You can listen to this episode by clicking here.
Speaker 1 (00:00:00):
This is Dr. Shirin Towfigh. We are here on yet another Tuesday for Hernia Talk. Tuesdays. As you know we do this as an avenue to kind of help all our patients get some of their questions answered with the experts in the field. Today I have the very honorable Dr. Paul Turek. Dr. Turek is a board certified urologist and he runs the Turek Clinic, which has two clinics as far as I know. Maybe you have more Dr. Turek, we’ll let you know. In northern California and Southern California. And I’m in southern California. I have the privilege of working with him. You could follow him on Instagram at Dr. Paul Turek. So can everyone please welcome Dr. Turek? Hi Paul.
Speaker 2 (00:00:48):
Hi, how are you Shirin?
Speaker 1 (00:00:49):
Good, thanks so much for the
Speaker 2 (00:00:51):
Most honorable
Speaker 1 (00:00:52):
The most. You are the most honorable. You really are. So it’s
Speaker 2 (00:00:56):
A pleasure.
Speaker 1 (00:00:57):
Thank you. Well, as everyone knows, I’m not a urologist. I don’t even play one on TV, but I do have a lot of great urology friends. You’re definitely one of them. And
Speaker 2 (00:01:10):
Urologists like their jobs.
Speaker 1 (00:01:12):
You guys are fun people.
Speaker 2 (00:01:14):
Yeah, we are.
Speaker 1 (00:01:15):
You really are. If anyone needs to invite anyone to a party, urologist. Urologist is one
Speaker 2 (00:01:20):
Rods squad, stream team. Yeah,
Speaker 1 (00:01:24):
<laugh> the stream teamer, pecker checkers. You guys are funny. What did you say?
Speaker 2 (00:01:31):
pecker checkers, rods
Speaker 1 (00:01:32):
Squad, Becker Checkers team stream team. Yeah, yeah, yeah. The jokes are just like one plus the stories and guys in general I think are happy. I think urology is a very happy specialty. And you also deal with not just kidney and bladder, but you know are specifically a specialist in men’s sexual health.
Speaker 2 (00:01:55):
Yeah, I’m a small part surgeon.
Speaker 1 (00:01:58):
Small part surgeon. But small parts but very big consequences. Yes.
Speaker 2 (00:02:04):
Right, right. So I’m a genital microsurges basically.
Speaker 1 (00:02:07):
Yeah. So maybe you can explain a little bit of how you got there and what you do because it’s very, very unique. Sure. I have a very niche practice, but yours is super niche as well.
Speaker 2 (00:02:19):
Yeah, I’d say so I went from college to medical school and went, and then I liked medicine and I liked surgery, so I thought, well maybe I’ll be a general surgeon, which is very noble as, and then I realized a lot of general surgeons weren’t really happy people and they were there all the time. And then I saw some microsurgery, which is very delicate stuff that’s under a microscope and you have to have a certain skill set. If you have a tremor, you can’t do it. And then I was in general surgery thinking, well I really like the urologist. So I went into urology instead of general surgery, which is my original goal. And then I discovered I had a gift. So my hands were very capable of doing wondrous things. And one of my marks was the attorney, the surgeon, general Sierra Coop was a general surgeon in Philadelphia and
Speaker 1 (00:03:16):
Sierra Coop. He was a big kind. So
Speaker 2 (00:03:18):
He had the world record resident for an orchiopexy fixing a kid’s testicles procedure at 19 minutes. And I beat him by a minute and a half as a resident
Speaker 1 (00:03:28):
Because he was a pediatric surgeon. Right.
Speaker 2 (00:03:30):
But he liked urology. So this world class guy, I did a procedure faster than he did. Wow. I got a little notoriety, but I realized, hey, take advantage of it. And then I went into a fellowship training in microsurgery in urology in Texas and worked with the heart surgeons and I just great time. And then now, sorry, my light is blinking and now I’ve gone into sort of small part stuff. So the big procedure for me would be a man who has no sperm and is blocked somewhere and we figure out where he is blocked and do microsurgery and reconstruct it. And these are five, six hour cases and they’re very gratifying and they’re very successful. And it requires lots of practice. You got to be in shape. It’s long stuff. And it’s concentrated.
