Microsurgical denervation of the spermatic cord

A 30 year old gentleman came with orchalgia on left side.He underwent multiple tests and took multiple medications but without any benefit.He had consumed several antibiotics including anti-tubercular drugs,hetrazan course,painkillers,nerve modulators,anti-epileptics but the pain persisted. 

We find several such patients in practice and the general view amongst the consultants about chronic idiopathic orchalgia has been very pessimistic.

There is even one joke circulating amongst doctors that the best revenge that a doctor can take over his  adversary is by referring a case of chronic orchalgia to him.But jokes apart; the treatment has been less fruitful and the patients agony continues while he visits multiple doctors.They even try alternative medicines  like acupressure,naturotherapy etc etc.

There is a recent interest in microsurgical denervation of the spermatic cord in refractory orchalgia.

We routinely do this microsurgical denervation in refractory cases with reasonable success.

Anatomic considerations:

 The classic and memorable description of the contents of spermatic cord in the male are:

• 3 arteries: cremasteric artery, deferential artery, testicular artery;
• 3 nerves: genital branch of the genitofemoral nerve (L1/2), autonomic and visceral afferent fibres, ilioinguinal nerve (N.B. outside spermatic cord but travels next to it)
• 3 fascial layers: external spermatic, cremasteric, and internal spermatic fascia;
• 3 other structures: pampiniform plexus, vas deferens (ductus deferens), testicular lymphatics

Pathophysiology behind orchalgia:

Orchalgia can occur because of plasticity of nerves...ilioinguinal,genitofemoral nerves or other nerves embedded in the fasciae surrounding the structures in the spermatic cord.There is a chonic upregulation of the central and peripheral nervous pathways .There is an altered function,gene expression,chemical receptors profiles and the structure leading to orchalgia.Its similar to pain syndromes like trigeminal neuralgia,interstitial cystitis etc.

Various reasons are flouted..

like chronic orchalgia from infection can lead to neuralgia even after the eradication of the infective pathology and nerve entrapment either due to previous surgical scars.or hernia.

How we go about it:

We routinely give a spermatic cord block with bupivacaine to see whether the pain eases off.If the pain subsides to a significant amount then we assume that the permanent denervation is going to be succeeded.

 

How is the procedure to be performed?

We use microsurgical method.The incision is inguinal or subinguinal but prefer inguinal as the anatomy of the cord is easier to understand.

The magnification that we use is 10-15 x.The cord is isolated over a penrose drain.We classically carry out " stripping of the spermatic cord".

All structures...vas deferens,testicular arteries,lymphatics are preserved.The rest of the structures .. all fasciae,nerves and even the adventitia of the vas are stripped.All these structures are denuded and the final structure should appear as the one containing one or two arteries and vas only.

BLOOD IN URINE

DEFINITION OF BLOOD IN URINE:

• Blood in urine is called as hematuria in medical terms.
• It is defined as the presence of Red blood cells in the urine.
• It can occur from any part of the Urinary tract Kidney, Ureter, Bladder or urethra in Men, Women and Children.

Functions of  

• Kidney: Filters blood and excretes harmful substances.
• Ureters: Transport the Urine from the Kidney to the Urinary Bladder.
• Urinary Bladder: Stores the Urine.
• Urethra: Expels the Urine from the body.

TYPES OF HEMATURIA 

• They are two types of hematuria 
• Gross Hematuria is blood in urine Visible to the naked eye. 
• Microscopic Hematuria is blood in urine only visible under microscope.

PREVALENCE OF HEMATURIA

• Blood in Urine is present in up to 16% of people in the general population. 
• It can occur in any age group but it is more common in older males and females. 

CAUSES OF HEMATURIA IN CHILDREN

• Kidney Inflammation also called Nephritis. 
• Urine Infection. 
• Urinary Stones. 
• Cancer of Kidney and Bladder 

CAUSES OF HEMATURIA IN YOUNG ADULTS

• Kidney and Urinary Tract Infection. 
• Kidney Stones. 
• Inflammation of the Urethra. 

