Tuesday, July 31, 2012

Future Possibilities of PE

Additional research is required to eventually develop a product which is acceptable to the patient by being effective all of the time with minimal side effects and that is easy and discreet to use without compromising spontaneity during sexual intercourse. Some of the possibilities are as follows:
  • 9-hydroxycanthin-6-one (9-HC-6-one), a β-carboline alkaloid isolated from Eurycomalongifolia. In vitro, it has been noted that 9-HC-6-one attenuated PE-induced contraction by blocking calcium channels [Chiou and Wu, 2011].
  • It has been noted that decreased levels of magnesium may give rise to vasoconstriction from an increased thromboxane level, increased endothelial intracellular Ca2+, and decreased nitric oxide. This mechanism has been attributed to PE [Mohammadreza et al. 2009].
However, there is a long way to go before these products can be marketed. Moreover, reproducible in vitro and in vivo studies are required and the formulation of a standardized definition of PE is possibly the first building block towards standardization of PE research.

Licensed SSRI (Dapoxetine)

 Dapoxetine is the only licensed drug in the treatment of PE. It has been approved for treatment for the treatment of PE in New Zealand, Sweden, Austria, Finland, Germany, Spain, Italy and Portugal. National approvals and licenses in five other European countries are expected to follow. Dapoxetine is not approved for marketing in the United States.
Dapoxetine is a drug specifically developed for the on-demand treatment of PE. It has been extensively evaluated in five randomized, placebo- controlled phase III clinical trials involving more than 6000 men with PE. This is the largest and most comprehensive clinical trial programme to date for a drug therapy to treat PE. It is a short-acting SSRI designed to be taken only when needed and is taken 1–3 hours before sexual intercourse is anticipated.
There is evidence of its efficacy, its relatively mundane الدنيوية side effect profile and its validity as an on-demand medication [Feige et al. 2011; Hoy and Scott, 2010; Kaufman et al. 2009; McMahon et al. 2009; Giuliano et al.2007]. However, the durability of the effects of dapoxetine has not yet been demonstrated in prospective, randomized trials since long-term follow up is not yet available [Safarinejad and Hosseini, 2006].

Medical Therapy for Premature Ejaculation: Treatment

PE is a common condition affecting around one in five men. It can be a cause of significant personal distress which may in turn affect the relationship of the man with his partner. While many men with PE do not seek medical attention, when they do, SSRIs, desensitizing creams and to a lesser extent PDE5-I have been used in the treatment. All of these medications are sold off-label for the treatment of PE except for the recently licensed dapoxetine (Priligy™) which provides an effective, on-demand treatment regimen with relatively minimal side effects. PSD 502 is currently in the development phase and with the conclusion of phase III trials, may soon be licensed as a topical aerosolised spray for the treatment of PE.

Nerve Sparing Boosts Continence After Prostatectomy

By David Douglas
NEW YORK (Reuters Health) Jul 06 - A nerve-sparing approach to radical prostatectomy seems to improve the odds of urinary continence afterward, Italian researchers say.
Their study wasn't randomized, and so the journal BJU International says their evidence is only "level 4." Still, the researchers say, "An attempt at a nerve-sparing approach should always be planned in order to increase the probability of achieving full continence after radical prostatectomy."
Dr. Nazareno Suardi, lead author of the June 21 online paper, and his colleagues at University Vita-Salute San Raffaele, Milan, noted that although a nerve-sparing approach significantly improves postoperative erectile function, the impact on urinary continence is controversial.
Their new conclusions are drawn from 1,249 men who had radical prostatectomy between 2003 and 2010, including 900 who had bilateral nerve-sparing, 49 who had unilateral nerve-sparing, and 300 whose surgeons used a non-nerve-sparing approach.
At a mean follow-up of 42.2 months, 933 patients (79.5%) had recovered urinary continence. Overall rates were 76% at one year and 79% at two years.
Stratified by procedure type, one- and two-year rates of urinary continence were 79.5% and 84.0%, respectively, after bilateral nerve-sparing surgeries, 62.8% and 75.9% after unilateral nerve-sparing, and 44.6% at both points when nerves weren't spared.
A number of factors were significantly associated with urinary continence recovery after the procedure, including preoperative risk group, medical comorbidities, and age. But after accounting for all variables, men who had bilateral nerve sparing still had a 1.81-fold higher probability of completely recovering urinary continence compared to those who had non-nerve sparing surgery.
"Therefore," said Dr. Suardi, "when technically and oncologically feasible, a nerve-sparing radical prostatectomy should be considered."
BJU Int 2012.