Speaker 1 (00:04:24):
Yeah, yeah. Well that’s how I came to know you because as you know, I do hernia surgery. I see patients that have testicular pain that are deemed to be due to their hernia. But I came to you because you do these really complicated microvascular surgeries related to fertility and post vasectomy. Post vasectomy patients. So the way that I see the complication from from a hernias, you see the complications from vasectomy, but sometimes hernia repairs or hernia Mesh or the scar tissues can affect your organs, the Vas and others. And they may be infertile or they may have an erosion to the vas, they may have testicular pain. And we’ve had multiple operations we’ve done together on patients that have done really, really well, but super complicated. They are, like you said, small surgery, right? We’re working in this amount of space but completely changing their lives because they are either fertile or don’t have their testicular pain. The godsend, when you start
Speaker 2 (00:05:35):
The basics, I mean when you see patients say the patients we see together, you say they had a hernia or something and a Mesh or something. The first thing that I’d look at is, the first thing I would say that we both do that I don’t know if anyone else does, is we assume that the pain is real and it’s not something that’s in their minds. And patients don’t get that. They get surgeons who say or whatever, doctors who say sorry or I think that’s normal or live with it, but you know didn’t have pain before and now you do. Or maybe the pain went away, it came back. But whatever you got to believe. Yes. I think the magic is believe them. And then the second thing is make sure they’re not doctors that tell you what they think it is because just be good observers of your pain and tell us all the details about it. When it happens, when it doesn’t, what makes it worse, what makes it better? Where is it? What’s it feel like? Those kinds of observations are powerful because it can really help. You’re basically a neurosurgeon of the area. It helps you figure out which nerves are involved. And then because there are nerve, both anatomists, right?
Speaker 1 (00:06:45):
There are nerves there. Yeah. People don’t know there
Speaker 2 (00:06:47):
Which ones are connected and which ones aren’t, but mm-hmm just being a good reporter of your symptoms is excellent for us. So we believe you and we track it. And then the next decision I think from the surgical point of view is this pain that’s starting in the organ that’s hurting or is it referred to the organ that’s hurting? And with a lot of Mesh stuff, it can be both. It can be in the Mesh itself, in the groin or it can be in the testicle because it’s in the Mesh in the groin. And we have to figure that out and then that tells us what to do and what’s involved. So the complete picture is you and I agree on which organs are involved and which nerves are involved. And then when that happens, usually we’re right. Yeah, usually we’re right and we can make a plan that will help the patient. That’s really satisfying. But there’s a lot of ifs in it. There’s a lot of ifs in if the reporting isn’t good or if the pain’s inconsistent or if the pain’s changing a lot or whatever. But I’d say that what’s really gratifying about our combined cases is they’re usually very complex, but we’re able to distill out what we both think is going on, tends to agree with the symptoms and then we go after it with that hypothesis and we’re usually right and we help people.
Speaker 1 (00:08:07):
So you’re absolutely right. So vasectomy, you start with vasectomy as kind of what sparked you and vasectomy. Oh, just do in the office you barely anesthesia. So many men get it. It’s a very high volume procedure done. And who figured out that vasectomy can cause chronic pain? Just people start listening to patients instead of poo-pooing. It is, it’s
Speaker 2 (00:08:31):
All, I don’t know because it’s a hundred year old technique, but I’ll tell you that the number that we roll around that really is true is 15% of men, oh wow. One-five after vasectomy will have pain three or more months after the procedure if you ask them. But I would also say that most surgeons don’t want to know that. They don’t want to know that they’re patient’s in pain. I did the same thing as I just explained. I said, I trust that you have pain and my vasectomy right now is solely so finely tuned from all the experience of other vasectomists coming to me because I listen to ’em that I would call it pain free. I mean I have a 1% chance of pain within a month, a one in 500, there’s four kinds of pain. I had to figure that out. But there’s like a 1% chance you’re going to have pain after a month of this procedure.
Speaker 2 (00:09:25):
It’s so dialed in. But I learned so much over 20 years from handling the pain post vasectomy, pain from other surgeons who couldn’t get the care they needed. And for instance, do it high, don’t do it low, do it high because the system gets congested and if you have more room to decongest it, there’ll be less pain. And the other thing is, and this is probably something you know, if a man is really nervous and it doesn’t look like it’s going to go very easily, do it under sedation because you can’t violate a man. It’s like the mouth. I mean there’s two really sensitive areas of the body and you don’t mess with the genitals of a guy and it can’t go wrong. It’s sort of like a performance. It has to go well. And if you think it’s not going to go well, I wouldn’t do it.
