Genital Surgery
Overview
Varicocele – Diagnosis
Your doctor will conduct a physical exam, which might reveal a nontender mass above your testicle that feels like a bag of worms. If it’s large enough, your doctor will be able to feel it.
If you have a smaller varicocele, your doctor might ask you to stand, take a deep breath and hold it while you bear down (Valsalva maneuver). This helps your doctor detect abnormal enlargement of the veins.
If the physical exam is inconclusive, your doctor might order a scrotal ultrasound. This test, which uses high-frequency sound waves to create precise images of structures inside your body, might be used to ensure there isn’t another reason for your symptoms. In certain cases, further imaging might be recommended to rule out other causes for the varicocele, such as a tumor compressing the spermatic vein.
Treatment
Varicocele treatment might not be necessary. Many men with varicoceles are able to father a child without any treatment. However, if your varicocele causes pain, testicular atrophy or infertility or if you are considering assisted reproductive techniques, you might want to undergo varicocele repair.
The purpose of surgery is to seal off the affected vein to redirect the blood flow into normal veins. In cases of male infertility, treatment of a varicocele might improve or cure the infertility or improve the quality of sperm if techniques such as in vitro fertilization (IVF) are to be used.
Clear indications to repair a varicocele in adolescence include progressive testicular atrophy, pain or abnormal semen analysis results. Although treatment of a varicocele generally improves sperm characteristics, it’s not clear if an untreated varicocele leads to progressive worsening of sperm quality over time.
Varicocele repair presents relatively few risks, which might include:
- Buildup of fluid around the testicles (hydrocele)
- Recurrence of varicoceles
- Infection
- Damage to an artery
Repair methods include:
This treatment usually is done on an outpatient basis, during general or local anesthetic. Commonly, your surgeon will approach the vein through your groin (inguinal or subinguinal), but it's also possible to make an incision in your abdomen or below your groin.
Advances in varicocele repair have led to a reduction of post-surgical complications. One advance is the use of the surgical microscope, which enables the surgeon to see the treatment area better during surgery. Another is the use of Doppler ultrasound, which helps guide the procedure.
You might be able to return to normal, nonstrenuous activities after two days. As long as you're not uncomfortable, you might return to more strenuous activity, such as exercising, after two weeks.
Pain from this surgery generally is mild but might continue for several days or weeks. Your doctor might prescribe pain medication for a limited period after surgery. After that, your doctor might advise you to take over-the-counter painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) to relieve discomfort.
Your doctor might advise you not to have sex for a period of time. Most often, it will take several months after surgery before improvements in sperm quality can be seen with a semen analysis. This is because it takes approximately three months for new sperm to develop.
Open surgery using a microscope and subinguinal approach (microsurgical subinguinal varicocelectomy) has the highest success rates when compared with other surgical methods.
Advances in varicocele repair have led to a reduction of post-surgical complications. One advance is the use of the surgical microscope, which enables the surgeon to see the treatment area better during surgery. Another is the use of Doppler ultrasound, which helps guide the procedure.
You might be able to return to normal, nonstrenuous activities after two days. As long as you're not uncomfortable, you might return to more strenuous activity, such as exercising, after two weeks.
Pain from this surgery generally is mild but might continue for several days or weeks. Your doctor might prescribe pain medication for a limited period after surgery. After that, your doctor might advise you to take over-the-counter painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) to relieve discomfort.
Your doctor might advise you not to have sex for a period of time. Most often, it will take several months after surgery before improvements in sperm quality can be seen with a semen analysis. This is because it takes approximately three months for new sperm to develop.
Open surgery using a microscope and subinguinal approach (microsurgical subinguinal varicocelectomy) has the highest success rates when compared with other surgical methods.
Your surgeon makes a small incision in your abdomen and passes a tiny instrument through the incision to see and to repair the varicocele. This procedure requires general anesthesia.
A radiologist inserts a tube into a vein in your groin or neck through which instruments can be passed. Viewing your enlarged veins on a monitor, the doctor releases coils or a solution that causes scarring to create a blockage in the testicular veins, which interrupts the blood flow and repairs the varicocele. This procedure isn't as widely used as surgery.
After embolization, you can often return to work after two days, and begin exercising after seven to 10 days.
After embolization, you can often return to work after two days, and begin exercising after seven to 10 days.