Prepubertal Spinal Injury May Impact Later Sperm Production

By David Douglas
NEW YORK (Reuters Health) Jul 10 - Spinal cord injury before the age of nine can irreversibly interfere with spermatogenesis, a new report suggests.
"The number of patients in this study is very small because there is a relatively low occurrence of spinal cord injury in children, therefore, the data must be interpreted with care," lead author Dr. F. Andrew Celigoj told Reuters Health by email.
However, he said, it appears that "if a child has a spinal cord injury before he reaches puberty, the spinal cord injury may interfere with normal sperm production when that child reaches adulthood. If the spinal cord injury occurs after the child has gone through puberty, then sperm production seems to be similar to that of someone injured in adulthood."
Dr. Celigoj and colleagues at Florida's University of Miami Miller School of Medicine studied 533 men with spinal cord injury and published their findings online June 15th in The Journal of Urology.
All of the men were enrolled in a male fertility research program. In a chart review, the team identified seven men who had been injured between the ages of four and 12. Their current ages ranged from 24 to 38 years and all were able to achieve erections.
Three, who were injured before the age of nine, were azoospermic. One who was injured at the age of 10 years and another injured at the age of 11.6 years had subnormal total sperm counts. The remaining two, who were each injured at the age of 11.9 years, had mean antegrade sperm concentrations within normal ranges.
Overall, 43% of prepubertal subjects were azoospermic, compared to 6.4% of those injured after the age of 12 (p=0.009).
"Although prior work has not been done in this area, these data suggest that there is neurological input at an early age required for spermatogenesis," the authors write.
They add, "Further confirmatory studies are required to understand the age and severity of injury at which semen quality is irreversibly damaged."
They acknowledge that other groups have reported that spinal cord injuries before age nine don't necessarily interfere with spermatogenesis.
"Until more definitive studies can be performed, we recommend that all adult men who sustained a spinal cord injury in childhood, and who wish to father children, undergo an evaluation by a practitioner who is trained in the specialized procedures required to manage infertility in men with spinal cord injury," Dr. Celigoj said.
J Urol 2012.

Varicocele part 10

Future and Controversies

In 1992, researchers introduced a new micromanipulation technique known as intracytoplasmic sperm injection (ICSI). With ICSI, surgeons inject a single spermatozoon into an oocyte to initiate fertilization and, eventually, a pregnancy. With the success of this technique, some researchers question the need for varicocele repair.
Conversely, a cost-analysis study by Schlegel shows the significant cost advantage of varicocele repair over ICSI. In addition, varicocele repair has the potential for improving the male factor, rather than using unknown sperm. ICSI also involves in vitro fertilization (IVF), which carries some risk for the female who donates surgically removed eggs.
Another current topic focuses on the benefit of varicocele repair in men who are azoospermic or severely oligospermic. Although numerous studies indicate that varicocele repair can improve spermatogenesis in up to one third of azoospermic men, the initiation of spontaneous pregnancy is highly unusual in this population. The remaining two thirds eventually require testicular sperm extraction and IVF-ICSI, even after varicocele repair. Couples must therefore be counseled realistically regarding the benefit of varicocelectomy in this setting.
Other concerns focus on the benefit of varicocele repair in infertile men with poor semen quality who have only ultrasound evidence of a varicocele. While opinions differ about the value of repairing subclinical varicoceles in infertile men, most experts do not recommend it.

