Men face a unique set of health issues that we provide treatments for through the Men's Health program of the Emory Urology Department. Common conditions treated by our Men's Health program include vasectomy and reversal services, erectile dysfunction, enlarged prostate, and elevated PSA.
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PSA, or prostate-specific antigen, is a protein secreted by normal prostate glands that allow normal sperm function and be measured in the blood. It is often used as a screening tool for prostate cancer, but levels can be elevated from infection, inflammation, trauma, or benign enlargement.
A variety of conditions lead to elevation of PSA, including inflammation, acute injury, benign enlargement, or prostate cancer. This blood test is used to identify men who are at high risk for prostate cancer and may benefit from more diagnostic tests to look for prostate cancer.
After discussion of the risks and benefits of cancer screening, most primary care physicians usually draw the PSA with routine blood tests at the time of annual physical examinations, starting at age 50 for most men or at age 40 for patients at higher risk. Higher risk patients include men with a family history of prostate cancer or African Americans. Screening may improve survival if the tumor is found and treated early.
Factors Affecting PSA Tests
Several activities can impact the results of a PSA test. Straddle activities like long-distance bicycle riding, recent sexual activity, a vigorous digital rectal exam (DRE), or a cystoscopy test may cause PSA levels to be temporarily elevated and should be avoided for at least 48 hours before the blood draw.
The medications finasteride (Proscar) and dutasteride (Avodart), used to treat enlarged prostate, can lower PSA levels by 50 percent. Once a patient starts one of these medications, a PSA should be drawn to establish a new baseline. Whenever future PSAs are done, this new baseline should be used for reference.
In men older than 75, PSA testing is controversial. This stems from the fact that these older men have a high likelihood of slow-growing prostate cancer while also having medical problems like heart disease, diabetes, neurologic conditions, and other cancers. In addition, PSA screening is not recommended in any patient with major medical problems and a life expectancy of less than 10 years, as these patients would be more likely to die with prostate cancer rather than from prostate cancer.
When preparing for a PSA test, patients should:
Interpreting Abnormal PSA Results
PSA should always be interpreted relative to previous PSA tests, patient age and the size of the prostate. The PSA slope refers to the change in PSA over a sustained period of time: years rather than months. While an individual abnormal PSA may prompt concern, many of these situations are temporary elevations from benign conditions, and the PSA will later return to normal. But when the PSA level steadily rises with significant jumps over a period of time, then there is greater likelihood of prostate cancer. Additionally, PSA normal levels different by age, with higher normal levels in older patients.
Regarding prostate size, since PSA is also made by normal prostate tissue (not cancer) it is possible that a very large prostate will generate a large (but still normal) amount of PSA. Size of the prostate should be determined by imaging rather than simple physical exam, and it is important to remember that having an enlarged prostate does not prevent the development of prostate cancer.
A digital rectal examination (DRE) is still a key part of an annual physical exam, even in the PSA era. A prostate nodule or an irregular-feeling prostate may indicate an early prostate cancer despite a normal PSA test.
Enlarged prostate, or benign prostatic hyperplasia (BPH), is the noncancerous enlargement of the prostate gland. The urethra carries urine through the prostate gland from the bladder and out the penis, and in some cases BPH can obstruct the flow of urine. Prostatic enlargement is common in men over the age of 50 and can cause a variety of bothersome symptoms.
Typical initial symptoms of enlarged prostate or BPH include:
Patients with minor problems are usually treated by modifying fluid intake and cutting back on coffee, tea or alcohol, particularly in the evening.
Erectile dysfunction (ED) refers to a man's inability to obtain and maintain an adequate erection for sexual activity. Most men occasionally experience ED, which is normal. However, ED is more common in older men, but can affect men at any age. When ED becomes a continuous problem, it can interfere with a man's psychological wellbeing as well as his and his partner's sex life.
It is also notable that ED may not be an isolated process. ED has also been found to be a harbinger of heart disease and some men with erectile dysfunction may benefit from seeing a heart doctor.
