By CUA on Friday, April 9th, 2010 08:13 AM
Imagine that your daughter is about to receive her college diploma when the feeling of urgency strikes. You squirm uncomfortably in your seat, torn between two concerns: you don’t want to go to the restroom and miss her big moment, but you fear the accident that will likely occur if you stay seated. As the pressure increases, you’re forced to dash to the bathroom just as the announcer calls her name. Another special moment is tarnished by urinary incontinence.
Urinary incontinence affects the lives of millions of people, regardless of age or gender. “Anyone can develop it”, notes Andrew Shapiro, MD, Director of the Chesapeake Urology Center for Continence and Pelvic Floor Disorders. Women tend to develop it more often than men do. However, men who have undergone prostate surgery, sustained spinal cord injuries, neurological injuries or strokes are at high risk as well. Urinary incontinence has three primary forms, stress, urge and overflow incontinence. These differ in symptoms, causes, as well as the type of person who suffers from these issues.
Stress incontinence frequently affects women, especially after childbirth. In addition, men who have undergone prostate surgery are also at risk. Stress incontinence is leakage caused by coughing, sneezing or any activity that puts stress on the abdominal muscles. Stress incontinence typically occurs during the daytime but in people with severe leakage, it may occur both day and night. The problem is normally worse when the bladder is full or partially full.
Urge incontinence is a common problem that affects both men and women. It becomes increasingly common as people age. Men and women with neurologic issues, such as Diabetes, Multiple Sclerosis, Parkinsons or major back issues, are far more likely to have this issue. People with urge incontinence experience a sudden and strong desire to urinate. This desire cannot be postponed and often leads to incontinence episodes. People with this condition will also go more frequently and may wake up at night to urinate. Urge incontinence can be triggered by several factors, including dietary irritants, urinary tract infections and nervous system damage. Sometimes, especially in elderly patients, this condition can lead to falls and even admission to a nursing home.
Although women tend to experience incontinence more frequently than men, overflow incontinence is predominantly a male condition. “As the male ages and his prostate enlarges, it can block his bladder. This in turn makes it difficult to empty the bladder. When men’s bladders no longer have the strength to empty well, they begin to leave large amounts of urine behind after they urinate. This can lead to “overflow” incontinence. Sufferers frequently complain of an inability to void, despite a constant feeling of the need to empty the bladder, and often experience urine leakage.
Incontinence can be diagnosed by talking to the man or woman suffering these symptoms. Normally, a good history, physical examination and a urinalysis will give us the necessary information to diagnose the problem and begin treatment. For people who have more complicated histories, have had prior pelvic surgery or who have failed conservative treatment, we rely upon office testing to give us more specifics.
Dr. Shapiro relies on two primary examinations to diagnose the specific type of urinary incontinence, a urodynamic test and a cystoscopy. The urodynamic test bears many similarities to an EKG and assesses bladder function. The test is done in the office and allows us to determine why people are having problems with their bladder. The second diagnostic measure is a cystoscopy, in which a tiny camera is inserted into the urethra to look inside the bladder and examine the lining for any blockages or abnormalities that may explain the symptoms.
The treatment options for urinary incontinence vary widely based on the patient’s needs and the form of incontinence that affects them. “In general, doctors like to begin with the most conservative treatment and move to procedures only when necessary,” Dr. Shapiro explains. For patients suffering from stress incontinence, the first line of treatment is pelvic floor physical therapy.
“Pelvic floor muscle exercises help increase muscle tone and the overall strength of the pelvic floor muscles,” Dr. Shapiro notes. Physical therapy is a non-invasive treatment that can be quite effective but does require time and patience as the improvement typically occurs over the course of months.
Women with stress incontinence may also benefit from an outpatient suburethral sling procedure, in which a physician places a piece of permanent mesh beneath the urethra to help re-support the weakened urethra. This procedure is minimally invasive and takes less than a half-hour to complete. It is an outpatient procedure with excellent success rates.
For women who desire an office based procedure or who are poor candidates for a sling, injectable therapy can be used. We can inject an agent which helps to seal the weakened urethra. This therapy is less invasive and can be safely done in the office. While it is not as permanent as a sling, it can be effective for the right candidate.
Men with stress incontinence can also be treated with injectables or slings. Male stress incontinence is far less common and is almost always related to a prostate procedure. For men with more severe leakage, an artificial sphincter may be necessary.
Urge incontinence is associated with bladder irritability and spasticity. Oral medications (pills) are often effective in reducing these symptoms. There are multiple options available and not one pill works for everyone. For men and women who do not get adequate improvement from medication, we have several other minimally invasive options. Interstim is a very effective procedure for men and women who have failed medications and dietary changes. Interstim is an implant which is like a bladder pacemaker. Thru a simple office test, we can tell whether or not you are a candidate for this therapy. This test is easy to perform with minimal risk and after 1 week we will know whether or not this therapy is suite for you, Dr. Shapiro explains. Another potential option would be injecting medication directly into your bladder.