Varicocele part 9


The prevalence of adverse effects following varicocele repair is remarkably low. Hydrocele or increased fluid around the testicles occurs in 2-5% of patients. Successful surgery often increases conception rates in infertile couples. The overall recurrence rate for varicoceles has been reported as high as 10%.
Injury to the testicular artery has been reported in 0.9% of microsurgical varicocele repairs. This incidence may be higher when optical magnification is not used for varicocele repair. Because the testis typically has additional arterial supplies from the vasal and cremasteric arteries, testicular atrophy is uncommon (5%) after division of the testicular artery. Smaller atrophic testes may be at greater risk for accidental testicular artery injury because of the smaller size of the artery in these cases.
In a patient in whom a varicocele is first identified during a vasectomy reversal, varicocelectomy at the time of the vasectomy reversal is controversial. Delaying the varicocelectomy preserves some venous return in these patients and avoids possible injury to the testicular artery. Consider varicocele repair 6 months later, after new vascular channels form.

Outcome and Prognosis

Following varicocelectomy, approximately 66-70% of patients have improved bulk semen parameters, and 40-60% of patients have increased conception rates. Because human spermatogenesis takes approximately 72 days, the first improvements in semen analysis results are typically not apparent until 3-4 months after surgery.
While many of the published studies are retrospective, a randomized, prospective, controlled study by Magdar and associates (1995) confirmed that varicocelectomy is an effective treatment for male subfertility. Magdar et al studied male counterparts in couples in 2 subject groups, groups A and B. Group A (20 male subjects with varicoceles) was studied for 1 year, and only 2 (10%) men initiated a pregnancy. Male subjects who could not initiate a pregnancy then underwent varicocele repair; within 2 years, 12 (66%) were successful in initiating a pregnancy.
Meanwhile, 25 male subjects in group B underwent immediate varicocele repair. Within the first year, 15 (60%) initiated a pregnancy. After 3 years, an additional 4 (16%) subjects achieved pregnancy. Semen parameters improved in all subjects who underwent varicocele repair, regardless of pregnancy occurrence. Semen parameters were unchanged among group A subjects during their 1 year of observation. This important study concluded that varicoceles are associated with reduced fertility and impaired testicular function, while repair improves sperm parameters and fertility rates.
In addition, Vasquez-Levin et al (1997) demonstrated that varicocele repair benefits sperm morphology, even when evaluated using so-called strict criteria.
Evers and Collins performed a meta-analysis of 7 randomized controlled trials. Because overall pregnancy rates were 21.7% in operated patients and 19.3% (pNS) in control patients, they concluded that varicocele repair did not improve natural pregnancy rates.The concerns with this meta-analysis are that inclusion criteria regarding severity of impairment in semen parameters were not uniform, the varicocele diagnostic criteria and grading were inconsistent, and female factors were not mentioned in their overall analysis.
The persistent or recurrent varicocele can be repaired microsurgically with significant improvements in sperm concentration, percent motility, and total motile sperm per ejaculate. In addition, as reported by Grober et al, a beneficial effect on serum testosterone levels, testicular volume, and pregnancy rates can be observed.
The optimal approach to varicocele ligation has not been proven in evidence-based studies. However, based on available experience and reports, the authors recommend varicocele ligation be performed through an inguinal or subinguinal approach with the use of an operating microscope and hand-held microvascular Doppler ultrasound probe.

Varicocele part 8

Postoperative Details

Patient instructions

·         Varicocele surgery is usually performed in an outpatient setting (ie, day-surgery unit). Patients may return to normal nonstrenuous activities (eg, work) after 2 days.
·         All outer dressings are removed 48 hours after surgery. The small strips of tape (Steri-Strips) are left in place for 7-10 days before removal.
·         Inform patients that bathing or showering is permitted 48 hours after surgery.
·         A normal, well-balanced diet can be resumed when patients return home. Advise patients to start with fluids and gradually return to solid foods.
·         Prescribe pain medication and advise patients to take as directed. After 2 days, patients may take nonprescription acetaminophen (eg, Tylenol) or ibuprofen (eg, Advil, Motrin) to relieve discomfort.
·         Patients can engage in normal, nonstrenuous activity when they feel up to it. If activity causes discomfort, it should be discontinued. Patients can resume more strenuous activities (eg, weightlifting, jogging) after 2 weeks.
·         Advise patients to refrain from intercourse for 1 week.


