Introduction

Since the 1990s, when medicine started to be involved more in erectile dysfunction, a lot of things happened in the field of andrology. After more than 20 years andrology has passed all its “childish” diseases and can now look the modern man into the eyes. Andrology can now understand his problems and be able to reliably recognize the causes of his problems, while offering effective solutions. Whether it is a symptom of an underlying disease (e.g. diabetes mellitus), or a disease with specific characteristics, erectile dysfunction has now a clear pathophysiological causative mechanism, clear characteristics and evolution, a clear diagnostic test, always based on and in accordance with the latest scientific data. In this way, we are now in a position to set clear therapeutic goals and offer effective solutions.

Whether its vascular, neurological, hormonal, or pharmaceutical etiology, erectile dysfunction always ends up being a pathological condition of dysfunction of the endothelium, the basic anatomical structure that finally make the erection happen. Erectile dysfunction may be due to a decreased blood supply to the cavernous bodies (arterial insufficiency), an inability to retain blood inside the cavernous bodies (venous escape), or a combination of the above. The causes may be:

Arterial hypertension, atheromatosis of the vessels, damage to the vessels that supply the penis and heart problems. It is even thought that erectile dysfunction is a precursor symptom, i.e. it occurs earlier, of coronary artery disease and a possible myocardial infarction.

The function of the penis is controlled by the autonomic nervous system. Any cause, disease or medication that affects the function of this system, is likely to lead to erectile dysfunction. Such causes may be multiple sclerosis, Parkinson’s disease, Alzheimer’s, diabetic neuropathy, spinal injuries e.g. from road accidents and the use of neuroleptic drugs (anxiolytics, sedatives, sleeping pills, etc.).

The entire sexual cycle (desire, arousal, erection, ejaculation, orgasm) is under total control of sexual hormones. Testosterone, prolactin and thyroid hormones play an important role in erectile function. Low testosterone that the body can use (bioavailable testosterone) may lead to erectile dysfunction, low desire or ejaculation, orgasm, fertility and systemic metabolic disorders. This happens whether due to dysfunction of the respective organs, testicles, thyroid gland, adrenal glands and liver, or due to a central disturbance of their production at the central nervous system level. This decrease in testosterone levels may also be due to increasing age (andropause).

This systemic disorder of the body is characterized by disorders of cholesterol, lipids, glucose metabolism (diabetes mellitus) hypertension and abdominal obesity. Metabolic syndrome is one of the most important risk factors for the occurrence of erectile dysfunction in modern men, as it is combined not only with medical factors, but also characteristics of the modern lifestyle e.g. sedentary lifestyle and lack of exercise. It looks like that the center of metabolic syndrome is testosterone deficiency again.

Antihypertensives, statins, neuroleptics, antidepressants, antiretrovirals, anticancer drugs are drugs that may in one way or another cause the appearance of erectile dysfunction. However, since most of them are medicines that are often absolutely necessary for the health and survival of the man, they must be regulated with the agreement and cooperation of the respective doctor and by the andrologist.

Special reference should be made to the use of anabolic drugs (whatever the recovery), which has a high probability of causing the appearance of erectile dysfunction, serious fertility disorders and the appearance of cancer.

Many surgeries, several of which are very common, are likely to lead to erectile dysfunction, often irreversible, even after the application of preventive protective protocols or after the implementation of rehabilitation strategies. For example, radical prostatectomy (removal of the prostate due to malignancy) and other pelvic surgeries (e.g. for colon cancer) have a strong chance of developing erectile disorder.

Special reference should be made to the relationship between erectile dysfunction and diabetes mellitus. However, it should be clear that it is not necessary for a man with diabetes mellitus to develop an erectile disorder. This depends on the levels of regulation of diabetes, on the existence of additional health problems, on the type of drugs used, on the existence of sexual desire and sexual partner. It is true that diabetes mellitus can potentially cause damage to the body’s vessels and nerves, testosterone disorders, disorders in the anatomy of the penis (e.g. Peyronie’s disease) and an intense psychological burden, due to the long course of the disease.

Last in line, but not last in importance, is stress. Stress is a normal state of homeostasis of the body, a way of defending and adapting to stressful stimuli. When this exceeds certain levels or when the way the man treats it is disturbed, a system called stress system is activated. The international medical community is now unanimous in agreeing that this is a powerful predictor of erectile dysfunction, even causing irreversible histological damage to a variety of organs, including the penis.

The basic diagnostic test includes:
• Medical and sexual history. How, when and under what circumstances did the problem occur?
• Clinical examination, especially of the genitals, chest and prostate.
• Dynamic penis ultrasound (triplex) with a provoked erection.
• Hormonal control of bioavailable testosterone and prolactin. It is a simple, painless and fast laboratory test that can identify the cause for the greatest rate of erectile dysfunction in a man.

Where appropriate and depending on the medical history or findings from the previous check-up, additional examinations may be deemed necessary. Such examinations can be: imaging and biochemical check of the prostate, cardiological evaluation and heart ultrasound, imaging control of large vessels and triplex of vessels of the lower extremities and special endocrinological evaluation.

Treatment options may be:

Oral medication:
Phosphodiesterase inhibitors are currently an excellent choice for the treatment of erectile dysfunction. However, the method of administration (daily or on demand), their combination with other medicines, the time window of administration and their side effects require deep knowledge, experience and attention from the prescriber doctor. The use of this medication is generally safe. However, they may not be used by patients taking nitrite drugs for heart problems and should be used in patients with recent cardiovascular events under medical supervision.

