Peyronies Disease

Peyronies disease is a not-to-infrequent disorder of the penis that is associated with penile curvature and sexual dysfunction. The actual etiology of the disorder is a mystery, though it is thought to be due, in part, to tiny, micro-traumas to the inner lining of the penis, though most men with Peyronies are unable to recall such traumatic events. Peyronies is also associated with certain autoimmune disorders, such as Dupytrens contractures of the wrist.

Men with Peyronies Disease complain of 3 things: pain, curvature, or sexual problems, or all three. Peyronies Disease has 2 phases: the acute and chronic phase. The acute phase occurs early on in the disease process and is when the man first experiences his symptoms. The acute phase can last up to 2 years and is the only time period in which non-surgical therapy may be effective. The chronic phase is associated with a stable, hard, and calcified plaque that is palpable in the penis and stable (non-worsening) curvature for 18 to 24 months.

Medical therapy is indicated for men still in the acute phase of the disease process. Medical therapies include:

• Vitamin E


• Potaba


• Colchicine and Vitamin


• Intra-lesional Verapamil (injected directly into the lesion)

All of the above medical therapies have side-effects and have never been demonstrated to be effective in good, randomized, placebo controlled studies. I have had good, anecdotal experience with Vitamin E.

Men with Peyronies should be evaluated with a good history, including sexual history, and physical examination. Often, the plaque is palpable. When curvature is not visible with the flaccid penis, I will ask the man to take a digital picture or Polaroid of the erect penis when he is at home and bring it to me on the next visit. This way, I can see the degree of the curvature. If he is unable to get an erection at home, I will give him an injection with caverject or trimix in the office and assess the curvature that way, and take a digital photograph. Men that opt for invasive forms of treatment, such as the incision and patch of the plaque, will need to undergo objective tests of erectile function, such as a penile doppler.

Men in the acute phase are offered Vitamin or Potaba, or if the curvature is mild or after informed consent, reassurance. Treatment in the chronic phase depends on the degree of curvature and the presence or absence of ED. Treatment options include:

• Reassurance


• Tunica albuginea plication


• Incision and patch


• Penile implant insertion

Surgical intervention must not be performed during the acute phase, or failure will occur. Failure is defined as worsening or progressive curvature after the operation. ED after Peyronies surgery is uncommon and if it occurs, it typically means it was present pre-op. If ED is present pre-op, the treatment option of first choice is the penile implant.

Thanks,

The IU.

The UPJ Obstruction

I saw an interesting case yesterday that I'd like to share with you. A 40 year old man was referred to me, stat, after a CT report showed severe hydronephrosis--swelling--on his kidney. The patient had no pain and was, in-fact, completely asymptomatic. the CT scan was done to evaluate an umbilical hernia.

The CT showed a classic UPJ obstruction. Here is how I plan to evaluate him.

• I ordered a lasix radionucleotide renal scan to determine the degree of obstruction and the degree of function within the kidney.
• If the kidney has good function, I may get an IVP to define the anatomy a bit better.
• Depending on my approach to correct the problem, I may get a CT angiogram to look for crossing vessels, which can complicate certain forms of management.

Now here are his options for treatment.

1. Observe: Maybe, if his kidney was not severely blocked. Though I would not recommend this in a young, healthy patient, it might be reasonable in certain situations, in certain patients.
2. Endopyelotomy: This is a minimally invasive approach that involves cutting the scarred segment that causes the blockage with an electric knife.
3. Pyeloplasty: This is the gold standard with the highest success rates. It is the most invasive.

Lets see what his tests show.

The IU.

Urologic Trauma

Isolated urologic injuries are uncommon after an MVA, such as Governor Corzines, but GU trauma does occur. I would not be surprised if the governor even had some. Here are some urologic injuries that he could have had, or might have.

• Kidney trauma: The kidneys are protected in their locations in the retroperitoneum, but can get injured in severe enough accidents. Renal traumas can range from minor bruises to fractured kidneys and major vascular tears. Seat belts, in general, would protect people from renal injuries.


• Ureters: The ureters carry urine from the kidneys into the bladder. Isolated ureter injury during blunt trauma--ie from an MVA--rarely, if ever happens. Sometimes in children involved in MVA, the connection of the kidney into the ureter can be disrupted. Seat belts can help prevent this.


• Bladder injuries: Bladder injuries are pretty common in MVA's and happen most frequently when the passenger/driver's bladder is full at the time of the accident. This causes the bladder to rupture and this can be life-threatening. Patients with pelvic fractures will often have bladder injuries, either as a result of bladder rupture or because a piece of the pelvic bone gets lodged into the bladder. Bone chips don't belong in the bladder and can cause recurrent UTI's. The lap portion of a seat belt can cause a bladder rupture.


• Urethral injuries: The urethra can get inured--severely--during an MVA. Injuries range from bruises to partial tears to complete disruptions. Complete disruption is very bad and men who have this injury will typically require many surgeries to correct the problem and can expect long-term disability, despite the best of care. The disability can be in the form of recurrent stricture disease and sexual dysfunction/ED. Urethral injuries are most often associated with pelvic fractures. Seat belts can prevent urethral injuries.

