Peyronies Disease

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Peyronies disease is a penile disease in which a plaque is formed within the penis which may lead to pain or deviation in the penis. The patient feels that a tumor of mass has grown within the penis that may even preclude intercourse. This plaque has been proposed to be formed due to micro trauma during sexual intercourse.

The Symptoms can be:

  • Feeling of a tumor or lump over the penis
  • Pain in the penis especially on erection
  • Deviation of penis
  • Inability to have intercourse due to deviation or erectile dysfunction.

 

Stages of Peyronies Disease

There are two phases of Peyronies disease, an active phase in which the plaque is tender and keeps growing in size and a stable phase in which there is no pain and no further growth in the size of the plaque. There are different protocols of management of the different stages. It is therefore important to identify which phase of the disease we are dealing with.

Active Phase: In this phase the Peyronie’s disease is growing or evolving which means that the plaque is painful and changing its shape. Steps to reduce the size of the plaque such as injection therapy or surgery are futile at this stage as there is active inflammation and the plaque may worsen or regrow despite therapy. This leads to failure of the therapy. In the active phase treatment is aimed at reducing pain and inflammation rather than trying to make the plaque vanish. In many cases the plaque may reduce in size on its own.

Chronic Phase: Once the digestion of blood and fibrosis has completed the disease enters the chronic phase in which the size of the plaque stabilizes and the pain subsides. The deformity increases and becomes fixed. In this phase surgical intervention can be planned and disease can be removed in entirety.

 

Management of Peyronie’s Disease

The condition requires proper examination and investigations before beginning treatment. Dr. Raman Tanwar evaluates the extent, number and location of the plaques and treatment is guided by the age and degree of sexual activity and motivation of the patient. If there is persisting pain in the plaque, there is need to bring down the ongoing inflammation. Only when the disease becomes stable and there is no more growth of the plaque can more aggressive management towards cure be started.

The management of the acute stage includes painkillers and supplements. The changes in the plaque are evaluated clinical by weekly visits. Extracorporeal shock wave lithotripsy can be used to manage acute pain.

In the stable phase three lines of treatment exist namely medical management with Vitamin E, Colchicine and Potaba, Injection therapy with Verapamil and Kenacort and excision of the plaque.  Medical supplementation therapy bears poor results and long term therapy is required. It is however effective for many patients and a reasonable step to start with. It is a good option for patients with low grade disease, soft plaque and rare sexual activity. Intralesional Injections for peyronie’s disease is effective but long term results are doubtful. Every week an injection is given with a very fine needle into the plaque. The duration of the course is for 6 weeks (Total of 6 injections).

 

Raman-tanwar-urologist-andrologist-best-gurgaon-gurugram-sexologist-prostate-kidney-stone-jyoti-top-urocentre-penile-tumor-peyronies

Surgical management requires that the penis is degloved and the plaque excised by shaving it off or by putting a graft. This procedure requires 1 to 2 hours and is a safe and minor surgery. To know more about the management of peyronie’s disease please book an appointment with Dr. Raman Tanwar. Dr. Tanwar has extensive experience in the management of peyronie’s disease and performs surgeries for its correction on a routine basis.

Overactive Bladder

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Overactive bladder is characterized by the need of frequent and quick visits to the washroom. The patient has the following symptoms:

  • Going to the toilet again and again
  • Inability to postpone urination leading to rushing to the washroom
  • Getitng up more than once to pee
  • Leakage of urine while rushing to pass urine

Bladder overactivity arises because the bladder becomes sensitive to urine collection or the brain develops high sensitivity towards the perception of urine. This can occur due to a variety of reasons such as:

  • Stress
  • After urinary tract infections when the bladder layers become swollen and inflamed
  • Allergies
  • Poor Lifestyle

In presence of these symptoms you need to visit a urologist like us who will try to figure out a cause for your symptoms as there are many other conditions which can present with similar symptoms such as:

  • Urinary Infections
  • Interstitial Cystitis/Bladder Pain Syndrome
  • Tuberculosis
  • Bladder or ureteric stones
  • Bladder Cancer

We try to differentiate between these conditions but looking at various factors like the severity of symptoms, age, associated complaints and other diseases such as diabetes. By a more detailed conversation and thorough physical examination it is possible to shortlist the possible causes. We may take the help of the following investigations if needed to further narrow down the list of possible causes:

  • Urine routine and microscopy test
  • Urine culture test
  • Voiding Diary
  • Ultrasonography of the KUB region
  • Urine culture for Tuberculosis
  • Urine for Malignant Cytology

Overactive bladder is a functional disorder and it is necessary to ensure that it is not mistaken for any other condition. Occasionally there may be a need for more invasive diagnostic tests like

Cystoscopy and urodynamics study to confirm the exact diagnosis. Once the diagnosis of overactive bladder is confirmed out team will initiate a comprehensive treatment which will consist of:

  • Lifestyle changes
    • Detressing the mind by engaging with friends and family
    • Meditation
    • Regular exercise especially pelvic floor exercise
  • Medicines
    Medicines can be started to support and motivate. We use two main kinds of medicines to treat overactive bladder:
  1. Medicines that help to store urine in the bladder
    1. Anticholinergic
    2. Beta 3 Agonist
  2. Medicines that can reduce excitatory signals from the bladder to the brain
  • Botulinum Toxin to partially paralyze the bladder
  • Neuromodulation to modify sensory signals from the bladder
  • Bladder Augmentation

Overactive bladder is a manageable condition that may take some time to get treated. We follow a stepwise approach to treatment of overactive bladder and offer the complete range of medical and surgical solutions to patients with overactive bladder.