Lifestyle and home remedies
If you have a varicocele that causes you minor discomfort, but doesn’t affect your fertility, you might try the following for pain relief:
such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others).
to relieve pressure.
Preparing for your appointment
You’re likely to start by seeing your primary care doctor. However, in some cases when you call to set up an appointment, you might be referred immediately to a urologist.
Here’s some information to help you get ready for your appointment, and know what to expect from your doctor.
What you can do
including any that might seem unrelated to the reason for which you scheduled the appointment.
including any major stresses or recent life changes.
vitamins and supplements that you're taking.
if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
your doctor.
Preparing a list of questions will help you make the most of your time with your doctor. List your questions from most important to least important. For varicocele, some questions to ask include:
- What's the most likely cause of my symptoms?
- What kinds of tests do I need?
- Is my condition likely temporary or more permanent?
- Will this condition affect my fertility?
- What treatments are available? Which do you recommend?
- I have these other health conditions. How can I best manage these conditions together?
- Are there any restrictions on sexual activity that I need to follow?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
In addition to the questions you’ve prepared, don’t hesitate to ask questions that arise during your appointment.
What you can do in the meantime
Take an over-the-counter pain reliever and wear an athletic supporter to relieve pressure.
Hydrocele - Diagnosis
Your doctor will start with a physical exam. It’s likely to include:
- Checking for tenderness in an enlarged scrotum.
- Applying pressure to the abdomen and scrotum to check for inguinal hernia.
- Shining a light through the scrotum (transillumination). If you or your child has a hydrocele, transillumination will show clear fluid surrounding the testicle.
Your doctor will start with a physical exam. It’s likely to include:
- Blood and urine tests to help determine if you or your child has an infection, such as epididymitis
- Ultrasound to help rule out hernia, testicular tumor or other causes of scrotal swelling
Treatment
In baby boys, a hydrocele sometimes disappears on its own. But for males of any age, it’s important for a doctor to evaluate a hydrocele because it can be associated with an underlying testicular condition.
A hydrocele that doesn’t disappear on its own might need to be surgically removed, typically as an outpatient procedure. The surgery to remove a hydrocele (hydrocelectomy) can be done under general or regional anesthesia. An incision is made in the scrotum or lower abdomen to remove the hydrocele. If a hydrocele is found during surgery to repair an inguinal hernia, the surgeon might remove the hydrocele even if it’s causing no discomfort.
After hydrocelectomy, you might need a tube to drain fluid and a bulky dressing for a few days. Your doctor is likely to recommend a follow-up exam because a hydrocele might recur.
Preparing for your appointment
You might be referred to a doctor who specializes in conditions of the urinary and reproductive tract (urologist). Here’s some information to help you get ready for your appointment.
What you can do
- List symptoms you or your child has had and for how long
- List all medications, vitamins and supplements you or your child takes, including the doses
- List key personal and medical information, including other conditions, recent life changes and stressors
- Prepare questions to ask your doctor
For hydrocele, some basic questions to ask your doctor include:
- What do you think is causing this swelling? Are there any other possible causes?
- What kinds of tests are needed?
- What treatment do you recommend, if any?
- What signs or symptoms will indicate that it's time to treat this condition?
- Do you recommend any restrictions on activity?
Don’t hesitate to ask other questions that arise during your appointment.
What to expect from your doctor
Your doctor is likely to ask you a number of questions.
If your child is affected, your doctor might ask:
- When did you first notice this swelling? Has it increased over time?
- Is your child in any pain?
- Does your child have any other symptoms?
If you’re affected, your doctor might ask:
- When did you first notice the swelling?
- Have you had any discharge from your penis or blood in your semen?
- Do you have discomfort or pain in the affected area?
- Do you have pain during intercourse or when you ejaculate?
- Do you have a frequent or urgent need to urinate? Does it hurt when you urinate?
- Have you and your partner been tested for STIs?
- Do your hobbies or work involve heavy lifting?
- Have you ever had a urinary tract or prostate infection or other prostate conditions?
- Have you ever had radiation or surgery in the affected area?
What you can do in the meantime
If you are a sexually active adult, avoid sexual contact that could put your partner at risk of contracting an STI, including sexual intercourse, oral sex and any skin-to-skin genital contact.
