What are the post-operative instructions the surgery?

What to expect after the procedure, click here.

If you would like a copy of the instructions in Spanish, click here.

If you would like a copy of the instructions in Russian, click here.

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What is the next step?

Patients are encouraged to contact Dr Karpman’s office at (650)-962-4662 to schedule an appointment to discuss the treatment options available for men interested in the penile implant procedure. You can arrange an informal short phone consult with Dr Karpman to discuss if the penile implant surgery is right for you.

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Does size matter?

Every patient asks about sizing the prosthesis. They are interested in knowing if we can increase the length of their penis simultaneously at the time of the operation or if we can place a bigger size prosthesis than their actual penis. The short answer is: No. However, there are steps that can be taken pre-operatively to increase your penile length and consequently the size of the prosthesis inserted. Dr Karpman places all of his patients on a penile lengthening protocol prior to the operation. Additional steps are taken at the time of surgery to maximize penile length.

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What is the cost of the surgery?

Patients are always surprised to learn that most major insurance carriers and Medicare will cover the entire cost of the surgery. For those patients with Medicare insurance and a supplemental plan, there are usually no out of pocket costs for the operation. The actual cost is around $8,000. There are additional costs for the hospital, anesthesia and professional services. Dr Karpman will arrange a fixed cost package for patients who require a cash rate for the operation. The cash price for the entire procedure is approximately $19,000. This price compares very favorably to other centers that offer the penile implant procedure.

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Does an implant look and feel like a natural erection?

The patient satisfaction rate in published studies of penile implant surgery is over 95% and this is largely attributed to the natural look and feel of inflatable implants. Many patients are surprised to find out that there are no external devices and that everything is concealed under the skin for discretion. Oftentimes, patients will request to see photos of previous procedures. We have included pre-operative photos, intra-operative photos and final cosmetic results of the flaccid and inflated penile prosthesis in the following section.

Flaccid Penile Prosthesis

Flaccid Penile Prosthesis

Inflated Penile Prosthesis

Inflated Penile Prosthesis

Pre-Operative Photo

Pre-Operative Photo

Immediately Post-Op Photo

Immediately Post-Op Photo

Six Week Post-Op Flaccid Photo

Six Week Post-Op Flaccid Photo

Six Week Post-Op Erect Photo

Six Week Post-Op Erect Photo

Six Week Post-Op Flaccid Photo

Six Week Post-Op Flaccid Photo

Six Week Post-Op Erect Photo

Six Week Post-Op Erect Photo

Pre-Operative Photo

Pre-Operative Photo

Immediately Post-Operative Photo

Immediately Post-Operative Photo

4 Weeks Post-Op Flaccid Photo

4 Weeks Post-Op Flaccid Photo

4 Weeks Post-Op Erect Photo

4 Weeks Post-Op Erect Photo

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Does Dr. Karpman perform the Minimally Invasive procedure?

Yes, Dr Karpman has performed both the traditional penoscrotal and the minimally invasive infrapubic approach. The preference is to always perform the minimally invasive infrapubic approach because of the small (3 cm) incision, minimal dissection required, decreased healing time and convalescence associated with the minimally invasive infrapubic approach. The surgery is done under general, regional or local anesthesia and takes 20- 30 minutes for the entire procedure. Patients are able to cycle the pump mechanism and resume normal activities faster than with the penoscrotal approach, usually returning to full sexual function in 3 weeks. Dr Karpman has trained numerous other surgeons on his minimally invasive technique and an instructional video has been developed of his procedure. You can watch a full length video of Dr Karpman performing the minimally invasive penile implant surgery:

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What types of Penile Implant is right for me?

There are three general different designs when it comes to these implants. The implants are made in a malleable form, two-piece and three-piece inflatable prosthesis. Based on manual dexterity, medical co-morbidities and previous surgeries, Dr Karpman will help select the penile prosthesis that is right for you.

The malleable prosthesis is ideal for patients with problems with manual dexterity or significant previous abdominal surgery. AMS 600 Malleable Implant
The 2-piece prosthesis is for patients with significant previous abdominal surgery but who desire a more natural feeling prosthesis than a malleable can offer. Ambicor
The 3-piece prosthesis is ideal for patients who desire a natural feeling erection. The 3-piece penile prosthesis is completely flaccid when deflated and more rigid when erect than a 2-piece prosthesis. AMS 700

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What is a Penile Prosthesis or Implant?

What is a Penile Prosthesis or Implant?

Penile implants have transformed the lives of men all over the world who live with erectile dysfunction, or ED. These prosthetic devices are placed directly into the corpora cavernosa to facilitate a full erection that is adequately rigid for penetrating intercourse. They are a safe, discreet and highly effective treatment for men with even the most severe cases of erectile dysfunction who do not respond to ED medications.

Malleable and Inflatable Penile Implants

There are two types of penile prosthetics – inflatable and malleable. Both are custom-fit to the patient and placed completely under the skin with no visible external components.

Inflatable implants are used in approximately four out of every five penile implant procedures, as they provide the most natural feeling and appearance. Two-piece implants include a pump and inflatable cylinders and require that patients gently pump the penis into an erect position and hold it in a downward position to release the erection after intercourse. Three-piece units also include an internal reservoir and valve system, which will quickly inflate and deflate by triggering the resevoir or releasing the valve.

The other type of penile implant – a malleable prosthetic – consists of a hard cylindrical implant that is placed within the penis where blood would normally flow to stimulate an erection. The implant remains firm and pliable at all times, allowing it to simply be lifted into the erect position and remain that way for any length of time. This type of implant is often recommended for patients with dexterity impediments.

High Success and Satisfaction Rates

We understand that many patients have concerns about the appearance, feel and function of a penile implant, as well as the recovery and safety of a penile implants procedure. However, penile implants carry a very high success rate and more than 95 percent patient and partner satisfaction rating. Furthermore, implants can be used on-demand, providing a far more hassle-free experience than alternative ED treatments, such as penile injections.

Inflatable penile implants are unnoticeable to others, and they will not affect the feeling of sex for either the patient or his partner. In fact, an inflated penile implant causes the penis to become thick and stiff like a natural erection without affecting sensation, orgasm or ejaculation.

Penile implants are FDA-approved and cause virtually no side effects. Implant procedures are very fast and performed using a minimally invasive technique whenever possible. This translates to a shorter recovery time and a quicker return to sexual activity after surgery. In fact, many patients who undergo penile implant surgery will return home the same day as the procedure.