Kidney Stones

Raman-tanwar-urologist-andrologist-best-gurgaon-gurugram-sexologist-prostate-kidney-stone-jyoti-top-urocentre-pcnl-kidney-stone-kidney stone-rirs-lithotripsy

Renal or Kidney Stones are a common urological problem that presents usually as dull aching pain in the loin region that also radiates to the groin. The pain can occasionally become very severe if the stone obstructs the passage of urine causing pressure to built up in the kidney.  Kidney stones can cause infection in urine and subsequently impair it function considerably. Renal Stones are in fact one of the leading cause of renal failure. If you are suffering from renal stones here are some important things that you need to know before you visit a urologist.

You may have Kidney stone if you have symptoms like:

  • Pain in the back that comes to the front of the lower abdomen
  • Burning or bleeding in Urine
  • Nausea or vomiting
  • Feeling to go to the washroom again and again

What are Kidney Stones and how do they form ?

Kidney stones are usually composed of calcium that is complexed with other salts. These salts are deposited in the kidney when they are excreted in urine in excess of the normal amount and when their size grows they break away from the kidney and fall into the renal pelvis or collecting System. So initially they are visible in the form of small concretions that are fixed to the kidney but subsequently they become dislodged and form stones that are then free to migrate anywhere in the urinary system.

Essentially there are 4-5 main types of renal stones:

  • Calcium oxalate: These are the most common type of stones that form in the kidney. They can be of the calcium oxalate monohydrate variety or Calcium Oxalate Dihydrate variety. These stones are usually hard and difficult to manage with dietary therapy alone.
  • Calcium Phosphate: The next most common form of stone is the calcium Phosphate variety. It is more common in pregnancy, presence of anatomical aberrations in the kidney and other special situations.
  • Uric Acid: Uric acid stones are also quite common and they are characterized by their radiolucency (Usually less than 400 HU) and can be managed well with medical therapy as well.
  • Cysteine: Cystine stones are formed in patients with metabolic anomalies where excess cysteine is excreted in the urine.
  • Struvite: Struvite stones are complex stones that form in the presence of infection. They are hazardous for the kidney are require early removal after the control of Infection

Kidney stones form because of excess secretion of these substance in the urine. This happens when there is a metabolic anomaly in the processing and elimination of these substance or persiting infection. Stones are also more common when there is a structural defect in the kidneys.

What is the treatment of Kidney Stones ?

The treatment for Kidney stones depends upon the size, location and constitution of the stone apart from other factors like number, body weight and associated co-morbidities.

Small stones less than 8-10 mm can be managed conservatively with diet without the need of surgery. Many patients have multiple small stones for which medical therapy is adequate. This therapy involves intake of supplements that inhibit stone nucleation, aggregation and crystallization.

For stones more than 10 mm surgery is advisable in the presence of symptoms. This can be done through a flexible scope passed from the ureter called as Retrograde Intrarenal Surgery (RIRS) or through a small hole made in the back with a surgery called Percutaneous Nephrolithotripsy (PCNL). Stones can be also broken using soundwaves without any surgery and this procedure is called Extracorporeal Shock wave lithotripsy (ESWL).

 

What are the investigations required to diagnose renal stones ?

Renal stones are usually diagnosed on Ultrasound or a plain X ray of the KUB region. The ultrasound of the KUB region provides an edge in that it can tell the exact size of the stone. If the stone cannot be identified with these investigations alone then a CT scan give valuable investigation. Due to its cost, radiation exposure and availability factor Dr. Raman does not prefer to get CT in every case. Here is a summary of the required tests:

X Ray KUB region:

X ray of the Kidney, Ureter and Bladder region (KUB) is one of the cheapest investigations that can provide a lot of information like Stone size, location, and radiolucency of the stone. Disadvantages of the X ray include the inability to give an idea about the renal function and the back pressure changes.

Ultrasound of the KUB region:

Ultrasound is a more versatile tool and is complementary to the X ray of the KUB region. It provides information about the status of the kidney and the bladder especially the degree of hydronephrosis, or back pressure changes and presence of co-existing pathologies. The ultrasound is costlier than the X-ray and it may not be good for locating middle and lower ureteric stones.

NCCT Abdomen and Pelvis:

The Non-Contrast CT scan is a gold standard for the diagnosis of renal and ureteric stones. It can also provide some information about the status of the kidney. The disadvantages include increased dose of radiation and the higher cost of this investigation.

