Richard Berger

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More successful methods of vasectomy reversal would benefit those undergoing this treatment and might also increase the popularity of vasectomy. We conducted a randomized, prospective clinical trial of vasectomy reversal methods, comparing a new absorbable stent with 2-layer reattachment.We studied 116 men seeking vasectomy reversal between November 1990 and March 1994. Data were analyzed primarily by intention to treat.Patients in the stent (64 cases) and no stent (52) randomized groups were similar in age distribution, age of spouses, years since vasectomy, proportion who had undergone prior vasectomy reversal and proportion who had previously achieved pregnancy. Operation time was more than 19 minutes shorter in the stent randomized group (p = 0.006). Fewer patients in the stent than the no stent group had patent vasovasostomies (81.0 versus 89.6%, respectively, p = 0.2) postoperatively. Fewer stent randomized patients had motile sperm (76.2 versus 81.3%, respectively, p = 0.5) and normal total motile sperm counts (49.2 versus 52.1%, respectively, p = 0.8) than did those without a stent. Conception occurred in 22 and 51% of all couples in the stent and no stent groups. The relative risk of conception among those in the stent group was 0.42 (95% confidence interval 0.24 to 0.71, p = 0.002). A Mantel-Cox log-rank test comparing pregnancies in each group according to the number of postoperative months revealed that the no stent group achieved more earlier pregnancies (p = 0.003).The 2-layer microscopic vasovasostomy results in greater pregnancy rates than vasovasostomy using the absorbable stent.

Background: Nonbacterial prostatitis is a syndrome characterized by persistent pelvic area pain in men with or without voiding symptoms. Its causes are poorly understood, and evidence-based treatments are lacking. Although psychological stress has been proposed as an etiological factor, the literature lacks prospective studies using standardized measures to examine associations between stress and male pelvic pain problems over time.Purpose: This study examined whether perceived stress was associated longitudinally with pain intensity and pain-related disability in a sample of men with nonbacterial prostatitis/pelvic pain.Methods: Men (N = 224) completed measures of perceived stress, pain intensity, and pain-related disability 1 month after a health care visit with a new nonbacterial prostatitis/pelvic pain diagnosis and 3, 6, and 12 months later.Results: Greater perceived stress during the 6 months after the health care visit was associated with greater pain intensity (p = .03) and disability (p = .003) at 12 months, even after controlling for age, symptom duration, and pain and disability during the first 6 months.Conclusions: These findings support further research into the associations between stress and male pelvic pain syndromes, as well as the assessment of stress in the evaluation of patients with pelvic pain.

Thirty-two men with abnormal (less than or equal to 11% penetration) Sperm Penetration (hamster ova) Assay (SPA) results were treated with doxycycline and reevaluated by SPA and seminal fluid analysis. Eighteen of the 32 infertile men with initially abnormal SPAs had normal SPAs (greater than or equal to 15% egg penetration) after treatment. None of 30 untreated infertile men with abnormal SPAs had a normal SPA on repeat testing (P less than 0.001). Improvement in SPA results was associated with a decrease in the number of leukocytes/ml in seminal fluid. Seven of the wives of the treated men conceived, while none of the wives of the untreated infertile men conceived during comparable intervals of time.

Physicians and psychologists almost always treat premature emission or ejaculation as a psychological problem. We report on 6 men who had sudden onset of severe premature emission after spinal cord injury. All men suffered spinal cord injury related to trauma at the T12-L1 level, and had areflexic bladders after the injury. Two men had normal penile sensation. None of the men had premature ejaculation before injury with average time of intercourse of 10 to 20 minutes before organsm. After the injury they noticed emission before or at vaginal entry. Two patients reported emission with any sexual thoughts and 1 had emission when started in a nonsexual manner. Sexual therapy using squeeze and stop/start techniques was unsuccessful in all cases. Patients were started on phenoxybenzamine, terazosin or prazosin and reported slight improvement. We believe that injury in the conus area of the spinal cord may disinhibit the ejaculatory mechanism and allow for premature emission.