Penile injections:
This therapeutic approach, although highly criticised, is undoubtedly a powerful and effective therapeutic tool in the treatment of erectile dysfunction. Although very often referred to as a second-line therapeutic means, they are sometimes the first treatment given to men e.g. after radical prostatectomy for prostate cancer or when the man is faced with extremely high levels of anxiety, which have the most negative effect on the mechanism of erection, with very low rates of side effects. The patient is trained to do them on his own, thus ensuring spontaneity in his love life which in the past was the main inhibitor for their use. Although their main side effect, prolonged erection, which is not accompanied by erotic desire, is rare (<1.2%), we should take it always under consideration especially in patients with hematological disorders or anatomical penile disorders (e.g. Peyronie’s disease). The frequent and long-term use of penile injections can lead (rarely nevertheless) to fibrosis of the penile cavernous bodies.

Shockwaves therapy:
This method (LiST, Low-intensity Shockwave Therapy) is the newest in the treatment of erectile dysfunction. This technique is based on the theory of neoangiogenesis, according to which the transmission of energy in the form of shock waves, leads to the activation of a mechanism, for the release of growth factors and the creation of new vessels, for the treatment of the root cause of the problem. This technique has been used successfully for several years in cardiac surgery, while in andrology it has found its way over the last 4-5 years with great success, always to specific and selected patients for whom there are appropriate indications, as in any medical practice. Data and clinical experience have shown that shock waves are able to significantly improve erectile dysfunction, have encouraging results after operations that have affected erection and may create the conditions for a man to be treated with oral medication again. The treatment of shock waves is cumulative, while at the same time it has a long-lasting effect.

Surgical treatment:
Surgical treatment of erectile dysfunction has been the final solution to the problem of erectile dysfunction, and is often the only solution in patients who cannot or do not want to take medication. Τhe surgical techniques are two:
Insertion of penile prosthesis: In the surgery of the penile prosthesis, two cylinders of special synthetic material are placed inside the cavernous bodies (cylinders filled with blood during normal erection). These cylinders can be semi-rigid, in which case the erection is advanced by manually changing the position of the penis. Otherwise, the use of cylinders filled with liquid can be chosen, with the help of a pump placed on the scrotum, behind the testicles. In the second case, the image of the penis in erection and flaccid state, simulates very much the normal form and function. Ejaculation and orgasm remain unchanged if not improved, as many patients achieve better control of their ejaculation. The insertion of the device is carried out with day surgery and the patient leaves the hospital on the same day or at the latest the next day in the morning.

Penile vascular surgery:
Whatever treatment will be applied, the goal remains the same: the return of the man to the situation he was in before the onset of the problem, always with respect to his expectations, his desires, without the addition of additional stress. The choice should always be individualized and should only concern the man and the partner.
Penile vascular surgery is one of the last weapons in the treatment of erectile dysfunction. In this case, either the blood supply to the penis is increased through the placement of a stent in the vessels of the organ, or the veno-occlusive mechanism is surgically corrected.

Introduction

Male subfertility may be due to sperm production and transfer problems. Causatively, a variety of factors are capable of affecting a man’s fertility ability

Endocrinological diseases that may cause infertility include hypothalamus-pituitary axis disorders, thyroid gland disorders and adrenal disorders. Even if the levels of the hormones tested are normal, in rare situations there is the possibility of non-sensitivity syndromes to androgens (AIS-Androgen Insensitivity Syndromes).

In the testicles, under the influence of testosterone, sperm cells are produced and matured. Any damage to the testicles, whether primary, or acquired, is likely to greatly affect spermatogenesis. A thorough evaluation of medical history is able to highlight conditions that may be related to a testicular lesion (cryptorchidism, drug taking, mumps, etc.). At the same time, the clinical examination and ultrasound will complete the diagnostic test, looking for possible inflammations, structural abnormalities or neoplasms. In cases where the cause of sperm absence is attributed to the non-production of these by the testicles, we refer to non-obstructive azoospermia.

After production, the spermatozoa are transferred to the epididymis, where their maturation is completed. Together with fluid from the seminal cysts and from the prostate gland, they constitute the product of ejaculation (sperm). Various congenital diseases resulting in abnormalities or obstruction of the efferent system can cause problems in the route of transport of sperm. More often, conditions such as inflammations and infections, as well as postoperative conditions result in effective spermatogenesis, but ineffective transfer of sperm. In these cases, the absence of spermatozoa in the sperm chart is referred to as obstructive azoospermia.
In the category of sperm transfer disorders, there are also situations in which sperm regresses to the bladder instead of being pushed into the urethra (taking medications, transurethral procedures), but also situations in which normal extrusion is inhibited (urethral stenoses, hypospadias).

We know today that infections by microorganisms are one of the most common causes of an affected sperm chart. This becomes more important, because urinary tract infection may not show symptoms in men. At the same time, conventional tests, such as simple urine culture, are not sufficient in diagnosing the infection. Proper guidance to the specialized tests required to detect microbes that have been shown to affect the parameters of a spermogram and to receive appropriate treatment is an important step towards the desired result.
Rarely, antisperm antibodies (ASA-Anti- Sperm Antibodies ) are detected, which appear to be responsible for 12-13% of diagnosed cases of infertility in men. Risk factors for the development of autoantibodies include infections, trauma, immunosuppression, varicocele and neoplasms.

