Urology Problems

We would like to explain to you about the common urology problems seen at Salisbury District Hospital, how we investigate them and the treatments offered. They are not exhaustive accounts and each patient receives unique specialist care.

Around 40% (4 in 10) of men aged 60 years or over will suffer from annoying urinary symptoms, some of which will significantly affect their quality of life. The risk of getting such symptoms increases with age and is usually caused by enlargement of the prostate (known as benign prostatic hyperplasia BPH). You will see from the diagram that the urethra (waterpipe) passes through the prostate so that as the gland enlarges the flow of urine is blocked. To overcome this, the bladder muscle works harder than normal to force the urine out. This leads to some or all of the symptoms listed below. It also makes it more difficult for a man to empty his bladder completely.

Symptoms associated with an enlarged prostate:

Difficulty starting the flow of urine and needing to strain.
A weak stream of urine.
Frequent visits to the toilet to pass urine.
Stopping and starting during the flow.
Urgency - needing to rush to the toilet and being unable to hold on.
Getting up frequently during the night to pass urine.

Investigations

Here are some of the key investigations that may be recommended to you if you suffer from troublesome urinary symptoms:

Flow test - This is performed in clinic to measure urinary flow. Following the flow a bladder scan is often performed to measure the amount of urine left in the bladder. The flow machine is situated in the toilet so you can pass urine in privacy.

PSA test - This is a blood test. PSA is a natural protein that leaks out of the prostate into the bloodstream and is raised in the presence of infection, if you have a urinary catheter. Sometimes it just appears for no particular reason which may be normal for you.

Other investigations that may be suggested:

Transrectal ultrasound and biopsy (prostate biopsies) - If a patient is found to have an unexplained high PSA reading we will recommend this test to check whether you might have prostate cancer. It involves passing a narrow lubricated tube into the back passage, to allow measurements of the prostate and the taking of biopsies (tiny pieces of tissue) under local anaesthetic.

Flexible Cystoscopy - This is a day case procedure and involves passing a narrow flexible telescope down the urethra (waterpipe) into the bladder under local anaesthetic

Rigid Cystoscopy - This is similar to the flexible cystoscopy, but uses a wider rigid telescope and is performed under general anaesthetic allowing any additional procedures to be done at the same time such as taking bladder biopsies.

Videourodynamics - This test investigates the function of the bladder – what happens as it fills and empties. It is performed in the Spinal X-ray department and involves passing very small tubes into the bladder and back passage under local anaesthetic and slowly filling the bladder with fluid while the pressures in your bladder are measured. Once you are full you are asked to pass the fluid out around the tube.

Treatment

Sometimes simple life-style changes are enough to improve your symptoms. Under 'General Urology Advice' you will find some useful tips about keeping your bladder healthy.
Medication - Depending on how bad your symptoms are, your urologist may offer you tablets to help relax the prostate or to shrink it. In some cases a combination of both of these may be recommended
Surgery - If medication has not worked or if your symptoms are severe, your urologist may recommend an operation called Transurethral Resection of Prostate. This is an operation to remove the central part of the prostate that is obstructing the passage of urine. Like the rigid cystoscopy already described, it involves passing a rigid telescope through the urethra and into the bladder. The stay in hospital is usually 1-2 days.

For further information about urinary problems, prostate investigations and treatments please visit 'Patient Information Leaflets' or 'Links'.

Top Tips for Patients:

Talk to others
Get out and about
Look after your skin
Seek advice from a continence advisor about your management option
Avoid constipation
Use pads correctly (urine only makes skin sore when in contact with the air, so use well fitting pads and knickers)
DO NOT CUT PADS - it will cause them to leak

Urinary incontinence – the sudden unintentional release of urine - is one of those things that nobody wants to talk about. It can affect your life to such an extent that you end up limiting or avoiding social activities, physical exercise, and travelling. The reduction in quality of life can have a huge impact on your emotional and psychological well - being. But there are a variety of ways to control the problem and overcome it altogether.

The problem is much more common in women and it is estimated that 75% will experience bothersome urinary leakage at some time during their life.