Male chronic pelvic pain syndrome (CPPS) is a chronic and debilitating symptom complex, and inconsistent outcomes of antibiotic and anti-inflammatory treatments have created an interest in investigating the neurological mechanisms of CPPS pain. Because chronic pelvic pain likely results in hyperexcitability of dorsal horn neurons, ie central sensitization, thermal algometry may be useful in the assessment of CPPS. We evaluated men with and without CPPS to determine if there were differences between the 2 groups in their responses to noxious heat stimuli.We recruited 66 healthy men without CPPS and 36 men with a history of CPPS for the study. Mean age of CPPS subjects was 43.1 years (range 18 to 62) and mean age of controls was 35.1 (range 21 to 61). All subjects with pain completed a National Institutes of Health-Chronic Prostatitis Symptom Index. We conducted thermal sensory tests with a small thermode programmed to deliver 2 series of 4 rapid bursts of noxious heat stimuli to the perineum and the anterior thigh. The subjects reported sensation on a computerized visual analog scale (COVAS) with a manual sliding lever. The average peak COVAS values and time to peak values from thigh and perineum of each series of thermal bursts were compared between CPPS and controls.The mean pain score on questionnaires was 9.7 (4 or greater indicating significant pain), mean urinary score was 4.7 (range 0 to 10) and mean quality of life impact score was 7.3 (range 3 to 13). Compared to controls men with CPPS reported higher mean peak COVAS values in the perineum. There was no difference between groups in the peak COVAS value on the thigh.Men with CPPS have altered heat sensation/pain sensitization in the perineum compared to controls. This finding is another that supports the resemblance of CPPS to other chronic pain syndromes and may help explain why CPPS is often refractory to treatment. Further investigations into male CPPS should focus on the mechanisms inducing and maintaining pain in an effort to treat this condition effectively.

We assessed symptoms and health related quality of life in men who received prostatitis-prostatodynia diagnoses at primary care and urology visits, and compared those in whom pain-discomfort had versus had not resolved approximately 1 month later.Telephone interviews were done with 357 men an average of 1 month after a prostatitis-prostatodynia diagnosis was made at a health maintenance organization visit. The interview included the National Institutes of Health Chronic Prostatitis Symptom Index, and pain and health related quality of life measures.The most common pain location was the pubic-bladder area. Mean scores on most health related quality of life measures were below average, and higher pelvic pain and urinary symptom scores were associated with worse quality of life. This episode of pelvic pain was the first lifetime episode in fewer urology (22%) than primary care (38%) patients (p = 0.02). Urology patients had longer symptom episodes (p = 0.000), more days with pain in the last month (p = 0.002) and higher National Institutes of Health Chronic Prostatitis Symptom Index pain scores (p = 0.002). Men with pain in the testicles, penis or between the rectum and testicles at the visit, and with longer symptom duration before the visit were significantly more likely to have continued pain between the visit and interview.Pelvic pain is often a persistent, recurrent condition that can have a significant negative impact on quality of life. The average symptom severity in men with pelvic pain in primary care and urology settings is lower than that in tertiary care samples.

Men with chronic pelvic pain syndrome (CPPS) type III experience pelvic pain of uncertain etiology. Pain has been attributed to prostatic, bladder and muscular origins. Few studies have documented pelvic and abdominal muscle function in men with CPPS or compared their muscular examination to that of men without pain. We hypothesized that the musculoskeletal examinations of men with CPPS types IIIA and IIIB would show more spasm, tenderness and dysfunction than in men without CPPS. A total of 62 men with CPPS and 89 healthy men without pelvic pain underwent a standardized musculoskeletal examination by a licensed physical therapist. Controls and patients with pain showed a significant difference in muscle spasm, increased muscle tone, pain with internal transrectal palpation of the pelvic muscles, and increased tension and pain with palpation of the levator ani and coccygeus muscles (p <0.001). Patients with pain also had significantly greater pain and tension with palpation of the psoas muscles and groin. Patients and controls did not differ significantly in strength testing of the lower abdominal and oblique muscles. Men with CPPS have more abnormal pelvic floor muscular findings compared with a group of men without pain. Abnormalities of the pelvic muscles may contribute to this pain syndrome.