Intravenous Pyelogram:

IVP is a very useful investigation in patients with renal stones. It can provide useful information about the degree of renal damage, the exact location of the stone, its relation to the renal system, the function of the kidney and the route for surgery. Since half the century this investigation has been an integral part of surgical management of stone. The disadvantage of the IVP is that contrast injection has to be given for this test which is associated with reactions which may rarely be risky.

Contrast Enhanced CT Scan:

Contrast enhanced CT is a better version of the IVP which is costlier but provides more anatomical detail especially in cases where the kidney has a poor function. The disadvantages are the high radiation exposure and the risk of contrast administration.

 

MR Urogram:

MR Urogram is a form of MRI investigation with Gadolinium as the contrast media. This investigation is the most expensive of all but can provide greater anatomical detail with less risk of contrast induced reactions and no radiation exposure. The disadvantage of the MRI is that patients with claustrophobia and those with pacemakers and implants may not be suitable for this investigation unless their implant is MRI compatible.

To know more about the diet that patients with stones should follow please visit the Stone Diet page.

Choosing the right Surgery for Kidney Stones

Options for Surgical treatment of kidney stones  include:

  • Lithotripsy – Extracorporeal Shock Wave Lithotripsy. Stone is broken from outside the body using Sound waves
  • PCNL – Percutaneous Nephrolithotripsy. Small hole made in the back to reach the stone and break and remove it
  • RIRS – Retrograde Intrarenal Surgery. Stone is approached through the ureter and fragmented

 

The comparative chart depicts the technical advantages and disadvantages of each of these procedures.

Modality Lithotripsy PCNL RIRS
Sessions 3-4 1-2 1-2
Total Surgeries

(DJ Stenting/removal)

1-2 2-3 3-4
Stay in Hospital In days 0 3-4 3-4
Ease of Procedure +++ ++ +
Duration of Procedure

(Per Sitting)

30-40 Minutes 40-90 Minutes 60-120 Minutes
Cost of Procedure $ $$ $$$
Success 60-70% 99% 95%
Limitation Needs Multiple Sittings

Lower stone clearance

May need Surgery

Stones upto 2 cm only

Invasive

Bleeding, Requires a small cut

Multiple procedures

Invasive

Ureteric Injury

Bleeding

Stones upto 1.5-2 cm only

Advantages No Surgery or Hospital Stay, Minimal Complications High Stone Clearance Scarless surgery with high clearance, Uses advanced technology

 

Interstitial Cystitis

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Interstitial Cystitis or Bladder Pain Syndrome is a unique disease characterized by symptoms like lower abdominal pain, difficulty in passing urine, and lower urinary tract symptoms like urgency, feeling to pass urine multiple times and getting up at night to pass urine. These symptoms are severe enough to impair the quality of life.

What is the usual presentation of Interstitial Cystitis / Bladder Pain Syndrome ?

Interstitial Cystitis/Bladder Pain Syndrome is suspected in those patients who have been treated multiple times for recurrent UTIs and have not received much benefit from the same. They have not had any organisms gown in their cultures and usually do not have any pus cells in urine. Interstitial Cystitis Bladder pain syndrome is also suspected in patients who have bothering pain in the lower abdomen which relieves to some extent on passing urine. Usually patients report discomfort in the lower abdominal area throughout the day.

Symptoms of Interstitial Cystitis / Bladder Pain Syndrome thus include:

  • Discomfort in lower abdomen
  • Constant urge to urinate
  • Passing urine multiple times in the day – Frequency
  • Slight relief in symptoms after passing urine
  • Difficulty in passing urine with feeling of incomplete emptying

How is the Diagnosis Made ?

The diagnosis of Interstitial Cystitis is presently one of exclusion. The diagnosis is made when all other conditions which may cause these symptoms like UTI, Stone, Foreign Body, Cancer, Tuberculosis, Diverticula, Sinuses and Fistulae have been excluded. There are many signs that point to a diagnosis of Interstitial Cystitis. These Include:

  • High Levels of Anti-Proliferative-Factor
  • Hunners Ulcer (Seen on Cystoscopy)
  • Glomerulations (Seen on Cystoscopy)

What are the suggested tests for the management of IC/BPS ?

The tests that may be required to diagnose and manage this condition depend upon the symptoms that the patient presents with. These tests may include:

  • Urine culture
  • Semen Culture
  • Uroflowmetry
  • Cystoscopy with hydrodistension
  • Bladder biopsy
  • Micturition diary
  • Pelvic floor muscle testing
  • Phenotyping

How can the severity of Interstitial Cystitis be assessed ?

Usually Dr. Tanwar follows the international consortium’s  guidelines. The severity and type of interstitial cystitis can be characterized by the presence of ulcers and glomerulations. This requires a cystopanendoscopy. It is an important step to categorize the disease into ulcerative IC and non-ulcerative IC. It allows a more strict and effective protocol based management to be followed.

Why Dr. Raman Tanwar for management of Interstitial Cystitis ?

Dr. Raman Tanwar has a vast experience in management of Interstitial Cystitis and he has been internationally trained for various procedures for the management of IC/BPS. He has been involved as the organizing secretary of the ESSIC 2016 meeting of the International Society of Study of IC/BPS, which has been the first international meeting on Interstitial Cystitis and Bladder pain syndrome in the country.