Urinary incontinence can broadly be divided into the following categories:

Stress Incontinence is leakage of urine on exertion (coughing and sneezing, straining, lifting heavy loads or exercising). It is common in women who have had children. Pregnancy and childbirth can result in weakness in the pelvic floor muscles which support the bladder and womb and also the muscle within the pelvic floor (the sphincter) which closes the the urethra (water pipe).
Urge Incontinence is leakage of urine associated with an urgent and frequent need to rush to the toilet. This is caused by an overactive bladder. It can often occur on its own without underlying disease, but it is also commonly associated with spinal injuries and neurological conditions such as multiple sclerosis.
Mixed Incontinence is the term given for a combination of stress and urge leakage.

Urinary incontinence in men

Although far less common, men can also experience this problem. The prostate gland which lies directly beneath the bladder commonly becomes enlarged in men over 60 years of age, obstructing the outlet from the bladder. Urinary leakage can occur due to overactivity of the bladder muscle as it tries to push the urine out against resistance. The obstruction can also lead to the bladder overflowing involuntarily, if it is not emptying effectively, and to a condition known as post micturition dribble (leakage of urine shortly after urination has finished). These problems are usually resolved once the enlarged prostate has been treated. Men may also suffer from temporary urinary incontinence following certain types of surgery to the bladder or prostate. However, this is uncommon following minor operations.

Other factors that increase the risk of incontinence are ageing, being overweight, straining to pass a bowel motion, and indirectly, smoking (chronic coughing puts pressure on the pelvic floor and increases the risk of urinary leakage).

Whatever the cause of the incontinence, there are many things that can help from lifestyle changes, pelvic floor exercises and medication to surgery.

The Continence Service can provide expert advice and support for all incontinence sufferers. To find out how to get in touch with them please go to the contacts page.

Some investigations and treatments available at Salisbury District Hospital that may be suggested to you:
Urine Flow Test followed by Bladder Ultrasound Scanning: This combined investigation shows how well the bladder empties and if there is a significant volume of urine left behind. It involves passing urine into a flow machine in the privacy of the toilet, shortly followed by the ultrasound scan. You will be shown into another room where the ultrasound probe is passed gently over the lower abdomen).
Videourodynamics investigates the function of the bladder – what happens as it fills and empties – it shows whether your incontinence is caused by an overactive bladder (urge incontinence) or a weak pelvic floor (stress incontinence). It is important to distinguish between the two so the right treatment can be planned. The test is performed in the Salisbury Spinal X-ray department and involves the passing of very small tubes into the bladder and back passage under local anaesthetic, and slowly filling the bladder with fluid while the pressures in your bladder are measured. Once your bladder is full you are asked to pass the fluid out around the tube).
Botulinum Toxin Injection (Botox): You may be more familiar with this in relation to cosmetic surgery, but Botulinum Toxin (Botox) works well in the bladder for patients with an overactive bladder who have not responded well to lifestyle changes or medication. In the same way as the muscles in the face become inactive, so do the bladder muscles. The procedure is usually performed in the Day Surgery Unit at Salisbury, under general anaesthetic. A cystoscope (telescope) is passed into the bladder via the urethra (water pipe) and several injections given into the wall of the bladder. The procedure usually needs to be repeated every 6 – 8 months)).
Tapes/Slings. TVT (tension free, trans-vaginal tape): For women, this is a minor operation under general anaesthetic to treat stress incontinence, usually performed in the Day Surgery Unit. The tape acts as a sling to support the urethra (water-pipe) and is put in place via a small incision in the vagina and two small incisions in lower abdomen. TOT(transobturator tape) is similar to the TVT but positioned slightly differently. Your surgeon will discuss with you what is best for you. Tapes for Men: Occasionally men suffer on-going urinary incontinence following major bladder or prostate surgery. Insertion of a male tape can bring about return of continence. All patients undergoing tape surgery are usually in hospital for one day and one night.
Colposuspension: This is an operation for stress incontinence in women. It is a bigger operation than the tape insertion described above, but is very successful - providing relief for patients when their bladder has dropped too low in the pelvis for tape surgery to be effective. The procedure is done through a small incision in the lower abdomen and involves lifting the bladder with a vaginal sling.
Artificial Urinary Sphincter: This operation is suitable for men and women who cannot regain continence after every other course of action has been tried and failed. The operation involves inserting a cuff around the urethra (water-pipe) which can be inflated from a small reservoir placed in the groin and controlled by a small button in labia in women and scrotum in men.