Overflow incontinence is most frequently due to an enlarged prostate. For many men, this can be fixed with an outpatient laser procedure to open up the obstruction. This is done thru a camera inserted into the urethra. It is typically performed as an outpatient with you sedated. The improvement is generally seen immediately and the procedure is generally safe.
Although urinary incontinence is a frustrating and embarrassing condition, many times it can be treated easily and successfully. “Women who have stress urinary incontinence have a greater than 90 percent chance of having a significant improvement or cure with sling surgery. Patients who have urge incontinence may see significant improvement from medication or minimally invasive surgery. Sadly, this very treatable condition is often either too embarrassing or people are unaware that it is treatable and they do not seek help. Dr. Shapiro recommends several outside resources to individuals struggling with urinary incontinence, including:
• The National Association for Continence (www.nafc.org)
• The American Urological Association (www.auanet.org)
Incontinence is a widespread condition that touches millions of lives, but some simple steps can be taken to reduce your chances of developing bladder control problems. There are ways to avoid or improve your control problems at home. We know that caffeine can worsen bladder symptoms. Therefore, minimizing or avoiding coffee, tea, soda and alcohol can improve your urgency. Losing weight is also very helpful in reducing your risk of developing incontinence, according to recent studies exploring the effects of weight on urinary incontinence. In addition, Kegel exercises can help improve or prevent stress incontinence. These exercises are often difficult to teach yourselves and a trained physical therapist can be very helpful for those patients who are unsure. Toning your pelvic floor, eating a healthy diet, exercising and maintaining a healthy weight can all be important factors in preventing or improving incontinence — which means that your special moments will no longer be interrupted!!
For more information or for an interview with Dr. Shapiro, please call CUA PR at 443-738-8107.
By CUA on Thursday, April 1st, 2010 09:47 AM
As long as humans have been experimenting with technology, there have been skeptic observers of it. The dawn of the Industrial Revolution, which set the stage for today’s technologies, witnessed a group known as the Luddites, who were responsible for the destruction of machines in their pursuit to prevent the advancements of technology and what they considered the inevitable end to the need for human workers. Innovations have continued to emerge throughout the years, ranging from personal computers to cellular phones to robotics. The latter has posed many philosophical debates concerning how far robotics can go and what they mean to the future of mankind. Essentially, can robots be constructed that render human beings unnecessary? While that debate may continue indefinitely, it cannot be denied that robotics can and do make life simpler and, in some cases, can improve human talent and ability, specifically in medicine.
Cancer results in 13 percent of all deaths in the United States annually, which makes it a major focus for research and new treatment options, including robot-assisted surgery. Prostate cancer, as one of the most common cancers among men, receives a considerable amount of attention from clinical trials and leads the movement for minimally invasive robot-assisted laparoscopic radical prostatectomies.
Treatment of Prostate Cancer
Prostate cancer is a disease that will affect one in six men in their lifetimes; however, with proper screening, most cases will be diagnosed early on. No requirement exists for prostate cancer screenings, but the American Urological Association suggests annual screenings for prostate cancer should be offered to asymptomatic men 40 years of age or older, and earlier for men with an elevated risk – for instance, if they are African-American or have a family history of prostate cancer.
Prostate cancer is not limited to one method of treatment. “There is a lot of consultation, and treatment depends largely on the patient’s preference,” states Dr. Benjamin H. Lowentritt with Chesapeake Urology Associates. “There are more treatment options every year. I tell my patients there is no right or wrong answer picking a treatment.” The variety of care largely depends on the stage of the disease and the comfort and beliefs of the patient. The least-invasive treatment is “active surveillance,” which assumes a localized cancer will advance so slowly as to not affect the patient during his life. However, if cancer spreads, another form of treatment may need to be considered.
Cryotherapy, the freezing and killing of cancer cells with liquid nitrogen, generally has good results with early-stage prostate cancer and can be repeated if necessary. It serves as an effective alternative for men who cannot have surgery or radiation therapy. However, a common complaint is impotence.
For a more widespread cancer or as an alternative to surgery, radiation therapy kills cancer cells either through high-energy X-rays or radioactive seeds. The risk of radiation is long-term damage to the nerves involved in sexual function. Radiation therapy, while causing little pain to the patient, can be somewhat intrusive, with sessions lasting as long as 10 weeks, from 10 to 30 minutes a day.