Speaker 2 (00:10:14):
I would back off local and say let’s do an sedation. Think of a few good men, right? Jack Nicholson’s, the general and on the stand. And Tom Cruise is going to go up and he’s going to make him commit guilty, the guy’s guilty, whatever, he pulled the order. But his team, Tom Cruises young lawyer, his team says, who? Demi Moore? If you can’t take him down, don’t go there because you’re going to die. And it’s the same thing with this kind of thing is if you think it’s not going to go well, then don’t do it because that starts this whole interplay of disfigurement and bother and it’s really post-traumatic stress. So it really is a man has pain. True. But the microphone that makes it unbearable is the fact that no one cares and he can’t get help for it. And then it becomes disfiguring and traumatic and it’s literally like war. It’s like post-traumatic stress. So I know a lot about that and I don’t go there, I will stop. But this hernia stuff is usually pretty straightforward and it develops later. But again, the bother score goes up because the pain is ignored.
Speaker 1 (00:11:30):
I feel like you’re basically talking about my specialty, the parallels are exactly the same. So we actually also quote 12 to 15% chronic pain at three months after hernia herniation. It gets
Speaker 2 (00:11:44):
Better quickly. Does that depend on what approach, like the plug or patch or laparoscopic or
Speaker 1 (00:11:53):
It’s considered all comers. Some are worse than others. It’s mostly data from anterior approach, anterior Mesh approach. But one great study done in Europe where they do a lot of tissue repair showed the same exact number with tissue repair. So it’s not a Mesh specific phenomenon, it’s an Inguinal hernia repair phenomenon. But with Mesh repairs, often it’s the Mesh that’s the cause as part of what it is. And then with the non Mesh it’s usually nerves and scar tissue or recurrences and so on. I think what is super important is knowing anatomy because patients come to see me and then I send ’em to you or vice versa and my notes this long, are your notes this long? Because we sit there, we totally go through everything and we kind of logically figure out the anatomy. I have so many patients that had already had their testicle removed and denervation and nerves triple neurectomy and all they had was a hernia recurrence or something crazy like that.
Speaker 1 (00:12:58):
But no one listened to them and they thought, oh, you already had your hernia repair. So now there’s all these other issues and now they have one less testicle and a bunch of nerves are gone. Totally unnecessary. But if you think about it, they’ll come to you and they’ll say, I have testicular pain or I have pain with sexual activities. And then you’re like, okay, but you also had this hernia pair above. You understand that just because you have testicular pain, it can be extra testicular. The reason could be higher up at the hernia repair than lower down because that’s just anatomy. It’s a trick of the nervous system. Nerves come
Speaker 2 (00:13:41):
From there. Trick of the nervous system. So it has a solid branch up high and it’s got fingers and you can tickle one finger, but the nervous system can’t tell which finger’s being tickled in the brain, but it’s all coming from down there. But that’s the referred pain thing. Yes. Phantom pain sometimes things like that. And it’s real because the nervous system senses it and you’re not crazy. Not crazy, but what can make a man crazy or woman is bother, right? If it’s there and no one believes them and no one does anything that can drive you crazy. That’s really disabling I think. Yeah. So I like it because yeah, my first, if you send me a patient with a hernia issue, my question is, is there a reason for him to have pain in the testicle or is, and I, I’ll say this to you in addition to being anonymous, is the physical exam matters enormously and most of medicine it doesn’t, right? Even in prostates, but
Speaker 1 (00:14:36):
How big are
Speaker 2 (00:14:36):
Year? The PSA is better, but I have ultrasound machines and all that. They sit there collecting dust because a good physical exam is priceless.
Speaker 1 (00:14:47):
So we have tons of questions already. Oh, there’s a lot of beep like benign prostatic hypertrophy and lower urinary tract questions. So I’m going to skip those because we can have a prostate kind of specialist in the future. A
Speaker 2 (00:15:03):
Live prostate talk, talk about a live prostate
Speaker 1 (00:15:07):
That Yeah. But the first question is how likely is chronic testicular pain after inguinal hernia repair surgery? I don’t know that we know that actual number because it’s very surgery and technique specific. But the point is it can be treated, correct?
