DEFINING ERECTILE DYSFUNCTION
Erectile dysfunction (ED) is defined as the inability to have an erection satisfactory for penetration. It is a very common complaint in men and fortunately, one that can be restored in most situations.
The causes are often psychogenic (anxiety, fear of not satisfying one’s partner, depression, etc.) or physical (trauma to the external genitalia , radiation injury, pelvic surgery, etc.). Rarely, the cause may be hormonal, i.e., secondary to a low serum testosterone (male sex hormone) level. Regardless of the cause, treatment is often effective in a single office session.
Erectile dysfunction can occur transiently as a result of the above causes which can be treated by reducing the psychogenic cause or if physical, have the ED treated by medical, injectable or surgical therapy. For example, erectile dysfunction (ED) in men who are anxious or who are afraid of “under-performing” can often be discerned on history and treated by reassurance and by reducing one’s fear of failure. If this approach is not successful, a small dose of medication used to increase blood flow to the penis is often enough to convince the patient that he does not have an ailment which can’t be corrected.
Medical therapy to improve penile blood flow has been the major advance in men’s health over the past several decades. There are a host of Food and Drug Administration approved medications around which can be utilized but the dosage and timing of these medications must be coordinated by a physician so that the incidence of negative side effects is kept to a minimum.
Hormonal therapy (testosterone supplementation) can often restore potency in men who have “low” serum testosterone levels. Testosterone is not absorbed orally so there is no testosterone medication a man can take by mouth. Testosterone therapy is provided in the form of a gel, drug patches or by deep tissue (muscle) injection. For those patients that do not respond to oral medical therapy, a vacuum pump device will often be satisfactory. The pump is a bit cumbersome but many couples find it to be acceptable.
Direct injection into the penile tissue of medications used to increase penile flow is another approach particularly in men who find the oral medications ineffective and/or who do not wish to use a vacuum pump. Men have to be taught by a physician how and where to inject the medication which one does prior to each sexual encounter. The erection provide by this technique is often very firm and can last for several hours. The downside to injection therapy is that it does cause a small amount of pain (particularly following the first few injections) and may stimulate the formation of some penile scar tissue. For those patients who do not respond to any of the above treatments, implantation of a surgical prosthesis (silicone rods) is the remaining option. This is a surgical procedure which is performed under an anesthetic in a hospital or ambulatory surgical care setting. The advantages are that no medication is involved and “one is always ready”. The downside is that this is a surgical procedure and there is a slight risk of infection since the rods are foreign bodies. If this does occur, the prosthesis may have to be removed.
Most cases of ED can be treated successfully. Usually one or a few physician visits can remedy the situation to everyone’s satisfaction.
Prostate cancer is the most common non-skin-related cancer in men in the United States. It is also the second leading cause of cancer death in men. One in seven men will be diagnosed with prostate cancer. African-American men face a one-in-three chance of being diagnosed. Over 29,000 men die each year from prostate cancer, but early detection may save lives.
Recent reports about PSA (prostate-specific antigen) testing may confuse patients about the value of prostate cancer screening. The PSA test is not perfect. However, when used correctly, this blood test gives important information. The PSA test can help diagnose, assess the risk of, and monitor prostate disease such as cancer. Men should talk to their urologist about whether to get screened or not. Talk with your urologist about the benefits and risks of testing. You should also talk about factors that can increase your risk for prostate cancer, including:
– your family history of prostate cancer (Did your
father, brother or other relative have prostate
– if you are African-American;
– a high BMI (a measure of your body fat)
– your age; and
– your previous health history
A number of things can change PSA levels and should be kept in mind when reading the results. High PSA levels can be caused by more than just prostate cancer. Other causes of higher PSA levels include:
– prostatitis (inflammation of the prostate) and other
types of urinary tract infections (UTIs);
– benign prostatic hyperplasia (BPH – enlargement of
– injury; or
– treatments such as prostate biopsies (tissue samples)
or cystoscopy (a test to look inside the urethra and
Men choosing the PSA test should know their results could be influenced by some important factors, such as:
– Blood PSA levels tend to rise with age.