With the term varicocele, we refer to the helical swelling of the venous network of the testicle, which is insufficient. Usually, for anatomical reasons, varicocele appears on the left. Varicocele can cause mild symptoms (weight, discomfort), prevent normal development of the testicle and affect spermatogenesis. Varicocele has also been associated with disorders in the genetic material of spermatozoa, a condition that is reversed after its correction. In many cases, varicocele is diagnosed only by ultrasound of the scrotum (subclinical varicocele). We know that varicocele occurs in 15% of all men, which increases to 35% of infertile men. The treatment of varicocele is surgical, with the method of microsurgery being the most effective and acceptable method.

Sexual dysfunction is a clinical entity that includes erectile dysfunction and ejaculation disorders. It is therefore clear that any of the above problems can lead to infertility situations, as long as normal sexual intercourse and the deposition of sperm in the vagina are disturbed. Erection problems, sexual habits and abstinence time, premature or delayed ejaculation, are important parameters that are often not considered in the control of the infertile man.

A variety of common and relatively common systemic diseases sometimes affect a man’s fertility. Diabetes mellitus, metabolic syndrome, obesity, liver problems, renal failure and a wide range of additional clinical problems should be properly assessed to assess the severity of their effect on fertility.

This category – which nowadays is becoming more frequent – includes air pollution, radiation exposure, smoking, exposure to chemicals (organic solvents, plastics, PVC,pesticides, insecticides, food additives, defrosters, inks, colors, perfumes, photographic fluids, etc.), extensive use of medicines and persistent physical and psychological stress.
Drugs such as cimetidine, allopurinol, erythromycin, tetracycline, gentamycin and cyclosporin may cause problems with spermatogenesis. A negative impact on sperm quality and/or function has been reported to be caused by sulfasalazine (anti-inflammatory for colon inflammation) and the antibiotic nitrophurantoin.
Also, known antipsychotic drugs, such as chloropromazine, alloperidol and thioridazine, antidepressants such as amitriptyline, imipramine, fluoxetine, paroxetine, and sertraline, as well as antihypertensives such as guanethidine, prazosine, phenoxybenzamine, phenolamine and reserpine, are likely related to erectile dysfunctions.

The treatment options, contrary to what most people think, as understood by the causes that cause it, are many and different and can be the solution for the infertile couple. Although some factors can hardly be changed or sometimes not at all, as in the case of genetic abnormalities, appropriate guidance and use of medicines (antibiotics, hormonal manipulations), where appropriate, as well as antioxidants. Surgical interventions, can offer permanent, valid and effective solutions to a man with subfertility problems. At the same time, changing certain habits of everyday life can also contribute to improving sperm parameters. The close collaboration between the fertility specialist and the couple with fertility problems is able to create the best conditions for achieving a pregnancy.

Introduction

The underlying reason for the disease is actually not known. Mainly, penile injuries during sexual intercourse and fractures of the penis have been mainly implicated. Other causes could be microbial infections, autoimmune diseases (e.g. rheumatoid arthritis), diabetes mellitus, arterial hypertension, systemic vascular disease, and even some types of cancer.

The main symptom is pain during erection, bending and curvature of the penis. There is palpable hardness in a large percentage of patients suffering from Peyronie’s disease. They may also have erectile dysfunction because of psychological factors or decreased blood flow (sometimes even due to penile bending).

Diagnosis is made by the urologist – andrologist and includes a complete history of the patient. The doctor looks for injury or fracture of the penis, the duration of symptoms, sexual scripts, painful erection, reduction or enlargement of the penis and the presence or absence of concomitant diseases such as diabetes mellitus, hypertension or autoimmune diseases..

Diagnosis is made by the urologist – andrologist and includes a complete history of the patient. The doctor looks for injury or fracture of the penis, the duration of symptoms, sexual scripts, painful erection, reduction or enlargement of the penis and the presence or absence of concomitant diseases such as diabetes mellitus, hypertension or autoimmune diseases.

Clinical examination is always carried out with the penis both in the flaccid and erectile state. The patient is examined for palpable hardness in the penis, the actual curvature of the penis, as well as the existence or not of pain during erection.

Imaging methods include dynamic triplex ultrasound, as well as MRI imaging of the penis.
Peyronie’s disease usually passes through two phases::

  • The first (unstable) phase is often combined with pain during erection and stiffness of the penis.
  • The second (stable) is characterized by stabilization of the curvature and absence of painful erection.

Treatment is usually pharmaceutical. From the onset of the problem until about 6 – 12 months later, the patient usually needs treatment for his pain. This treatment involves taking orally a large dose of vitamin E or other medicine, as well. This depends on the patient’s comorbidities. In addition to oral treatment, local treatment can be applied to the penis with verapamil and cortisol iontophoresis and/or shock waves in special protocols for Peyronie’s disease. The objective of medical treatment is to stop the progression of the disease without affecting the erectile function and the curvature of the penis. In particular, for young men, protecting erectile function is very important. After the end of this period, the only therapeutic solution is surgery.

After the clinical (pain) or imaging (stable plaque size) stabilization of the disease, the treatment is only surgical. In this case, it should be stressed that surgery is about restoring the shape of the penis and not about treating the disease. There are various techniques. The chosen technique depends on the size and form of the lesion, the coexistence or not of erectile dysfunction, the degrees of the angle, the existence or not of other diseases and last, but not least by the patient’s preference.

Schematically, the techniques are practically divided into three categories:

        1. Plication techniques, Nesbit, Stage
        2. Graft techniques and geometrical correctio
        3. Techniques with simultaneous placement of penile prosthesis

In some patients, the simultaneous use of different techniques is necessary, as these surgical procedures are completely personalized.

Introduction

The scrotum is the sac in which the testicles are located. It is often overlooked as a part of the male anatomy. As time goes by, the skin loses its elasticity and firmness, causing the scrotum to hang even lower.