Speaker 2 (00:15:27):
Yes. I mean that’s your question. Yeah,
Speaker 1 (00:15:30):
Yeah. So
Speaker 2 (00:15:31):
Chronic pain, so where can it happen? It can happen in the testicle after hernia. It can happen above the testicle in what’s called a spermatic cord, which is the cord that leads to it. It can happen in the epidermis, which is an organ around the testicle. It can happen in the groin. So it can feel just completely unrelated to it. But yeah, if you do a good exam and there’s no reason to have testicular pain, then I would boot and say it’s got to be referred from a pie. And there are nerves that go through the cord, go through that area to the testicle that innovate it. So anatomically it makes perfect sense. So you often send me patients saying there’s complicated cases at hernia repair, but then you had a vasectomy. So which one do you think it is? And I can tell you that difference because that’s pretty clear, which is congestion and which isn’t. And we’ve done cases like that where we’ve done removed organs that aren’t whole organs that help out, but that that’s pretty fundamental. I think you can pretty much, and the mechanism you can explain which is the cord is wrapped and trapped and a lot of these hernia repairs are compressive and if they’re meshed they can compress over time and there’s inguinal nerves and inguinal branches and things like that that are involved. So
Speaker 1 (00:16:50):
First the question is, is it really testicular pain? So some people say they have testicular pain, but if it’s more referred pain, like their testicle itself, if you touch it doesn’t hurt. That’s referred pain towards a testicle. So that’s important to figure out. And some people anatomically mistaking their testicle for their scrotal, the scrotal skin got it is different than what’s inside, which is the testicles. So yeah,
Speaker 2 (00:17:13):
There’s separate nervous systems essentially.
Speaker 1 (00:17:15):
So the nerve that feeds the scrotal skin may be injured, that’s a different nerve. That’s a general
Speaker 2 (00:17:21):
Al nerve. And then maybe the inner thigh is a problem and that’s a different nerve ilio or there’s nerve, there’s leg pain, which is a different nerve. So we could tell whether it’s simple pain or complex pain or you can point to the hip, it can point to a completely different organ or the pubic bone. So I diagnosed the patient with a hip problem last week because he said he had scrotal pain and he had a varicocele, which is something that can cause it or a hydrocele. But I said the pain doesn’t, the pattern doesn’t fit that
Speaker 1 (00:17:57):
Right. Just because you have that doesn’t mean
Speaker 2 (00:17:59):
That’s a constant. And he said, well, I said, when is it worse? And he said, when I run and he said, and when I sit down and when is it best? When I stand up and stand there, I’m like, so he’s got a hip issue. When his hip is flexed, it hurts is when he is running it hurts. And when he stands there it’s fine. So we ordered an x-ray and he’s is probably going to have a hip problem. Yeah, cured, right? Didn’t touch the guy, right?
Speaker 1 (00:18:25):
Yeah,
Speaker 2 (00:18:26):
There’s a lot of stuff in the pelvis.
Speaker 1 (00:18:28):
What people don’t know is there’s this whole thing concept of triple neurectomy in hernia surgery and that’s the cutting of the three big name nerves, which is ilio, inguinal nerve, nerve, the general femoral nerve. Those are at risk with open hernia surgeries, not so much with laparoscopic but with testicular pain what happens is the nerves around the vas, what are they called? The nerves around the Vas are often injured either because it was just manhandled, not woman handled, but manhandled during surgery
Speaker 2 (00:19:09):
You’re allowed, you’re allowed
Speaker 1 (00:19:11):
<laugh>, but more commonly it’s like injured and the there’s inflammation from surgery and then the Mesh gets stuck to it or the Mesh is too tight and it’s like guillotining or eroding that vas and therefore the nerves along the vas or with laparoscopic surgery, what I see here is your spermatic cord, the Mesh lays on the cord for a long length of it and because of that it either adheres to or tugs on the spermatic cord and the nerves associated with the vas, and downstream you get sensitive testicle, swaying of a testicle hurts, but they prefer to wear tight briefs and just kind of undoing that interaction, gets rid of the symptoms.
Speaker 2 (00:20:06):
I think a leather big component of the evaluation is the character quality, et cetera of the pain. So doc, I have a low grade pressure like sensitivity in my left testicle and it never gets worse, it never goes anywhere else, but it bothers me and I had a hernia repair and I would say and examine them and they have a varicocele which is a vascular issue that probably happened at puberty and that is a separate surgery with a separate problem, highly curable and relatively unrelated. Although the microphone that the surgery brought to the area brought it out because maybe he didn’t have it before. Now he does. And so that’s quite curable, things like that. So if you said it’s sharp pain or stabbing or it’s totally different. So those kinds of accurate reporting details really make a difference because a combination of the right pain pattern with the right finding is usually right.
Speaker 1 (00:21:11):
Also pain
Speaker 2 (00:21:12):
Again, you have to care. You have to care. There’s
Speaker 1 (00:21:14):
A difference between pain with, so people with hernia related either hernia or hernia related problems usually don’t have sexual dysfunction, but it’s painful. So if you have a pelvic floor disorder or hernia or a complication for a hernia and those muscles are contracting from orgasm, then that could be misinterpreted as sexual dysfunction. Whereas it’s really a problem up in the pelvic floor. Right.