– Larger prostates make more PSA.
– Change in PSA levels over time (known as PSA
velocity) can be markers of both cancer risk and how
quickly a cancer may be growing.
A prostate biopsy (tissue sample) is the only way to know for sure if you have prostate cancer. The decision to go ahead with a prostate biopsy should be based mostly on PSA and findings on a digital rectal exam (physical exam of your prostate). Other factors to take into account include your family history of prostate cancer, your race, results of any prior biopsies and other major health issues you may have.
The choice to use PSA for early detection of prostate cancer is a personal choice. While PSA screening has been shown to have benefits, it also carries risks.
Possible benefits of having a PSA test:
– A normal PSA test may put your mind at ease.
– A PSA test may find prostate cancer early before it
– Early treatment of prostate cancer may help some
men slow the spread of the disease.
– Early treatment of prostate cancer may help some
men live longer.
Possible risks of having a PSA test:
– The PSA test is not perfect. A normal PSA result
may miss some prostate cancers (a “false negative”).
– Sometimes the test results suggest something is
wrong when it isn’t (a “false positive”). This can
cause unneeded stress and worry.
– A “false positive” PSA result may lead to an
unneeded prostate biopsy (tissue sample).
– A positive PSA test may find a prostate cancer that
is slow-growing and never would have caused you
– Treatment of prostate cancer can cause side effects.
Short- or long-term problems that can occur are
issues with getting erections (“ED”), leaking urine,
or bowel function.
Before you decide to have a PSA test, talk with your urologist about the benefits and risks of testing. Also talk about your individual risk of prostate cancer, including your personal and family health history.
This blog is in response to the following article:
LinkedIn.com Article – click here to read
In this article the writer goes over the the hurdles our healthcare providers go through to get paid for their day to day claims. Some of these hurdles are affecting our patient care adversely. In many cases even treatment plans are affected because insurance do not cover certain medications or procedures. This leaves our patient community in a healthcare limbo since the plan doesn’t “want” to pay for a service and the patient also does not want to be responsible. As the article goes on to indicate, many providers who were polled would like a single payer system. While we don’t necessarily agree with this assessment for our practice, we do believe our current healthcare hodgepodge helps only the health insurance community and not the patients or the doctors who render their services in good faith and in the best interest of our patients.
Our practice which has a large young and middle age patient population is plagued with the current HIGH DEDUCTIBLE issue. This means that our patients are responsible for the first $2000 to $5000 worth of medical services. In most instances patients don’t satisfy their deductibles before seeing one of our doctors. Many of them do not need that many services in a year. This causes a payment lag for the doctors services which in turn hurts the medical practice as a whole. Many patients are finding it hard to pay for medical services immediately once the claims have been processed.
Another issue discussed is related to the time and effort spent on trying to get the insurance plan to approve and pay for services and medications. This alone consumes several hours a week of the doctors’ and their staff. This time could be better spent caring for our patients. Add to that constant records requests and all sorts of questioning and second guessing the doctor’s judgement and yes, they go mad!
We’re interested in our patients and would like to see some progress in the healthcare machine that will put the patient’s health and the doctors’ efforts first. Our patients need care, our doctors need to be compensated for the care they provide. Web searches, deferred treatment and ER visits do not cut it. But thats the way things are going because of our current circumstances. Things need to improve.
Thousands of patients annually are plagued by urinary leakage, yet many feel reluctant to raise this sensitive issue with their doctor. Many patients have been led to believe this is a “normal part of the aging process” or “an unavoidable consequence of childbirth”. Although age and child bearing can impact the bladder, this is an area where there are a growing number of treatment options which can improve the quality of life.
It’s critical to understand there are two types of urinary leakage. And it’s important to differentiate between the two as the treatment options depend on the type.
Stress Urinary Incontinence is the involuntary passage of small amounts of urine that occurs when one laughs, coughs/sneezes or exercises. This is often experienced after pregnancy/childbirth but can also be seen with significant weight gain and conditions associated with chronic pushing/coughing such as chronic constipation or asthma. It may also be more noticeable after the onset of menopause.