Symptoms of erectile dysfunction include:
Causes and Risk Factors of ED
There are many causes of erectile dysfunction (ED), some physical and some psychological. Occasionally, ED may be caused by both physical and psychological factors. However, ED can be one of the first signs of an underlying physical illness. Your physician can help you determine what is causing the ED and work out a treatment that is right for you.
Some of the more common causes of ED are listed below:
Diagnosing ED
A patient's medical history and recent physical and emotional changes will play an important role in diagnosing erectile dysfunction (ED). Blood tests to check for diseases and disorders such as low hormone levels, diabetes and heart disease may also be necessary.
Other tests to check for physical causes of ED may include:
ED Treatments
Several erectile dysfunction treatment options are available. You and your doctor will decide which ED treatment options are right for you.
The following treatments are available:
Testosterone is often considered one of the most important male hormones. It is made in the testes and secreted into the bloodstream. Some testosterone is also made in the adrenal glands, which are organs located above the kidneys. However, in men, the majority of the testosterone is from the testes. It is responsible for muscle mass, male distribution of body hair, and is important for energy and memory.
Testosterone is known to decline with age. In addition, the presence of other diseases such as diabetes, obesity, and heart disease can also predispose to having low testosterone.
Symptoms of low energy, low libido, poor erections, decreased muscle mass and forgetfulness can be suggestive of low testosterone. However, to make a diagnosis of low testosterone, blood tests are needed to measure the level of testosterone in the blood. For best accuracy, these tests should be collected before 10 am.
Low Testosterone Treatments
Testosterone replacement therapy is the most common method to treat low testosterone. Testosterone can be given as an injection, as a gel, as a pellet implanted in the office, or as a patch. Future blood tests are also usually necessary prior to initiating therapy as well as for those patients already being treated.
The benefits of testosterone treatment may include improvements in energy, libido, erection quality, better memory and increased muscle mass.
Patients who have cancer of the prostate or are suspected to have cancer of the prostate should not use testosterone replacement. Testosterone replacement may cause elevated red blood cell counts, impairment of fertility, liver dysfunction or exacerbation of heart failure.
Vasectomy is the most popular and effective form of permanent birth control for men, and about 500,000 men in the US choose vasectomy every year. The vas deferens is the tube that carries sperm from the testicle to the penis. Vasectomy blocks the normal flow of sperm and provides permanent sterility. At Emory we routinely perform the no-scalpel vasectomy (NSV), which is an innovative technique by which we can perform the entire procedure through a tiny puncture site in the scrotal skin. With the NSV, a tiny puncture hole is used and blood vessels around the vas deferens are spread apart instead of cutting with a scalpel (as is commonly done during a traditional vasectomy). The no-scalpel vasectomy has been shown to have lower rates of bleeding (hematoma), lower rates of infection, and lower level of pain during the procedure when compared to a traditional vasectomy.
Vasectomy is performed as an outpatient procedure and it usually takes about half an hour. While the procedure can be performed under local anesthetic, some patients prefer additional oral medication to ensure relaxation, comfort and ease of mind. For this purpose, the procedure is performed in an ambulatory surgery center. Please do not hesitate to discuss this with your Emory urologist to ensure that all your needs are met. Vasectomy is nearly 100 percent effective for achieving sterility. It is intended to be permanent, and it doesn't limit sexual pleasure. After a vasectomy sexual intercourse will be exactly the same with the only difference being that if one were to microscopically examine a man’s ejaculate, one would not see sperm cells. In all other aspects, a man’s ejaculate will remain the same.
In addition to the NSV, we also offer a no-needle, no-scalpel vasectomy (NNNSV). The NNNSV uses a high-pressure jet injector to anesthetize the area without the use of a needle. This allows the surgeon to do the procedure without the need for a conventional vasal block with local anesthetic, which often is the most anxiety provoking portion of the procedure.
Infertility is a disease defined by the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women over age 35 years. Ten to fifteen percent of couples will experience infertility. A male factor is present in up to half of cases of infertility and often can be treated.
There are number of known causes of male infertility including genetic abnormalities, previous testicular surgery, varicocele, testicular trauma, ejaculatory dysfunction to name just a few. Unfortunately, in half of men with infertility evaluation reveals “idiopathic” infertility, of infertility due to an, as of yet, unknown cause.