  • Fellow of the Global Society for IC/BPS
  • Internationally recognized expert on IC/BPS
  • Well versed with all management programs
    • Medical Therapy
    • Hydrodistension
    • Intravesical Therapy
    • Botulinum Toxin Injection
  • Successful IC/BPS Lifestyle Program adopted by numerous patients
  • In house team for perfect pain management

What is the IC/BPS Lifestyle Program ?

The IC/BPS Lifestyle program is an online program which includes videos and presentations along with various lifestyle and dietary modification tips and articles that slowly bring in a positive change in the approach of patients towards the disease. The program also includes testimonials and stories of patients who have been successful in the battle against this disease who would like to provide tips from their side as well. The program is easily accessible and is a part of education and counselling by Dr. Raman Tanwar.

What are some of the Educational Resources that I can go through ?

Dr. Tanwar would strongly recommend that patients who have been diagnosed by him to have interstitial cystitis to go through the following resources:

The diagnosis and treatment of IPBF

IC/BPS Lifestyle Management Plan

Premature Ejaculation

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What is Premature Ejaculation ?

Premature ejaculation or early ejaculation is a common sexual disorder that one out of three men face in their lifetime. Premature ejaculation is characterized by early ejaculation or emission of semen that leads to subsequent loss of erection. This leads to partner dissatisfaction and poor self esteem. Many patients would want to postpone sexual intimacy because of this problem just to avoid embarrassment.

In reality premature ejaculation is not a disease but just a normal variation. Just like different people have different heights and varying weights, time to ejaculation also varies from person to person. Sometimes this time is so less that the patient is not able to even penetrate before ejaculation occurs and this normal phenomenon becomes distressing for the couple. Premature ejaculation has little to do with the penis and is mainly a disorder of coordination.

How does ejaculation occur normally ?

Normally the ejaculation occurs once the brain perceives that it has reached the climax of sexual pleasure. Ejaculation is all about how and when the brain perceives that the climax has reached. Once the climax is reached signals run from the brain to cause the muscles to contract and release the semen. Along with this the signals for erection are also withdrawn and ejaculation is always followed by complete loss of erection.

What causes Premature Ejaculation ?

Premature Ejaculation can occur because of:

  • Mental stress
  • Anxiety
  • Fear of performance during intercourse
  • Guilt
  • Sexual Abuse
  • Previous Unpleasant Sexual Experiences
  • Associated erectile dysfunction
  • Hormonal disturbances

Is premature Ejaculation Treatable ?

Premature Ejaculation is completely treatable. In fact it is not a disease in the first place. Treatment involves a few exercises or maneuvers, oral medicines and locally applied creams.

When does one need treatment for Premature Ejaculation ?

One should go for the treatment of premature ejaculation when there is:

  • Inability to perform sexual intercourse
  • Inability to satisfy the partner

What are the general tips for reducing premature ejaculation ?

Premature ejaculation management is all about delaying the climax in such a way that the ejaculation is also delayed. Here are the list of things you can do to control PE:

  1. Wear an extra thick protection: With a wide variety of condoms available in the market you can choose a thicker condom that can help reduce the sensitivity of the glans and the glands on the prepuce. Reduced sensitivity means that you can last longer without ejaculating.
  2. Use the Stop-Squeeze Method: Ask your partner to squeeze your penis when you are about to reach the climax. A two to four second pause may be enough to let the moment pass and you can start back again without loosing much erection.
  3. Follow the Start Stop Technique: Alternative to squeezing you can stop for 20-30 seconds before you reach the climax and start again.
  4. Ejaculate an hour or two before coitus: Prior ejaculation makes the sensations refractory for further action up to a certain time period. You need to figure out your refractory period and use it to your benefit.
  5. Initiate pelvic floor rehabilitation: There is some evidence that Kegels exercises can help control premature ejaculation. You can learn about these exercises here.

What are the medical therapies available for Premature Ejaculation ?

Medical therapy works by either increasing serotonin in the brain or helping the glans to become numb. For this we have SSRIs, Topical Anesthetic agents and pain medications like tramadol. Based on your need Dr. Raman can prescribe you a single or combination therapy. There are a number of other agents like Silodosin, Modafinil and Phosphodiesterase inhibitors that may be added to increase effectiveness of therapy on subsequent follow up visits.

Are there any Surgeries available for premature ejaculation ?

Dr. Raman Tanwar has performed selective dorsal neurectomy for refractory cases of PE and Glans augmentation with Hyaluronic acid. He also performs chemical neurectomy with Botulinum Toxin. Before surgery the protocol at our centre is to assess the effectiveness with prior temporary nerve block. If the patient is satisfied with the effects of the nerve block further permanent therapy is undertaken. We also perform ultrasound guided Dorsal nerve block in association with the radiologist.

Why choose Dr. Raman Tanwar for management of Premature Ejaculation?

Premature ejaculation is a common problem and treatment can often be frustrating.

