Under the covers with men’s sexual health issues
New treatments on offer for many problems men may perceive as being embarrassing or distressing
No worrying or ‘embarrassing’ health problem can be addressed if a man doesn’t approach his GP or health professional about it. Photograph: iStockphoto
Dr Ivor Cullen, University Hospital Waterford: With men living longer and our increasingly elderly demographic, Cullen says there is a need for particular focus to be paid to late onset hypogonadism – often termed the ‘male menopause’ – in older men. Photograph: Mary Browne
Do a quick Google search for women’s health. You’ll receive approximately 152 million results. Do the same for men’s health and you will get 22.3 million. Is this sexism in another guise, or is it purely indicative of male reluctance to discuss their health issues, even with Dr Google?
Consultant urologist and andrologist at University Hospital Waterford (UHW) Ivor Cullen says men should be aware that there is a wide range of solutions to many problems they may perceive as being embarrassing or distressing.
Cullen trained in several ground-breaking techniques during his time working in the leading urology centre at University College London Hospital. Many of these have not been available in Ireland until now.
Breakthroughs in fertility medicine have not just been confined to female fertility issues; the area of male infertility has seen a revolution in recent times, says Cullen.
Sexual dysfunction has also moved on from the “little blue pill”. When Viagra doesn’t work, there are many other options for men struggling with erectile dysfunction.
The important thing to remember is that no worrying or “embarrassing” health problem can be addressed if a man doesn’t approach his GP or health professional about it, Cullen says.
However, for those men who do not respond to these treatments, there is now the surgical option of an inflatable penile prosthesis.
As part of this procedure, hydraulic pumps are inserted so that men with erectile dysfunction can have functioning erections and have sex normally.
Although this procedure has been offered in Ireland before, in Cullen’s opinion, the uptake has been quite poor, mainly owing to a lack of knowledge in the area among both patients and the health profession at large.
“Penis implant surgery is just not requested or desired by patients as they are unaware of the option,” says Cullen, contrasting this with his experience in London where a significant proportion of men with ED are aware of and will choose the implant surgery as an option when the medications fail.
“It has been offered to a limited number of patients in one or two centres. There is very little knowledge about penis implant surgery. No one talks about it here, but in other parts of the world that’s not the case, it’s quite commonplace.”
According to Cullen, common candidates for this procedure are younger men with type 1 diabetes who often ultimately get erectile dysfunction early in life, often starting after the age of 40 and medication eventually does not work.
In addition, men who have had their prostates removed or had radiation or hormonal treatment, usually as a result of prostate cancer, would also benefit from this surgery, as the majority of these will lose the ability to have an erection and often will not respond to the usual medications.
The procedure can be carried out by Cullen and his team at UHW. A three-piece hydraulic inflatable implant is inserted, which isn’t visible externally. A small pump sits in the scrotum, much like a third testicle, explains Cullen. The two-piece prosthesis is implanted in the penis, while a reservoir is laced in the lower abdomen. When the pump is squeezed, the fluid goes from the reservoir into the prosthesis and makes it erect.
This ensures a rigid erection every time, satisfactory for penetrative intercourse and dispensing with the need for expensive medications or injections.
“Obviously that’s not for everyone but it is a fantastic addition to our options. Satisfaction rates with penile implant surgery are always remarkably high – 90-95 per cent. In a well-chosen patient who is properly counselled, it can be a wonderful option for erectile dysfunction,” Cullen says.
“Peyronie’s disease does not refer to a mild curve,” explains Cullen.
“Every man’s penis has a minor degree of curvature, but problems arise when there is over a 30-45 degrees of curvature, making penetrative sex impossible.
“The curve develops because of abnormal deposition of scar tissue – “plaque” in the erectile bodies within the penis – which shortens the affected side and results in curve development.
“Men cannot have a satisfactory sex life due to the shape of their penis, which can resemble a boomerang.”
Several surgical options exist for patients, whereby the penis can be straightened. One possible option to correct the curvature is the Nesbit procedure, which involves plication (suturing) of a section of the penis opposite the problematic plaque or scar. This operation will usually ensure a straight penis albeit with a minor loss of length.
Other potential approaches range from injections of a digesting enzyme (collagenase) into the scar tissue to break it down, grafting procedures and potentially implant surgery, if the co-existing erectile dysfunction is significant.
Again Cullen says that in most cases men are not forthcoming about what they might see as an embarrassing problem.