CAUSES OF HEMATURIA IN YOUNG ADULTS 

• Long-distance runners are especially prone to exercise-induced urinary bleeding.
• The condition is called jogger's hematuria. But anyone who works out strenuously can develop symptoms. 

Honeymoon Cystitis:

• It is a Urinary tract Infection that occurs following a Lady's First Sexual Intercourse Which Traditionally Occurs on the Wedding night.
• It is a Urinary tract Infection that commonly occurs following a Lady's First Sexual Intercourse after marriage.
  
  

CAUSES OF HEMATURIA IN MALES

• Enlarged Prostate and Prostate Cancer.
• Kidney, Ureter and Bladder Cancer.
• Stones in the Urinary Tract.
• Bacterial and Tuberculous Infection. 

OTHER CONDITIONS MIMICKING BLOOD IN URINE

• Certain food like blackberries and beet root can turn the Urine red. 
• Medications such as Rifampicin and Pyridium can turn the Urine Red. 
• Poisoning from Lead can also make the urine Red. 

BLOOD IN URINE

• Blood in Urine can be detected in routine testing or can be seen.
• In both situations it should not be neglected as blood in Urine is not normal and can be the first sign of a serious condition.
• It should be fully investigated by a Urologist.

Diseases commonly occurring in the Urinary Tract:

• Kidneys: Nephritis ,Cancer, Infection and Stones.
• Ureters: Stone and Cancer.
• Urinary Bladder: Infection (Bacterial and Tuberculous) Honeymoon Cystitis, Stones ,Cancer and Joggers Hematuria.
• Prostate: Benign Prostatic Hypertrophy, Cancer.
• Urethra: Infection, Stones and Cancer.

CIRCUMCISION

Definition: 

Male circumcision taken from Latin Word circumcidere, meaning "to cut around” is the surgical removal of the foreskin (prepuce) from the human penis.

Prevalence: 

Approximately one-third of males worldwide are circumcised, most often for reasons other than medical indication. 

It is commonly practised between infancy and the early twenties. 

The WHO estimated in 2007 that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), almost 70% of whom are Muslim. 

History: 

Circumcision is the world's oldest planned surgical procedure, suggested by anatomist and historian Grafton Elliot Smith to be over 15,000 years old, predating recorded history. 

There are different theories how it came to be practised worldwide. One theory is that it began in one geographic area and spread from there. Another is that several different cultural groups began its practice independently. 

In his book, History of Circumcision, physician Peter Charles,suggested that it began as a less severe form of emasculating a captured enemy. 

The practice of circumcision is followed mainly through the cultures and peoples in two separate regions.,The procedure was practised by the ancient Egyptians and then by the Jews and Muslims, with whom the practice travelled to and was adopted by the Bantu Africans.

The earliest historical record of circumcision comes from Egypt, in the form of an image of the circumcision of an adult carved into the tomb of Ankhmahor at Saqqara, dating to about 2400–2300 BC 

Circumcision was done by the Egyptians possibly for hygienic reasons, but also was part of their obsession with purity and was associated with spiritual and intellectual development 

No well-accepted theory explains the significance of circumcision to the Egyptians, but it appears to have been endowed with great honour and importance as a rite of passage into adulthood. 

Performed in a public ceremony emphasizing the continuation of family generations and fertility. It may have been a mark of distinction for the elite.

Preparing for a Jewish ritual circumcision with a Mogen shield (on the table, next to the scalpel) 

For the Jews of the time, circumcision was not as much a spiritual act as it was a physical sign of their covenant with God, and a prerequisite for the fulfillment of the commandment to produce offspring. 

Circumcision is very important to Judaism, with over 90% of adherents having the procedure performed as a religious obligation. The basis for its observance is found in the Torah of the Hebrew Bible. 

Jewish circumcision is part of the brit milah ritual, to be performed by a specialist ritual circumciser (a mohel) on the eighth day of a newborn son's life (with certain exceptions for poor health). 

Jewish law requires that the circumcision leave the glans bare when the penis is flaccid. Converts to Judaism must also be circumcised. 