Diagram of artificial sphincter mechanism showing cuff around waterpipe and control button

NB: It is important to note that artificial urinary sphincters are very expensive and require funding approval from your GP. If your consultant recommends this treatment an application will be made on your behalf.

Most stones in the urinary tract form in the kidney, some of which pass down the ureter (the tube that connects the kidney to the bladder) and into the bladder. Most of the stones that are small will pass on their own in the urine and will not need treatment other than pain killers. If the stone is too large to pass on its own (greater than 5mm) it may need help to be removed.

Some Investigations and Treatments in Salisbury District Hospital that you may be offered:

Investigations:

Radiological examinations to establish the size and position of the stone:
- X-ray
- CT Scan
- Ultrasound Scan
Renogaphy - to test the function of the kidney
Blood test - to test the chemistry of the blood and the function of the kidney
Urine test – to test for bacteria and blood in the urine
Stone analysis – once it is removed

Treatments

If the stone is small (less than 5mm) and any pain can be controlled, it is possible for the patient to be monitored for a few weeks to see if the stone passes on its own.
Insertion of JJ stent – A stent is a narrow tube placed into the ureter to allow drainage from the kidney when a blockage has occurred, or to aid the passage of fragments of stone once it has been broken. Therefore a stent is often inserted as part of the procedures described above. The procedure is performed under general anaesthetic using a telescope passed into the bladder via the urethra (waterpipe). Patients may need to stay in hospital overnight.
ESWL – Extra-corporeal Shock Wave Lithotripsy is available in Salisbury every month. Stones can be broken up into small fragments using vibrational shock wave energy. The procedure is performed as a day case without anaesthetic, but painkillers may be necessary. Although it can be successful, most patients require repeat treatment.
Ureteroscopy and Laser – This procedure uses a narrow telescope which is inserted via the urethra (water-pipe) into the bladder and then up into the ureter (the tube connecting the kidney to the bladder) to remove stones. The stones sometimes need breaking up and this can be done by laser. The procedure is performed under general anaesthetic and patients usually stay in hospital overnight
PCNL – Percutaneous Nephrolithotomy is the procedure used for larger stones in the kidney. It involves passing a narrow tube into the loin over-lying the kidney and passing a telescope directly onto the stone which is then fragmented and removed. A general anaesthetic is required and patients usually stay in hospital for 2 – 3 days.
Cystolitholopaxy (removal of bladder stone) – Stones can also form in the bladder, especially if there is a urinary catheter present, or they can drop down from the kidney via the ureter and become lodged in the bladder. If this occurs a cystoscopy is performed to examine the inside of the bladder and the stone broken into fragments with laser. The fragments are then small enough to pass out with the urine. The procedure is done under general anaesthetic and can be done as a day case if the patient is fit enough to go home. Sometimes bladder stones may be caused by poor bladder emptying and the operation to remove them may need to be combined with a prostate operation. If this is the case the stay in hospital is usually 1 – 2 days.
Nephrectomy (complete removal of the kidney). Although this is usually performed as the treatment for kidney cancer, if stones are large or numerous enough to cause the kidney to severely malfunction, cause infection or pain, the kidney may need to be removed. This procedure is often carried out laparoscopically (keyhole surgery) under general anaesthetic and the stay in hospital is 2-3 days. With stones that have caused a lot of infections or scarring in the kidney a laparoscopic approach may not be successful.

Prevention

A good intake of fluids is the most important preventative measure against stone formation, especially in hot weather or if you live or work in hot centrally heated buildings.

Try and drink at least 2 litres per day aiming to keep your urine a pale yellow colour. It is important to remember that alcohol has a dehydrating effect so restricting your intake will be beneficial.

Dietary advice

A normal intake of calcium found in dairy products is recommended. Restricting calcium actually increases stone formation.
Try to avoid an excessive intake of oxalate found in strawberries, beetroot, spinach, nuts chocolate rhubarb and black tea.
Meat eaters, especially if large quantities are eaten, are more prone to stone formation, so it is advisable to reduce your intake and substitute it with more fruit and vegetables.

Other kidney procedures:

Pyeloplasty - This is an operation to correct narrowing of the ureter (the tube that connects the kidney to the bladder) where it joins the kidney, if the narrowing is affecting kidney function, causing stone formation or pain.