More than 90 percent of men with prostate cancer are candidates for some form of radical prostatectomy – the removal of the prostate and surrounding tissue. The advantages of surgery include reducing nerve damage, monitoring how the cancer spreads and offering a minimally invasive procedure. Several methods are available for radical prostatectomy, beginning with the traditional open surgery to the less invasive laparoscopic surgery to the innovative new robot-assisted laparoscopic da Vinci surgery.
The da Vinci surgery received its name because Leonardo da Vinci invented the first robot and because of his accuracy of the human body in his work. This state-of-the-art system performs surgery in a similar fashion to traditional laparoscopic prostatectomy. Six 1- to 2-centimeter incisions are made in the abdomen, so the incisions are less painful. Furthermore, there is less blood loss compared to the open technique. The surgeon uses robotic appendages to enter the incisions and remove the cancerous prostate. Although the surgeon’s hands do not physically touch the patient or the tools during the bulk of the procedure, the surgeon is in complete control throughout the procedure, with the robot serving as an extension of the surgeon.
The da Vinci surgery uses 3-D camera imaging to give the surgeon a greater view of the prostate than is possible with traditional laparoscopic surgery. This magnified image allows the surgeon more accuracy and the ability to better distinguish nerves that are vital to sexual function. “It’s essential to be able to see as clearly as possible and to be able to make decisions at that time,” Dr. Lowentritt explains.
Generally, the surgeon is positioned at the controls of the robot a few yards from the patient. From there, the surgeon can make very small gestures to operate the robotic arms and remove the prostate. An interesting design feature that increases the safety of robot-assisted surgery is tremor reduction, which protects the patient from an unintended shaking hand movement that might result in an inadvertent action. This type of technology offers laparoscopic prostatectomy more safety and precision than a surgeon could prior to the use of robotics.
As a minimally invasive surgery, robot-assisted laparoscopic prostatectomies also allow the patient to return to his daily routines at a much quicker pace than some treatments of prostate cancer. Dr. Lowentritt explains, “Radiation therapy can take seven or eight weeks to complete. With this surgery, the patient may be fully recovered in that time.” After the surgery, the patient will spend the night in the hospital while recovering from the anesthesia, but patients typically spend no more than two nights in the hospital.
Robot-assisted surgery troubles many patients because they fear the surgery is controlled by a machine. However, the da Vinci system is 100 percent controlled by the surgeon. According to Dr. Lowentritt, the military initially developed robot-assisted surgery so it could allow the surgeon to operate on a patient in the midst of combat from a secure location.
During the robot-assisted surgeries done in Chesapeake Urology, the surgeon is present with the patient, as well as a surgical team. “There is always an assistant at the bedside passing instruments,” Dr. Lowentritt adds. “And there’s never a moment when I can’t step up to the operating table.”
Fear of surgery is another factor that pushes some patients away from robot-assisted or traditional laparoscopic prostatectomy. “Some patients have so much anxiety about surgery that they understandably pursue another treatment,” Dr. Lowentritt points out. “Currently, between 70 and 80 percent of prostatectomies in the United States are done by robotic assistance. It is becoming a fairly common treatment.”
“There is a lot of personal belief surrounding surgery,” Dr. Lowentritt continues. “People want the cancer out. They don’t want to leave it in their bodies.” Surgery ensures a greater opportunity to detect any recurrences or any rogue cancer cells than other forms of treatments do.
As a surgeon, Dr. Lowentritt states that he almost never chooses the open prostatectomy over the robot-assisted prostatectomy. He believes that robot-assisted surgery has made him a better and more precise surgeon, attributing this to his increased visibility and greater dexterity with the robotic arms.
“Within Chesapeake, we offer seven fellowship-trained robotic surgeons, and the number of experienced surgeons in this field is beyond compare to any group that I know of,” he states. “Prostatectomies are becoming less and less invasive, and robotic surgery is here to stay. Only the imagination can limit where it goes.”
By CUA on Thursday, April 1st, 2010 09:14 AM
Undergoing surgery can be a stressful and frightening time for a patient, and no amount of planning and preparation may relieve that stress. Ambulatory surgery centers do, however, take patients through the surgery with as much comfort as possible. In a typical hospital setting, surgery may be performed by a team that is not specifically trained in the patient’s condition, whereas an ASC can offer a team that specializes in certain operations.
“It allows us to have quality and consistent care,” explains Stacy Zemencik, Director of Nursing with Chesapeake Urology. “We’re prepared for any emergency; all training is in urology so our nurses know just how to handle any situation. Surgery is more personal, and the staff is more friendly.”
The dedication of the staff at Chesapeake’s Summit ASCs is reflected in the recent achievement of accreditation. The Accreditation Association for Ambulatory Health Care (AAAHC) offers one- and three-year accreditations — both are a voluntary process. Accreditation shows to patients the dedication of the ASC’s staff and their willingness to test and prove their worth.