Stress urinary incontinence is treated with physical exercises. When this fails, there are surgical options. Surgery for stress urinary incontinence is an outpatient procedure with excellent outcomes.
Conversely, Urgency and Urge Incontinence is the involuntary passage of urine that is accompanied by the desire to urinate. Individuals feel they are unable to “make it to the toilet in time”. Patients often describe specific triggers, such as “putting a key in their apartment door” or “opening the bathroom stall”. This condition is often more noticeable with age, and is often worsened by bladder irritants. The most common bladder “triggers” are caffeine, tobacco, alcohol and artificial sweetener.
For urgency and urge incontinence, counseling and behavioral modifications are sometimes all that is required to improve bladder symptoms. For some, bladder medications provide relief. There are many medications from which to choose, including a newer medication with fewer side effects. When these options fail to bring relief, patients may choose to have a Botox bladder injection which will relax the bladder and thus prevent the spasms which are responsible for the leakage. Or, they may choose to try a sacral neuromodulator which is a tiny device that sends an electrical impulse to the bladder to prevent involuntary bladder contractions and therefore improve leakage.
In 2017 we are fortunate to have many tools in our armamentarium to offer to those suffering with urinary leakage. Please give us a call or request an appointment online to see how we can help.
We have recently seen some exciting responses using an innovative treatment for Peyronie’s Disease. This condition often causes pain and angulation in the erect penis. It may also inhibit full erections. Some of our patients found out they had this condition while being seen for having difficulty during sexual activity. Specially trained and certified urologists are now using the medication Xiaflex (TM), a form of botox to soften the angle and reduce the nodular plaque that often occurs in this condition.
While not everyone is a candidate, some men can benefit from this treatment. Typically 6 applications are required, although some of our patients have reported improvement after as few as 2! An evaluation is required to determine if this treatment is likely to help an individual. If you’re having difficulties with penile pain and/or erectile dysfunction, and would like to be evaluated for this exciting therapy, kindly call our office for an appointment.
Note that many plans require authorization for prescriptions. It seems that even commonly prescribed medications require it. Unfortunately, this way your insurance makes the process of providing you with your needed medications most time consuming. Insurance suggest that the doctor calls to obtain authorization. However, it is a most time consuming process. More often than not the doctors have several requests for pre-authorization at hand. Rather than making a call, our practice prefers to fill out a pre-authorization form. These are normally provided by your insurance and contain all information and/or questions pertinent to your particular prescription.
For that reason, if needed we ask you to obtain the required PRE-AUTHORIZATION forms from your PRESCRIPTION INSURANCE and have them forwarded to our office for the doctor’s review and fulfillment. This will allow the doctor to tend to the patients at the office as opposed to being held on the phone for several minutes a day jumping through insurance imposed processes.
Without the pre-authorization forms you will have to pay for your prescriptions out of pocket. Also, some plans have no coverage for certain medications. You’re welcome to have the insurance fax these to our main fax line:
In preparation for the forecasted blizzard, our office will be closed today. The inclement weather makes it unsafe for some of our patients and our core staff members to commute. We hope all of you stay safe, warm and cozy as this weather clears. We shall be open tomorrow, at 9am as usual. See you then.
Kidney stones may present in various ways. Most often, they present with intermittent radiating pain on one side and can be accompanied by waves of nausea and/or vomiting. Other, may lead to significant changes in voiding patterns, such as increased urgency and frequency of urination, intermittent flow, burning and/or blood in the urine. Sometimes kidney stones are completely asymptomatic and may be picked up as an incidental finding when patients undergo imaging for other reasons. Patients may have a “positive urine analysis” and be found to have microscopic blood or inflammatory markers in the urine. Kidney stones may be diagnosed with medical imaging such as ultrasound, xray and/or CT scan of the Abdomen and Pelvis. Once diagnosed, if a patient is asymptomatic, it is important to follow them to confirm passage of the stone, either with spontaneous passage or with some type of intervention.