Cancers can occur in the kidney, bladder, prostate, testes and penis. If you are concerned about cancer in any of these areas, your GP will refer you without delay to one of the consultants for specialist advice.

The most commonly seen urological cancers are:

Prostate Cancer
Bladder Cancer
Kidney Cancer

Prostate Cancer

Prostate cancer is the commonest cancer in men and about 34,000 men in the UK are diagnosed with it every year. It generally affects men over 50, and is rarely found in younger men. Approximately one half of all men in their 50s have some cancer cells within their prostate and 8 out of 10 men (80%) over the age of 80 have a small area of prostate cancer. Most of these grow very slowly and so, particularly in older men never cause any problems. The causes of prostate cancer remain unclear but it is thought that diet and ethnic race may have an influence. Men with a father or brother with prostate cancer and 50% more likely to develop it themselves.

Prostate cancer is usually diagnosed in the early stages but in 1 in 10 men (10%), the prostate cancer will be advanced when it is diagnosed.

The treatments vary depending on when the diagnosis is made but if the cancer is caught early it can be cured.

Bladder Cancer

Each year over 10,000 people in the UK are diagnosed with bladder cancer and is the fifth most common cancer. It is more common in men and rarely seen in patients under 40. The most common cause is smoking. It takes many years for the chemicals from cigarettes to cause bladder cancer. Exposure to certain chemicals used in dye factories and in industries working with rubber, textiles, paints and printing were linked to bladder cancer in the 1950s and 60s and have since been banned. However, it can take more than 25 years for the bladder cancer to develop. If you think you may have experienced this type of exposure, let your doctor know.

Repeated (chronic) urinary infections and untreated bladder stones have also been linked with a less common type of bladder cancer called squamous cell cancer.

Most bladder cancers develop in the lining of the bladder and can be managed successfully with minor surgery via the water-pipe (urethra). Following this kind of treatment the bladder will need regular inspections to check whether the cancer has returned. If the cancer has grown into the muscle of the bladder, this is more serious and will require removal of the bladder or chemotherapy and in some circumstances both treatments at once.

Kidney Cancer

Each year, about 7,800 people in the UK are diagnosed with kidney cancer. It is more common in men than women and becomes commoner as people get older.

It is rare for people under 40 to get kidney cancer but there is an uncommon type called Wilms’ tumour, that affects very young children.

Usually only one kidney is affected and it’s rare for cancer to occur in the other kidney.

Doctors don’t know exactly what causes kidney cancer and for many people the cause is never found, but a number of things are known to increase the risk of developing it.

Cigarette smoking
Being overweight (obese)
Some medical conditions, such as having high blood pressure (hypertension), may increase the risk. People with advanced kidney disease, especially those who need to have dialysis, have a higher risk of developing kidney cancer.
Exposure to certain materials at work may affect a person’s risk, such as, blast furnaces or coke-ovens in the steel and coal industries, or working with Trichloroethylene (Tric) a petroleum by-product used in the heavy engineering industry. Being exposed to cadmium, lead or asbestos at work may also increase risk.
Inherited risk. Most kidney cancers aren't inherited but occasionally, two or more members of the same family develop kidney cancer. If this happens, the other members of the family may have a higher than average risk of getting kidney cancer.

Surgery is the main treatment for kidney cancer. If all of the cancer can’t be removed by surgery, other treatments may be used such as chemotherapy.

Symptoms: What should I look out for?

Blood in the Urine (Haematuria)

The causes of blood in the urine are not always serious but they should always be investigated. Investigations include urine testing, cystoscopy (examination of the bladder with a telescope usually under local anaesthetic) and an ultrasound scan of your kidneys and bladder. The bleeding can be caused by infection or inflammation of the bladder or the presence of stones. In men it can be caused by an enlarged prostate but it can also be caused by cancer in the bladder, kidney or prostate (in men) so should not be ignored.

Urinary Symptoms in Men

Some men may experience urinary symptoms such as frequency of urination and a weak flow and should seek advice from their GP. 40% of men over 60 years of age have Benign Prostatic Hyperplasia (an enlarged prostate). Investigations will include a digital examination of the prostate via the back passage, a flow test to establish the rate of flow and a PSA (prostate specific antigen) blood test. PSA is a natural protein that leaks out of the prostate into the bloodstream and is raised; when the prostate is enlarged, in the presence of cancer of the prostate, if there is an infection, and if you have a urinary catheter. Sometimes the raised level just appears for no particular reason which may be normal for you. If the PSA is raised in the absence of infection, you will most likely be advised to have prostate biopsies to exclude the diagnosis of prostate cancer.