Common discomforts and symptoms that do not require medical attention

Patients may experience some postoperative discomfort. Complications are rare. Common discomforts or symptoms do not require a doctor's attention and may include the following:
·         1- Minor bruising and slight discoloration may appear around the groin incisions but are self-limited.
·         2- The sensation of hardness around and beneath the incision site resolves in approximately 3 weeks.
·         3- The slight redness and tenderness around the incision from the normal healing process resolves in a few days.
·         4- A very small amount of thin, clear, pinkish fluid drains from the incision for a few days after the procedure. Advise patients to keep the area clean and dry.
·         5- A sore throat, headache, nausea, constipation, and general body ache occur because of the surgical procedure and anesthetic. Advise patients that these problems resolve within 24 hours.


Postoperative complications that require prompt medical attention

·         If wounds become infected (usually 3-5 d after surgery), antibiotics may be necessary. Wounds can become warm, swollen, red, and painful, with significant drainage from the incision site, and patients may develop fever.
·         Hematomas may form. Extreme discoloration around the abdominal incisions results from bleeding underneath the skin, which causes throbbing pain and bulging wounds.


Check the patient's semen 3-4 months after surgery. Because spermatogenesis requires approximately 72 days, any effects from the varicocele repair on semen analysis results are delayed.

Patient instructions

·         The patient returns to the clinical office for a wound evaluation in approximately 7-10 days.
·         Schedule a follow-up examination for a wound check and varicocele examination for 8 weeks after surgery.
·         Schedule a semen analysis and consultation for 4 months after surgery. At this time, the timing of subsequent appointments can be discussed.
For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomyand Testicular Pain.



Varicocele part 7

Medical Therapy

A varicocele is an anatomic abnormality that can impair sperm production and function. No effective medical treatments for varicoceles have been identified. While some investigators are evaluating the role of antioxidants for the treatment of elevated levels of reactive oxygen species, this treatment approach is still experimental.

Surgical Therapy

The primary form of treatment for varicoceles is surgery. Because of the potential to cause significant testicular damage, evaluate the varicocele during the physical examination. The presence of a varicocele does not mean surgical correction is necessary.
The ultimate goals of varicocele repair should include occlusion of the offending varicosity with high success, preservation of arterial flow to the testis, and the minimization of patient discomfort and morbidity. Viable options for repair include radiographic obliteration and surgical repair of various approaches. The efficacy of the myriad techniques is nearly equivalent. Therefore, special attention must be paid to the morbidity of the individual procedure and the expertise of the operating surgeon.
Results from a prospective, randomized controlled trial from Saudi Arabia compared subinguinal microsurgical varicocele repair to observation.Inclusion criteria included infertility lasting 1 year or longer, demonstration of a palpable varicocele, and presence of at least one impaired semen parameter (sperm concentration < 20 million/mL, progressive motility < 50%, or normal morphology < 30%). A total of 145 participants had follow-up within 1 year; spontaneous pregnancy was achieved in 13.9% of controls compared with 32.9% of treated men (odds ratio, 3.04). In treated men, the mean of all semen parameters significantly improved in follow-up compared with baseline (p < 0.0001). This study provided an evidence-based endorsement of the superiority of varicocelectomy over observation in infertile men with palpable varicoceles and impaired semen quality.

Preoperative Details

Perform varicocele surgery in an outpatient setting using one of various anesthetics (eg, general, regional, local). A general anesthetic provides maximal patient comfort.

