TRAUMA (PENIS):

TRAUMA (PENIS):

Dear Sumner:

This letter follows my call to you re John, who is a very embarrassed and frightened 24 year old man who was having a rather vigorous sexual experience with his girlfriend (she was in the dominant position), when heard an actual snapping sound and felt a sharp pain in his penis. He has been unable to urinate since then. As you have probably observed yourself by this time, his penis is very tender, swollen and discolored. He is sure that this is the end of his sex life! How can you find out what is going on here and, more importantly, what can you do to “make it all better?” Both John and his girlfriend would be extremely grateful for your help.

Dear Elsie:

This was surely one very distressed young man. My diagnosis was that of a penile fracture…i.e. disruption of one or both of the compartments which fill with blood during erection (the corpora cavernosa). Generally, imaging studies are not necessary since, in such cases, you can usually feel a distinct firm mass on the penis, which represents the hematoma at the site of disruption. However, it is important to be certain there is no associated injury of the urethra. Especially since John was unable to urinate since his injury, I obtained a urethrogram. His channel appeared intact.

Penile fracture is obviously not a very common occurrence and some physicians treat this problem conservatively, hoping for spontaneous healing to take place. However, because of the high incidence of complications with that approach, such as penile curvature and erectile dysfunction, early surgical intervention may be preferable. Accordingly, after a rather detailed discussion with John and his girlfriend weighing the pros and cons of surgery, we did proceed with the repair. The surgery went smoothly and I am optimistic that John and his girlfriend will have a happy future together (though perhaps a bit less vigorous than in the past).

POST-VASECTOMY PREGNANCY:

POST-VASECTOMY PREGNANCY:

Dear Sumner:

John is a 43 year old patient of mine who had a vasectomy about 9 months ago (not by you). He had his semen checked at about 4 months after the procedure, and no sperm was found. Contraception was then discontinued. It came as quite a surprise to John and his wife when she missed her period last month, particularly when a pregnancy test done a few days ago was positive. I immediately ordered another semen check, with no sperm being found once again. This couple has been married for 25 years and has 3 children, ranging in ages from 10 to 18. They are currently trying to decide whether to have an abortion. Needless to say, this pregnancy has caused considerable strain in their marriage. His wife categorically denies any extramarital activity. They have always seemed like an exemplary couple and have done a wonderful job raising their kids. I would be very distressed if this marriage broke up because of this pregnancy. I would appreciate if you would see John and try to help sort things out.

Dear Mel:

Post vasectomy pregnancies are very rare and usually occur within the first few weeks of vasectomy because the couple has incorrectly assumed that there is no need for contraception once the vasectomy has taken place. However, there may still be residual sperm present within the ductal system at that time. In 1972, I reported on a more uncommon phenomenon: the transient reappearance of sperm after vasectomy (JAMA: 219:1753, 1972). I had a good talk with both John and his wife re this study. They both seemed VERY relieved after our visit together and decided not to interrupt the pregnancy.

Mel, I feel that it is important that the involved physicians be aware of the possible transient reappearance of sperm after vasectomy and convey this information to the marital partners. I think you will agree with me that it is better to err on the side of incorrect paternity and let the couple work out the situation themselves than to destroy a marriage by denying the possibility of the husband’s transient fertility.

ERECTILE DYSFUNCTION:

ERECTILE DYSFUNCTION:

Dear Sumner:

I have asked George, a 62 year old man, to call you for an appointment, since, unfortunately, I have been unable to provide him with satisfactory solutions for his problem with maintaining erections. He states he is able to gain a fairly firm erection, but as soon as he attempts insertion, the penis becomes flaccid. He has tried oral and intraurethral medications, penile injections as well as a vacuum pump, all with variable degrees of success. I found no obvious causes for his difficulties. It’s your turn now! Thanks in advance for your help.