Peyronie's disease - Diagnosis
If you are a sexually active adult, avoid sexual contact that could put your partner at risk of contracting an STI, including sexual intercourse, oral sex and any skin-to-skin genital contact.
Tests to diagnose Peyronie’s disease and understand exactly what’s causing your symptoms might include the following:
Your doctor will feel (palpate) your penis when it's not erect, to identify the location and amount of scar tissue. He or she might also measure the length of your penis. If the condition continues to worsen, this initial measurement helps determine whether the penis has shortened.
Your doctor might also ask you to bring in photos of your erect penis taken at home. This can determine the degree of curvature, location of scar tissue or other details that might help identify the best treatment approach.
Your doctor might also ask you to bring in photos of your erect penis taken at home. This can determine the degree of curvature, location of scar tissue or other details that might help identify the best treatment approach.
Your doctor might order an ultrasound or other tests to examine your penis when it's erect. Before testing, you'll likely receive an injection directly into the penis that causes it to become erect.
Ultrasound is the most commonly used test for penis abnormalities. Ultrasound tests use sound waves to produce images of soft tissues. These tests can show the presence of scar tissue, blood flow to the penis and any other abnormalities.
Ultrasound is the most commonly used test for penis abnormalities. Ultrasound tests use sound waves to produce images of soft tissues. These tests can show the presence of scar tissue, blood flow to the penis and any other abnormalities.
Treatment
Treatment recommendations for Peyronie’s disease depend on how long it’s been since you began having symptoms.
You have penile pain or changes in curvature or length or a deformity of the penis. The acute phase happens early in the disease and may last only two to four weeks but sometimes lasts for up to a year or longer.
Your symptoms are stable, and you have no penile pain or changes in curvature, length or deformity of the penis. The chronic phase happens later in the disease and generally occurs around three to 12 months after symptoms begin.
For the acute phase of the disease, treatments range from:
When used early in the disease process, penile traction therapy prevents length loss and minimizes the extent of curvature that occurs.
Medical and injection therapies are optional in this phase, with some more effective than others.
Surgery isn't recommended until the disease stabilizes, to avoid the need for repeat surgery.
For the chronic phase of the disease, several potential treatments are available. They may be done alone or in combination:
- Watchful waiting
- Injection treatments
- Traction therapy
- Surgery
Medications
A number of oral medications have been tried to treat Peyronie’s disease, but they have not been shown to be effective consistently and are not as effective as surgery.
In some men, drugs injected directly into the penis might reduce curvature and pain associated with Peyronie’s disease. Depending on the therapy, you might be given a local anesthetic to prevent pain during the injections.
If you have one of these treatments, you’ll likely receive multiple injections over several months. Injection medications may also be used in combination with oral drugs or traction therapies.
Medications include:
The only FDA-approved medication for Peyronie's disease is collagenase clostridium histolyticum (Xiaflex). This medicine has been approved for use in adult men with moderate to severe curvatures and a palpable nodule.
This therapy has been shown to improve curvature and bothersome symptoms associated with Peyronie's disease. The treatment works by breaking down the buildup of collagen that causes penile curvature. Collagenase appears to be more effective when used in conjunction with "modeling," which is forcible bending of the penis in the opposite direction of the bend.
This therapy has been shown to improve curvature and bothersome symptoms associated with Peyronie's disease. The treatment works by breaking down the buildup of collagen that causes penile curvature. Collagenase appears to be more effective when used in conjunction with "modeling," which is forcible bending of the penis in the opposite direction of the bend.
This is a drug normally used to treat high blood pressure. It appears to disrupt the production of collagen, a protein that might be a key factor in the formation of Peyronie's disease scar tissue. The drug is well tolerated and may reduce pain, too.
This is a type of protein that appears to disrupt the production of fibrous tissue and help break it down. One placebo-controlled trial showed improvement using this therapy over placebo. Interferon also has been shown to reduce penile pain in men with Peyronie's disease.
Surgery
Your doctor might suggest surgery if the deformity of your penis is severe, sufficiently bothersome or prevents you from having sex. Surgery usually isn’t recommended until you’ve had the condition for nine to 12 months and the curvature of your penis stops increasing and stabilizes for at least three to six months.
Common surgical methods include:
A variety of procedures can be used to suture (plicate) the longer side of the penis — the side without scar tissue. This results in a straightening of the penis, although this is often limited to less severe curvatures.