Is a Penile Implant Right for You?

If you are one of the 30 million men who suffers with erectile dysfunction, treatment is available. The team here at Dr. Karpman’s office will be happy to discuss your options for treatment and answer any questions you may have about penile implants. Call us today at (650)-962-4662 to speak with one of our helpful staff members and schedule an appointment. We look forward to serving you soon.

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What is the success rate of a vasectomy reversal?

The success rate for vasectomy reversal is greater than 95% when sperm are identified at the time of surgery. The chances of finding sperm at the time of vasectomy reversal is determined by two important factors: the time elapsed since the vasectomy and the site of the vasectomy. When the time interval between the vasectomy and the vasectomy reversal is greater than 15 years, the chances of developing a secondary epididymal obstruction is approximately 70%. Also, when the vasectomy is performed low on the vas deferens then these chances are compounded. If sperm are not identified at the time of vasectomy reversal, an epididymovasostomy will be required to reverse your vasectomy. Vasectomy reversal success with epididymovasostomy is 65-70%. Regardless of the amount of time elapsed since the vasectomy, the success rate should be constant and only dependent on the type of surgery that is required.

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How is a vasectomy reversal performed?

There are two different techniques for reversing a vasectomy: vasovasostomy and epididymovasostomy. Both techniques involve bypassing the obstruction in the reproductive tract. Vasovasostomy is the preferred method of vasectomy reversal when sperm are identified in the vas deferens at the time of surgery. Epididymovasostomy is the preferred method when sperm are not seen in the vas deferens.

Vasovasostomy

Vasectomy reversal performed by vasovasostomy is done using an operating microscope that provides magnification 25 times the normal image size. This is important since the size of the vas deferens is about the same as a piece of spaghetti and should be sewn in two-layers to offer the highest pregnancy rates. Microscopic suture (10-0 nylon) unseen by the naked eye is used during the vasectomy reversal. It is important to use this fine suture to prevent leakage of sperm and to minimize obstruction of the lumen of the vas deferens by the suture itself. The cost of the suture itself is over $900 per vasectomy reversal!

The initial step during a vasectomy reversal is to identify whether or not there are sperm in the testicular end of the vas deferens. If sperm are identified, then a vasovasostomy can be performed successfully using microsurgical technique. If sperm are not identified then a secondary epididymal obstruction has developed and re-connecting the vas deferens at the site of vasectomy will universally be unsuccessful. This occurs 30% of the time and is dependent on several factors such as the time since your vasectomy and the site of your vasectomy. If sperm are not seen then an epididymovasostomy will be required in order to reverse the vasectomy. (see below) Vasovasostomy 1
The next step in a vasectomy reversal is to re-approximate the ends of the vas deferens in a tension-free manner. The 10-0 Nylon suture provides a water-tight closure for the sperm to travel through the vas deferens. If larger sized suture is used, it can cause obstruction in the vasal lumen itself. Vasovasostomy 1
The typical appearance of the vasal lumen after it has been precisely sewn together using 10-0 nylon suture. The suture is made of the finest non-reactive material to prevent scarring of the lumen after the surgery. Vasovasostomy 1
An outer layer of 9-0 nylon suture is placed to reinforce the inner layer and to relieve tension from the important inner layer. Numerous interrupted sutures are placed around the outer layer ensuring a tension-free closure. Vasovasostomy 1

 

Epididymovasostomy

Epididymovasostomy is required during vasectomy reversal when there is absent sperm in the vas deferens. This signifies that a secondary epididymal obstruction has developed upstream from the vasectomy site. This situation is encountered in approximately 40% of individuals after a vasectomy. Epididymovasostomy can only be performed using a high powered operating microscope, under general anesthesia, by microsurgeons using the finest suture (10-0 nylon).

The epididymis is opened and a single tubule is isolated to bypass the obstruction that has developed. Vasovasostomy 1
The vas deferens is then attached to the epididymis using fine sutures (9-0 nylon). This attachment brings the vas deferens into close proximity of the single epididymal tubule. Vasovasostomy 1
The single epididymal tubule is sewn to the inner lumen of the vas deferens using microscopic sutures to create a water-tight closure, similar to vasovasostomy. Vasovasostomy 1
Additional fine sutures are placed in the outer layer of the epididymis to secure the vas deferens in place and to release tension off of the fine inner sutures. Vasovasostomy 1
This final lower power image shows the relationship of the testis, epididymis and the bypass site after an epididymovasostomy. Sperm are made in the testis, stored in the epididymis and bypass the second obstruction through the bypass site. Vasovasostomy 1

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Who should perform my vasectomy reversal?

The leading reproductive society, ASRM, has issued practice guidelines stating that:

“Since it is seldom possible to determine pre-operatively if epididymovasostomy will be required in a man undergoing vasectomy reversal, only surgeons skilled in both epididymovasostomy and vasovasostomy should perform vasectomy reversal.”

It was also stated in the practice committee guidelines that the success and pregnancy rates of men undergoing micro-surgical (24 times magnification) vasectomy reversal was much higher than in men undergoing the macro-surgical technique (2.5 times magnification, Loupe assisted).

Choosing a doctor who is a fellowship trained microsurgeon will guarantee that your surgeon meets the guidelines established by the leading reproductive society in this country. Many urologists offer vasectomy reversal services, but only 1-2% of urologists hold the distinction of being fellowship trained and capable of assuring their patients that they meet the guidelines set forth by the leading reproductive society in this country.

Staff Staff

Some urologists will try to compensate for the lack of this advanced training by offering their patients seasonal specials, vacation packages or even a money back guarantee along with their vasectomy reversal. These are gimmicks! Most respectable physicians do not ethically participate in such business practices. These specials are designed to lure unsuspecting patients into a sub-optimal situation for a vasectomy reversal. It is important to remember that the ultimate goal of your process and journey is to have a natural pregnancy after your vasectomy and not receive a free vacation or cut-rate procedure. Additionally, most of these money back guarantees are designed to only give you back a small portion of your investment and not the entire amount. Read the fine print and you will see that it really isn’t a true money back guarantee!