Male factor infertility is initially evaluated by obtaining a semen analysis and simply blood testing. A semen analysis is a microscopic examination of the ejaculate after a man ejaculates into a specimen cup. It will tell you a number of factors including the sperm count, how well the sperm move, and how healthy the sperm look under a microscope. The semen analysis and blood testing for an endocrine evaluation constitute the initial evaluation of an infertile man.
Male Infertility Treatments
Treatment of male infertility depends on the cause of infertility and should only be determined after a complete evaluation by a urologist. Treatment options may include simple lifestyle changes, medications, and/or surgery. Most surgeries for male infertility are optimally performed with the use of an operating microscope, which requires specialized training for the surgeon for best results. Treatment options include:
Peyronie’s Disease (PD) is a condition where scar tissue (also called plaques) forms in the tissue layer covering the vascular erectile tissue in the penile shaft. This is not a cancerous process but can cause severe bending of the penis and shortening. It interferes with erections and may curve enough to prohibit sexual activity. This disease causes much stress for both the man and his partner.
The exact cause of PD is still unknown, though much of the research suggests that it is a disorder of poorly organized wound healing. Some experts believe that microscopic fractures that happen during normal sexual activity may lead to this exaggerated wound healing reaction in PD patients. Why some people form Peyronie’s plaques while others don’t is still unknown.
There are a number of treatments available to Peyronies Disease patients that will help reduce the curvature though none “cure” the disease since no treatment reverses this abnormal wound healing process. Most therapy for Peyronies disease are aimed at halting further curvature, or straightening out the penis so that the man can have a functional erection once again.
Peyronie’s disease may be associated with pain, especially in the initial stages, and with penile shortening. Many men with Peyronie’s disease will develop erectile dysfunction along with curvature.
Peyronie’s Disease Treatments
If symptoms of Peyronie’s disease are severe or worsen over time, a doctor may recommend medications or surgery. A number of oral medications have been tried to treat Peyronie's disease, but they are not as effective as surgery. In some cases, drugs injected directly into the penis may reduce curvature and pain associated with Peyronie's disease. The patient will likely receive multiple injections over several months and will be given a local anesthetic to prevent pain during the injections.
If the deformity of the penis is severe or prevents the patient from having sex, a doctor may suggest surgery. Surgery usually isn't recommended until the curvature of the penis stops changing, and erections have been pain-free for at least six months. This is to reduce the risk of new worsening curvature after surgery has been completed.
Common surgical methods include:
The type of surgery used will depend on the patient’s condition. The doctor will consider the location of scar tissue, the severity of the symptoms and other factors. If a man is uncircumcised, the doctor may perform a circumcision during surgery.
Varicoceles are abnormally dilated testicular veins of the pampiniform plexus in the scrotum, which result in abnormal reflux of venous blood into and around the testicle, similar to varicose veins of the legs or hemorrhoids. Varicoceles are more common on the left side but can occur on either or both sides.
Varicoceles can be found in up to 15% of the general population and most men with varicoceles will not experience symptoms or problems from their condition. However, having a varicocele can raise the risk of abnormal semen parameters, low testosterone, and testicular pain. In fact, 35% of men with primary infertility have varicoceles, and 81% of men with secondary infertility (inability to have more children after having at least one before).
Although most men with varicoceles go on to father children, there is ample evidence that varicoceles cause progressive impairment of male testicular function (both sperm production and testosterone production). It appears that surgical repair of varicoceles not only halts this decline in testicular function, but often reverses it. Up to 80% of men who undergo surgical repair of varicoceles will see improvements in their semen parameters.
Varicocele Treatments
Varicocele treatment may not be necessary. However, in some cases, if a varicocele causes pain, testicular atrophy or infertility, varicocele repair may be necessary. The purpose of surgery is to seal off the affected vein to redirect the blood flow into normal veins.
Repair methods include:
Our caring team of urology experts can help you with your urology concerns. To learn more or schedule an appointment, please call 404-778-4898, Mon–Fri 8:00 a.m.–5:00 p.m.