Dear Craig:

Most of my time with George involved listening: having him tell me when and under what conditions he had difficulties (or no difficulties) achieving and/or maintaining erections. I questioned him about his occupation, interpersonal relationships, the time and situation of onset of his erectile dysfunction and how he performs sexually under varying circumstances, including self stimulation or with a partner-- or partners. (I had a patient consult me because he was having problems maintaining an erection when with his wife. He had no such problems when with his mistress.) When I learned that George was able to have firm erections during vacation without the use of medications or devices I felt confident that he had no physiological disturbance of his erectile “mechanism.”

My main approach was one of counseling--and reassurance. I pointed out to him that while a teenager may be able to attain an erection “at will”, this ability lessens with age (and George realizes that he is no longer a teenager). Our discussion included the fact that most men over the age of 50, and often younger men as well, experience intermittent difficulty with erectile function.

But perhaps the most meaningful point of discussion for George was his realization that he often tried to gain an erection even when there was no sexual stimulation. Almost every time he was unsuccessful. This series of failures eventually turned into a self-fulfilling prophecy of erectile dysfunction—at least when he was not on vacation.

If his problem continues, I suggested he utilize variations of the techniques of Masters and Johnson, sometimes referred to as “sensate exercises”. This involves stimulating and subsequently bringing his partner to orgasm without his inserting, the purpose being to avoid any pressure on him to “perform. “ (Usually, during the time of his partner’s being stimulated, he himself becomes aroused--and erect). Hopefully, after awhile, George will be more relaxed when with his partner and the “problem” will straighten itself out spontaneously. I am optimistic that the self realization that his reactions are not abnormal will itself be therapeutic. He was somewhat concerned about his wife’s reaction to his perceived failure of performance. If his problem does not resolve, he agreed to make another appointment for both him and his wife . Craig, I’d like to share a story with you how one’s attitude can influence his reaction to his erectile function. One of my patients told me that on his 85^th birthday he wrote in his diary: “Last night I had an erection. I was unable to bend it with both hands.” On his 86^th birthday he entered in his diary: “Last night I had an erection. I was able to bend it with both hands. I must be getting stronger.”

URINARY STRESS INCONTINENCE:

URINARY STRESS INCONTINENCE:

Dear Sumner:

I have a delightful 92 year old woman as my patient who has had progressive bouts of urinary incontinence over the past 20 or so years. The problem occurs only when she does any physical activities; there is no leakage when she is in bed. This is particularly distressing since one of her great pleasures in life had been attending church, but the embarrassment of wet panties has curtailed this activity. She is very reluctant to undergo any surgical procedures and has asked me whether there is some “non-invasive” procedure which will help her. Let me know what you and she decide is best for her. By the way, Myrtle is one of my favorite patients, and I am sure she will soon be one of yours as well.

Dear Kim:

After meeting and talking with Myrtle, I can certainly understand why she is one of your favorites. Not only is she delightful, she is also very bright and seemed to grasp the entire subject of the various approaches to urinary incontinence. For example, she explained to me that urinary stress incontinence is usually secondary to decreased local support of the urethra and bladder most often occurring in women after multiple vaginal deliveries. We talked about the options for restoring the supporting mechanism. As you know, she wanted a non-surgical approach. We decided to try the “old fashioned” vaginal pesssary, (which is particularly useful for high risk women with medical diseases or for women who just want to avoid any surgical procedures). I told her that sometimes local inflammation can occur with the use of a pessary, and occasionally it can become displaced or even fall out. I asked her what she would do if the pessary popped out when she was walking down the aisle in church. Without a moment’s hesitation she looked at me with a twinkle in her eye and said: “Why, Dr. Marshall, I’d just pick it up off the floor, and hold it up in the air and ask: Did anyone here loose this?”

Happily, the insertion of the vaginal pessary did provide satisfactory local support for her cystourethrocele, resulting in marked improvement of her urinary control (and it stayed in place both during, as well as after, church services!)

By the way, Kim, a vaginal tampon can provide local support for a woman with mild stress incontinence during such activities of tennis or square dancing.

POST-VOID DRIBBLING:

POST-VOID DRIBBLING:

Dear Sumner:

What can you do with a man who claims he always has a few drops of urine wetting his underpants when he finishes urinating? This is complaint of my 48 year old patient Roger, who has never had any documented urinary tract infections or venereal diseases and is otherwise totally asymptomatic. I have been unable to find any cause for his problem. I would appreciate your input.