I wish the Governor of the Great State of NJ well and a speedy recovery.

The IU.

The Testis Biopsy

The testicular biopsy is done during the evaluation of infertilility in men that do not have sperm in the ejaculate--azoospermia. The testis biopsy is essentially done to differentiate between the 2 causes of azoospermia--obstruction vs testis failure. Testis biopsies will typically reveal 1 of several possible pathology types:

• Normal


• Hypospermatogenesis


• Germ Cell Aplasia


• Inflammation

Testis biopsies are not performed, in general, in the evaluation of a testicular mass or tumor, such as testicular cancer.

The testis biopsy is a diagnostic procedure only and does not, in and of itself, help couples become pregnant. Occasionally, a testis biopsy is done in conjunction with a testicular sperm aspiration.

The above testis biopsy result was from a patient with azoospermia and shows hypospermatogenesis.

Thanks.

The IU.

5 ways to manage kidney stones

Kidney stones have increased in prevalence in the USA in recent years, probably due to dietary factors. Most, but not all kidney stones are painful. In addition to pain, kidney stones cause cause urinary infections, chronic kidney inflammatory disorders, and silent blockages. Kidney stones may be managed in a variety of ways, depending upon a variety of factors, such as stones size and location, patient and urologist preference, and underlying medical conditions within the patient. In general, here are the 5 treatment options.
1: Observation: This is OK for small, lower pole kidney stones that are not growing and not causing problems. Observation is also OK for ureter stones that are not causing severe blockage or pain or infection.
2: Lithotripsy: This is a great option for all but the largest stones and is suitable for stones in many locations within the kidney and ureter. Lithotripsy is non-invasive.
3: Ureteroscopy: This is a good option for stones in the lower third of the ureter, but is invasive. It is possible in upper ureter and even renal stones, but is more difficult in these locations.
4: Percutaneous Stone Extraction: This is the best option for very large renal stones but is the most invasive approach. For some stones, it is the only viable option.
5: Stenting: This is a temporizing approach that is only used to stabilize an infected patient prior to one of the more definitive approached mentioned above.

Any other questions, contact Dr Schoor.

The Vas Deferens

This is what a vas deferens looks like under the microscope. Vasectomies are typically done in the office. Now I do a no needle, no scalpel approach.

Easy.

The IU.

Sexual Health Rejuvenation: Restore Your Sexuality.

Sexual problems in the man can be caused by a variety of conditions but is typically treatable. Dr Schoor sees many patients with ED and applies a methodical approach to its evaluation and therapy. Here are some of the things he can do to treat your problem.

1: Hormone therapy
2: Oral medication treatment
3: Injection therapy
4: Penile implant therapy--the only cure for ED
5: Referrals to his team of sexual counselors.

Please feel free to contact Dr Schoor for an appointment.

The Artful Vasectomy

I enjoy doing vasectomies. A well done vasectomy is a beautiful thing: a work of art. Doing a vasectomy well requires a well planned and well orchestrated sequence of events that starts from the moment the man contacts the office until he returns for his follow-up care. Remember, he is nervous and really does not want the procedure. Therefore, I give him every opportunity to contact the office and schedule the vasectomy. The consultation must be low stress and the patient must develop an impression that the procedure is “no big deal” and that you are supremely confident in your ability to perform it and perform it artistically. A well performed vasectomy is painless—truly painless—and quick and easy. The well performed vasectomy is a joy to do. It is your job to convey this to the patient.

Vas day:

Only you and the patient should be in the room. Men don’t like crowds for their vasectomies. Even the presence of one medical assistant in the room will make some men nervous, and a nervous patient translates into a more challenging case. My Dad—a retired periodontist—used to give his patients a glass of Harvey’s Bristol Cream before the procedure. Old school—and wonderful.

For a right handed person, the left vas is approached from the patient’s left and the right vas from the patient’s right.

The best way to immobilize the vas, the most secure way, is to gently pinch it between your thumb and index finger. By this way, only the vas and small amount of perivasal tissue sits in that space and within this space, it is very easy to numb the vas and engage it in the vas clamp.

I use The No Needle Technique that allows for absolutely pain-free delivery of the local to the site without distortion of the anatomy. But if you do not, here is how to inject the local. After injecting the perivasal space with lidocaine, gently message down the bubble of local anesthetic. This serves several functions. It restores distorted anatomy to normal anatomy. It guarantees that the local hits the intended target, the vas and it gives a few extra seconds the lidocaine to take effect.

Never, ever, ever start the vas until the patient is 100% numb. It is at this time in the procedure, the beginning, that the patient is the most nervous, and unnecessarily inflicting pain on him will adversely impact his confidence in you and make your case that much more difficult. It is a wonderful when your patient asks you if you’ve started as you are finishing.

Gently lean the vas clamp over your thumb after you have successfully engaged the vas. This will deliver the vas, and nothing else, directly into optimal position.

Incise the sheath of the vas directly above the vas, then gently user the sharp spreader to free the vas. Now the vas will essentially “jump” into the field.

The rest is easy. Cut, cut, burn, dunk. That is it.

Next time I’ll tell you how I do facial interposition.

The IU.