Chesapeake received a three-year accreditation — the highest form of certification available. “When you’re accredited, it shows the value that you have for [patient care],” Zemencik says. “It means you have gone above and beyond. Our patients are getting the best possible treatment.”
By CUA on Thursday, April 1st, 2010 09:09 AM
Imagine being able to access the latest medications and treatments in the field of urology, even before they are available on the market, through your local pharmacy or your personal physician.
Traditionally, this has only been possible in a university setting. However, Chesapeake Urology has a distinguished research division, called Chesapeake Urology Research Associates (CURA), under the direction of Dr. Ronald Tutrone, who has conducted more than one hundred trials during his career and is highly respected for his work.
“Clinical trials provide our patients with cutting-edge technology and drug treatments not normally available in the community. We can give our patients access to treatments before they are even approved,” says Dr. Tutrone, who received his medical degree from Rutgers and did his residency training at Harvard.
Safe and personal
CURA’s clinical trials provide patients with advanced treatments for conditions ranging from overactive bladder to erectile dysfunction, prostate cancer and more. Clinical research is safe, Dr. Tutrone emphasizes. CURA patients are closely monitored, resulting in better patient self-awareness and management of their illnesses.
“Patients receive specialized treatment and have a better understanding of their disease and symptoms through participation in the trials,” says Virginia Michaels, CRC, Research Coordinator. Patients enjoy coming in for treatment. They especially like the extra attention given to them by the research team.
In fact, research is one of the primary reasons that CUA stands out from other large single-specialty practices in Maryland.
The CURA team is woven through a network of four CUA offices in the greater Baltimore area, located at GBMC’s campus, Bellona Avenue in Towson, Franklin Square Hospital’s campus and in Glen Burnie.
Patients who opt for clinical trials receive thorough support from the entire CURA staff, which includes highly experienced research coordinators and a seasoned administrator. Passionately committed to the detail of work necessary to follow complex research protocols, the staff form a close bond, whose participation in a trial can extend anywhere from 12 weeks to as long as five years.
The best in clinical trials
CURA chooses only the most promising and reputable trials. “Due to our outstanding reputation and patient population, we’re able to be particular with our trial selection,” explains Heather Thomas, RT, CCRC and CURA Research Administrator, who directs the opening of new trials. “Pharmaceutical companies are impressed with Dr. Tutrone’s research experience and the magnitude of our practice.” Companies and organizations actually seek out CURA as a resource to test their new drug therapies and devices.
“Through clinical trials, our well-trained staff offers one-on-one services that patients may not be able to receive elsewhere,” states Angela Somers, CRC, Research Coordinator.
Making the right referral
Chesapeake Urology’s physicians are diligent at looking for opportunities and referring appropriate patients for trials. “We enjoy offering new options to patients, and we have thousands of patients with varying conditions who can potentially benefit from trials,” explains Thomas, who has worked on more than 70 clinical trials with Dr. Tutrone since 1995. “The clinical research coordinators meticulously screen patients for eligibility.”
“It’s a wonderful accomplishment to see the whole process of the trial through,” explains Debi Robertson, CRC, research coordinator, who is presently involved in a five-year Bioniche bladder cancer trial. Debi has worked in research across the U.S. and brought valuable national experience with her to CUA.
Each day counts
“We have the satisfaction of making every study visit for the patient comfortable and accommodating. Especially with cancer trials, we desire to help patients for whom there are very few alternatives. We try to give them some longevity and quality of life,” Dr. Tutrone says.
Current clinical trials
Chesapeake Urology Research Associates is now offering clinical trials for the following conditions. For more information, go to www.ChesapeakeUrology.com/Research, or contact the research associates provided.
By CUA on Thursday, April 1st, 2010 08:52 AM
What is pelvic prolapse?
Perhaps you’ve heard of pelvic prolapse occurring after childbirth or following a hysterectomy. Another risk factor for developing a prolapse is obesity. However, prolapses can also occur because of weak supportive tissue and can happen to anyone.
The pelvic organs, composed of the urethra, bladder, rectum, small bowel, uterus and vagina, are held in place by three different kinds of support: ligaments, connective tissue and muscles.
When this support is stretched, damaged or decreased as a result of a hysterectomy, a prolapse can occur in which an organ slips down and presses against the vaginal wall.
There are three main types of pelvic prolapse which we will discuss. Though they do not generally cause a lot of pain, they often cause vaginal discomfort and may also cause discomfort with intercourse.
Cystocele: This is a bladder prolapse that occurs to the front of the vaginal wall. The bladder almost pushes inside out into the vaginal walls. A cystocele can be felt through a physical examination.