Intraoperative Details

The 3 most common surgical approaches used to correct a scrotal varicocele include inguinal (groin), retroperitoneal (abdominal), and infrainguinal/subinguinal (below the groin) approaches. With all 3 approaches, all abnormal veins are tied permanently to prevent continued abnormal blood flow. Avoid the vas deferens and the testicular artery during the surgery. The inguinal approach is depicted below.
Incision for an inguinal approach to varicocele repair.
The inguinal and subinguinal approaches are those most commonly used by the vast majority of adult urologists and infertility specialists. The familiar anatomy, low morbidity, and high efficacy make these approaches almost ideal. Inguinal ligation is achieved by incising the inguinal canal down to the external inguinal ring. After cord isolation, the testicular artery is preserved and the veins of the cord are ligated and divided.
The subinguinal approach is performed in a similar fashion, but access is achieved through an incision at or near the pubic tubercle that obviates the opening of the external oblique aponeurosis. The advantages of subinguinal varicocele ligation, especially with use of magnification, include decreased pain and easier access to the spermatic cord, especially among obese men and those with a history of inguinal surgery. However, at this level, a greater number of veins are present, especially periarterial anastomosing veins, that make subinguinal ligation technically challenging.
The use of the microsurgical technique has advanced the surgical treatment of this disorder by allowing optimal visualization. While the approach to cord isolation is no different, the 6-25X magnification facilitates the identification of small anastomosing veins that might otherwise be missed. Furthermore, the risk of testicular ischemia and testis atrophy due to inadvertent ligation of the testicular artery is greatly reduced with this improved visualization. This risk of arterial ligation can be further reduced by using a mini-Doppler ultrasound probe (Vascular Technology, Inc. [VTI] 20-MHz microvascular Doppler) with the use of a topical vasodilator.
The retroperitoneal approach offers great proximal control of the spermatic vein near its insertion at the renal vein, and this approach may be accomplished laparoscopically. This technique, however, carries a high recurrence rate (nearly 15%) due to inguinal and retroperitoneal collateral veins, failure to ligate fine periarterial veins when the testicular artery is preserved, an inability to preserve lymphatics, and potential hydrocele formation when the artery and vein are ligated en bloc. This approach to varicocele ablation remains popular among pediatric urologists.
Percutaneous embolization represents the least invasive means of varicocele repair. The internal spermatic vein is accessed primarily via cannulation of the femoral vein through a retrograde approach with subsequent balloon and/or coil occlusion of the varicocele. The advantages of percutaneous embolization include preservation of the testicular artery and the relatively noninvasive nature of the technique. However, the percutaneous approach can be fraught with troublesome access to the vein, and postoperative complications such as contrast allergies, arterial injury, thrombophlebitis, and coil migration are uncommon but tangible risks. This approach is often reserved for recurrent varicoceles after open surgical repair.

Varicocele part 6

Laboratory Studies

·         When the clinical examination findings are equivocal, high-resolution color-flow Doppler ultrasonography is the diagnostic method of choice. The Male Infertility Best Practice Policy Committee of the American Urological Society recommends that imaging studies are not indicated for the standard evaluation unless the physical examination provides inconclusive findings. If a patient has sudden onset of a varicocele, a single right-sided varicocele, or any varicocele that is not reducible in the supine position, consider possible retroperitoneal pathology (eg, renal cell carcinoma) as the cause of spermatic vein compression. Investigate further with appropriate ultrasonography or CT scanning before repairing the varicocele.
·         Although varicocele diagnosis may be assisted with numerous methods (eg, venography, radionuclide angiography, thermography, ultrasonography), the current standard of care is high-resolution color-flow Doppler ultrasonography. High-resolution real-time scrotal ultrasonography using a 7- to 10-MHz probe defines a varicocele as a hollow tubular structure that grows following a Valsalva maneuver.
·         Color-flow Doppler ultrasonography defines the anatomic and physiologic aspects of varicoceles by using real-time ultrasonography and pulsed Doppler in the same scan. The color of the signal identifies the blood flow and direction within the varicocele. The characteristic reverse flow of varicoceles is confirmed by prolonged flow augmentation within a colored flow area; the flow changes color (ie, reverses) on real-time imaging.
·         Although the exact size definition is controversial, most surgeons consider a varicocele to be a vein 3 mm in diameter or larger while the patient is at rest. McClure et al define a varicocele as the presence of 3 or more veins, with 1 having a minimum resting diameter of 3 mm or an increase in venous diameter with the Valsalva maneuver. Because other surgeons use 2-3 mm as a cutoff, comparing results of these ultrasound-based varicocelectomy studies is difficult.