In other cases, even from birth, the position of the scrotum makes sitting difficult. In addition, when the sac of the scrotum starts from the body of the penis, the image of the scrotum may lead to the perception of a shorter penis. In any case, whether the problem is functional or cosmetic, scrotoplasty can give a solution. Scrotoplasty aims at the reconstruction of the scrotum sac. It includes both the clear separation of the sac from the penis, as well as the removal of excess skin. This leads to the image of a younger scrotum, with excellent aesthetic result, without scars and with immediate return to daily life.

Scrotoplasty can be performed as a single procedure, or at the same session with another reconstructive or cosmetic surgery. Thus, it is addressed to every age; whether it is a scrotum that starts in front of the lower surface of the penis (giving the impression of a short or hairy penis), or a scrotum too loose and asymmetrical to the penis. Alternatively, scrotoplasty can considerably improve the appearance of the genitals after an operation to correct penile curvature (Peyronie’s disease) or after an operation to put a penile prosthesis for erectile dysfunction. Finally, scrotoplasty combined with phalloplasty can lead to spectacular results, both in the objective gain in length, as well as in the subjective perception of a larger penis.

Scrotoplasty is basically a cosmetic procedure, which in no way affects the function of the penis or testicles or even the fertilizing capacity. It is a minimally invasive intervention. It can be carried out under sedation and guarantees an quick return home and focus on daily activity.

Introduction

The insertion of penile prosthesis is the surgical procedure which restores erection in men to whom the medication doesn’t work or in patients who cannot follow medical treatment due to medical or other conditions.

The erection starts through a pump that is behind the testicles and is not visible. The final hardness is given by the man for as long as he wishes. No part of the penile prosthesis is visible, as the whole device is implanted inside the penis.

Surgery maintains the man’s ability for spontaneous sexual intercourse. The intensity of the erection is ideal in hardness and duration which means that the man can maintain his erection for as long as he wants without the fear of losing it anymore.
The success rates of the couple’s satisfaction based on international studies range to 97%. Penile prosthesis is the therapeutic approach that restores normal erections in men to whom medication no longer works or cannot be treated due to medical or other conditions.
It is a surgery to treat erectile dysfunction in which the corpora cavernosa of the penis are strengthened with advanced plastic cylinders.

The operation is usually performed under dorsal or general anesthesia, where the two tubes of the penis are opened and dilated after a small incision at the base of the penis. Then, two elongated silicone rollers are placed. A pump is placed behind the scrotum, behind the testicles through which you transfer fluid to the tubes mentioned. In the hydraulic prosthesis the pipes are inflated giving the man a natural feeling of hardness and softness.

Sexual intercourse is forbidden for 4-6 weeks after surgery.

Introduction

Premature ejaculation affects about 1 in 5 men, which remains stable regardless of age, making it the most common sexual dysfunction in men under the age of 60. In the case of premature ejaculation, it occurs in up to 1 minute from vaginal penetration, without substantial control on the part of the man. In the cycle of sexual response, desire and arousal are very short, while escalation is rapid, resulting in frustration, anxiety, lack of satisfaction from sexual intercourse and aversion to sexual activity.

Premature ejaculation may occur from the beginning of the love life (primary or chronic), but it can also occur suddenly, whereas the man was in control of ejaculation or the time of contact was satisfactory (secondary or acquired). In the first case, we consider that the condition is due to a greater degree of neurobiological disorders, while in the second, a multitude of conditions have been associated with the problem (prostate diseases, hyperthyroidism, erectile dysfunction, anxiety, negative experiences, low self-confidence). In either case, the result is the same.

Failure to obtain satisfaction from sexual activity by both partners, performance anxiety, fear of poor control over ejaculation, anger, low self-esteem, abstinence from sexual activity, are just a few of the situations a man can experience in the context of this condition.

Delayed ejaculation, or absence of ejaculation, is an increasingly common clinical entity. In most cases the desire is present, but the stimulation is not able to escalate and result in orgasm and ejaculation. The discomfort between partners in these cases is due to the man’s attempt to have an orgasm and to the frustration of the sexual partner who feels insufficient to stimulate the sexual partner and lead him to the climax.

Specific conditions, such as hypothyroidism are able to lead to situations of delayed ejaculation or difficulty ejaculation. In addition, experiences, images and stimuli, fantasies and their association or mismatch with everyday sexual practice play a particularly important role. The ease of access to erotic content of all forms and the lack of communication between partners, can be one of the most important factors for the development of an ejaculation disorder.

In any case, seeking help from the specialized andrologist is one of the most important steps towards solving the problem. This first step is perhaps the most important, considering that the majority of men with ejaculation problems hardly share their problem, while considering that there is no solution.

In most cases, the problem occurs randomly, in the context of checking for different symptoms. The specialized andrologist is completely familiar with the discussion of sexual issues and will make you feel comfortable. After the description of the problem, taking the sexual history and carrying out the necessary diagnostic tests, we will organize together the therapeutic strategy that will be in line with the needs of each individual man.

Whether it is an underlying condition such as hypothyroidism or chronic prostatitis, self-help techniques, psychosexual therapy techniques, or medications (or a combination of the above) will be tested. The goal is always better control of ejaculation, greater self-confidence and improved sexual satisfaction.

