate and can be done in the clinic without the need for anesthesia. These procedures are offered as an out-patient therapy and have very few complications with excellent results.
For those with more advanced enlargement of the prostate, our physicians are very experienced in the surgical treatment of the enlarged prostate gland. The standard transurethral resection of the prostate formerly was associated with a large number of complications, however newer technologic advances have decreased these complications. The Department of Urology at the University of Kansas Medical Center is always seeking options to improve the outcomes of our patients who suffer from an enlarged prostate.
Urethral Stricture
Causes: In most cases, patients present with urethral strictures and no obvious reason for the stricture. They can be congenital, inflammatory, infectious, or traumatic. The inflammation, inflection, or injury to the urethra results in scarring of the spongy tissue around the lining of the urethra, and that scarring causes contracture and a smaller opening for the patient to be able to urinate.
Symptoms: Most of patients present to the urology clinic with slowing of their urinary stream. Other symptoms include burning with urination, and at times, some bleeding with urination.
Treatment: The treatment of urethral stricture disease can be done by cutting the stricture, dilating the strictured area, or trying to definitively fix the stricture with an open operation. Dilating or cutting the stricture with a knife or a laser results in a re-stricture the vast majority of the time. Reconstruction of the urethra using a piece of the mouth called buccal mucosa or using a flap of penile skin, results in a long-term success rate of approximately 94%. At the University of Kansas Department of Urology, we have one of the largest experiences in the country repairing all types of urethral strictures. We perform buccal mucosal urethroplasty, vascularized pedicle flap urethroplasty, two-stage mesh graft urethroplasties, and posterior urethroplasty repair from trauma to the pelvis. Two surgeons in our department perform the majority of these reconstructions, Dr. J. Brantley Thrasher and Dr. Josh Broghammer. Both have fellowship training in reconstruction of the urinary tract and an extensive experience in all repairs of the urinary tract.
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