Varicocele part 5

Relevant Anatomy

The testes are the paired male genital organs that contain sperm, cells that produce and nourish sperm (spermatogonia and Sertoli cells, respectively), and cells that produce testosterone (Leydig cells). The testes are located in a sac called the scrotum. The epididymis is a small tubular structure attached to the testes that serves as a storage reservoir wherein sperm mature.
Sperm travel through the vas deferens, which connects the epididymis to the prostate gland. The vas deferens is in the scrotum and is part of a larger tissue bundle called the spermatic cord. The spermatic cord contains the vas deferens, blood vessels, nerves, and lymphatic channels.
The pampiniform plexus is composed of the veins of the spermatic cord. These veins drain blood from the testes, epididymis, and vas deferens and eventually become the spermatic veins that drain into the main circulation of the kidneys. The pampiniform venous plexus may become tortuous and dilated, much like a varicose vein in the leg. In fact, a scrotal varicocele is simply a varicose enlargement of the pampiniform plexus above and around the testicle. Two other veins, the cremasteric and the deferential, also drain blood from the testicles; however, they are rarely involved in the varicocele process.
The image below illustrates the basic anatomy.

A large varicocele is seen through the scrotal skin. In a patient with a varicocele, the dilated vessels of the pampiniform plexus are easily appreciated within the scrotum.


Opinions vary regarding the value of repairing subclinical varicoceles in infertile men, but most experts do not recommend it. In addition, discovery of a varicocele at the time of vasectomy or vasectomy reversal is a relative contraindication to immediate repair. A 6-month delayed repair is recommended to allow the development of collateral vessels in order to decrease the chance of vascular compromise to the testicle.

Varicocele part 4


Reasons for surgical correction of a diagnosed variocele include relieving significant testicular discomfort or pain not responsive to routine symptomatic treatment, reducing testicular atrophy (volume < 20 mL, length < 4 cm), and addressing the possible contribution to unexplained male infertility. A varicocele may cause progressive damage to the testes, resulting in further atrophy and impairment of seminal parameters.
The Male Infertility Best Practice Policy Committee of the American Urological Society recommends that varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present:
·         A varicocele is palpable.
·         1- The couple has documented infertility.
·         2- The female has normal fertility or potentially correctable infertility.
·         3- The male partner has one or more abnormal semen parameters or sperm function test results.
4- In addition, adult men who have a palpable varicocele and abnormal semen analyses findings but are not currently attempting to conceive should also be offered varicocele repair.
A scrotal varicocele is the most correctable factor in a male with poor semen quality; therefore, varicocele repair should be considered a viable choice for appropriately selected individuals and couples with otherwise unexplained infertility because varicocele repair has been shown to improve semen parameters in most men and possibly improve fertility; in addition, the risks of varicocele repair are small.
The results of treating varicoceles in adolescents are not as clear as the results of treating varicoceles in adults. Although varicoceles first become apparent in adolescence, their natural history and its timeline for the onset of detrimental effects on testicular function remain unclear. Varicoceles occur in approximately 10-15% of the fertile male population, but not all varicoceles impair sperm function, overall semen quality, or fertility.
Important determinations to be made regarding varicoceles in adolescents are whether (1) the varicocele is a progressive lesion and (2) early repair of the varicocele would prevent infertility.
In 1977, Lipshultz and Corriere suggested that varicoceles were associated with testicular atrophy that was progressive with age.They also observed that testicular biopsy specimens taken from prepubertal boys with varicoceles already revealed histologic abnormalities. However, Diamond et al from Harvard have challenged this concept.
In 1987, Kass and Belman were the first to demonstrate a significant increase in testicular volume after varicocele repair in adolescents.Although Kass and Belman noted catch-up growth, they did not study semen parameters. Collecting a semen sample from an adolescent is not always easy; consequently, studying the effects of a varicocele and the benefits of treatment is difficult.
The indications for repairing varicoceles in adolescents include the presence of significant testicular asymmetry (>20%) demonstrated on serial examinations, testicular pain, and abnormal semen analysis results. Very large varicoceles may also be repaired; however, in the absence of atrophy, this indication is relative and controversial. Young men with varicoceles but normal ipsilateral testicular volume should be offered follow-up monitoring with annual objective measurements of testicular volume, semen analyses, or both.