Instead of offering gimmicks or vacation packages, we provide the highest quality service. We are so proud of our technique and quality of vasectomy reversal that every patient receives high resolution photographs of the critical steps of their reverse vasectomy procedure. We stand behind the quality of our work by providing you proof of the high quality of the procedure with actual photos from the surgery. Without these photos, patients are left wondering what happened on the inside and oftentimes only can evaluate the quality of the incision, which has no relevance to the success of the reverse vasectomy procedure.

This is why the California Vasectomy and Reversal Center is the leading vasectomy and vasectomy reversal center in Northern California. We provide our patients with the latest techniques and most sophisticated equipment when it comes to their vasectomy or reverse vasectomy procedure. We are conveniently located to all major metropolitan areas of San Jose, San Francisco, Oakland, Sacramento, Santa Cruz, Monterey, Fresno, Stockton, Santa Rosa, and Modesto. Our patients come from virtually every corner of California, Nevada, Oregon and Hawaii. Patients from Reno, Las Vegas, Portland, Bakersfield, Los Angeles, San Diego, Orange County, Riverside, Palm Springs, San Luis Obispo, Visalia and Santa Barbara have all had successful reverse vasectomy procedures performed at our center.

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More Photos of Actual Vasectomy Reversal and Reverse Vasectomy Procedures performed at the California Vasectomy & Reversal Center

Microdot Technique Vasovasostomy

The Microdot method for performing vasectomy reversal is a variation of the standard multi-layer reverse vasectomy procedure. Similar 10-0 Nylon and 9-0 Nylon sutures to microsurgical vasovasostomy are used to re-approximate both layers of the vas deferens. Microdot Technique Vasovasostomy
The microdot technique allows for easy placement of the mucosal 10-0 Nylon sutures. The microdots guarantee even placement of the mucosal sutures. Re-alignment of the vas deferens is performed during the reverse vasectomy procedure to ensure patency of the lumen of the vas deferens and to prevent long-term scarring of the vasectomy reversal procedure. Microdot Technique Vasovasostomy
Once the inner luminal sutures are tied, the knots are cut precisely. Because of the very small size of the vas deferens lumen, any redundant suture material can obstruct the flow of sperm along the vas deferens. Likewise, sperm leakage outside of the lumen can cause obstruction of the vas deferens. A water tight closure of the vas deferens mucosa prevents sperm from leaking out of the vas deferens after the procedure. Microdot Technique Vasovasostomy
The outer serosal sutures are equally important in the reverse vasectomy procedure. These sutures relieve tension off of the finer inner luminal sutures and prevent the ends of the vas deferens from separating after the reverse vasectomy procedure. Liberal placement of these outer serosal micro-sutures needs to be done under a microscope as well to ensure that the ends of the vas deferens are precisely approximated. Microdot Technique Vasovasostomy

Epididymovasostomy (LIVE – Longitudinal Intussuception VasoEpididymostomy Technique)

In those cases where sperm are NOT identified in the testicular vas deferens, an epididymovasostomy or “bypass” operation is required. The typical appearance of the epididymis many years after the vasectomy procedure. Microdot Technique Vasovasostomy
A single tubule from the epididymis is isolated for the reverse vasectomy procedure. This procedure can only be accomplished under the highest magnification and the patient laying completely still under a general anesthetic. Two microsurgical 10-0 Nylon sutures are passed through the single epididymal tubule along the longitudinal axis of the epididymal tubule, prior to opening the tubule. Microdot Technique Vasovasostomy
The abdominal end of the vas deferens is re-approximated to the serosal edge of the tunic of the epididymis. The attachment of the vas deferens to the tunic of the epididymis secures the vas deferens and allows for accurate placement of the inner mucosal sutures. Microdot Technique Vasovasostomy
The microsurgical 10-0 Nylon sutures are passed through the mucosa of the vas deferens in their corresponding locations on the mucosa of the vas deferens. Microdot Technique Vasovasostomy
The 10-0 Nylon sutures are tied creating a water-tight closure between the epididymal tubule and the mucosa of the vas deferens. The single epididymal tubule is pulled (intussucepted) into the lumen of the vas deferens. Microdot Technique Vasovasostomy
Additional microsurgical sutures are placed between the tunic of the epididymis and the outer (serosal) edge of the vas deferens. The additional microsutures on the outer layer of the vas deferens relieve the tension off of the important inner luminal sutures. Microdot Technique Vasovasostomy
The final appearance of the vas deferens attached to the epididymis at slightly lower magnification. The “bypass” procedure restores continuity of sperm flowing through the vas deferens when an obstruction or “blockage” is identified at some part of the epididymis. Microdot Technique Vasovasostomy

Vasectomy Reversal Recovery, Healing and Pictures of Incisions

Patients always wonder what the recovery process is after a vasectomy reversal and what their incisions should look like after surgery. Fortunately, vasectomy reversal is not a very extensive operation regardless of which of the two surgeries are Patients always wonder what the recovery process is after a vasectomy reversal and what their incisions should look like after surgery. Fortunately, vasectomy reversal is not a very extensive operation regardless of which of the two surgeries are not getting on a plane for 3-4 hours or sitting in the car for an equal amount of time was not a problem as soon as the day after performed. The amount of time required for surgery and the need for general anesthesia should make patients think that surgery.

Your restrictions for activity after a vasectomy reversal are designed more for the actual healing process that is on-going inside the scrotum, than the actual discomfort a patient feels. The tiny microscopic sutures are all that is holding everything together after the vasectomy reversal and it is imperative that these sutures are not disrupted while allowing the surgical site to heal. There is no good medical justification to tell patients to “take it easy” for 2, 3, 4, or 6 weeks. These restrictions are quite arbitrary and usually based on a vasectomy reversal specialist’s own experience with the healing process. We feel that patients are able to resume all of their physical activities 2-3 weeks after surgery based on our surgical technique at the California Vasectomy & Reversal Center.

Vasectomy Reversal Healing

The typical appearance of the scrotum 1 week after vasectomy reversal surgery. The vasectomy reversal recovery shows minimal if any swelling and bruising in the scrotum. The scrotal rugae or “wrinkles” are apparent and indicative of resolution.

Vasectomy Reversal Healing

Close inspection of the right wound reveals some scab formation on the incision line. The scab can liquefy and cause some staining on the scrotal support, gauze or underpants.

Vasectomy Reversal Healing

The left side has virtually no swelling or bruising. The incisions are both approximately one inch in length. Compared to the previous vasectomy incisions/scars, the wounds are bigger. Both incisions are in the spectrum of normal healing 1 week after the vasectomy reversal.