Dear Gretchen:

I am optimistic that we have helped Roger solve his problem. I think the underlying basis for the leakage is a disturbance of the coordination of the voluntary and involuntary muscular components of his urethral sphincter, sometimes referred to as “dyssynergia”. Ordinarily these two components contract synchronously. Roger, in a conscious effort to stop the urinary flow, would initiate the voluntary muscle component of the urethral sphincter, perceiving that he had completed the act of voiding. However, before the involuntary muscle component contracted, the small amount of urine “trapped” in the posterior urethra would dribble out spontaneously and soil his pants. (How’s that for an esoteric explanation for a rather common phenomenon?) By relaxing his perineal muscles at the time of perceived completion of urination--possibly allowing time for contraction of the involuntary component--and by applying direct pressure with his finger on the area of his penoscrotal junction, Roger was able to eject those last few drops from the urethra and thereby avoid the embarrassing wet spots on his pants.

BED WETTING (ENURESIS):

BED WETTING (ENURESIS):

Dear Sumner:

I need your advice on how to handle Beverly, a four year old girl, who wets her bed nightly. I realize that this situation of itself is not unusual, but her parents are very distraught, and are not willing to accept the fact that she will likely “outgrow it.” Her mother has told me--numerous times--how bright and well-adjusted she is and how she gets along so well with her pre-school classmates. However, as soon as Beverly walks through the door of my office, she becomes very emotional and immediately starts crying and clinging to her mother. Her urine is free of infection and no gross abnormalities are noted on physical exam. When I suggested a trial of medication, her parents refused this approach. When I suggested some “counseling” they became very angry. However, they did agree, and in fact, were most pleased, when I suggested that they have you see her. Are you willing? I hope so since they’ve already made an appointment.

Dear Phil:

I appreciated very much your introductory note on Beverly, particularly with the warning of her seeming emotional lability. As my office manager always tells me: “Forewarned is forearmed!” For that reason, when Beverly first walked into my office (clinging to her mother), I informed her that I’m a cookie doctor, not a “shot” doctor. (I always have a supply of chocolate chip cookies in my office). I chose to examine her in my office (consultation room), rather than in a separate examining room. Sitting on her mother’s lap during the exam seemed to add to her feeling of security. Before embarking on my examination of Beverly, she and I examined her doll. No abnormalities were found on either Beverly or her doll.

My approach with Beverly was an attempt to involve her in solving the problem. Assuming that Beverly really wanted to stop wetting the bed, I asked her to make a calendar and, if she woke up dry, to affix a star of her favorite color to that day (for daytime wetting one can modify the calendar accordingly). If she wet, she will record possible causes—with the help of her parents. (Phil, I want you to know that some of the things the kids write down are quite original: e.g. “the dog peed on my leg “or “my pajamas fell into the toilet.”) In addition, I asked her to postpone voiding as long as possible, noting the maximum volume of urine she could produce at any one time. Obviously one of her parents will have to help her collect and measure the urine. (Whether this actually increases her bladder capacity is not as important as making her aware of the sensation of bladder fullness, and then recognize that the time has come to deposit the urine in a proper receptacle.) I further suggested that she stop and start the stream during voiding to try to reinforce her awareness that she can control her voiding pattern. I am well aware that these steps may not result in totally dry beds, but if we can get any dry nights, this will be a positive start.

I then asked the family to make an appointment for 3-4 weeks hence in order for me to go over the record with the child. (Her parents’ eyebrows rose at the thought of paying for another office visit, but quickly relaxed when they are told there will be no charge for that subsequent visit.) Phil, it is very gratifying when a child appears with a big smile, so pleased that there are some stars on the calendar to show me (besides which, she also gets a chocolate chip cookie along with my encouraging words). The main point is that she must answer to a person other than a parent.