Symptoms: Most people complain of vaginal pressure and may feel a bulge in their vagina. Of the three types of prolapses, the bladder causes the most problems. Patients can suffer from urgency, incontinence, trouble emptying their bladder and recurrent urinary tract infections.
Enterocele: This is a herniation of the small bowel, which pushes into the upper, deepest portion of vaginal wall.
Symptoms: Patients may feel a bulge in the vagina or a “pulling” sensation in the pelvis.
Rectocele: This is the rectum pushing inside out and up into the vaginal wall, creating a bulge.
Symptoms: Patients have a difficult time having a bowel movement and feel constipated. If the rectocele is severe, stool may get trapped. Continued straining for bowel movements may further weaken the pelvic muscles, causing more prolapsing.
Can Kegel exercises help prolapse?
Contrary to common belief, Kegel exercises cannot cure pelvic prolapse. Kegels may strengthen some of the pelvic muscles but will not reverse a prolapse. However, very good medical and surgical treatments are available.
How are prolapses treated?
One treatment is a pessary, which is a small supportive device inserted into the vagina. This is done in the doctor’s office. Pessaries come in various shapes and sizes to provide a custom fit. They push up, providing support to the weak areas and reducing the pressure of the prolapsed organ.
Patients who may consider pessaries include those who:
- Are not surgical candidates or do not want surgery
- Are not sexually active
Although some pessaries can be removed for sexual activities, in general, they are taken out every three months by a physician to be cleaned in order to prevent infection. Some patients can be taught to do this, too.
Can surgery repair pelvic prolapse?
Surgery can be a very good option to treat prolapse and is usually very successful, though there can be a small risk of recurrence. There are various types of surgery that use either mesh or graft materials to create support for prolapsed organs.
The choice of mesh or graft materials depends on the patient. Graft materials, which are often made from pig or cow tissue, are high-quality but may not last as long as mesh, which is a polypropylene material. Older patients with thin vaginal tissue are usually candidates for the graft, while mesh is usually an option for younger patients.
Surgery for a single prolapse takes approximately one to one and a half hours. Occasionally, patients suffer from all three types of prolapses, which can be surgically repaired at the same time. Performing all three repairs does take several hours. Patients usually stay in the hospital for one night following surgery.
Can stress incontinence occur with a prolapse?
Yes, and I do urodynamic testing for the patient whom I suspect also suffers from incontinence, so that she has a thorough examination. If she also has stress incontinence, this can be fixed during the same procedure as the prolapse surgery and only takes an additional ten minutes to repair.
What if my prolapse doesn’t bother me?
Small prolapses may not have symptoms and may not need to be repaired. A doctor can monitor them in case symptoms worsen and need to be addressed. Patients with small prolapses should be careful not to aggravate the prolapse by squatting too much, straining for bowel movements or lifting heavy objects.
By CUA on Thursday, April 1st, 2010 08:08 AM
Many men decide that they need a more permanent solution for their birth control needs. They’ve had as many children as they want, or maybe they don’t want children at all. So they have a vasectomy – an interruption of the flow of sperm into the semen through a transection or a severing of the vas deferens, which carry the sperm into the ejaculate. Approximately 500,000 American men undergo this procedure each year, according to the Centers for Disease Control and Prevention.
But circumstances may change for some of these men, and they might want the ability to have children again. Although a vasectomy is a more permanent form of birth control, it can be reversed – and the professionals at Chesapeake Urology are experts in this area of surgery.
A microsurgical vasectomy reversal can be done with one of two procedures: a vasovasostomy or an epididymovasostomy. A vasovasostomy involves the reconnection of the two severed ends of the vas deferens. An epididymovasostomy involves the reconnection of the vas deferens to the epididymis to bypass an obstruction in the epididymis.
The time between the vasectomy and its reversal is not a cause for concern, Dr. Boyle says. “Even if it’s been years, we can reverse it,” she states. “The longest interval I’ve seen is 38 years between when a man had a vasectomy and when we reversed it for him – and that couple was pregnant within three months of the reversal.”
These are highly specialized procedures, Dr. Boyle notes, involving three to four hours of microsurgery and sutures smaller than can be seen by the naked eye. They should only be performed by a skilled microsurgeon who has been fellowship-trained in these procedures, such as the surgeons in Chesapeake Urology’s Male Fertility and Sexuality Group. “We can successfully reverse well more than 90 percent of vasectomies,” Dr. Boyle says. “Whatever the reason – wanting a larger family or finding a new partner who wants a baby – we can help make it happen for our patients.”
By CUA on Thursday, April 1st, 2010 07:51 AM
Settling down with that special someone, making a home, raising a family together – these are common dreams and desires for people from all walks of life. But when those dreams are put on hold because of infertility, many couples don’t know where to go for help. Fortunately, the specialists at Chesapeake Urology Associates are there for them.