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Can a vasectomy be reversed?

Vasectomy reversal is the most cost-effective way of achieving pregnancy after a vasectomy. Whether a couples desires more children in a relationship or the desire for children in a new relationship, vasectomy reversal offers the best chance of pregnancy.

There are over 35,000 vasectomy reversals performed annually in the United States. The most common reasons for this procedure include divorce/remarriage, desire for more children in a current relationship or death of a child. Occasionally, a vasectomy reversal will be performed simply because a man has changed his mind and wishes to restore continuity of his reproductive tract or he has developed pain after his vasectomy.

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Peyronie’s Treatment with Xiaflex®

Collagenase Clostridium Histolyticum (CCH) (Xiaflex®) is the first and only FDA approved medication for the treatment of Peyronie’s disease.  Xiaflex® is indicated for men with at least 30 degree curvature in their penis with minimal or no plaque calcifications seen on penile duplex ultrasound.

In clinical studies, Xiaflex® has been shown to significantly improve the degree of curvature and bother due to Peyronie’s disease.  It is administered by Dr Karpman in the office.  The patient receives two injections per cycle approximately one week apart.  The patient returns to the clinic one week after the second injection for penile stretching and straightening.  Oftentimes, Dr Karpman will recommend a penile traction device for use 2 weeks after the final injection for further correction of the Peyronie’s disease curvature.  A maximum of 4 cycles can be done to correct the penile angulation.

Xiaflex® is covered by Medicare and most PPO health insurance plans. Dr Karpman’s office will check your insurance benefits prior to scheduling your injections so that you are aware of any out of pocket costs for the procedure.

Patients who receive Xiaflex® are not allowed to have sex or masturbate for 2 weeks after the final injection.  Penile fracture has occurred in clinical studies in men who had sex within 2 weeks of their final injection.  The actual incidence of this occurrence is very low and listed below.

Below are pictures of a patient before and after Xiaflex® treatment.

IMG_1443              post Xiaflex 1

 

          Before                                                                 After      

WARNING: CORPORAL RUPTURE (PENILE FRACTURE) OR OTHER SERIOUS PENILE INJURY IN THE TREATMENT OF PEYRONIE’S DISEASE

Corporal rupture (penile fracture) was reported as an adverse reaction in 5 of 1044 (0.5%) XIAFLEX-treated patients in clinical studies. In other XIAFLEX-treated patients (9 of 1044; 0.9%), a combination of penile ecchymoses or hematoma, sudden penile detumescence, and/or a penile “popping” sound or sensation was reported, and in these cases, a diagnosis of corporal rupture cannot be excluded. Severe penile hematoma was also reported as an adverse reaction in 39 of 1044 (3.7%) XIAFLEX-treated patients.

Signs or symptoms that may reflect serious penile injury should be promptly evaluated to assess for corporal rupture or severe penile hematoma which may require surgical intervention.

Because of the risks of corporal rupture or other serious penile injury, XIAFLEX is available for the treatment of Peyronie’s disease only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the XIAFLEX REMS Program.

Erectile Dysfunction FAQ

Erectile dysfunction (ED) is defined as the inability to attain or maintain an erection of satisfactory quality to complete intercourse. It is sometimes referred to as impotence. The degree of ED can range from mild cases where there is a slightly diminished rigidity in the penis to severe cases where a man is unable to attain any erection.

We know that the incidence of ED increases with age and that approximately 25 million Americans suffer from this condition making it one of the most common sexual problems in men. The incidence in 40 year olds is around 5-10% and increases to 25-30% in 65 year old men. Some studies have shown that up to 50% of men over the age of 50 have ED.

How Does an erection occur?

The penis is an organ made up of two chambers called the corpora cavernosa that run along the full length of the penis. These chambers are filled with a spongy tissue made up of smooth muscle that becomes filled with blood, expands in size and becomes firm. The corpora are surrounded by tough connective tissue called the tunica albuginea.

Penile Anatomy

Cavernous Nerve AnatomyNormally functioning nerves are also important for an erection. These nerves originate from the spine and run along the prostate until they reach the penis. These nerves give the penis the signal to start an erection.

An erection is a very complex process involving coordinated normally functioning arteries, veins and nerves. In addition to the above, an normal erection also requires a normal level of testosterone. Adequate sensory stimulation from the brain is important for the initiation of an erection.

Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa. The vast majority of cases of E.D. have an organic etiology. Organic causes of E.D. account for 90% of cases of this condition.

Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is alcoholism, multiple sclerosis, atherosclerosis, high blood pressure, vascular disease, and neurologic disease—account for about 70 percent of ED cases. Between 35 and 50 percent of men with diabetes experience ED. Damage to the nerves causing erection can occur with prostate, colon or pelvic surgery or radiation.

The choices we make in life can lead to degeneration of the erectile tissue and the development of ED. Smoking, drug or alcohol abuse, particularly over a long period of time, will compromise the blood vessels of the penis. Lack of exercise and a sedentary lifestyle will contribute to the development of ED. Correction of these conditions will contribute to overall health and may in some individuals correct mild ED. Treatment of many medical conditions can interfere with normal erections. Drugs used to treat these risk factors listed above may also lead to or worsen ED.

In addition to understanding the causes of E.D. it is also important to recognize that E.D. may be an early warning sign of more serious medical conditions such as atherosclerosis and heart disease. Emerging research has shown us that up to 50% of men with isolated E.D. as their only symptom will go on to develop heart disease or atherosclerosis in the subsequent 5 years. In essence, we need to look at E.D. as an early warning sign for a much more serious condition and not only treat it as an isolated symptom.


How is erectile dysfunction (E.D.) diagnosed?

This dysfunction is diagnosed by taking a thorough history and performing a physical examination. Your doctor might ask you to fill out a questionnaire to better evaluate the degree of erectile dysfunction. Laboratory tests include hormonal evaluation, PSA, and possible cardiac profile testing. Your doctor might recommend evaluating the blood flow in your penile arteries using a Doppler Ultrasound. This is a non-invasive test , however, the test needs to be performed with a flaccid and erect penis and this can only be accomplished by injecting a medication into the penis causing an erection. This is done with a tiny diabetic needle. Additional testing with biothesiometry, corpus cavernosometry and cavernosography, nocturnal penile tumescence and angiography is only recommended in select situations.