An assumption exists that men with older female partners who seek treatment of post-vasectomy infertility should undergo in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) rather than vasectomy reversal. Although several studies have reviewed ICSI success rates with advancing maternal age, to our knowledge none has compared them to outcomes for vasectomy reversal in men with older partners.The records of all patients with ovulating partners older than 37 years who underwent vasectomy reversal from 1994 through 1998 were reviewed. Patients were contacted to establish pregnancy and birth rates. Costs of vasectomy reversal, testicular sperm extraction, IVF and ICSI were obtained from the financial office of our institution.A total of 29 patients underwent vasectomy reversal with a followup of 3 to 59 months (median 25). Median male age was 46 years (range 37 to 67) and median female age was 40 years (range 38 to 48). A total of 5 pregnancies and 4 live births were achieved. In the 23 patients followed for more than 1 year the pregnancy rate was 22% and live birth rate was 17%. Using this 17% birth rate at our $4,850 cost for vasectomy reversal the cost per newborn was $28,530. In comparison, using the 8% birth rate per cycle of ICSI for women older than 36 years at a cost of $8,315 for testicular sperm extraction and 1 cycle of IVF with ICSI, the cost per newborn was estimated at $103,940.Vasectomy reversal appears to be cost-effective to achieve fertility in men with ovulating partners older than 37 years.

Two cases of post-traumatic high-flow priapism after blunt trauma to the penis are presented. Diagnosis of high-flow priapism was accomplished with the use of both color-flow Doppler ultrasound and arteriography, which demonstrated arteriocorporal fistulas. In each patient, angiographic embolization was attempted but abandoned because the distal artery feeding the fistula could not be safely catheterized. Both patients were definitively treated with surgical ligation of the arteriovenous fistula, guided by intraoperative ultrasound. Operative management with arterial ligation provides a safe, selective, and effective alternative treatment to embolization. Two surgical approaches are discussed, one extracorporal and the other transcorporal. We believe that although transcorporal dissection poses increased risks, it is appropriate for arterial priapism of prolonged duration, especially if a well-formed vascular pseudocapsule is identified.

Idiopathic prostatitis is a common, often chronic condition in which psychological factors are suspected to play a role. Men with chronic prostatitis (n = 51) and a control group of 34 men without any chronic pain condition, equivalent on demographic characteristics, were compared on psychological and perineal muscle tension measures. Prostate-specific antigen and expressed prostatic secretion cell counts were also measured. Chronic prostatitis patients were consistently more elevated than controls on hypochondriasis, depression, and hysteria (MMPI), and on somaticization and depression (Brief Symptom Inventory), and were less elevated on masculine/instrumentality (Personal Attributes Questionnaire) scales. A cluster analysis of MMPI profiles revealed that 57% of the chronic prostatitis patients produced generally unelevated MMPI profiles, whereas the remaining 43% fell into two groups with distinct patterns of distress. The results indicate depression and psychosocial distress are common among chronic prostatitis patients, calling for careful evaluation and attention to psychological symptoms.

Because of its implications for possible therapy, the ability to establish a diagnosis of erectile dysfunction (ED) solely on the basis of history and physical examination has been a matter of controversy. The determination of the etiology of ED based on history and physical examination is evaluated in this present study.Consecutive patients presenting for evaluation of ED were evaluated by careful history, physical examination, psychologic evaluation, and RigiScan monitoring. They were then stratified into either organic or psychogenic groups based on each of these modalities. These diagnoses were then compared to a final diagnosis obtained through additional testing.History and physical examination had a 95% sensitivity but only a 50% specificity in diagnosing organic ED. The accuracy rates of history and physical examination in diagnosing ED were 80% and 60%, respectively.A multifaceted comprehensive approach is required to evaluate fully and to diagnose ED.