  • While most experts have only a handful of drugs to offer, Dr. Raman Tanwar is fellowship trained in surgical management as well.
  • He is always in touch with the latest and even experimental therapy for Premature Ejaculation.
  • He has a wide experience in management of thousands of cases of Premature ejaculation with good success

To get the best results it is recommended that you be in regular follow up with the doctor. It is imperative to share your feelings, success and failures with his therapy so that the next line of therapy can be offered. Dr. Raman Tanwar follows the underlaid protocol:

Assessment of PE and Stressors → Behavioral and Solitary Medical Therapy → Combination therapy of SSRI with Opioid Analgesics → Addition of Topical Acting agents → Newer SSRI → Temporary block with Anesthetics → Chemical Neurectomy → Selective Dorsal Neurectomy / PGA (Hyaluronic Acid)

 

Erectile Dysfunction

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Erectile Dysfunction is a disease associated with the inability to produce an erection. It affects 5-10% of young men and as age increase, 50-70% of the men fall prey to this disease. So practically all men at some point in their life are going to suffer from erectile dysfunction. Lets understand more about erectile dysfunction in this article.

Pathway of erection

Normal erection process involves three main steps.

  1. The first station is the brain which produces a signal for erection based on visual, auditory or self created mental stimuli. The propagation of these stimuli leads to the creation of a fantasy that powers erection.
  2. The second step is the conduction of these signals to the penis through the nerves of the spinal cord and the pudendal nerve. This requires healthy nerves to produce a healthy erection.
  3. The third step is the widening of the arteries of the penis once the signal is received. This leads to filling of blood into the spongy tissue of the penis called as corpora cavernosa. Erection therefore also requires a health corpora.

Why does erectile dysfunction develop ?

Grossly erectile dysfunction can develop due to fault at any of the above mentioned steps.
Medically erectile dysfunction is said to have two main reasons, psychogenic or organic. Unfortunately patients with erectile dysfunction may not clearly belong to any one time and usually both psychogenic and organic erectile dysfunction co-exist making the management challenging.

Psychogenic erectile dysfunction implies that there is no problem in the organs i.e. penis and the nerves which organic erectile dysfunction implies that there is some damage in the concerned organs of the body. Psychogenic erectile dysfunction usually affects the first step of the erection production while organic dysfunction can result from any of the three steps.

Difficulty in producing a Fantasy is the most common reason for erectile dysfunction in younger men. When the brain is under stress or anxiety it may fail to produce signals strong enough for an appreciable erection. This can also happen when the visual or other stimuli are not strong enough such as in cases where one may not like their partner or have aversion to a particular partner.

Organic Erectile Dysfunction can result from:

  1. Nervous diseases
  2. Spinal cord injury
  3. Spinal Disc diseases
  4. Arterial Insufficiency
  5. Diabetes Mellitus
  6. Hypertension
  7. Cardiac Disease
  8. Obesity
  9. Tobacco abuse
  10. Previous Pelvic Surgery
  11. Urological conditions such as prostatitis
  12. Drugs – antihypertensives, antidepressants and statins

Organic erection problem arises from real disease in the brain, nerves or the penis and its arteries. This requires medical therapy of the root cause as well as management of erections with medicines or surgery for a long term.

How to find the cause of erectile dysfunction ?

Dr. Raman Tanwar carefully examines and tries to find clues that point towards erectile dysfunction. Since there are a number of factors involved, it requires more than one visit to find the exact cause. It also requires cooperation and trust of the patient to open up and come forward with the facts. The steps that are usually followed to assess the cause of erectile dysfunction include:

  1. Administration of Phosphodiesterase inhibitors: Erections with the help of medications is an indicator that the penile tissue is capable of responding to increase in blood flow
  2. Evaluation of Sugar, Lipids and Testosterone: Biochemical parameters can be assessed to rule out come conditions leading to erectile dysfunction such as low testosterone
  3. Intracavernosal Injection of Papaverine: Assess of erections by the andrologist has a role to play in understanding the status of the corpora cavernosa or the penile spongy tissue
  4. Penile Doppler Study: Doppler study of the cavernosal arteries can help to rule out arterial insufficiency and venous leakage as the causes of erectile dysfunction. Normally the peak systolic velocity should be more than 35 cm/sec and the peak diastolic velocity should be less than 5 cm/sec.
  5. Internal Pudendal artery selective angiography
  6. Rigiscan: This is an expensive test in which the natural erections can be assessed during sleep.