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Introduction

Since the 1990s, when medicine started to be involved more in erectile dysfunction, a lot of things happened in the field of andrology. After more than 20 years andrology has passed all its “childish” diseases and can now look the modern man into the eyes. Andrology can now understand his problems and be able to reliably recognize the causes of his problems, while offering effective solutions. Whether it is a symptom of an underlying disease (e.g. diabetes mellitus), or a disease with specific characteristics, erectile dysfunction has now a clear pathophysiological causative mechanism, clear characteristics and evolution, a clear diagnostic test, always based on and in accordance with the latest scientific data. In this way, we are now in a position to set clear therapeutic goals and offer effective solutions.

1. ETIOLOGY

Whether its vascular, neurological, hormonal, or pharmaceutical etiology, erectile dysfunction always ends up being a pathological condition of dysfunction of the endothelium, the basic anatomical structure that finally make the erection happen. Erectile dysfunction may be due to a decreased blood supply to the cavernous bodies (arterial insufficiency), an inability to retain blood inside the cavernous bodies (venous escape), or a combination of the above. The causes may be:

VASCULAR CAUSES

Arterial hypertension, atheromatosis of the vessels, damage to the vessels that supply the penis and heart problems. It is even thought that erectile dysfunction is a precursor symptom, i.e. it occurs earlier, of coronary artery disease and a possible myocardial infarction.

NEUROLOGICAL CAUSES

The function of the penis is controlled by the autonomic nervous system. Any cause, disease or medication that affects the function of this system, is likely to lead to erectile dysfunction. Such causes may be multiple sclerosis, Parkinson’s disease, Alzheimer’s, diabetic neuropathy, spinal injuries e.g. from road accidents and the use of neuroleptic drugs (anxiolytics, sedatives, sleeping pills, etc.).

HORMONAL CAUSES

The entire sexual cycle (desire, arousal, erection, ejaculation, orgasm) is under total control of sexual hormones. Testosterone, prolactin and thyroid hormones play an important role in erectile function. Low testosterone that the body can use (bioavailable testosterone) may lead to erectile dysfunction, low desire or ejaculation, orgasm, fertility and systemic metabolic disorders. This happens whether due to dysfunction of the respective organs, testicles, thyroid gland, adrenal glands and liver, or due to a central disturbance of their production at the central nervous system level. This decrease in testosterone levels may also be due to increasing age (andropause).

METABOLIC SYNDROME

This systemic disorder of the body is characterized by disorders of cholesterol, lipids, glucose metabolism (diabetes mellitus) hypertension and abdominal obesity. Metabolic syndrome is one of the most important risk factors for the occurrence of erectile dysfunction in modern men, as it is combined not only with medical factors, but also characteristics of the modern lifestyle e.g. sedentary lifestyle and lack of exercise. It looks like that the center of metabolic syndrome is testosterone deficiency again.

MEDICATION

Antihypertensives, statins, neuroleptics, antidepressants, antiretrovirals, anticancer drugs are drugs that may in one way or another cause the appearance of erectile dysfunction. However, since most of them are medicines that are often absolutely necessary for the health and survival of the man, they must be regulated with the agreement and cooperation of the respective doctor and by the andrologist.

Special reference should be made to the use of anabolic drugs (whatever the recovery), which has a high probability of causing the appearance of erectile dysfunction, serious fertility disorders and the appearance of cancer.

SURGICAL PROCEDURES

Many surgeries, several of which are very common, are likely to lead to erectile dysfunction, often irreversible, even after the application of preventive protective protocols or after the implementation of rehabilitation strategies. For example, radical prostatectomy (removal of the prostate due to malignancy) and other pelvic surgeries (e.g. for colon cancer) have a strong chance of developing erectile disorder.

DIABETES MELLITUS

Special reference should be made to the relationship between erectile dysfunction and diabetes mellitus. However, it should be clear that it is not necessary for a man with diabetes mellitus to develop an erectile disorder. This depends on the levels of regulation of diabetes, on the existence of additional health problems, on the type of drugs used, on the existence of sexual desire and sexual partner. It is true that diabetes mellitus can potentially cause damage to the body’s vessels and nerves, testosterone disorders, disorders in the anatomy of the penis (e.g. Peyronie’s disease) and an intense psychological burden, due to the long course of the disease.

STRESS

Last in line, but not last in importance, is stress. Stress is a normal state of homeostasis of the body, a way of defending and adapting to stressful stimuli. When this exceeds certain levels or when the way the man treats it is disturbed, a system called stress system is activated. The international medical community is now unanimous in agreeing that this is a powerful predictor of erectile dysfunction, even causing irreversible histological damage to a variety of organs, including the penis.

2. DIAGNISTIC EVALUATION

The basic diagnostic test includes:
• Medical and sexual history. How, when and under what circumstances did the problem occur?
• Clinical examination, especially of the genitals, chest and prostate.
• Dynamic penis ultrasound (triplex) with a provoked erection.
• Hormonal control of bioavailable testosterone and prolactin. It is a simple, painless and fast laboratory test that can identify the cause for the greatest rate of erectile dysfunction in a man.

Where appropriate and depending on the medical history or findings from the previous check-up, additional examinations may be deemed necessary. Such examinations can be: imaging and biochemical check of the prostate, cardiological evaluation and heart ultrasound, imaging control of large vessels and triplex of vessels of the lower extremities and special endocrinological evaluation.

3. TREATMENT

Treatment options may be:

Oral medication:
Phosphodiesterase inhibitors are currently an excellent choice for the treatment of erectile dysfunction. However, the method of administration (daily or on demand), their combination with other medicines, the time window of administration and their side effects require deep knowledge, experience and attention from the prescriber doctor. The use of this medication is generally safe. However, they may not be used by patients taking nitrite drugs for heart problems and should be used in patients with recent cardiovascular events under medical supervision.