Most often, stones that are found within the ureter (the tube that drains the kidney and connects to the bladder) or those that are obstructing the kidney (which means they are causing backup of urine, thereby putting pressure on the kidney) require treatment. An “obstructing stone” prevents drainage of urine from the kidney and can lead to infection, sepsis and over an extended period of time, loss of renal function. These could also lead to formation of ureteral strictures. Kidney stones don’t always require immediate intervention. They may not need any treatment, other than making dietary and or medication changes to avoid an increase in stone size and number.
Management of stones depends on the location, size and number of stones. It must be individualized to each patient and depends often depends on one’s overall medical health. For evaluation, a full dietary intake with a complete medical history and physical is required. Though most stones are composed of calcium oxalate, the reason one forms stones will vary from patient to patient. Issues may include poor hydration status, acidic urine, high salt intake, large meal sizes, too much animal protein (which is found in beef, chicken and fish). Excessive intake of vitamins C, D, high dietary salt intake or calcium supplements can also contribute. You should not make dietary or medication changes until a full evaluation has been completed. For example if you have been diagnosed with osteopenia or osteoporosis (i.e. bone loss), and have kidney stones, do not change your bone health medications without the proper medical advice. Patients with gout or high blood levels of uric acid have a higher risk of forming stones. Interventions shown to decrease stone recurrence rates include drinking at least 2.5 liters of water per day, maintaining a normal calcium diet and adhering to a low salt diet. Appropriate modifications can be made once a 24 hour urine collection is performed.
If you feel you may have a kidney stone, please call our office (212-570-6800) for an appointment. We can offer same day evaluation and treatment as indicated.
PATIENT RESPONSIBILITY DISCLOSURE
As the new year goes on, our patients are being confronted with subtle changes in their insurance plans. Patient responsibility is newly assigned. Commonly, the new year means Deductibles reset and start again at zero. Many of our patients who had no deductibles in the previous year have them now. A large number of them are “not aware” of these changes and in turn it makes it more challenging to collect on these claims which are not paid by the plan since they represent patient’s responsibilities.
For that reason, we some time have to remind our patients that our participation with Insurance Plans does not imply you as our patient will not get a bill for services rendered during your visits or surgical procedures. Note that your Insurance Policy may have multiple ways to assign the responsibility of our fees to you. This is done through DEDUCTIBLES, COINSURANCE and COPAY. It is important to be familiar with these aspects of your plan to avoid unexpected bills and be able to manage your medical costs efficiently and effectively.
DEDUCTIBLES are assigned as per your policy to ALL SERVICES or just to CERTAIN PROCEDURES. Your insurance will not pay for your claims until the total of your deductible has been satisfied by assigning it to approved claims. These DEDUCTIBLES may range anywhere from a total of $200.00 per year to a total of $5000.00 (or more). Note, most often it will take several claims to satisfy a large deductible. As an example, if one visit claim for a patient was around $350.00 and the total deductible is more than that, then your claim for $350.00 may be payable by you, as per your plan’s provisions. Please be aware of this.
CO-INSURANCE is a percentage (%) of your total approved insurance claim which is billable to you as per your insurance policy. This varies widely through the insurance companies. A common CO-INSURANCE is 20% of the approved claim. Normally coinsurance is due after DEDUCTIBLES have been satisfied.
Additionally, a COPAY is a set amount (anywhere from $5.00 to $75.00 or more) collected from the patient at the time of the visit. This is usually stated on your insurance card. Some plans will specify different amounts for your General Doctor and for Specialists.
We hope this helps keep things clear.
The Board of Directors of the American Urological Association (≥ 16,000 members worldwide) conferred Honorary Membership on John A. Fracchia, MD. This will be effective May of 2017.
According to the AUA, this is an honor bestowed on the few (<100 living) whose diligence and commitment surpasses the AUA’s greatest expectations. Honorary Membership is reserved for scientists who have achieved outstanding prominence in a field of medicine related to Urology, Officers of the Association, and/or distinguished Urologists.