Although there is debate within Islam over whether it is a religious requirement, circumcision called khitan is practiced nearly universally by Muslim males. 

The procedure is not mentioned in the Quran, but rather adherents believe it is a tradition established by Islam's prophet Muhammad directly , and so its practice is considered a sunnah(prophet's tradition). 

For Muslims, circumcision is a matter of cleanliness, purification and control over one's baser self (nafs). There is no agreement across the many Islamic communities about the age at which circumcision should be performed 

It may be done from soon after birth up to about age 15, with it most often performed at around six to seven years of age. The timing can correspond with the boy's completion of his recitation of the whole Quran. 

with a coming-of-age event such as taking on the responsibility of daily prayer or betrothal. Circumcision may be celebrated with an associated family or community event. 

INDICATIONS FOR CIRCUMCISION:

Routine Indications: 

Religious Beliefs.

Medical Indications: 

Phimosis.

Balanoposthitis.

Recurrent Urinary Tract Infections. 

Indicated also for treatment of 

HPV 

Phimosis.

Balanitis.

Balanoposthitis. 

Studies have shown that Circumcision reduces the risk of HIV . 

                            

CONTRAINDICATIONS:

Infants with Genital Structure Abnormalities like (hypospadias, Epispadias, & Ambiguious Genetalia.) 

PROBLEMS WHICH COULD OCCUR IF CIRCUMCISION IS NOT PERFORMED 

PARAPHIMOSIS

DIFFICULTY IN SEXUAL INTERCOURSE DURING THE FIRST NIGHT OF MARRIAGE WITH ALARMING BLEEDING DUE TO FRENULUM TEAR. 

BALANOPOSTHITIS.

TECHNIQUE:

Removal of Foreskin: 

For infant circumcision, devices such as the Gomco clamp, Plastibell and Mogen clamp are commonly used in the USA. 

These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin (preputial epithelium) from its attachment to the glans. 

The practitioner then places the circumcision device (this sometimes requires a dorsal slit), which remains until blood flow has stopped. 

Finally, the foreskin is removed . 

The procedure is best performed done by Urologist. 

PLASTIBELL TECHNIQUE :

It also is another technique used in some centers . 

RECOVERY PERIOD FOR ADULTS AND CHILDREN:

The hospital stay is after circumcision is only a few hours for children and adults. 

At Ramayya Pramila Urology Hospital the dressing after circumcision is applied in such a way that it disconnects automatically within a few hours. This makes the postoperative recovery painless. 

Children are back to normal in about 24 to 48 hrs. 

Adults require about a week before they can resume normal activities. 

                                                            

NEW DRUG TO TREAT OVERACTIVE BLADDER

The FDA has approved a new drug called Myrbetriq to treat overactive bladder Myrbetriq is an extended-release pill taken once a day. Overactive bladder is a condition in which the bladder muscle cannot be controlled, so it contracts at inappropriate times. Symptoms of overactive bladder include: The need to urinate too often (urinary frequency). Inability to put off urination (urinary urgency). Involuntary urine leakage (urge incontinence). In a news release, the FDA says Myrbetriq's safety and effectiveness were demonstrated in 3 studies that compared the drug to a placebo. The studies involved more than 4,000 patients. Myrbetriq (mirabegron) is the first of a new class of drugs. It works by stimulating receptors in the bladder's detrusor muscle. This causes the bladder to relax, which reduces urinary urgency symptoms. In the company-sponsored trials, conducted in the U.S. and Europe, people who took the drug had significantly fewer symptoms of urgency, urinary frequency, and urge incontinence than people who took placebo pills. Side effects that include: dry mouth constipation Memory loss. People with overactive bladder first try making changes in behavior. These changes can include limiting or eliminating bladder irritants such as: coffee tea alcohol soda.

Why Circumcision May Protect Against HIV

A new study conducted in Uganda suggests that circumcision drastically alters the microbes of the penis and may result in changes that explain why circumcision protects against HIV and other viral infections.