Penile injections:
This therapeutic approach, although highly criticised, is undoubtedly a powerful and effective therapeutic tool in the treatment of erectile dysfunction. Although very often referred to as a second-line therapeutic means, they are sometimes the first treatment given to men e.g. after radical prostatectomy for prostate cancer or when the man is faced with extremely high levels of anxiety, which have the most negative effect on the mechanism of erection, with very low rates of side effects. The patient is trained to do them on his own, thus ensuring spontaneity in his love life which in the past was the main inhibitor for their use. Although their main side effect, prolonged erection, which is not accompanied by erotic desire, is rare (<1.2%), we should take it always under consideration especially in patients with hematological disorders or anatomical penile disorders (e.g. Peyronie’s disease). The frequent and long-term use of penile injections can lead (rarely nevertheless) to fibrosis of the penile cavernous bodies.

Shockwaves therapy:
This method (LiST, Low-intensity Shockwave Therapy) is the newest in the treatment of erectile dysfunction. This technique is based on the theory of neoangiogenesis, according to which the transmission of energy in the form of shock waves, leads to the activation of a mechanism, for the release of growth factors and the creation of new vessels, for the treatment of the root cause of the problem. This technique has been used successfully for several years in cardiac surgery, while in andrology it has found its way over the last 4-5 years with great success, always to specific and selected patients for whom there are appropriate indications, as in any medical practice. Data and clinical experience have shown that shock waves are able to significantly improve erectile dysfunction, have encouraging results after operations that have affected erection and may create the conditions for a man to be treated with oral medication again. The treatment of shock waves is cumulative, while at the same time it has a long-lasting effect.

Surgical treatment:
Surgical treatment of erectile dysfunction has been the final solution to the problem of erectile dysfunction, and is often the only solution in patients who cannot or do not want to take medication. Τhe surgical techniques are two:
Insertion of penile prosthesis: In the surgery of the penile prosthesis, two cylinders of special synthetic material are placed inside the cavernous bodies (cylinders filled with blood during normal erection). These cylinders can be semi-rigid, in which case the erection is advanced by manually changing the position of the penis. Otherwise, the use of cylinders filled with liquid can be chosen, with the help of a pump placed on the scrotum, behind the testicles. In the second case, the image of the penis in erection and flaccid state, simulates very much the normal form and function. Ejaculation and orgasm remain unchanged if not improved, as many patients achieve better control of their ejaculation. The insertion of the device is carried out with day surgery and the patient leaves the hospital on the same day or at the latest the next day in the morning.
Penile vascular surgery:
Whatever treatment will be applied, the goal remains the same: the return of the man to the situation he was in before the onset of the problem, always with respect to his expectations, his desires, without the addition of additional stress. The choice should always be individualized and should only concern the man and the partner.
Penile vascular surgery is one of the last weapons in the treatment of erectile dysfunction. In this case, either the blood supply to the penis is increased through the placement of a stent in the vessels of the organ, or the veno-occlusive mechanism is surgically corrected.

Introduction

Male subfertility may be due to sperm production and transfer problems. Causatively, a variety of factors are capable of affecting a man’s fertility ability

Hormonal disorders

Endocrinological diseases that may cause infertility include hypothalamus-pituitary axis disorders, thyroid gland disorders and adrenal disorders. Even if the levels of the hormones tested are normal, in rare situations there is the possibility of non-sensitivity syndromes to androgens (AIS-Androgen Insensitivity Syndromes).

Testicular disorders

In the testicles, under the influence of testosterone, sperm cells are produced and matured. Any damage to the testicles, whether primary, or acquired, is likely to greatly affect spermatogenesis. A thorough evaluation of medical history is able to highlight conditions that may be related to a testicular lesion (cryptorchidism, drug taking, mumps, etc.). At the same time, the clinical examination and ultrasound will complete the diagnostic test, looking for possible inflammations, structural abnormalities or neoplasms. In cases where the cause of sperm absence is attributed to the non-production of these by the testicles, we refer to non-obstructive azoospermia.

Disruptions of the efferent system

After production, the spermatozoa are transferred to the epididymis, where their maturation is completed. Together with fluid from the seminal cysts and from the prostate gland, they constitute the product of ejaculation (sperm). Various congenital diseases resulting in abnormalities or obstruction of the efferent system can cause problems in the route of transport of sperm. More often, conditions such as inflammations and infections, as well as postoperative conditions result in effective spermatogenesis, but ineffective transfer of sperm. In these cases, the absence of spermatozoa in the sperm chart is referred to as obstructive azoospermia.
In the category of sperm transfer disorders, there are also situations in which sperm regresses to the bladder instead of being pushed into the urethra (taking medications, transurethral procedures), but also situations in which normal extrusion is inhibited (urethral stenoses, hypospadias).

Infections-Inflammations-Immunobiological reasons

We know today that infections by microorganisms are one of the most common causes of an affected sperm chart. This becomes more important, because urinary tract infection may not show symptoms in men. At the same time, conventional tests, such as simple urine culture, are not sufficient in diagnosing the infection. Proper guidance to the specialized tests required to detect microbes that have been shown to affect the parameters of a spermogram and to receive appropriate treatment is an important step towards the desired result.
Rarely, antisperm antibodies (ASA-Anti- Sperm Antibodies ) are detected, which appear to be responsible for 12-13% of diagnosed cases of infertility in men. Risk factors for the development of autoantibodies include infections, trauma, immunosuppression, varicocele and neoplasms.