Varicocele part 3


Several theories have been proposed to explain the harmful effect of varicoceles on sperm quality, including the possible effects of pressure, oxygen deprivation, heat injury, and toxins.
Despite considerable research, none of the theories has been proved unquestionably, although an elevated heat effect caused by impaired circulation appears to be the most reproducible defect. Supporting this hypothesis is the fact that a varicocele created in an experimental animal led to poor sperm function with elevated intratesticular temperature. Regardless of the mechanism of action, a varicocele is indisputably a significant factor in decreasing testicular function and in reducing semen quality in a large percentage of men who seek infertility treatment.
Although unproved, a varicocele may represent a progressive lesion that can have detrimental effects on testicular function. An untreated varicocele, especially when large, may cause long-term deterioration in sperm production and even testosterone production. If an infertile male has bilateral varicoceles, both are repaired to improve sperm quality.


A patient with a varicocele is usually asymptomatic and often seeks an evaluation for infertility after failed attempts at conception. He may also report scrotal pain or heaviness. Careful physical examination remains the primary method of varicocele detection. An obvious varicocele is often described as feeling like a bag of worms. Scrotal examination for varicocele should be a facet of the standard urologic physical examination because of the potential for varicoceles to cause significant testicular damage. The presence of a varicocele does not mean that surgical correction is a necessity.
In men with a varicocele, the presence of an initially abnormal semen quality may be a risk factor for future deterioration of semen quality. In a prospective study of men with a mean follow-up of 5 years, among men with an abnormal semen analysis at presentation, the quality of semen degenerated in 28 subjects (87.5%); however, but among men with initially normal semen quality, only 6 patients (20%) had degenerated quality during follow-up.

Varicocele part2


A varicocele is a dilatation of the pampiniform venous plexus within the scrotum. Approximately 15-20% of the healthy fertile male population is estimated to have varicoceles; however, 40% of infertile men may have them. How a varicocele impairs sperm structure, function, and production is unknown, but researchers believe it interferes with testicular thermoregulation.



Although varicoceles appear in approximately 20% of the general male population, they are much more common in the subfertile population (40%). In fact, scrotal varicoceles are the most common cause of poor sperm production and decreased semen quality. Varicoceles are easy to identify and to surgically correct.


Varicoceles are much more common (approximately 80-90%) in the left testicle than in the right because of several anatomic factors, including (1) the angle at which the left testicular vein enters the left renal vein, (2) the lack of effective antireflux valves at the juncture of the testicular vein and renal vein, and (3) the increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (ie, nutcracker effect). Also of importance is that a one-sided varicocele can often affect the opposite testicle. Up to 35-40% of men with a palpable left varicocele may actually have bilateral varicoceles that are discovered upon examination. A 2004 study by Gat et al suggested that up to 80% of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing.[1]
Varicoceles vary in size and can be classified into the following 3 groups:
·         Large - Easily identified by inspection alone
·         Moderate - Identified by palpation without bearing down (Valsalva maneuver)
·         Small - Identified only by bearing down, which increases intra-abdominal pressure, thus impeding drainage and increasing varicocele size

Varicocele part 1 • Author: Wesley M White, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS


A varicocele is a dilatation of the pampiniform venous plexus and the internal spermatic vein. Varicocele is a well-recognized cause of decreased testicular function and occurs in approximately 15-20% of all males and in 40% of infertile males. Understanding the significance of this anatomic abnormality in the infertile patient requires a brief review of the history, background, and current concepts of functional anatomy, as well as the methods and results of surgical repair.