Other urological cancers:

Lumps in the testicles - Most lumps in the scrotum are benign and if painful are unlikely to be cancer. However, it is very important to discuss the problem with your doctor. Testicle cancers are uncommon and with correct speedy treatment more than 90% of patients are cured. It is important to remember that regular self examination is known to detect testicular cancer early and reduce the amount of treatment necessary.

Penile Cancers - These are fortunately extremely uncommon. Initial diagnosis and treatment would be at Salisbury, but any subsequent reconstructive surgery would be carried out in London.

Where will I have my cancer treatment?

Cancer treatments are given in Salisbury, Bath, Poole, Southampton and London – where you go will depend on the nature of the cancer, where it is and the recommended treatment. Following diagnosis the details will be discussed fully with you.

NB. These cancers are not infectious and cannot be passed on to other people

Sexual problems such as loss of sex drive and problems with erections are very common.

It can be very upsetting and affect your personal relationships. Embarrassment can often get in the way of seeking help.

Erectile dysfunction (impotence) is not being able to get or maintain an erection that is firm enough to have sexual intercourse. It unfortunately becomes commoner as you get older (40% or 4 in 10 men over 40) and in some men can represent early heart or vascular problems.

There are many causes of erectile dysfunction and they can be physical, psychological or both. A purely psychological problem occurs in very few men (10% or 1 in 10 men). But, psychological issues are often part of the problem. Because many different things may together cause the problem, it is important to look at the whole person when assessing and treating the condition.

Your GP may suggest several appointments to talk about the problems with you and your partner, and you may not need specialist advice or treatment. However, our urologists can help by offering a variety of tests and treatments if the problem is physical. We may recommend that you speak to a psychosexual counsellor if necessary.

Most men have a physical cause (9 in 10 or 90%). The causes are often:

Obesity, high blood pressure, high cholesterol, diabetes and renal (kidney) failure - these conditions are often found together.
Hormone problems – a fall in the production of testosterone (the male hormone) can lead to loss of libido (the desire for sex) or there can be disturbances of other hormones.
Some prescribed drugs may have side-effects that include erectile dysfunction.
Life-style factors such as stress, smoking, alcohol and recreational drug consumption.
Neurological problems (conditions affecting the brain, spinal cord and nerves).
Pelvic surgery or trauma.
Physical abnormalities - such as a tight foreskin and Peyronie’s disease (a condition that causes the erect penis to bend, making intercourse painful or impossible).

Assessment and investigations

(Usually organised by your GP but can also take place following referral to one of our urologists)

A full history including a detailed sexual history to find out why you are having problems with erections and under what circumstances. It is important to tell your GP or urologist if you have uncontrolled ejaculation before or immediately after penetration (premature ejaculation) or frequency of urination and slow urine flow (symptoms associated with the prostate) because they are often associated with erectile dysfunction.
Sexual Health in Men (SHIM) questionnaire – To help us find the causes of your condition and the best way to treat it, we may ask you to fill in a short questionnaire about your symptoms and how they affect you.
Physical examination - this will include assessment of the male genitals, pulses in your legs and nerve reflexes in your legs, penis and anus (back passage).
Blood pressure
Blood tests – to look for abnormalities in the blood such as a raised sugar level which may indicate the presence of diabetes.
Urine testing - to see if your urine contains sugar which might mean that you have diabetes.
Hormone measurements – blood levels of testosterone and other hormones that may be causing your erectile dysfunction.

Other specific tests that may possibly be arranged by the urologist include:

Ultrasound of the penis – to measure the blood flow.
Trial of injection of Caverject (a drug that is injected into the penis) – if it results in a good erection it means that the blood supply to the penis is likely to be normal.

Available treatments

Treatment of abnormality such as circumcision or penile straightening.
Treatment of any hormone abnormality (this is only indicated if your testosterone levels are low as it may be harmful if they are normal).
Lifestyle changes – such as reducing stress, stopping smoking, reducing alcohol consumption and recreational drugs.
Weight loss and increase exercise – which may reduce the risk of erectile dysfunction by up to 70%.
Psychological support.