Infertility is defined as the inability to conceive after a couple has unprotected sexual intercourse for at least one year if the female partner is under the age of 35, according to Dr. Karen Elizabeth Boyle, Director of Chesapeake Urology’s Male Fertility and Sexuality Group and nationally recognized leader in the field of male infertility, microsurgery and sexuality. “If the woman is over 35, that time period drops to six months,” she adds.
Oftentimes, couples immediately assume their fertility issues are related to the woman’s physiology. “But in 30 percent of cases, the man is the sole cause,” Dr. Boyle states. “And in another 20 percent, there’s a combination of male and female causes.”
According to a study published by the Centers for Disease Control and Prevention, infertility affects about 7.3 million men and women in the United States, or about 12 percent of the reproductive-age population. “So, of those, half have a male factor,” Dr. Boyle says. “But the majority of infertile couples never have the male partner evaluated to see if the problem lies there.”
Despite these facts, most people – and many medical professionals – think of infertility as exclusively a female malady. “The majority of patients and doctors are just not aware of what treatments are available for the infertile male patient,” Dr. Boyle declares. “Often, even urologists are either not interested in male infertility or do not have the education and training to help infertile couples.
“The general sequence goes something like this: the couple can’t get pregnant; the woman goes to her OB/GYN; typically, a semen analysis is the first test ordered, because it is easy and inexpensive. Then, regardless of the semen analysis results, the couple is referred to reproductive endocrinology for a female partner evaluation. We should be seeing all male patients with abnormal semen parameters so that we can evaluate them – this should be done automatically.”
Dr. Boyle and her fellow Male Fertility and Sexuality Group physicians, Dr. Brad D. Lerner, F.A.C.S., and Dr. David M. Fenig, see hundreds of patients each year to help them diagnose and treat the causes of their fertility problems. There are several conditions that can cause male infertility, including:
- Varicocle – varicose veins in the scrotum, which cause a decreased sperm count
- Hormonal imbalance – caused by an incorrect function in the brain’s pituitary gland
- Blockage – a physical obstruction of semen
- Genetic defect – being born without the correct anatomy or with an abnormal Y chromosome or other chromosomal abnormalities
Dr. Boyle says roughly 90 percent of men have no outward symptoms to notice, aside from their inability to conceive, which is why it’s important for couples experiencing fertility issues to have the male partner evaluated by a urologist trained in male infertility. “The first step is a semen analysis,” she explains. “We’ll also do a detailed history and a physical examination. From there, we may need to do bloodwork to check for hormonal or genetic factors or more advanced tests with ultrasound. Based on what we find, we can make recommendations on what we need to do from there.”
The ultimate goal is to allow patients to conceive as naturally as possible. Many medical professionals, after determining that a man has a low sperm count, will send the couple to a reproductive endocrinologist to begin the process of assisted reproduction – such as through in vitro fertilization. But Chesapeake Urology has a different philosophy. “Our goal is to help couples get pregnant as naturally as possible – sometimes this is possible, and sometimes we rely upon assisted reproductive techniques, such as intra-uterine insemination (IUI), which is done for couples with slightly decreased sperm counts, and in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), which is done for couples with extremely low sperm counts or no sperm at all.” Dr. Boyle says.
There are several different approaches for helping make that possible. If the physician determines that the patient has no sperm in the semen, Chesapeake Urology’s trained specialists may recommend surgery to help diagnose a problem and help a couple conceive.
One choice is a diagnostic testicular biopsy, which involves the removal of a pea-sized amount of tissue from the testicles and sending them to a pathology laboratory for testing. This is done to confirm whether or not the patient has an obstruction blocking the semen.
When testicular failure is suspected, as in men with small testes and an abnormal hormonal evaluation, a Microdissection Testicular Sperm Extraction (MicroTESE) can be performed. During a MicroTESE, the surgeon microsurgically identifies normal areas within the testes to extract sperm for IVF/ICSI.
In addition, Chesapeake Urology’s experts can successfully perform a repair of varicocles, prescribe hormonal treatments, correct blockages and prescribe medications to correct the conditions that cause their patients’ infertility – even reversing vasectomies for men who have changed their minds about having a child (see sidebar).
These treatment methods are extremely effective in most cases. “For varicocle repair, 85 percent of men see an improvement in their sperm counts, and a large number of those men can go on to father children naturally.” Dr. Boyle says. “For men with severe disorders that would require a microdissection, we are able to find viable sperm in a majority of our patients – men who would otherwise never be able to biologically conceive their own child.”