Varicocele

With the term varicocele, we refer to the helical swelling of the venous network of the testicle, which is insufficient. Usually, for anatomical reasons, varicocele appears on the left. Varicocele can cause mild symptoms (weight, discomfort), prevent normal development of the testicle and affect spermatogenesis. Varicocele has also been associated with disorders in the genetic material of spermatozoa, a condition that is reversed after its correction. In many cases, varicocele is diagnosed only by ultrasound of the scrotum (subclinical varicocele). We know that varicocele occurs in 15% of all men, which increases to 35% of infertile men. The treatment of varicocele is surgical, with the method of microsurgery being the most effective and acceptable method.

Sexual dysfunction

Sexual dysfunction is a clinical entity that includes erectile dysfunction and ejaculation disorders. It is therefore clear that any of the above problems can lead to infertility situations, as long as normal sexual intercourse and the deposition of sperm in the vagina are disturbed. Erection problems, sexual habits and abstinence time, premature or delayed ejaculation, are important parameters that are often not considered in the control of the infertile man.

Systemic diseases

A variety of common and relatively common systemic diseases sometimes affect a man’s fertility. Diabetes mellitus, metabolic syndrome, obesity, liver problems, renal failure and a wide range of additional clinical problems should be properly assessed to assess the severity of their effect on fertility.

Environmental factors

This category – which nowadays is becoming more frequent – includes air pollution, radiation exposure, smoking, exposure to chemicals (organic solvents, plastics, PVC,pesticides, insecticides, food additives, defrosters, inks, colors, perfumes, photographic fluids, etc.), extensive use of medicines and persistent physical and psychological stress.
Drugs such as cimetidine, allopurinol, erythromycin, tetracycline, gentamycin and cyclosporin may cause problems with spermatogenesis. A negative impact on sperm quality and/or function has been reported to be caused by sulfasalazine (anti-inflammatory for colon inflammation) and the antibiotic nitrophurantoin.
Also, known antipsychotic drugs, such as chloropromazine, alloperidol and thioridazine, antidepressants such as amitriptyline, imipramine, fluoxetine, paroxetine, and sertraline, as well as antihypertensives such as guanethidine, prazosine, phenoxybenzamine, phenolamine and reserpine, are likely related to erectile dysfunctions.

The treatment options, contrary to what most people think, as understood by the causes that cause it, are many and different and can be the solution for the infertile couple. Although some factors can hardly be changed or sometimes not at all, as in the case of genetic abnormalities, appropriate guidance and use of medicines (antibiotics, hormonal manipulations), where appropriate, as well as antioxidants. Surgical interventions, can offer permanent, valid and effective solutions to a man with subfertility problems. At the same time, changing certain habits of everyday life can also contribute to improving sperm parameters. The close collaboration between the fertility specialist and the couple with fertility problems is able to create the best conditions for achieving a pregnancy.

Introduction

The underlying reason for the disease is actually not known. Mainly, penile injuries during sexual intercourse and fractures of the penis have been mainly implicated. Other causes could be microbial infections, autoimmune diseases (e.g. rheumatoid arthritis), diabetes mellitus, arterial hypertension, systemic vascular disease, and even some types of cancer.

The main symptom is pain during erection, bending and curvature of the penis. There is palpable hardness in a large percentage of patients suffering from Peyronie’s disease. They may also have erectile dysfunction because of psychological factors or decreased blood flow (sometimes even due to penile bending).

Diagnosis is made by the urologist – andrologist and includes a complete history of the patient. The doctor looks for injury or fracture of the penis, the duration of symptoms, sexual scripts, painful erection, reduction or enlargement of the penis and the presence or absence of concomitant diseases such as diabetes mellitus, hypertension or autoimmune diseases..

Diagnosis is made by the urologist – andrologist and includes a complete history of the patient. The doctor looks for injury or fracture of the penis, the duration of symptoms, sexual scripts, painful erection, reduction or enlargement of the penis and the presence or absence of concomitant diseases such as diabetes mellitus, hypertension or autoimmune diseases.

Clinical examination is always carried out with the penis both in the flaccid and erectile state. The patient is examined for palpable hardness in the penis, the actual curvature of the penis, as well as the existence or not of pain during erection.

Imaging methods include dynamic triplex ultrasound, as well as MRI imaging of the penis.
Peyronie’s disease usually passes through two phases::

  • The first (unstable) phase is often combined with pain during erection and stiffness of the penis.
  • The second (stable) is characterized by stabilization of the curvature and absence of painful erection.

Treatment is usually pharmaceutical. From the onset of the problem until about 6 – 12 months later, the patient usually needs treatment for his pain. This treatment involves taking orally a large dose of vitamin E or other medicine, as well. This depends on the patient’s comorbidities. In addition to oral treatment, local treatment can be applied to the penis with verapamil and cortisol iontophoresis and/or shock waves in special protocols for Peyronie’s disease. The objective of medical treatment is to stop the progression of the disease without affecting the erectile function and the curvature of the penis. In particular, for young men, protecting erectile function is very important. After the end of this period, the only therapeutic solution is surgery.

After the clinical (pain) or imaging (stable plaque size) stabilization of the disease, the treatment is only surgical. In this case, it should be stressed that surgery is about restoring the shape of the penis and not about treating the disease. There are various techniques. The chosen technique depends on the size and form of the lesion, the coexistence or not of erectile dysfunction, the degrees of the angle, the existence or not of other diseases and last, but not least by the patient’s preference.

Schematically, the techniques are practically divided into three categories:

        1. Plication techniques, Nesbit, Stage
        2. Graft techniques and geometrical correctio
        3. Techniques with simultaneous placement of penile prosthesis

In some patients, the simultaneous use of different techniques is necessary, as these surgical procedures are completely personalized.