If the above treatments or life-style changes fail to help the following may be suggested:

Prescribed drugs such as Viagra, Cialis or Levitra – These drugs require sexual stimulation to be effective and will not produce an erection without it. They will not affect your sex drive.

Warning:

These drugs should not be taken if you are taking nitrates such as GTN (or Isosorbide) for angina.
You should only take these drugs if prescribed by your GP or urologist after a full consultation and discussion about the risks and benefits. It is dangerous to get them from the internet or any other source as it is not possible to ensure the quality of medication obtained in this way.
These drugs are only only available on the NHS in certain circumstances (such as if the problem is due to diabetes, pelvic cancer, pelvic surgery or pelvic trauma, or is causing a severe psychological problem.)

Other Treatment:

If drugs are ineffective or you have side-effects other treatment may be suggested.

Penile injection to produce erections – this is a simple way of getting an erection. We will show you how to give yourself the injections and what to do if the erection stays for too long a time.
Medicated urethral system for erection (MUSE) – This involves a pellet being put into the urethra (water-pipe). It is only used occasionally today because of its limited success rate and side-effects but for some men it can be effective.
Vacuum erection assistance devices (VEDS) provide a Simple and effective way of getting an erection by drawing blood into the penis and holding it in place with a ring. It lasts for 30 - 45 minutes, is safe and has no known side-effects.
Penile Prosthesis is an artificial penile implant which is a highly effective treatment. It can be used when all other treatments have failed and there is considerable emotional distress as a result. Major surgery is needed and the operation has a high risk of complications such as infection. It is an expensive operation and your urologist will need to make a special application to your GP for funding.

1 in 7 couples in the UK are unable to have a child. In about 30% of these couples, the problem lies wholly or partially with the male partner. Urological investigation may reveal a reversible underlying cause for male infertility or sub-fertility, so full assessment by an urologist is recommended.

One of our Consultant Urologists, Mr Alister Campbell, specializes in male infertility and can offer a variety of treatments at the Salisbury Infertility Centre.

If you have been trying unsuccessfully for a baby for 1-2 years, without using contraception, you should first contact your GP for further advice. Initial investigations may reveal that fertility problems with either the male or the female partner are contributing to the problem. If specialist advice is recommended dual referral should be made to the Salisbury Infertility Clinic. The information in this website applies to the causes of male infertility and how we investigate and treat it.

As a male what should I expect when I visit my GP?

1. A full history – you may be asked about:-

Lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption)
Whether you have fathered children before.
Whether you have had previous testicular infections or operations. When you are having sexual intercourse – ideally three times per week, to coincide with your partner’s ovulation (usually between days 10 and 17 of a normal 28 day menstrual cycle).

2. A physical examination – paying particular attention to the testicles and the presence or absence of all the structures which attach to the testicles and carry sperm. Your GP will also look for evidence of enlarged, varicose veins (called varicoceles) in your scrotum. Your blood pressure is often measured as part of this examination.

3. Additional tests that may be performed by your GP:

Sperm counts – At least one semen specimen is needed for analysis
Blood tests
Hormone measurements

Other specific tests usually performed by urologists or the infertility clinic team

Chromosomal studies
Ultrasound scan of the scrotum and possibly the prostate area

In 75% of infertile men, the cause remains unexplained. It may however be possible for couples to conceive naturally, even with a low sperm count

Known causes of male infertility

1. Physical abnormalities:

Absence or blockage of the tubes that carry sperms (vas deferens) is uncommon but may be treatable. Cutting of the tubes (vasectomy) for contraceptive purposes is the most common cause of blockage. Scarring due to infection is another cause.
Varicose Veins in the testicles (varicoceles) are seen in 15% of the normal male population but up to 40% of infertile men. Surgical treatment has some effect on pregnancy rates but is usually reserved for those with symptoms, such as aching discomfort, or to improve semen quality in couples undergoing assisted conception. The NHS does not support varicocele repair for fertility reasons.
Childhood surgery, especially for undescended testicles, tescticular torsion (twisting) or hernias, may be associated with reduced fertility in later life. Patients with undescended testicles on both sides are usually infertile. If only one testicle is undescended, fertility can be normal.