Management of Erectile Dysfunction

Dr. Raman Tanwar follows a step ladder approach to management of erectile problems

  • Lifestyle Changes
    • Stop Smoking
    • Daily walk of about 30 to 60 minutes
    • Increase raw fruits and vegetables rich in anti-oxidants
    • Kegels Exercises
    • Meditation to reduce stress
  • Medical Management
    • Phosphodiesterase Inhibitors
    • Neutraceuticals
    • Testosterone replacement
  • Injection therapy – Intracavernosal Injection
    • Papaverine
    • Bimix (Papaverine with chlorpromazine)
    • Trimix (Bimix with alprostadil)
  • Shockwave therapy – ESWT
    • Only for selected cases
    • Requires atleast 6 sessions to notice an improvement
  • Penile Implant therapy

 

If you would like to know more about erectile problems please feel free to book an appointment with Dr. Raman Tanwar at +91-8383812737

Male Sexual Problems

Raman-tanwar-urologist-andrologist-best-gurgaon-gurugram-sexologist-prostate-kidney-stone-jyoti-top-urocentre-erectile-dysfunction-erection-problem

As an andrologist it is very common to get mails asking help related to a bad experience or failure to perform on the first night. Most patients are trying for sex for the first time and unfortunately many of them do not have a smooth experience. Some sexual problems are common and others are unique. Herein are the five most common sexual problem that I get a consult for:

1. Ejaculated too early – Premature Ejaculation

Most men are habitual to self-stimulation and the initial encounter with the partner makes them ejaculate at the very sight itself or the first touch. The story ends before it begins and it is a huge let down for most men on the first night. Once the refractory period starts it is difficult to induce erection too soon as there is a latency period between orgasm for majority of men. The sexual / visual stimulation is generally too strong and the event is associated with so many expectations that rapid stimulation and early ejaculation is natural. Subsequently it may get better once you are used to the stimuli. I do not advise any therapy for this but if it occurs too often, you may need some help. If the ejaculation occurs to early after penetration, thicker condoms can also help to reduce the sensitivity and avoid this sexual problem.

2. Couldn’t get hard enough – Erectile Dysfunction 

The first sexual experience is a big thing for most men and along with it comes anxiety and apprehension. There is a pressure to perform on the first night as the first impression may be the last impression. Moreover no one wants to hear how they failed on the first night. Some even fear that they may never get a second chance. This pressure leads to psychogenic erectile dysfunction and men can’t get it hard enough to penetrate. Erection is a process that involves the penis as well as the mind and if either is troubled, the results will not be upto the expectations. Usually counselling can help in such cases and an informed partner can play a big role in allaying the anxiety. The first night is not a stage to make an impression or dominate but to start working in communion. If the erectile sexual problem persists you may need some investigations and drugs to help you re-establish your confidence.

3. Painful Sex – Dyspareunia

Pain is a very common concern with many men. Mostly it results from being too rash and being too anxious leading to severe pain and injuries. Being smooth requires a lot of balance and toning of muscles that are usually never used much and thus initially minor injuries are very common. The advice is to not experiment too much on the first encounter and keep it simple and stupid but pleasurable on the first night. Many a times there are severe injuries like penile fractures that happen because things get out of control and this leads to permanent disabilities. Many men also have phimosis or constricted foreskin so that it does not go back during intercourse. This leads to severe pain and makes a supposedly pleasurable experience painful. In such situations a condom can be really helpful, but it also means that there is a need to see an andrologist.

4. Inability to penetrate 

Sex is a mutually pleasurable activity, but for many women the pleasure comes in a little late. Initial sex for most women is difficult as the intoitus is narrow and penetration is difficult leading to vaginismus. As men we cannot predict if it will happen on our first night but many couples are not able to consummate the first time. It takes more efforts and understanding on how to have an intercourse before they are successful. There are many ways to avoid this situation. The first and foremost is to avoid making the first night such a big deal. Use of lubricant and allowing the female partner to take lead are very important to avoid injuries and a painful experience. Man on top with the partner having her hands on the man’s chest to provide resistance and to guide is a good way to go and avoid bitterness on the first night.

5. Fear of pregnancy

Even if all goes well the fear of pregnancy can subsequently ruin your experience. Most young couples are not ready to have a child just yet and protection is the key factor to avoid anxiety after sex. Condoms are a key and thinner condoms provide better sexual experience for men. Combined with lubricants that are also spermicidal, the conception rates approach nullity and you can be rest assured that chances of pregnancy are cut down.  Other issues that raise alarm and exposure of semen to the vagina through fingers or breakage of the condom barrier. It is uncommon to expect pregnancy if semen touches the outer genital region but it cannot be completely nullified.

These are some of the commonest issues that men face on the first night or the first sexual encounter, but of course there are many new fears that can come up and disturb the special moments. If you have any such queries please feel free to mail us your feedback and queries.

Bladder Stone

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Stones may form inside the bladder or get deposited in the bladder and grow to enormous sizes. Many times they may lead to symptoms like difficulty in passing urine, blood in urine, pain in the lower abdomen, retention of urine and severe burning in passing urine. Bladder Stone or Vesical calculus needs to be managed essentially by surgery. This surgery is done either without any cut or with a very small cut and is the most effective way of management of these stones.

How do bladder stones form ?

Bladder stones may form in two ways. Most commonly the stones form in the kidney and pass from the ureter or the urine pipe of the kidney into the urinary bladder. In the bladder these stones grow and become large enough to cause an obstruction to the flow of urine thereby producing symptoms. Stones can also start to develop in the bladder because of severe obstruction or blockage in the flow of urine. This can happen because of an enlarged prostate, contracture of the bladder neck or a stricture in the urethra.

