Andrology

Erectile dysfunction covers all problems in connection with the rigidity of the penis (no or insufficient rigidity and/or too short duration of erection). Most of all patients with erectile dysfunction suffer from organic problems due to modern medicine evidence. Those underlying organic causes should be diagnosed and individually treated if possible. As erectile dysfunction is never a pure organic problem, accompanying psycho-sexual disorders should also be addressed. Whenever possible the patients female or male partner should be included in the treatment modalities. With tablets (4 different PDE-5-Inhibitors like Avanafil, Sildenafil, Tadalafil and Vardenafil), intracavernous self-injection therapy (SKAT), vacuum devices and penile implants we have very good and effective options for today’s therapy of erectile dysfunction. Together with our patients we try to find out the individually best option in each case.

Peyronie´s disease is a benign soft tissue disorder of the tunica albuginea (outer layer of the penile corporal bodies). The disease is named after his first scientific author Francois Gigot de la Peyronie. In the German speaking countries the disease is called: “Induratio penis plastic (IPP)”. The exact pathogenesis of the disease is still unknown. In patients with Peyronie´s disease it comes to an keloid formation of fibrotic tissue in the area of the tunica albuginea. In the course of the disease there is a palpable knot or plaque. Typically patients report about pain in the first phase of the disease (especially when they have erections). After 12 to 15 month the pain disappears normally without specific treatment. Due to the plaque formation most of the patients get a penile curvature. The curvature is typically upwards (i. e. dorsal in medical nomenclature) and less often downwards (i. e. ventral) or lateral. The curvature can cause problems or pain during intercourse for the patient or his partner. The medical treatment in the first, inflammatory phase of the disease is only minor effective. Therefore the main therapeutic option is the penile straightening operation for patients with disturbing curvature. According to the guidelines such operations should only be performed if there is a stable situation of the disease for more than 6 months, i. e. no further change of the penile deviation, because in up to 20 % of all cases spontaneous improvement is possible in the first 2 years.

Premature ejaculation is the most common sexual disorder in men. Scientific studies show a prevalence of 5 - 15 % of men in all age-groups. Like in many other diseases there is a distinction between life-long and acquired forms. Most patients with the life-long premature ejaculation have an interval of less than 60 seconds before they have their orgasm and ejaculation. In men with the acquired form the intravaginal latency time (IELT) is typically 3 minutes. In both groups the patient report a total loss of control, i. e they don´t have any possibility to influence their orgasm and ejaculation. The disorder leads to high bother in both patient and partner.  For the treatment there are the following options:

1. The intake of tablets before sexual intercourse, which lead to a prolonged IELT. The only licensed substance is dapoxetin, a serotonin-reuptake-inhibitor.
2. Reduction of the sensetory level of the penis (for example local anesthetics or special condoms). The oral intake of pain medication in this context is not recommended.
3. Behavioral therapy/ Sexual therapy (i. e. Start-Stop-Technique)
   
4. Use of PDE-5-Inhibitors

By definition a testosterone deficiency syndrome is proven, if a man has a two-times laboratory-controlled deficiency of serum total testosterone and related clinical symptoms. Typical symptoms are:

Loss of libido, loss of energy, being more tired, reduced power, reduction of muscular strength, concentration problems, depressive symptoms, erectile dysfunction and after long-time deficiency male osteoporosis (reduction of bone mineral density)

There is a differentiation between disorders of the testicles (primary hypogonadism) and disorders of the central structures in the brain like hypothalamus or hypophysis (secondary hypogonadism). The so called “late onset hypogonadism (LOH)” of aging males is typically a mixture of both of the before mentioned conditions. In those patients one finds often the risk factors obesity, diabetes mellitus, hypertension or lipid disorders. Those comorbidities should be treated firstly or at the same time like the hypogonadism. In most cases a testosterone replacement therapy (TRT) is useful. The missing testosterone can be replaced in form of testosterone-gel, which is applied on the skin every morning, or intra-muscular injections, which are given every 3 month.

The dilated veins in the area of the spermatic cord can either lead to an impairment of male fertility or produce clinical symptoms like pain or discomfort in the related testicle. Due to special anatomical conditions the varicocele occurs in more than 80 % on the left side. By sclerosis or operative ligation of the dilated veins there is an effective therapy for the varicocele. In our institution mainly the microsurgical operative treatment is performed as this option has excellent results, a very low recurrence rate and low complications.

If a couple does not get pregnant after 1 year of regular sexual intercourse without anti-contraceptive methods, this is per definition: unfulfilled wish for pregnancy. In 50 % of all cases there is a male factor for this problem. Beneight medical history, clinical examination, laboratory tests and sonography the sperm analysis is the most important diagnostic procedure. According to the WHO-recommendations for sperm analysis patient must have 3 to 7 days of abstinence, i. e. they should not have any ejaculation in this time period. The sperm analysis has to be done immediately in the laboratory. In relation to the sperm analysis results there will be an individual recommendation for the couple. In those cases we have a very good cooperation with our fertility center (IVF-Ambulanz), which offers any kind of modern reproductive medicine procedure.

For men with severe erectile dysfunction the penile implant is very good and effective treatment option for more than 40 years. Instead of former semi-rigid implants today in almost all cases 3-piece hydraulic penile implants are used. They provide a natural function without compromising the sensitivity of the penis; i. e. patients can have normal orgasm and ejaculation with such an implant. In addition the passage of the urine is also not influenced.  By activating the scrotal pump the patient can move fluid from the reservoir to the penile cylinders. This causes the necessary rigidity to have intercourse. The satisfaction rate for this treatment option is very high with 90 % on the side of the patients and 90 % on the side of their partners. The Andrological Section of the clinic of Urology Freiburg is a centre of excellence for penile implantation which means such procedures were done here in high number and excellent quality.

In the clinic of Urology Freiburg transgender operations (male to female) are done routinely. The diagnosis must be proven by 2 independent written expert opinions. Furthermore the cross-gender hormonal therapy should have been started 12 month before the operation. Our way to perform this kind of operation is always in 2 steps.

In men with non-obstructive azoospermia (their sperm analysis does not show any spermatozoa) we perform in close cooperation with our Fertility Center (IVF-Ambulanz Universitäts-Frauenklinik) operative testicular biopsies. In general anaesthesia 3 little probes from each testicle are excised and thereafter analysed if there are any sperm in this tissue. If sperm are detected, a cryoconservation is performed. In the end the sperm are frozen in liquid nitrogen (- 196° Celsius). These sperms can be used for artificial reproductive therapy where one sperm is injected in one egg (the so called ICSI = intracytoplasmatic sperm injection).

In men with definitive decision to have no further children of their own we perform after a detailed consultation, clinical examination and informed consent the vasectomy on both sides. This procedure can be done in most cases as an out-patient operation in local anaesthesia. In the clinic of Urology Freiburg today only the no-scalpel-vasectomy technique is performed. This special technique leads to minimal complications. After this kind of operation 2 sperm counts with detection of zero sperms are necessary to prove the success of the procedure.

As one of only very few institutions in Europe the clinic of Urology Freiburg offers the possibility to get the new minimal invasive intralesional injection therapy with 2 collagenases derived from clostridium histolyticum [XIAPEX®]. After inducing an artificial erection and exactly documenting the location and degree of the penile curvature 0,25 ml of XIAPEX® are injected directly into the plaque. This procedure is repeated every 4 weeks up to 6-times. In between these injections the patient has to perform the before in detail demonstrated penile modelling 3-times a day. By this combined therapy 60 % of all men with Peyronies disease experience an improvement of their penile curvature with an average reduction of – 30°. Those patients would not need a penile straightening operation.