Introduction

The scrotum is the sac in which the testicles are located. It is often overlooked as a part of the male anatomy. As time goes by, the skin loses its elasticity and firmness, causing the scrotum to hang even lower.

In other cases, even from birth, the position of the scrotum makes sitting difficult. In addition, when the sac of the scrotum starts from the body of the penis, the image of the scrotum may lead to the perception of a shorter penis. In any case, whether the problem is functional or cosmetic, scrotoplasty can give a solution. Scrotoplasty aims at the reconstruction of the scrotum sac. It includes both the clear separation of the sac from the penis, as well as the removal of excess skin. This leads to the image of a younger scrotum, with excellent aesthetic result, without scars and with immediate return to daily life.

Scrotoplasty can be performed as a single procedure, or at the same session with another reconstructive or cosmetic surgery. Thus, it is addressed to every age; whether it is a scrotum that starts in front of the lower surface of the penis (giving the impression of a short or hairy penis), or a scrotum too loose and asymmetrical to the penis. Alternatively, scrotoplasty can considerably improve the appearance of the genitals after an operation to correct penile curvature (Peyronie’s disease) or after an operation to put a penile prosthesis for erectile dysfunction. Finally, scrotoplasty combined with phalloplasty can lead to spectacular results, both in the objective gain in length, as well as in the subjective perception of a larger penis.

Scrotoplasty is basically a cosmetic procedure, which in no way affects the function of the penis or testicles or even the fertilizing capacity. It is a minimally invasive intervention. It can be carried out under sedation and guarantees an quick return home and focus on daily activity.

Introduction

The insertion of penile prosthesis is the surgical procedure which restores erection in men to whom the medication doesn’t work or in patients who cannot follow medical treatment due to medical or other conditions.

The erection starts through a pump that is behind the testicles and is not visible. The final hardness is given by the man for as long as he wishes. No part of the penile prosthesis is visible, as the whole device is implanted inside the penis.

Surgery maintains the man’s ability for spontaneous sexual intercourse. The intensity of the erection is ideal in hardness and duration which means that the man can maintain his erection for as long as he wants without the fear of losing it anymore.
The success rates of the couple’s satisfaction based on international studies range to 97%. Penile prosthesis is the therapeutic approach that restores normal erections in men to whom medication no longer works or cannot be treated due to medical or other conditions.
It is a surgery to treat erectile dysfunction in which the corpora cavernosa of the penis are strengthened with advanced plastic cylinders.

How it is done – How it works

The operation is usually performed under dorsal or general anesthesia, where the two tubes of the penis are opened and dilated after a small incision at the base of the penis. Then, two elongated silicone rollers are placed. A pump is placed behind the scrotum, behind the testicles through which you transfer fluid to the tubes mentioned. In the hydraulic prosthesis the pipes are inflated giving the man a natural feeling of hardness and softness.

Sexual intercourse is forbidden for 4-6 weeks after surgery.

Introduction

Premature ejaculation affects about 1 in 5 men, which remains stable regardless of age, making it the most common sexual dysfunction in men under the age of 60. In the case of premature ejaculation, it occurs in up to 1 minute from vaginal penetration, without substantial control on the part of the man. In the cycle of sexual response, desire and arousal are very short, while escalation is rapid, resulting in frustration, anxiety, lack of satisfaction from sexual intercourse and aversion to sexual activity.

Premature ejaculation may occur from the beginning of the love life (primary or chronic), but it can also occur suddenly, whereas the man was in control of ejaculation or the time of contact was satisfactory (secondary or acquired). In the first case, we consider that the condition is due to a greater degree of neurobiological disorders, while in the second, a multitude of conditions have been associated with the problem (prostate diseases, hyperthyroidism, erectile dysfunction, anxiety, negative experiences, low self-confidence). In either case, the result is the same.

Failure to obtain satisfaction from sexual activity by both partners, performance anxiety, fear of poor control over ejaculation, anger, low self-esteem, abstinence from sexual activity, are just a few of the situations a man can experience in the context of this condition.

Delayed ejaculation, or absence of ejaculation, is an increasingly common clinical entity. In most cases the desire is present, but the stimulation is not able to escalate and result in orgasm and ejaculation. The discomfort between partners in these cases is due to the man’s attempt to have an orgasm and to the frustration of the sexual partner who feels insufficient to stimulate the sexual partner and lead him to the climax.

Specific conditions, such as hypothyroidism are able to lead to situations of delayed ejaculation or difficulty ejaculation. In addition, experiences, images and stimuli, fantasies and their association or mismatch with everyday sexual practice play a particularly important role. The ease of access to erotic content of all forms and the lack of communication between partners, can be one of the most important factors for the development of an ejaculation disorder.

In any case, seeking help from the specialized andrologist is one of the most important steps towards solving the problem. This first step is perhaps the most important, considering that the majority of men with ejaculation problems hardly share their problem, while considering that there is no solution.

In most cases, the problem occurs randomly, in the context of checking for different symptoms. The specialized andrologist is completely familiar with the discussion of sexual issues and will make you feel comfortable. After the description of the problem, taking the sexual history and carrying out the necessary diagnostic tests, we will organize together the therapeutic strategy that will be in line with the needs of each individual man.

Whether it is an underlying condition such as hypothyroidism or chronic prostatitis, self-help techniques, psychosexual therapy techniques, or medications (or a combination of the above) will be tested. The goal is always better control of ejaculation, greater self-confidence and improved sexual satisfaction.

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