2. Genetic Causes (e.g. Cystic Fibrosis, Kleinfelter's Syndrome and small deletions of the male Y chromosome) underlie male infertility in about 10% (1 in 10) of cases. These men typically have very poor sperm counts or no sperm at all. If there are no sperm, hormone measurements and chromosome tests will help to determine whether this is genetic or associated with obstruction. Unfortunately if the reason you have no sperm is genetic it may be untreatable, but if it is due to obstruction it can usually be treated.

3. Other factors

Smoking, excess alcohol consumption, tight-fitting clothes, prolonged sitting and a number of prescribed and recreational drugs (such as cannabis, cocaine), are known to be harmful to sperm.

Treatments

Many couples achieve a pregnancy whilst undergoing investigations or treatment for infertility (85% within the first year) but, for those who do not, a number of
treatments are available.

General measures

If you have poor sperm counts:

Stop smoking
Stop your recreational drug consumption
Avoid anabolic steroids (body-building drugs)
Avoid very hot baths or saunas
Adopt a healthy life-style
Review any medication that you are using with your GP

Dietary supplements for men with low sperm counts

Normal supplements of the following are recommended:

Vitamin C
Vitamin D
Zinc

Drug treatment

It is important to ask your doctor about any prescribed drugs you are taking as some are harmful to sperm e.g. Cimetidine, Calcium-channel blocking drugs and Chemotherapy.

NB: If you need to be treated with chemotherapy a sample of your sperm can be saved and frozen before you start treatment.

Surgical procedures for male infertility performed at Salisbury District Hospital:

Reversal of vasectomy – is an operation to re-join the tubes (vas deferens) that carry the sperm from the testes. The operation is performed under general anaesthetic using a microscope and is more complicated than the original vasectomy. Reversal of vasectomy is 75-90% successful in restoring sperm production if carried out less than 5 years after the vasectomy. Unfortunately, pregnancy is not guaranteed if your sperm count is low or if your sperms are of poor quality.
Reversal of vasectomy is not normally done on the NHS.
Vasovasotomy – is the name of the operation for re-joining the tubes (vas deferens) that carry the sperm from the testes. As well as reversal of vasectomy this procedure is also used to treat some other obstructive (blockage) causes of infertility.
ICSI (Intra-Cytoplasmic Sperm Injection). This is an assisted conception technique and involves direct injection, using a microscopic needle, of a sperm into a human egg (separately retrieved from the female) before replacing in the womb. Men who have very poor sperm counts can often still have sperm obtained directly from the testes or from the sperm sac (epididymis). At Salisbury we are able to obtain sperm in this way and freeze it should it be needed in the future.
Percutaneous Epididymal Sperm Aspiration (PESA). This procedure is performed under general aesthetic and involves passing a needle into the sperm sac (epididymis) and drawing sperm out through the needle. These sperm are frozen and used later for ICSI.
Testicular Excision Sperm Extraction (TESE). This procedure is performed under general anaesthetic and involves removal of small pieces of tissue from the testicle in order to investigate male infertility (loss of sperm production). Any viable sperm can be frozen and used for ICSI later.
Microdissection. This procedure is where there are very few sperm producing areas in the testicles. It is performed under general aesthetic and involves the use of a high powered microscope to find the best possible area to extract sperm.
Laparoscopic varicocele repair (repair of varicose veins in the testicle by key hole surgery). (Please see paragraph on known causes of male infertility)

A urinary catheter is a soft tube that is usually placed through the urethra (water-pipe) into the bladder to provide drainage of urine when normal bladder function is impaired. An indwelling catheter (a catheter that stays in the bladder) drains either into a bag or via a tap.

Why might I need a catheter?

Urinary retention is an inability to pass urine - it can occur suddenly or gradually over a long period of time. A catheter is usually only necessary until you have received further treatment for the problem.
Urinary incontinence (sudden involuntary release of urine) – A catheter is put in only after a full continence assessment has been made, and all other alternatives to catheterisation have been tried and found to be unsuccessful.
In severe illness to provide comfort and to allow measurement of urine output.

Other reasons that you might need a catheter in while in hospital or visiting as an outpatient:

Bladder drainage after surgery - urology surgery or after other major operations.
Bladder drainage following pelvic trauma after an accident.
Bladder treatments - some treatments require a brief insertion of a catheter in order to deliver medication directly into the bladder.
Bladder investigations: such as some x-ray examinations.

If I need a catheter, who will put it in?