The dream of starting a family is one that many people share – and it’s one that the medical professionals at Chesapeake Urology are committed to making possible for their patients. “We’re one of the few groups with surgeons who are fellowship-trained in these procedures,” Dr. Boyle affirms. “The three of us work with all areas of reproductive health and technology, and we offer the most comprehensive care available to our patients.”
By CUA on Wednesday, March 31st, 2010 11:15 AM
It’s Sunday afternoon on a hot summer day, and the whole family is enjoying a picnic and sipping lemonade. Pretty soon, it will become evident that Dad cannot fully enjoy his family day. After the first glass of lemonade, he excuses himself for what seems like hours. Unfortunately for Dad, he suffers from benign prostatic hyperplasia (BPH), and this bothersome experience is all too common.
BPH is a common condition occurring in 50 percent of all men 50 years and older and more than 70 percent of men older than 70. As men age, their prostates may enlarge, causing the prostate to place pressure on the urethra, making urination difficult. Although the cause of the enlarging prostate is not definitive, some factors can amplify symptoms, including caffeine, spicy or acidic foods and certain medications.
Difficulty urinating may be the easiest symptom to recognize, but symptoms can also include a frequent and sudden need to urinate, difficulty starting urination, awaking at night more frequently to urinate and an inability to empty the bladder. “BPH is prevalent in most older men, but not all are symptomatic,” explains Dr. Kenneth F. Langer of Chesapeake Urology Associates. “Like a man going gray, symptoms may appear gradually and may not be noticeable until they are acute. As symptoms worsen over time, they can cause complications like inability to urinate, bladder or kidney damage, bladder stones or urinary infections.”
There are various methods for determining if a patient has BPH. The first step is a general physical evaluation that includes a medical history. Typically, a symptom score and a urine flow test, which allows the doctor to see if the urine flow has decreased, are included in the initial evaluation. A digital rectal exam (DRE) will be performed, and, in most cases, a prostate specific antigen (PSA) test will be done. This test can indicate BPH, prostatitis (prostate inflammation) or prostate cancer. Other tests may include an ultrasound, a CT scan and a cystoscopy. New technologies are allowing doctors a greater ability to determine whether a patient is suffering from BPH, overactive bladder or another condition, and it gives them a better vehicle to determine treatment. “Technology is helping us better evaluate a patient’s condition, and it gets us to the next step,” Dr. Langer adds. “For example, a urine flow test and bladder scan will provide significant information on voiding and emptying to help determine the best treatment.”
Treatment for BPH depends on the severity of the symptoms and the extent to which they interfere with a patient’s lifestyle. Minimal symptoms may require only lifestyle changes, while more pronounced symptoms may require medication or surgery.
There is no simple response to the debate of which is a better form of treatment for BPH – medication or surgery. On the side of medicine, alpha blockers offer a less-invasive solution than surgery. This medication relaxes the muscles of the bladder neck, allowing easier urination and less frequent urination. According to the Mayo Clinic, alpha blockers increase urinary flow in a matter of days.
Another common medication for BPH is 5-alpha reductase inhibitors. This medication works by inhibiting an enzyme that is responsible for prostate growth. Blocking this enzyme reduces the size of the prostate. However, unlike the fast-acting alpha blocker, this method takes several months to shrink the size of the prostate and sometimes impedes sexual function.
Medications are effective for some men, but there are several minimally invasive treatments that provide a simple, one-time solution to open a passage through the prostate to allow urine to flow with less effort. Most of these procedures can be done with local anesthesia in the doctor’s office.
Dr. Langer discusses the use of heat treatments (thermotherapy) that are used to shrink and relax the prostate. “There are several forms of heat treatment from low to high heat,” he explains. “The low-heat therapies cause less shrinkage and work more like the alpha blockers. These therapies are normally performed in less than an hour under local anesthetic and significantly improve urinary issues in most men.” High-heat therapies, such as transurethral needle ablation (TUNA) – a common technique is known as Prostiva(TM) – use radiowave heat to shrink the prostate and release pressure from the bladder, so it is easier to urinate.
Until recently, transurethral resection of the prostate (TURP), a treatment for a moderate-sized prostate, has been one of the most common procedures for BPH. This procedure removes obstructing tissue in the prostate through a cystoscope and reduces difficulty with urination. Though the procedure yields good results, it is invasive and requires a hospital stay.
The latest advancement in BPH treatment is laser vaporization. “As we do the procedure, we can see the obstructing tissue melt away,” Dr. Langer says. “It is an outpatient treatment that improves the urinary stream with low risks and reduced complications. Healing normally takes one month, and urination is back to normal. The laser is quickly replacing TURP as the standard of care.”
With new BPH treatments emerging every year, Dr. Langer recognizes that treatment options depend largely on the patient’s interests. “I will explain the pros and cons of all possible treatments – medications and surgical procedures – with the patient. For a simple slow flow, I might recommend the patient start with a medication. Later, we may discuss surgery and whether or not he is a candidate,” Dr. Langer states. “I tailor treatments carefully to the individual patient.”