How is erectile dysfunction (E.D.) treated?

There are several treatment options available for men with E.D. Dr Karpman will discuss any and all available treatment options. A treatment plan will be tailored to every individual’s needs. The optimal goal is to provide the least invasive yet most effective treatment that reliably delivers a firm and solid erection that is adequate to have penetrating intercourse of adequate duration to satisfy both you and your partner. The treatment options include:

  • Oral medicines (Viagra, Cialis, Levitra)
  • Penile Rehabilitation
  • Hormonal Therapy
  • Urethral Suppositories (Muse)
  • Vacuum Erection Device (VED)
  • Penile Constriction Bands
  • Penile Injection Therapy (Bimix, Trimix)
  • Penile Prosthesis / Penile Implant


Are there any natural alternatives to E.D. treatment?

There is a list of over-the-counter medications that have been shown to be successful to some extent in treating erectile dysfunction. It is important to note that any neutraceutical (herbal, over-the-counter) treatment is not evaluated or approved by the FDA and therefore not subject to the scrutiny that prescription medications must undergo in terms of substantiating claims made by the manufacturers or in quantifying the purity of these products. Use of these alternative medications is at your own risk.

Arginine

This is a precursor amino acid to nitric oxide. Human clinical trials have yielded mixed results. Up to 40 % of patients in one trial reported improvement in results, whereas other trials have shown no improvement. It appears more effective in ED patients with alterations in endothelial L-arginine-NO activity and a reduction in NO availability.

Yohimbine

This is a centrally acting alpha-2 antagonist which causes a reduction in brain norepinephrine levels. Human clinical trials have yielded mixed results. A randomized double blind placebo controlled crossover study showed that 14% of the treatment group experience full-stimulated erections and 20% had a partial response.

Panax ginseng

This is found to possess antioxidant and organ-protective action associated with enhanced NO synthesis in the endothelium of the corpus cavernosum. Ginsenosides have been shown to cause a dose-dependent relaxation of the corpus cavernosal smooth muscle in rabbits by increasing release of NO. A double blind placebo controlled crossover study showed significant improvements in IIEF scores and penile tip rigidity by Rigiscan.

Maca

This is a root vegetable cultivated in the central Peruvian Andes that belongs to the mustard family. Dried Maca root is rich in amino acids, iodine, iron and magnesium. This also an aphrodisiac with fertility enhancing properties. There is only one human randomized double blind placebo controlled trial published in a Peruvian journal. This root improved subjective evaluation of sexual desire in treated men. No other information was attainable.

Ginkgo biloba

Used to ameliorate antidepressant-induced sexual dysfunction. Initial open label human trials showed it to be 76% effective in alleviating symptoms related to all phases of the sexual response cycle in men, including erectile function. However, a subsequent double blind RCT reported no significant difference in sexual function between ginkgo and placebo.

DHEA and Tribulus terrestris

Inverse relationship between DHEA and ED has been well established in the Massachusetts Male Aging Study. A double blind RCT in humans using DHEA 50mg has shown an improvement in achieving and maintaining erections sufficient for satisfactory sexual performance compared to placebo. However, a small sample size made conclusions from this study difficult. An extract called protodioscin extracted from Tribulus terrestris plant improves erectile function, increases sexual function and improves sexual behavior. Most of this information comes from Hungary and is published in small journals.

Inflation and Deflation of Penile Implant

Video demonstrating inflation and deflation of an inflatable penile prosthesis:


Male Incontinence

Definition and Incidence

Male urinary incontinence is an oftentimes overlooked and underdiagnosed problem. Recent reports have shown that as many as 9-13% of American men suffer from urinary incontinence. Urinary incontinence is not a disease or a normal consequence of aging, therefore, most cases can be cured or improved. It is a symptom with many causes and is the medical term used to describe the condition of not being able to control the flow of urine from your body. It usually happens because the bladder sphincter is damaged or scarred and cannot squeeze or close off the urethra. This means urine can leak or flow freely from the bladder.


Physiology

Male continence is maintained by two sphincters: internal and external. The internal sphincter is part of the bladder neck and is under involuntary or reflex control by higher centers of urination in the brain. The external sphincter, which is part of the pelvic floor muscles, is a voluntary sphincter and is actively relaxed at the time of urination. Oftentimes, the internal sphincter is removed or damaged as is the case during radical prostatectomy or bladder neck surgery such as TURP. In these situations the man must rely entirely on the external sphincter to maintain continence. Unfortunately, the external sphincter may be damaged as well during these same types of surgeries rendering the patient incontinent.

Male Anatomy


Classification and Causes of Male Incontinence

Male urinary incontinence can be classified into 4 different categories:

  • Stress Incontinence
  • Urge Incontinence
  • Mixed Incontinence
  • Overflow Incontinence

Stress Incontinence – Occurs when you leak urine during physical activity such as exercise, walking, lifting, coughing and sneezing.

Urge Incontinence – Occurs when you have an overwhelming need to urinate and are not able to hold urine long enough to reach the toilet.

Mixed Incontinence – A combination of stress and urge incontinence, where you have symptoms of both conditions.

Overflow Incontinence – When your bladder never completely empties which causes urine to leak. This type of incontinence is found in men with prostate enlargement, scars/strictures of the urethra or bladder neck and can also be due to dysfunctional bladder function, as seen in diabetic patients.


Diagnosis of Male Urinary Incontinence

Diagnosis of the specific type of incontinence in men can be more complex than in women. The typical evaluation includes a detailed medical history and physical examination. Sometimes your physician will request a voiding diary or pad weight log to determine the nature and degree of incontinence. It is important to rule out simple causes of male urinary incontinence such as urinary tract infection with a formal urine culture, non-invasive flow rate and residual urine measurement. Additional testing should include complex urodynamics and cystoscopy.


Treatment Options for Male Urinary Incontinence

Voiding regimen, and is typically recommended for the frail and elderly. Bladder retraining is a way men can go to the bathroom at specific times in the day where times can gradually be extended to longer intervals. This type of therapy is effective in treating urge and mixed incontinence.

 Pharmacological – Depending on symptoms, medications can be given to help men with incontinence. Anticholinergic agents can be used as first-line treatments for urge incontinence because they inhibit detrusor contraction, and may help increase bladder capacity. Stress incontinence is typically treated with surgery.