A health care professional. Although it is a simple procedure this kind of catheter should only be inserted into the bladder or removed by a healthcare professional. In some circumstances a catheter is initially put in by your GP or district nurse. However, if investigations and expert urological advice are needed you GP will arrange for you to come to hospital.

Changing catheters

If it is necessary to keep your catheter in for some time it will be changed by your district nurse, normally every 10 - 12 weeks, although sometimes more frequent changes are required.

Alternative methods of bladder catheter drainage

Supra-pubic catheter (placed in the lower abdomen above the pubic bone). This may be suggested if you need to have long-term catheterisation. It is more comfortable and avoids trauma to the urethra (water-pipe) that can occur if a urethral catheter is in place for a long time. If this option is recommended you will need to have it put in in hospital under a general anaesthetic. Supra pubic catheters are usually changed by the district nurse every 10 -12 weeks. Occasionally they are inserted temporally at the time of prostate or other pelvic procedures.
If you are unable to empty your bladder properly Intermittent self catheterisation may be suggested to you as a means of draining your bladder instead of an indwelling catheter. It involves passing a catheter into the bladder yourself or with the help of your carer, waiting for the urine to drain and removing the catheter. If this is the option for you, one of our specialist nurses will teach you the technique and provide on-going support until you are confident.

Catheterisation is only recommended when absolutely necessary and after a full assessment. Whether you need one temporarily or permanently, your healthcare professional will show you how to look after your catheter and provide on-going support.

Salisbury District Hospital offers treatment to children with minor urological disorders, such as foreskin problems, undescended testicles and lumps in the scrotum. These conditions can be worrying but they often do not require immediate treatment. If they do, emergency treatment is available at Salisbury.

Children who need to come into hospital in Salisbury are treated by general urology specialists in the Children's Unit. If a child needs complex urology surgery, they are referred to the Paediatric Urology surgeons in Southampton.

Some common minor childhood urological procedures carried out in Salisbury:

Circumcision is a surgical procedure that involves partial or complete removal of the foreskin of the penis. In some boys, the foreskin will not retract by up to the age of 10. For most boys, it will loosen naturally, and circumcision is only required for medical reasons in about 1 in 100 (1%) of cases. Only occasionally does the problem continue into adulthood. For parents who are concerned about this problem a simple examination by a specialist can tell you whether surgery is required or not. NB. Circumcision for religious reasons is not covered by the NHS.
Orchidopexy (Correction of undescended testicle) - Undescended testicles occur when a testicle has not descended into the scrotum before birth. This is usually seen during a routine examination that is carried out on all new-born babies. But occasionally it can be missed until later check-ups in infancy or childhood. Occasionally, the testicle will descend after birth, but otherwise an operation will be needed ideally before the boy's second or third birthday. It is a minor procedure performed in the groin under general anaesthetic.
Lumps in the scrotum are quite common in new-born babies. They can be due to a number of causes such as a fluid-filled sac (hydrocele) or a groin protrusion (inguinal hernia). They require specialist assessment and some may need minor surgery whereas others may resolve on their own.

Emergency Treatment

The procedures described above are generally carried out routinely. Occasionally a child will need emergency treatment and the most common reason for this is testicular torsion (twisting of the spermatic cord, which cuts off the blood supply to the testicle and surrounding structures within the scrotum). Surgery is usually needed and should be carried out as soon as possible after symptoms begin. If surgery is done within 6 hours, most testicles can be saved.

When in childhood is this likely to occur?

It is more common during infancy (first year of life) and at the beginning of adolescence (puberty).

What to look out for?

Sudden, severe pain in one testicle, with or without previous trauma or infection. In older children it can occur as a result of strenuous exercise.
Enlarged testicle
Testicle on the affected side is usually higher
Nausea and vomiting
Distress

If you suspect testicular torsion, seek medical advice immediately

Other childhood urological problems:

Urinary incontinence, particularly at night (enuresis), is a problem for some children and parents often seek help. One of our urologists specializes in childhood incontinence. If you are worried about your child being incontinent, your GP may refer your child for specialist assessment and treatment.

On this website page we have covered the common urological disorders children may have. Your family doctor is there to advise you if you are concerned. If a specialist urological assessment is required, a referral will be made and you and your child will be seen in the paediatric out-patient clinic at Salisbury District Hospital.

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