Several plication techniques may be used, generally resulting in similar success rates depending on surgeon experience and preference.
Several plication techniques may be used, generally resulting in similar success rates depending on surgeon experience and preference.
With this type of surgery, the surgeon makes one or more cuts in the scar tissue, allowing the sheath to stretch out and the penis to straighten. The surgeon might remove some of the scar tissue.
A piece of tissue (graft) is often sewn into place to cover the holes in the tunica albuginea. The graft might be tissue from your own body, human or animal tissue, or a synthetic material.
This procedure is generally used in men with more-severe curvature or deformity, such as indentations. This procedure is associated with greater
risks of worsening erectile function when compared with the plication procedures.
A piece of tissue (graft) is often sewn into place to cover the holes in the tunica albuginea. The graft might be tissue from your own body, human or animal tissue, or a synthetic material.
This procedure is generally used in men with more-severe curvature or deformity, such as indentations. This procedure is associated with greater
risks of worsening erectile function when compared with the plication procedures.
Surgically placed penile implants are inserted into the spongy tissue that fills with blood during an erection. The implants might be semirigid — manually bent down most of the time and bent upward for sexual intercourse.
Another type of implant is inflated with a pump implanted in the scrotum. Penile implants might be considered if you have both Peyronie's disease and erectile dysfunction.
When the implants are put in place, the surgeon might perform additional procedures to improve the curvature if needed.
Another type of implant is inflated with a pump implanted in the scrotum. Penile implants might be considered if you have both Peyronie's disease and erectile dysfunction.
When the implants are put in place, the surgeon might perform additional procedures to improve the curvature if needed.
The type of surgery used will depend on your condition. Your doctor will consider the location of scar tissue, the severity of your symptoms and other factors. If you’re uncircumcised, your doctor might recommend a circumcision during surgery.
Depending on the type of surgery you have, you might be able to go home from the hospital the same day or you might need to stay overnight. Your surgeon will advise you on how long you should wait before going back to work — generally, a few days. After surgery for Peyronie’s disease, you’ll need to wait four to eight weeks before sexual activity.
Other treatments
A technique known as iontophoresis uses an electric current to administer a combination of verapamil and a steroid noninvasively through the skin. Available research has shown conflicting results on penile curvature and erectile function.
Several nondrug treatments for Peyronie’s disease are being investigated, but evidence is limited on how well they work and possible side effects. These include using intense sound waves to break up scar tissue (shock wave therapy), stem cells, platelet-rich plasma and radiation therapy.
Coping and support
Peyronie’s disease can be a source of significant anxiety and create stress between you and your sexual partner.
Here are some tips for coping with Peyronie’s disease:
- Explain to your partner what Peyronie's disease is and how it affects your ability to have sex.
- Let your partner know how you feel about the appearance of your penis and your ability to have sex.
- Talk to your partner about how the two of you can maintain sexual and physical intimacy.
- Talk to a mental health provider who specializes in family relations and sexual matters.
Preparing for your appointment
If you have Peyronie’s disease symptoms, you’re likely to begin by seeing your family doctor or general practitioner. You might be referred to a specialist in male sexual disorders (urologist). If it’s possible, encourage your partner to attend the appointment with you.
Preparing for your appointment will help you make the best use of your time.
What you can do
Make a list ahead of time that you can share with your doctor. Your list should include:
you're experiencing, including any that might seem unrelated to Peyronie's disease
including any major stresses or recent life changes
that you're taking, including any vitamins or supplements
to the penis
of Peyronie's disease, if any
to ask your doctor
List questions for your doctor from most important to least important in case time runs out. You might want to ask some of the following questions:
- What tests will I need?
- What treatment do you recommend?
- Can you tell if symptoms are likely to worsen or improve?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend?
In addition to the questions you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them might reserve time to go over any points you want to discuss further. Your doctor might ask:
- When did you first notice a curve in your penis or scar tissue under the skin of your penis?
- Has the curvature of your penis worsened over time?
- Do you have pain during erections, and if so, has it gotten worse or improved over time?
- Do you recall having an injury to your penis?
- Do your symptoms limit your ability to have sex?
Your doctor might also ask you to complete a survey, such as the International Index of Erectile Function, to help identify how the condition affects your ability to have sex.
PHIMOSIS
What is phimosis?