Biofeedback/Electrical Stimulation – Biofeedback/Electrical Stimulation is practiced to help people gain awareness and control of their urinary tract muscles. The principle of biofeedback is simple: a variety of instruments are used to record small electrical signals that are given off when specific muscles are squeezed to urinate. These muscle squeezings are then converted into audio (hearing) and/or visual (seeing) signs that patients can recognize and learn in order to control muscular activity. With biofeedback, weak muscles can be better activated on demand, overly tense muscles can be relaxed and overall muscle activity can be coordinated.

Surgical Options – Surgical procedures are available to treat male urinary stress incontinence.

  • Injections of bulk – producing agents, such as collagen, into the urinary sphincter.
  • Implanting a “male sling,” a device designed to support the muscles around the urethra. The AMS AdVance™ Male Sling System and the Virtue™ Male Sling are highly effective, minimally invasive procedures to correct mild to moderate stress urinary incontinence.

Advanced Male

  • Implanting an artificial urinary sphincter, which mimics the function of a normal, healthy urinary sphincter. Currently the only artificial urinary sphincter available, the AMS 800™ Urinary Control System is an effective solution for moderate to severe stress urinary incontinence following prostate surgery.

AMS 800 Urinary Control System


How do I contact a male urinary incontinence specialist?

Patients are encouraged to contact Dr Karpman’s office at (650)-962-4662 to schedule an appointment to discuss the treatment options available for men interested in male urinary incontinence treatment.

Penile Prosthesis And Implant Surgery FAQ

san jose penile implant

Warning – Prior to viewing these links, please be advised that explicit pictures may be shown.

The penile implant has been a mainstay of treatment for erectile dysfunction for over 30 years. There have been over 300,000 of them inserted worldwide allowing surgeons to offer this form of therapy with the confidence of knowing that penile implants are a safe, reliable and effective way of treating even the most severe cases of erectile dysfunction (ED). The implants have a greater than 95% patient and partner satisfaction rating.

Peyronie’s Disease

Peyronie’s Disease is the presence of excess collagen formations (often called plaque) that affects the erectile bodies of the penis. The fibrotic lesions reduce penile tissue elasticity and can result in penile curvature, painful erections, constrictions (hour-glass deformity), loss of length or girth and erectile dysfunction. The prevalence of PD is reported as high as10% of the male population with a slightly increasing incidence with older age.  Men who have undergone radical prostatectomy procedures for prostate cancer are at higher risk of developing Peyronie’s disease with reports as high as 20%.

A man’s initial response to palpating a hard nodule on the penis can cause a lot of anxiety and concern about a possible malignancy. Patients can easily be reassured by their physicians that Peyronie’s plaques are benign lesions and are only associated with sexual dysfunction.

Trauma to the penis is one of the most common causes of PD and can result during regular sexual intercourse when the penis bends or is struck severely, leading to scar tissue formation or plaques. These plaques can decrease normal tissue elasticity with the resultant changes in penile appearance. Genetics can predispose patients to PD. The presence of a family member with PD or other fibrotic tissue disorders such as Dupuytren’s contracture or plantar fibromatosis is associated with this condition. Medications belonging to certain drug classes have been reported to cause PD. Beta-blockers, anti-seizure medication (phenytoin) and certain supplements such as glucosamine / chondroitin or large doses of vitamin C are associated with PD.

Treatment options for patients with PD are various and depend on the degree of curvature and sexual disability in the individual patient. Many proven and unproven treatments exist. Your physician will determine which treatment option is appropriate for you. Treatment options found to be beneficial include:

  • Penile Plication – the penis is straightened by placing some plication sutures in the tunic of the corpora cavernosa
Penile Plication Before

Before

Penile Plication Affter

After

  • Penile Grafting – the penis is straightened by excising the plaque and placing a graft material over the defect
Penile Plication Before

Before

Penile Plication Affter

After

  • Penile Prosthesis and Modeling – the penis is straightened by placing a penile prosthesis and modelling the penis over the prosthesis. This is the treatment of choice for men with Peyronie’s Disease and concomitant erectile dysfunction (E.D.)
Penile Plication Before

Before

Penile Plication Affter

After

  • Penile Prosthesis and Penile Plication/Grafting – in cases of severe Peyronie’s Disease associated with erectile dysfunction, a combination of penile implantation and penile plication/grafting is required to achieve a good functional and cosmetic result.
Penile Plication Before

Before

Penile Plication Affter

After

Dr. Karpman will evaluate the degree of penile deformity and recommend treatment options. You are encouraged to bring in photographs taken from the best angle demonstrating the degree of the penile deformity to your appointment. These images will also be used as a baseline to assess the degree of improvement after therapy.

Prostate Disease (BPH)

What is BPH?

BPH is an acronym for the condition known as Benign Prostatic Hyperplasia or what is commonly referred to as prostate enlargement. Oftentimes, patients confuse BPH with prostate cancer. As the name of this condition implies this is a benign condition and is not associated with malignant or cancerous prostate conditions.  The symptoms of BPH include slowing of the urinary stream, frequent urination, getting up at night to urinate, incomplete emptying of the bladder, urgency to urinate, hesitancy during urination and post void dribbling.

The Greenlight laser XPS/Moxy procedure is the latest and most sophisticated procedure for the treatment of enlarging prostate symptoms. Patients can experience the same excellent results that the traditional TURP procedure gives them with significantly fewer side effects. The procedure can be done on an outpatient basis and men can return to their normal activities sooner than with the TURP procedure.

Many men are concerned about any procedure on their prostate because they often confuse the risks of removing their entire prostate (radical prostatectomy) with this minimally invasive Greenlight Laser procedure. Instead, they opt to stay on medications that are associated with recurring costs, risks and only show minimal objective improvements in urination. Inadequate treatment of a man’s BPH symptoms with medications can lead to serious irreversible bladder and kidney damage.

Greenlight Laser Enucleation of the Prostate (GLEP or GreenLEP procedure)

The most effective way to treat enlarged prostates or severely large prostates is with an enucleation procedure.  GreenLight Laser Enucleation of the Prostate (GLEP) is a technique performed by Dr Karpman that ensures that the maximum amount of tissue overgrowth can be removed.  Dr Karpman’s technique is internationally recognized and has been published in the urologic literature.  This technique will give patients the most durable result compared to any other minimally invasive procedure your surgeon can perform.  The following is an instructional video of the actual GLEP procedure.