“Men are often very bashful and shy and don’t talk about these problems with their partners or friends, much less see their doctors about them,” says Cullen.
“It can often be slowly destroying their relationship or marriage, and they need to understand that this is a recognised and correctable phenomenon, and easily fixable surgically.”
Male factor infertility
There is a plethora of reasons as to why someone might have what is deemed an “abnormal” semen analysis, says Cullen.
“They may have a low count, poor motility, or a low number of normal sperm forms. We evaluate them and investigate them and, in many cases, we have medical, surgical options or lifestyle interventions that can improve the quality of their sperm. It could be something as simple as stopping them from using daily saunas and Jacuzzis, to putting them on zinc and folic acid supplements.”
One of the more common reasons for a subnormal semen analysis is a varicose vein of the spermatic cord, known as a varicocoele. This condition can raise the temperature of the testicle and impair sperm production.
“Lots of men have a minor degree varicocele, which is of no clinical significance, but when we find a significant varicocoele in a gentleman with an abnormal semen analysis, simply tying off the extra varicose veins will typically improve that man’s sperm analysis.”
Unfortunately, there are also men with no sperm at all in their semen, a condition known as azoospermia. Cullen says these are the most c’hallenging patients he will treat with respect to male infertility.
“It is a devastating diagnosis for a man; they will usually have been trying for a family for 12-18 months before someone says, let’s get checked. To find out there is no sperm at all is just a disaster for them.”
Tests are carried out to determine if the condition is due to an obstruction in the transport of sperm cells from the testicle to the ejaculate, or if there is a fundamental problem with sperm production within the testis.
The obstructive type could be due to scarring of the vas deferens or epididymis, sometimes as a result of chlamydia or gonorrhoea.
A hernia repair or undescended testicle repair may also be the culprit. This can often be treated with a procedure that is much like a vasectomy reversal.
“With this scenario, it really isn’t the end of the world, because even if you can’t fix it, their testes are still full of sperm,” explains Cullen. If this is the case, an option is a intracytoplasmic sperm injection (ICSI), where the sperm is injected directly into the egg. This treatment is offered in a number of clinics in Ireland.
“That works so well now that all we need is sperm.”
In cases of non-obstructive azoospermia, a man will have no sperm at all in his semen. Recent advances in treatment have meant that at last these men have therapeutic options.
In the past, these couples had no choice other than using donor sperm or going down the route of adoption. In particular, a technique known as microdissection testicular sperm extraction (micro-TESE), has revolutionised the approach to finding small numbers of hidden sperm for use in the ICSI procedure.
The technique is another Cullen learned during his time in London; he now offers the procedure in conjunction with the Cork Fertility Centre. He warns, however, that there is only a 50/50 chance of “success”; small numbers of sperm will be located in approximately half of the men he treats, while no sperm will be found in the other 50 per cent.
“What I am trying to do is find their sperm for use in ICSI or as part of an IVF regime. But before I carry out the procedure I like to make sure that couples have had a chance to discuss and develop a back-up plan and perhaps speak to the sperm donor service if they so wish.
“When there is no success, it can be devastating for a couple, and anticipating and discussing the implications of not finding sperm in advance of the operation often helps tremendously.”
It is the counterpart to gynaecology, which deals with medical issues specific to the female reproductive system.
It is a recognised subspecialty of urological surgery. Although andrology is a well-established subspecialty in mainland Europe and also the UK, thus far Ireland has had low numbers of specialists trained in this field.
Cullen suspects this is because of the well-recognised need for prostate, bladder and kidney specialists in Ireland, with the majority of his contemporaries instead choosing these routes for subspecialisation. The area remains under-served in Ireland.
“Andrology is a fascinating subspecialty, which offers tremendous medical and surgical options to gentlemen with a variety of male specific ailments,” says Cullen, who has spent 13 years training in this area.
With men living longer and our increasingly elderly demographic, he says there is a need for particular focus to be paid to late onset hypogonadism – often termed the “male menopause” – in older men.
Symptoms range from sexual, such as erectile dysfunction, physical, with a loss of vigour and frailty, as well as having significant psychological impact.
This can be successfully treated with testosterone replacement therapy, although lifestyle modification, weight reduction and appropriate treatment of comorbid diseases is the first step, Cullen is keen to emphasise.
“Symptoms of low testosterone are well recognised and correctable in the hands of a specialist, which can lead to tremendous improvement in cardiovascular, sexual, mental and metabolic health.”