“I’ve been in practice over 19 years, and the technology is always improving,” Dr. Langer confirms. “Chesapeake Urology provides the most skilled physicians, advanced equipment and integrated services to enable us to provide the best possible care for our patients, including the best treatments for BPH. That includes clinical trials with state-of-the-art technology for most urologic conditions, including BPH.”
By CUA on Wednesday, March 31st, 2010 10:35 AM
When it comes to your health, finding the right medical professional to help you is extremely important. For patients with disorders of the urinary tract, the expert to call is a urologist. In the greater Baltimore and Mid-Atlantic areas, Chesapeake Urology Associates, with 48 urologists on staff, is the premier treatment center for patients with urologic conditions.
Urology is a medical specialty that deals with the function of the urinary tract in both men and women, as well as the genitals of both sexes. The urinary tract includes the kidneys, the ureters, the urinary bladder, the prostate and the urethra. Urology also includes erectile function, infertility and the testicular problems in the male patient.
Becoming a urologist requires four years of medical school and five to six years of residency. According to Dr. Geoffrey Sklar, Chief Medical Officer at Chesapeake Urology, many urologists also complete fellowships for a year or two in order to receive even more specialized training. Although urology is a surgical specialty, urologists must have a thorough knowledge of many other specialties because of the different conditions they encounter. These other specialties include internal medicine, pediatrics, oncology and gynecology, among others.
The number of conditions urologists treat on a regular basis is vast. “The most common condition that we treat is the benign growth of the prostate in men, also called BPH,” Dr. Sklar notes. “We also treat prostate cancer, bladder and kidney cancers, testicular cancer, kidney stones, urinary tract infections, incontinence, leakage of urine, erectile dysfunction, and male infertility and sexuality, among many other problems.”
Urologists’ scope of care includes:
- Incontinence in both males and females (see related article on page 20)
- Kidney stones
- Erectile dysfunction
- Benign prostatic hyperplasia (see related article on page 8 )
- Vasectomies and vasectomy reversals
- Male infertility and vasectomy reversals (see related article on page 10)
- Hematuria, or blood in the urine
- Cancer of the prostate, testicle, bladder, penis and kidney
- And other disorders
Watching out for abnormal urinary symptoms is crucial to catching problems early, Dr. Sklar emphasizes. These symptoms can include:
- Blood in the urine
- Discomfort or a burning sensation when urinating
- Pain in the flank or side
- Urinating more frequently than normal
- Erectile problems for men
Taking swift action to correct these symptoms is very important. “For cancers, when they’re diagnosed early, many are curable,” Dr. Sklar says. “If the problem is kidney stones, they can affect long-term kidney function, and if they’re allowed to advance, the damage may be permanent. And the same goes for erectile dysfunction – it’s much easier to treat early rather than when it’s been there for years.”
When patients in the Baltimore area have a problem with their urinary tract, the professionals at Chesapeake Urology are here to help. “We have 53 doctors, and we have someone who specializes in every area of urology at Chesapeake Urology,” Dr. Sklar points out. “Many of our doctors are chiefs of urology at area hospitals. Another is chief of surgery and two are urological consultants to the NFL Baltimore Ravens and Baltimore Orioles. We care about our work and what we do here, and we care about our patients. Our doctors make us the best!”
By CUA on Wednesday, January 13th, 2010 12:45 PM
Baltimore…Chesapeake Urology Associates (CUA), a group practice of 46 board-certified urologists, is will hold it’s first Man to Man meeting of 2009 at the CUA Prostate Center, 2 Park Center Court, Owings Mills, MD 21117, on Thursday, February 5, 2009, from 6:00 p.m. to 8:00 p.m. All prostate cancer survivors and patients and their guests are invited to attend. Light refreshments will be served.
Marc H. Siegelbaum, M.D., Chesapeake Urology Associates, Chief of Urology and Medical Director of the Urologic Oncology Institute at St. Joseph Medical Center, and Urological Consultant to the Baltimore Orioles will speak on Incontinence and Treatment Options.
For reservations call (443) 738-9393.
As one of the East Coast’s premier urology private medical practices, Chesapeake Urology Associates, P.A. (CUA) provides superior care often limited to university programs. More than 320 staff members, including a team of fellowship-trained urologists, provide men, women and children with the highest quality, comprehensive urologic care in an environment of compassion and dignity. CUA offers the most advanced minimally-invasive laparoscopic and robotics procedures and leading-edge diagnostic techniques at 16 medical offices and 14 ambulatory surgical centers offices in the Baltimore Metropolitan Area.