 

Aquablation of the Prostate

A new minimally invasive procedure called Aquablation of the prostate has gained FDA approval in December 2017.  Aquablation is a minimally invasive procedure that is image guided and driven by robotics.  Dr Karpman has been involved with the development of this technology since the earliest days.  Aquablation provides patients an effective way to remove tissue caused by the adenoma without using heat sources.  A pressurized water beam driven by a computer can precisely remove the majority of adenomatous tissue causing a patient’s urinary symptoms.  The following video demonstrates a real Aquablation procedure.

Aquablation 480p

Urolift

A minimally invasive procedure called Urolift has recently received FDA approval and has become available for patients in the United States.  Urolift is a 10 minute procedure that can help men suffering from BPH symptoms relieve their symptoms if they have the right prostate geometry.  Urolift is the only BPH surgical procedure that does not affect a man’s ejaculatory function, preserving the fluid that normally is released during climax.

The following pictures represent the typical appearance of the prostate before and after the Urolift procedure.  The tissue is retracted out of the urethral lumen decreasing the impedance of flow in the prostatic urethra.

 

Urolift BA photos

Testosterone Deficiency
Testosterone Replacement

Testosterone Deficiency

The disease state of low testosterone is referred to by many different names such as hypogonadism, andropause and androgen deficiency in the aging male (A.D.A.M.). These terms are oftentimes used interchangeably and create confusion even amongst healthcare professionals. All of these terms refer to a condition of low testosterone that is associated with other symptoms. Some of the signs and symptoms include a decreased sex drive, fatigue, erectile dysfunction, falling asleep after dinner, memory and concentrating difficulties, bone density loss and diminished work performance. Oftentimes these symptoms are overlooked or attributed to some other condition such as normal ageing. Effective therapy for testosterone deficiency exists.

Why is my testosterone level low?

It is a well known fact that a man’s testosterone level begins to decline as early as the age of thirty (30). In fact, large longitudinal population studies have shown that a man’s tetsosterone decreases by approximately 1% per year after the age of 30. The incidence of low testosterone has been reported to be around 40% in men over the age of 45. Similar to when a woman goes through menopause, men go through andropause but at a much slower rate. Consequently, many of the symptoms associated with this condition can be insidious.

What are some other conditions associated with Hypogonadism?

Certain common conditions are frequently associated with low testosterone. The following table lists some of these conditions.

Ageing Metabolic Syndrome COPD/Sleep Apnea
Obesity Kidney Disease Stress
Diabetes Mellitus HIV/AIDS Chronic Infections
Chronic Opiod Use Sickle Cell Disease Medications

 

Alerting your physician to any of the symptoms asssociated with low testosterone is important. A health inventory questionnaire called the A.D.A.M questionnaire was designed to identify patients who potentially might have low testosterone levels. If you answer yes to any three questions or to any single sexual question, there is a strong possibilty that you have a low testosterone level. Your physician will order confirmatory lab tests prior to commencing any therapy.

What types of treatment options are available for men with low testosterone levels?

There are a variety of treatment options available for the man with low testosterone levels. Currently, there are oral, buccal, transdermal gels, patches, intramuscular injections and subcutaneous pellets available to treat hypogonadism. Each form of therapy has specific advantages and disadvantages associated with it. You can discuss with your physician which form of therapy is right for you.

One of the long-term treatment options is the insertion of subcutaneous pellets called Testopel®.  This is done with a short 3 minute procedure in the office every 4 months for most patients.  Current Medicare guidelines allow us to only place enough Testopel pellets to last 3 months in Medicare patients.  The following is a video of Dr Karpman doing the Testopel procedure.

What are the risks of testosterone replacement therapy?

In general, testosterone replacement therapy is very safe, after all, nobody ever tells a young man with a healthy testosterone level that he is in any danger and it should be reduced to a lower level. Why should any man be told that testosterone replacement therapy (TRT) is dangerous for him when his counterpart of equal age, but normal testosterone level, is not told that he might be in danger with such a high testosterone level?  People oftentimes confuse the difference between replacing testosterone in the body to return it to normal physiologic levels with taking testosterone to achieve “super-physiologic” levels for performance enhancement. These are clearly two different situations.

Recently, there has been a new concern over possible cardiovascular complications such as heart attack, stroke and death with TRT based on 2 severly limited and flawed studies published in the medical literature.  First, these two studies were retrospective database studies and not prospective randomized controlled studies as one would expect of such headline-grabbing results we have seen in the popular press.  Both studies had significant limitations in the their ability to reach the conclusions they made in their papers.  The Vigen et al paper had two revisions after the paper was initially published because of errors and omissions. The biggest error was the conclusion that TRT increased the “absolute rate” of these adverse events from 19.9% in the untreated group vs 25.7% in the testosterone treated group.  This is not true.  The absolute rate was actually 21.2% in the untreated group vs 10.1% in the testosterone treated group.  Their conclusion was only obtainable after doing highly complex and not validated statistical methodology that increased the the percentage of events in the testosterone treated group 3-fold!  This paper now becomes an example of how misleading statistics can make any outcome seem even when the “actual” data reflects a different conclusion.  This highly talked about paper was also flawed by excluding men who were not on TRT and had an adverse event, but were subsequently started on TRT.  These men should be included in the untreated group.  Finally, they accidentally included 10% of the dataset that were women in an all male study.  Because of this, a group of international testosterone replacement experts started the Androgen Study Group to educate the public and combat misinformation in the press.

The other concerns about testosterone replacement therapy are related to prostate health and the development of prostate cancer. Some hypogonadal men might notice a slight worsening of their urinary symptoms or increase in their PSA. This occurs because the prostate and PSA are directly controlled by testosterone. Replacing testosterone into the normal range only increases urinary symptoms and PSA into the range where they would be if the testosterone level was not low in the first place. Men with testosterone levels in the normal range (300-1000 ng/dl) are at no greater risk of developing prostate cancer than their hypogonadal counterparts. Hypogonadism is not only NOT protective against prostate cancer, there is some evidence to suggest that hypogonadal men might develop a more aggressive form of prostate cancer. The risks of osteoporosis and fractures are reduced in men on testosterone replacement therapy.

Vasectomy Procedure 

Frequently Asked Questions

What is a vasectomy?