History of the Procedure

Varicocele was first recognized as a clinical problem in the 16th century. Ambroïse Paré (1500-1590), the most celebrated surgeon of the Renaissance, described this vascular abnormality as the result of melancholic blood (introverted اﻻنطوائية and thoughtful مدروس). Barfield, a British surgeon, first proposed the relationship between infertility and varicocele in the late 19th century. Shortly thereafter, other surgeons reported that varicocele is associated with an arrest of sperm secretion and the subsequent restoration of fertility following repair. Through the early 1900s, reports by other surgeons continued to describe the association of varicocele with infertility.
In the 1950s, after a report of fertility following varicocele repair in an individual known to be azoospermic, the idea of surgically correcting varicoceles as a clinical approach to certain kinds of male infertility gained support among American surgeons. Research continued, leading to many published studies that associated varicoceles with impaired semen quality.
In these studies, researchers documented a recurrent pattern of low sperm count, poor motility, and predominance of abnormal sperm forms; this became known as the stress pattern of semen. Although not synonymous or specific to varicocele, the term suggests early evidence of testicular damage. Urologists then began to assess male infertility through the study of sperm, which are evaluated for count, percentage of motile forms, forward movement or motility, and morphology (shape or form); the semen is also evaluated.

Ubiquinol Improves Sperm Quality in Infertile Men

NEW YORK (Reuters Health) Jul 13 - Ubiquinol, a form of coenzyme Q10, has a beneficial effect on sperm quality in infertile men with idiopathic oligoasthenoteratozoospermia, according to a new study.
"Despite great advances in the field of infertility, many cases of male infertility are diagnosed as idiopathic ... and remain untreated," Dr. Mohammad Reza Safarinejad, of the Clinical Center for Urological Disease Diagnosis in Tehran, Iran, told Reuters Health by email.
"There is a direct correlation between seminal plasma coenzyme Q10 concentration and semen parameters," he said. The study, published online in the Journal of Urology, was supported by Kaneka Corporation in Japan, which manufactures ubiquinol.
To test the safety and efficacy of ubiquinol supplementation, Dr. Safarinejad and his colleagues randomly assigned 228 infertile men to receive oral ubiquinol 200 mg or placebo daily for 26 weeks. They also followed the men for another 12-week off-drug period.
At 26 weeks, the mean sperm density in the ubiquinol group was 28.7 million/ml and 16.8 million/ml in the placebo group (p=0.005); sperm motility was 35.8% vs. 25.4% (p=0.008); and sperm strict morphology was 17.6% and 14.8% (p=0.01), respectively, of normal sperm.
Dr. Safarinejad said the substance was well tolerated.
"Improved semen quality does not translate into an improved pregnancy rate," the researchers concede. "In infertility treatment the ultimate outcome would probably be the pregnancy rate."
Nevertheless, they point out that considering the important role of oxidative stress in semen quality, antioxidants such as ubiquinol "deserve further attention from pharmaceutical companies and researchers."
Overall, concluded Dr. Safarinejad, "ubiquinol is significantly effective in men with unexplained infertility for improving sperm density, sperm motility and sperm morphology."
J Urol 2012.

Relationship Between Penile Size and Somatometric Parameters in 2276 Healthy Young Men

To inform a man who perceives his penis as being inadequate, and before surgical planning for penis enlargement, urologists must know the normal penile length in their patients' specific population. In this study, the mean flaccid, stretched and circumferential lengths were found to be 8.95, 13.98 and 8.89 cm, respectively. Significant inter-correlations were observed between all measures of penile dimensions. Penile dimensions are found to be correlated with somatometric measures, such as height, weight and BMI. A significant difference was observed between the penile dimensions reported from different countries. The results demonstrate that, like other studies, penile lengths and circumference measurements are somatometric characteristics and, as such, are related to somatometric parameters, even if this relationship is not of clinical significance. To gain more insight into the morphological aspects of penile dimensions, a multi-centered, multi-ethnic study is needed.

Posted: 07/11/2012; Int J Impot Res. 2012;24(3):126-129. © 2012 Nature Publishing Group

Sunday, July 29, 2012

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