What are the symptoms of Bladder Stone ?

Bladder stones can cause the following symptoms:

  • Pain in the lower abdomen
  • Straining to pass urine
  • Recurrent urge to pass urine
  • Increase in frequency
  • Getting up many times in the night to pass urine
  • Blood in urine
  • Pain or burning while passing urine
  • Difficulty in emptying the bladder completely
  • Feeling of incomplete emptying of the bladder
  • Retention of urine

How are Bladder stones treated ?

Very small bladder stones of less than 10mm may be treated with medicines that open the urethral passage and dissolve the stone. However larger stones need to be removed by surgery. There are various surgeries available for management of Bladder Stones. These include the minimally invasive Cystolithotripsy, the small incision Percutaneous Cystolithotripsy and the conventional Cystolithotripsy.

Cystolithotripsy Percutaneous Cystolithotripsy Cystolithotomy
Applicable for Stones upto 2 cm Applicable for stones up to 4 cms Can be done for stones of any size
Duration of surgery is 1 hour Duration of Surgery is 30 minutes to 3 hours depending size of stone Duration of surgery is 1 hours irrespective of size of the stone
No cut or incision is made 1 cm cut or incision is made over the lowerlower abdomen 4-10 cm incision is made in the lower abdomen depending on size of stone
Stone is extracted in pieces Stone is extracted in large pieces Entire stone is extracted in toto
Recovery time is 24 hours Recovery time is 48 hours Recovery time is 48 hours
Catheter is kept after surgery for 24 hours Catheter is kept after surgery for 7 to 10 days Catheter is kept after surgery for 10-14 days
Minimal Complications like mild hematuria Mild complications like hematuria and infection

What are the complications of surgery for bladder stones ?

Bladder stone surgery can be associated with complications like:

  • Persistent Hematuria or bleeding in urine
  • Infection
  • Urethral Stricture or narrowing of the urine pipe
  • Bladder rupture
  • Vesico cutaneous fistula

The complications are very rare and can be managed with medication or further surgery.

How to prevent recurrence of bladder stones?

There are many cases who undergo surgery for the bladder stones but the main reason behind the stones is never addressed. Stones form in an obstructed system and it is important to assess where the obstruction is. Usually patients have an enlarged prostate or a urethral stricture which can be managed along with removal of the bladder stone.

Bladder Cancer

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Bladder is a hollow organ in the body that stores urine and helps in passing it out. The bladder is situated in the lower abdomen and is connected with the kidneys by the means of the two ureters. The floor of the bladder contains the urethral opening and it is through the urethra that the urine is discharged. The bladder has three main layers, the first layer being the epithelium or the Urothelium. Below this lining is the muscular layer which contains the detrusor muscle which contracts to flush out urine. The last layer of the bladder is the adventitia which is closely associated with the perivesical fat. You can read more about the bladders anatomy in the Anatomy of the Urinary Tract Section. Bladder cancer arises from the epithelium or urothelium.

Bladder cancer is a condition characterized by presence of blood in urine which is characteristically not associated with any pain (Painless hematuria). Bladder cancer related risk factors include smoking, exposure to dyes and certain chemicals and various genetic and racial factors. Bladder cancer can affect individuals above the age of 35 years and is the leading cause of painless gross hematuria or blood in urine above the age of 50 years.

Bladder cancer can arise from various layers of the bladder but the most common variety is the one which arises from the mucosa of the bladder which is also called the urothelium. Such a tumor is called as urothelial cancer. Cancers arising from other layers are different and could be rhabdomyosarcomas (Arising from the muscle layer), Adenocarcinomas (Arising from the urachal remnants), Fibromyosarcoma, Squamous cell carcinomas (Arising from metaplastic epithelium) etc.

Once the bladder cancer arises from the surface of the bladder wall (called epithelium) it begins to invade into the deeper layers as well as the lumen of the bladder in order to establish its blood supply. As the cancer progresses the tumor keeps invading until it either involves the entire wall of the bladder or gains access to the main vessels and travels into various parts of the body. Most commonly the bladder cancer cells metastasize or make home in the lungs, liver and brain. The cancer also spreads to the lymph nodes surrounding the bladder.

As the cancer grows more and more, it becomes difficult to eradicate the cancer completely and the chances of cure as well as years of survival reduce. There are many factors which govern survival in a patient with bladder cancer including:

  • Size of the tumor
  • Grade of the Tumor (Which reflects how mature the tumor is)
  • Level of Invasion of the tumor into the various layers of the bladder
  • Involvement of Lymph nodes
  • Involvement of any distant organs via the bloodstream

Based on these factors Dr. Raman Tanwar decides the further course of management of the cancer and explains the pros and cons of various available treatment modalities. The various questions that need to be answered to manage bladder cancer include:

  • Duration of bleeding
  • Association with pain
  • History of recurrence
  • Presence of symptoms indicating involvement of adjacent organs
  • Presence of risk factors for bladder cancer
  • Size of the tumor
  • Extent of tumor involvement
  • Systemic Symptoms like loss of appetite and weight
  • Extent of tumor on examination