As a reward for sending me this “challenge,” I’d like to share with you a couple of experiences I had with some other families involving bed wetters. As you know it is critical to observe the interchange between the child and family members. For example, I had one 5 year old boy who sat quietly in the room sucking his thumb as his mother pointed an accusing finger at him, telling me how “this little brat can never stay dry and always embarrasses us with his constant wetting.” This is certainly not a very healthy family constellation! Another example involved a 6 year old youngster who came to office with his mother. Unlike with the other case, this mother looked lovingly at her son, smiling at his every word and action. “Dear Johnny,” said she, “tries so hard to stay dry and whenever he does, we give him a reward. Why last week alone he got a new tricycle, a special puzzle and a Mickey Mouse watch.” When I talked to Johnny separately, I asked him how he felt about being dry. He acknowledged that, while it did make him happy to wake up dry. he didn’t want to wake up dry every day, at least not right away. His reason: “Doc, I got it made! Do you see the way I got my Mom twisted around my little finger?”

However, not all parents will accept my approach. I had one mother who wore a very satisfied look on her face when she brought her son back for a follow-up visit. “Doctor” she said, “you may have all your fancy calendars and chocolate chip cookies, but I discovered a quicker way to stop my son from wetting. I got him an electric blanket and told him that if he wet the bed, he’d electrocute himself. (I personally do not recommend this approach for the treatment of enuresis!)

Medications or alarm systems remain other options.

HEMATURIA:

HEMATURIA:

Dear Sumner:

How do you handle a 62 year old man with red urine? Harry, who I has been my patient for 22 years, told me during his yearly routine checkup that for the past 6 months or so he has noted a reddish discoloration of his urine. Since this was intermittent, lasting only for one or two urinations and he had no associated discomfort, he figured that there was nothing seriously wrong and saw no need to call me earlier. I didn’t want to alarm him, but, quite frankly, I am, indeed, worried about a possible serious problem. (I seem to remember from my medical school days that with gross blood in the urine a tumor somewhere within the urinary tract must be ruled out. Am I correct in this assumption? I suggested he call your office for an appointment for the very near future.

Dear Ben:

First of all, thanks for encouraging Harry to see me so promptly. Statistically speaking, hematuria is more likely to be secondary to a benign process such as from an inflammatory/infectious process or a stone, although I always worry about the possibility of a tumor within the urinary tract. Of course, it is possible that the reddish discoloration of his urine was secondary to dye or some breakdown products in medication or foods rather than from blood. When I checked Harry’s urine today, I did not find any red blood cells in either the urethral washings or mid-stream urine samples. However, that does not mean he didn’t have them before, and with the history as presented, I feel that Harry’s urinary tract should be visualized via some radiological study and urine examined for abnormal cells (cytology). (I have a general rule that every patient with hematuria be it gross or microscopic only, gets a minimum of a renal/bladder ultrasound and urine for cytology; with gross hematuria, I will add cystoscopy to the workup).

If there is anything suspicious noted on the renal ultrasound, or if the urine is subsequently found to contain red blood cells, or if the urine cytology shows any abnormal cells, then I will follow with an intravenous pyelogram (IVP). A CT scan or MRI study as well as cystoscopy may also be done. I will let you know my findings and further thoughts.

Dear Ben:

The renal/abdominal ultrasound study showed no gross abnormalities and the urine cytology, no abnormal cells. However, I subsequently found red blood cells in both the 1^st and 2^nd glass urines, suggesting their source to be proximal to the bladder neck, i.e. from the bladder, ureters or kidneys. I did obtain a CT scan which, happily, revealed no obvious tumors or enlarged lymph nodes. On cystoscopy, however, I found a sessile lesion which had the gross appearance of a low grade tumor and, indeed, on histological examination that diagnosis was confirmed. (By the way, Ben, a negative cytology does not rule out the presence of a tumor, only that, if a tumor is present, it is likely low grade and probably not invading the deeper layers of the bladder wall). I will be looking in Harry’s bladder at three month intervals for one year and then at increasing intervals thereafter. Should there be multiple recurrences, and then consideration would be given to the use of intravesical therapy, such as chemotherapeutic or immune boosting agent. Hopefully, the use of such will not be necessary. Generally in cases of superficial tumors of the bladder, the overall prognosis is quite good