Vasectomy is the most common form of surgical sterilization performed in the United States. Approximately 600,000 vasectomies are performed annually. It is a procedure done to surgically sterilize the male. Once a vasectomy has been successfully completed and the semen has been confirmed to be absent of any sperm, then the couple can enjoy intercourse without the fear of having an unwanted pregnancy. Vasectomy is 99.9% successful.

How is a vasectomy performed?

Vasectomy is usually performed in the doctor’s office using a local anesthetic. Only in rare instances will the vasectomy have to be performed in the operating room. Vasectomy is performed through a small opening in the scrotal skin. The skin is anesthetized with a local anesthetic similar to when you have a medical procedure. The vas deferens, the tube carrying sperm from the testicle to the penis, is isolated. The vas deferens is tied usually in two locations and a small segment of the vas deferens is cut out. The small opening in the scrotum is then closed. The entire procedure takes less than 20 minutes.

What is a no-scalpel vasectomy (NSV)?

No-scalpel vasectomy refers to a special technique of vasectomy where the scrotal skin is not cut with a scalpel. Instead, a fine pair of instruments is used to create an opening in the scrotum. The remainder of the procedure is similar to a conventional vasectomy. The advantages of a no-scalpel vasectomy have been reported to be decreased pain at the vasectomy site and decreased chances of bleeding. There is a big psychological advantage to the patient knowing that a scalpel will not be used. Most male reproductive surgeons are well trained to perform this type of procedure.

The following video is a full length unedited video of a NSV procedure performed at the California Vasectomy & Reversal Center by Dr Edward Karpman.

What is a no-needle vasectomy (NNV)?

No-needle vasectomy refers to a technique of performing vasectomy where the local anesthetic is delivered through a jet anesthetic device avoiding the use of a needle. This device delivers the same type of anesthetic that a regular vasectomy receives. The transient discomfort of placing a needle into the scrotal skin is alleviated.

How long is the recovery after a vasectomy?

Usually, the recovery after vasectomy is very short. Oftentimes your physician will recommend light activity for 1-3 days after the procedure. Most people are able to return to work the next day, especially if they have a sedentary job. Some people prefer to have the procedure performed on a Friday and rest throughout the weekend.

Will my vasectomy be covered by my insurance?

Most insurance companies will cover the total or partial costs of a vasectomy. It is cheaper for the insurance company to pay for the vasectomy than it is to pay for another pregnancy. Even if your insurance carrier does not cover the costs of a vasectomy, most male reproductive surgeons will perform this procedure for under $1000. Considering the cost to raise a child per year is approximately $10,000, vasectomy is a very affordable option.

What are the alternatives to vasectomy?

There are many different options for male contraception, however, none of them are as reliable as a vasectomy. Unfortunately, a reliable male contraceptive pill is not available. A couple can choose to use condoms. These come in various sizes and sexually transmitted diseases. Condoms can break and they must be applied every time prior to intercourse. Many men report decreased satisfaction during sexual intercourse when they wear a condom. Also, care must be taken not to use a latex condom in couples who have latex allergies. The “withdrawal” method/coitus interruptus or the timing method are other techniques used to prevent pregnancy. These techniques are not reliable and are associated with unacceptable pregnancy rates.

Female contraception includes birth control pills, spermicides, sponges, intra-uterine devices, implantable hormone pellets, and tubal ligation. Birth control pills and implantable hormone pellets are reliable forms of contraception but increase the woman’s risk of multiple medical problems such blood clots and cancer. Spermicides and sponges can be irritating to both the male and female partners. Intra-uterine devices can migrate out of position and require a small office procedure to place them by a physician. Tubal ligation is an operation that must be done under general anesthesia and requires abdominal surgery.

Should I freeze sperm (cryopreserve) prior to my vasectomy?

Most people who wish to have a vasectomy are sure that they do not want to have any more children in the future. Any doubts about their decision to have a vasectomy can be alleviated by knowing that they have two very important options. The first is to freeze some sperm prior to the vasectomy. This can be arranged by your physician. Sperm can be frozen for many years. The latest successful pregnancy after using frozen sperm is 28 years. The other option is to have a vasectomy reversal. This procedure surgeon. Vasectomy reversal has been successfully accomplished up to 30 years after a vasectomy. How soon can I have unprotected intercourse after my vasectomy? Normally, your physician will require proof that your vasectomy is successful prior to authorizing unprotected intercourse. This is usually determined by demonstrating two semen samples without any sperm. It can take up to 24 ejaculates to clear all of the sperm downstream from the vasectomy site. Your physician will arrange the timing for your semen analysis. It is important to remember that vasectomy does not protect you from sexually transmitted diseases. Other precautions are required in these situations.


Vasectomy Incision Pictures

The following pictures demonstrate the general healing process immediately after the the vasectomy. Dr Karpman uses a No-Scalpel Technique with tiny “keyhole” openings through which the procedure is performed. Typically, maximal swelling is seen 48-72 hours after the procedure and maximal bruising is seen 4-5 days after the procedure.

Day 1 Pictures immediately after vasectomy procedure. Two small openings performed high on the scrotum using a no-scalpel vasectomy technique. Vasectomy incision Day 1 Vasectomy incision Day 1
Day 2 Incisions are clean and dry. Minimal swelling, no bruising. Vasectomy incision Day 1 Vasectomy incision Day 1
Day 3 Maximal swelling is seen approximately 48 hours after the procedure. Minimal swelling is seen in these pictures. Slight bruising is seen above the left incision on the left photo which is normal. Vasectomy incision Day 1 Vasectomy incision Day 1
Day 4 The swelling usually begins to subside at this point. Incisions have two small scabs. Bruising seen over the left incision is not progressing. Vasectomy incision Day 1 Vasectomy incision Day 1
Day 5 Swelling has completely subsided. Maximal bruising is usually seen at this point after the vasectomy. The bruising remains small and confined to just above the left incision. Vasectomy incision Day 1 Vasectomy incision Day 1

Vasectomy Reversal FAQ

san jose vasectomy reversal

Frequently asked questions about vasectomy reversal

Vasectomy Reversal

Additional Information

NEW: Video of Dr. Karpman performing a microsurgical vasectomy reversal (vasovasostomy). Click the image below.

NEW: Video of Dr. Karpman performing a microsurgical vasectomy reversal (epididymovasostomy). Click on the image below.

 

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