Phimosis is a condition of the penis that occurs in some adults and children who aren’t circumcised. If you have phimosis, your foreskin can’t be pulled back (retracted). It may look like your penis has rings around the tip.
Having phimosis isn’t necessarily a problem. It only becomes a problem when it causes symptoms. This could be when phimosis is severe and leaves an opening the size of pinhole.
Actually, there are two types of phimosis: physiologic and pathologic. The physiologic type is associated with childhood and usually resolves as you age. The pathologic type is associated with a condition called balanitis xerotica obliterans (BXO).
Who does phimosis affect?
The foreskin (also called the prepuce) is tight when babies are born, but usually gets looser by the time the child is 2 years old. During the years between ages 2 and 6, the foreskin loosens up and begins to separate from the head of their penis. Phimosis can also happen after childhood.
How common is phimosis?
Phimosis is found in virtually all newborns, and then the foreskin changes gradually so that it can be pulled back. It’s estimated that only 1% of people still have phimosis when they’re 16 years old.
SYMPTOMS AND CAUSES
What are the symptoms of phimosis?
Someone with phimosis may have the following symptoms:
- Redness or discoloration, which may occur when infected/irritated.
- Swelling (infammation), which may occur when infected/irritated.
- Soreness.
- Pain while urinating (dysuria).
- Pain with erections or with sexual activity.
What causes phimosis?
If you or your child has pathologic phimosis (which is caused by some type of condition), there are various reasons it might develop, including:
- Poor hygiene. This could actually be a cause and a result of phimosis. It might be irritating and painful to try to clean thoroughly, but not cleaning could lead to infection.
- Skin conditions such as eczema, psoriasis, lichen planus and lichen sclerosus. When it affects your penis, lichen sclerosis is known as penile lichen sclerosis or balanitis xerotic obliterans (BXO).
- Preputial adhesions, or scar tissue, that keep the foreskin attached to the tip (glans) of your penis.
- Injuries.
- Infections, including sexually transmitted infections (STIs).
DIAGNOSIS AND TESTS
How is phimosis diagnosed?
Your healthcare provider can diagnose phimosis during a physical examination. In addition, they might order tests to fnd out if there’s an infection present in urine or penis discharge.
MANAGEMENT AND TREATMENT
How is phimosis treated?
Physiological phimosis (congenital) typically doesn’t need treatment. Usually, your child grows out of it. Your provider might also call this primary phimosis.
Pathological phimosis, also called secondary phimosis, does need to be treated.
- ● Your healthcare provider will probably suggest a steroid cream to apply to the skin of your penis.
- ● Your provider might suggest that you gently start stretching the foreskin after about two weeks of using the steroid cream. You should stretch the skin very gently, pulling it back only as far as you can without it hurting at all. You can use the cream on the part of the glans that’s exposed by the stretching exercises.
- ● The next step would be surgery. If your child is having difculty, their provider might make a small cut in the foreskin so you’re able to pull it back. If you’re an adult with lots of scar tissue, your provider will probably recommend circumcision. This procedure will remove the foreskin and free the glans.
- ● Your healthcare provider is almost sure to suggest circumcision if balanitis xerotic obliterans (BXO) is causing the phimosis and steroid creams don’t work. Your provider might suggest it anyway. Phimosis can make sexual activity uncomfortable for adults. Also, BXO can cause urinary tract problems and is associated with a higher risk of cancer of the penis.
What complications are related to phimosis or phimosis treatment?
The complications associated with steroids aren’t usually an issue with the creams used to retract the foreskin. Those issues are mostly related to long-term oral use of steroids.
While circumcision used to be a common procedure performed on newborns, it’s not necessarily done right away anymore. Risks associated with circumcision include:
- Bleeding.
- Infection.
- Having a foreskin that is too long or too short.
- Pain.
How soon will I feel better after circumcision to treat phimosis?
Recovery from circumcision takes about a week to 10 days.
PREVENTION
How can I prevent phimosis?
Physiological phimosis can’t be prevented. It’s present in nearly all newborns.
It’s important, though, to keep the penis clean. Parents or caregivers should be given directions on the best way to clean a penis. They should also be told not to worry so much about the fact that the foreskin isn’t movable for the frst few years of life. When the children are old enough to take care of themselves, they should be taught to clean their own penis.
Emergency Cases
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