Treatment of Bladder cancer depends on the location and size of the tumor. The size and location can be ascertained by the following tests:

  • Ultrasonography of the abdomen and pelvis
  • Contrast enhanced CT scan of the abdomen and Pelvis
  • Cystoscopy

Tumors that are superficial and less than 3 cms can be directly removed using a scarless procedure called transurethral resection of the Bladder Tumor (TURBT). Tumors more than 3 cms can also be removed by this procedure but not completely. Many times a simple piece of the tumor may be taken and sent for analysis to confirm the cancer. Once the tumor has been completely removed using endoscopy, the patient need to follow up for prevention of recurrence of the tumor. During the follow up, patient is given immunotherapy to reduce the chances of recurrence and regular cystoscopy is performed for early detection. Know more about the follow up protocol for bladder tumor patients.

Tumors which cannot be removed with endoscopic surgery or those that have spread to deeper layers of the bladder are managed with removal of the urinary bladder itself. This surgery is called radical cystectomy. The passage of urine is then reconstructed using the intestines. Dr. Raman Tanwar discussed the options of reconstruction with the patient and the family before taking the final decision.

Many times the tumor spreads beyond the bladder and is then best managed with radiation and chemotherapy. The spread of the tumor is assessed with imaging tools such as CT scan or a PET scan. The team of associated best manages these cases under supervision of Dr. Raman Tanwar.

Bed Wetting

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Bedwetting is defined as the involuntary passage of urine while asleep.

Bedwetting is a very common urinary problem in children. Some children will continue bedwetting upto the age of 6 years. However subsequently, many of children are able to achieve good bladder control by the age of 15 years. About 15% children wet the bed at the age of 5 years but by the age of 15 only 1% of the children continue to wet the bed.

The ideal age to see a urologist if the problem of bedwetting continues is above 5 years as there may be underlying urological issues that may cause subtle damage to the urinary system if not managed in time. In most patients the problem of bedwetting is more of a functional problem than a disease.

Here are some important questions that Dr. Raman will be interested to know about the condition:

  1. How many times does the child wet the bed at night ?
  2. How many nights in a week does the child wet the bed ?
  3. Is there a particular time when this bedwetting occurs ?
  4. What is the normal voiding pattern of the child ?
  5. Are there associated bowel complaints as well ?
  6. Are there any associated symptoms or abnormalities that the child may have ?
  7. Is is primary or secondary nocturnal enuresis ?

Bedwetting or nocturnal enuresis is of two main types. Primary Nocturnal enuresis is a condition in which the child never achieves control over urine while in secondary nocturnal enuresis there is a period wherein the child does not wet the bed for at least six months and subsequently starts to wet the bed again. The two conditions are different and managed differently

Nocturnal Enuresis can occur due to problems at various levels.

  1. Brain – Cerebral Palsy, Down’s Syndrome, Developmental Delay, Drugs, Stress, Sleep Apnea etc
  2. Spinal Cord and Nerves – Neuropathy, Spina Bifida etc.
  3. Bladder and Bladder Outlet – Neurogenic Bladder, Dyssynergia of the sphincter, Posterior Urethral Valves etc.

It is essential that the pathology be ruled out if any to prevent further damage to the urinary system. In most cases there is a functional disturbance which needs to be corrected.

The following steps can be taken for cure:

  • Investigations
    • Urine Routine and Microscopy Examination: To rule out infections, renal damage, stones and other pathologies
    • Urine Culture: To detect and manage infections
    • Ultrasound of the Abdomen and Pelvis: To screen the urinary system and adjoining structures for any abnormalities, assess the bladder wall and post void residual urine
    • Routine Blood Workup: Includes Hemogram, Kidney Function Tests and other special blood tests
    • Uroflowmetry: Helps to assess the stream of urine and pattern of void
    • Urodynamic Study: Can give a good idea about bladder pressures and overactivity
    • Micturating Cystourethrogram: A dye is filled in the bladder and can help to delineate the bladder, assess its capacity, rule out reflux or posterior urethral obstruction and when combined with the retrograde urethrogram, it can help assess the entire urethra
  • Behavioral Therapies
    • Wake up the child at night
    • Reward the child for keeping dry
    • Reward for Voiding before going to bed
    • Improve access to toilet at night
    • If child wakes up encourage voiding before going back to sleep
    • Avoid fluids 3 to 4 hours prior to going to bed
  • Alarm Therapy: A bedwetting alarm is a great way to cure nocturnal enuresis. We have the resources at our disposal to procure and train you for using bedwetting alarms. These alarms sense the leakage of urine and help the child wakeup. It conditions the mind to subsequently wake up to pass urine when there is an urge. Vibration watches are also available that can act as reminders for children to go and pass urine.
  • Drug Therapy: Drug therapy is also an effective way to manage nocturnal enuresis. Drugs can cause side effects like constipation and dry mouth and sometimes stopping the therapy prematurely can lead to recurrence of the symptoms.

Steps of management include:

  • Correct parental response
  • Behavioural Modification
  • Establish Cause
  • Maintain normal voiding pattern