Peyronie's disease is a poorly understood scarring condition of the tunica albuginea that often causes pain and deformity of the penis. When Peyronie's disease is present predominantly unilaterally, bending of the penis to 1 side occurs. With bilateral or circumferential disease the tunica albuginea does not expand, and penile shortening and/or narrowing occurs. We performed unilateral or bilateral penile lengthening procedures on 22 patients with penile shortening due to Peyronie's disease who refused a procedure, such as tucks or the Nesbit operation, that might result in further penile shortening. Five men underwent incision of the plaque and dermal patch without implantation of a penile prosthesis, while 8 underwent penile implantation plus incisions in the tunica albuginea without patches, and 5 underwent circumferential incision of the tunica albuginea and its septum with patching and placement of a penile implant. (Average length gain with circumferential incision was 1.5 inches with this procedure.) There were 18 patients available for followup: 1 had penile skin slough secondary to a compression dressing, 2 required removal of the implant and replacement at a later date, and 2 had progressive penile shortening after dermal patch requiring subsequent prosthesis implantation. Penile lengthening procedures to correct functionally significant penile shortening can be performed successfully, although significant complications were experienced.

The chronic prostatitis/chronic pelvic pain syndrome is a common clinical syndrome characterized by lower genitourinary tract symptoms, particularly pain in the perineum or genitalia, voiding symptoms, such as dysuria or frequency, and sexual dysfunction in the absence of uropathogens in the urine or prostatic secretions. The term prostatitis is based on the presumption that prostatic inflammation is important in the pathophysiology of this syndrome. To our knowledge there has been no systematic characterization of the degree and nature of inflammation in the prostate in symptomatic cases.Prostate histopathology in 368 biopsies from 97 patients with the chronic prostatitis/chronic pelvic pain syndrome was characterized.Prostatic inflammation was detected in only 33% of patients, including 29% with mild (less than 10 leukocytes per 1 mm. field) and 4% with moderate (between 10 and 200) or severe (more than 200) infiltrate. Of the 3 patients with moderate inflammation 1 had glandular, 1 periglandular and 3 multifocal or diffuse distribution of leukocytes in the interstitium. Some patients had more than 1 pattern of inflammation.The finding of moderate or severe inflammation in only 5% of 97 patients argues for the need to reevaluate current concepts of the pathophysiology of the chronic prostatitis/chronic pelvic pain syndrome.

... Richard E. Berger, MD, E. Russell Alexander, MD, George D. Monda, MD, Julian Ansell, MD, Gerald McCormick, DO, and King K ... Prostatic secretions, semen and one drop of epididymal aspirate were also inoculated onto chocolate agar containing 1 per cent Isovitalex but ...

Although antibiotics represent the first line of treatment for prostatitis syndromes, physicians can document infection in remarkably few cases. We examined the relationship of genitourinary infection to inflammatory prostatitis in 85 subjects without bacteriuria. Evaluation consisted of cultures of urethra, urine and transperineal prostate biopsies, specifically for commensal and fastidious organisms, and leukocyte counts of expressed prostatic secretions. Men with inflamed expressed prostatic secretions (25) were more likely to have any bacterial isolation (p = 0.01), positive cultures for anaerobic bacteria (p = 0.03), higher total bacterial counts (p = 0.02) and more bacteria, species isolated (p = 0.02) in prostate biopsy cultures than men without expressed prostatic secretion inflammation (60). Bacterial colonization/invasion of the prostate may be associated with inflammatory prostatitis in some cases.

There is evidence that many patients experiencing chronic idiopathic prostatitis or prostadynia not only have recurrent physical symptoms but also display a range of psychological symptoms, such as depression or anxiety, suggesting that the symptoms of chronic prostatitis may seriously impact on quality of life functioning. We investigated the degree of sickness impact of chronic prostatitis, and the differential importance of physical and psychological symptoms in predicting sickness impact. The sickness impact profile as well as several symptom measures were administered to 39 patients with chronic prostatitis. Multiple regression analyses were performed to evaluate what proportion of the variance in quality of life or functional status was explained by physical and psychological symptoms. The sickness impact profile mean total score of chronic prostatitis patients was within the range of scores reported in the literature for patients suffering myocardial infarction, angina or Crohn's disease. Pain was the only physical symptom that significantly contributed towards explaining variance in sickness impact. Psychological symptoms added significantly to the amount of predicted variance. The results indicate a need for careful evaluation and attention to sickness related dysfunctions in patients with chronic prostatitis.