Speaker 2 (00:21:45):
And honestly, I mean you’re not a guy so you don’t know this, but if a guy knows that he’s going to have painful sex every time, guess what happens?
Speaker 1 (00:21:55):
Not
Speaker 2 (00:21:55):
Going to happen. He doesn’t get good erections and he doesn’t want sex then he feels he got this problem because he wants to have sex, but he knows it’s going to hurt every time he does. Exactly. And it’s just this weird catch 22 conundrum where you end up having wild sexual dysfunction and the relationship’s a mess and you’re like, you have no idea what to do about it.
Speaker 1 (00:22:16):
And then the other one is I always ask is if they have pain with ejaculation because that implies some obstruction within the vas which carries the spark. Is that correct?
Speaker 2 (00:22:29):
I would say within the reproductive tract, yeah, you’re really limiting it to
Speaker 1 (00:22:32):
The reproductive
Speaker 2 (00:22:33):
Tract, the reproductive tract because they share a tube, the urethra with ejaculate and urine but they separate with ejaculation is different. So the number one place to look for post ejaculate pain is the prostate for ejaculatory duct obstruction. Very simply done with an ultrasound, not a fun ultrasound like two fingers up your butt for 20 minutes but But if you’re good at it, very simple to figure out if that’s the issue. And man, I have to say I’ve had a lot of post ejaculatory pain guys coming in after 10 years and 10 doctors and being called prostatitis and inguinal this and inguinal that and I do an ultrasound, I figured out treat it and bam cure. Yeah. Now a jack duct obstruction, which is kind of unusual, can also refer to both testicles.
Speaker 1 (00:23:31):
It is unusual.
Speaker 2 (00:23:32):
So it one out or the other,
Speaker 1 (00:23:35):
We had one together.
Speaker 2 (00:23:36):
Yeah. So can you start out with one-sided groin pain in a man with a hernia, but the pain only occurs after ejaculation. It may not be the hernia at all. It may be a duct obstruction referring to that side. Yeah. So yeah, that’s picked that up a couple times and that’s a very important distinction. The pain. The pain is everything.
Speaker 1 (00:24:04):
Yeah, absolutely. And I think as someone who really cares to listen to your story and then also knows our anatomy really well, can help dissect out the little intricacies of what specifically causes pain. And here’s a question that was asked earlier. I’ll share the screen with you so you can see it’s related to that is can a hernia repair complication affect my sexual function? Just to clarify, there are no nerves that I get next to that in any way affects sexual function directly. You would agree with that, right?
Speaker 2 (00:24:40):
But the answer to the question is yes,
Speaker 1 (00:24:43):
Yes,
Speaker 2 (00:24:44):
But it’s not nerve related. It’s the whole story of I’m worried or I’m in pain and I’m worried that if I have sex, the pain or something will get worse. I’ll break something and therefore you get a secondary stress related erectile dysfunction or sexual dysfunction. Very common.
Speaker 1 (00:25:04):
And just to clarify, because this question comes up often fixing that complication. So revisional surgery also does not affect any of those nerves that would dictate function? Correct?
Speaker 2 (00:25:20):
Either. Either erection or ejaculation or unrelated.
Speaker 1 (00:25:24):
So sometimes I have patients that have penile tip burning or pain. What is that from?
Speaker 2 (00:25:31):
So good one penile tip, I think about something in the midline. So something in the urethra, the penis, the urethra, the prostate, the bladder or go backwards spine or pelvis. Yeah, that’s something in the midline going on, so Got it. So typically a kidney stone can do it if it’s sort of low. But typically penile tip pain without anything at the penile tip could probably be prostatitis or a bladder stone or something. But you got to look down the midline, a slip disc, something.
Speaker 1 (00:26:07):
Got it. Another question has to do with fertility. This has been a question that we don’t have a perfect answer for, which is, does having a hernia affect fertility and does having a hernia repair affect fertility? What are your answers? Questions?
Speaker 2 (00:26:22):
Great questions.
Speaker 1 (00:26:23):
Audience whatcha talking about?
Speaker 2 (00:26:25):
Great. Yeah, I don’t know. Why don’t,
Speaker 1 (00:26:27):
My audience does great. They do so much research.
Speaker 2 (00:26:30):
Are these planted questions that you plant these ones?
Speaker 1 (00:26:32):
These are completely, I believe doctor
Speaker 2 (00:26:35):
For example, doctor I believe you <laugh>. So a hernia is tissue, bowel, tissue, bowel coming next to the testicle, entering the scrotum. So I would say generally no. But if the hernia is large and it has gone down and filled the scrotal sac with a hot organ like the bowel, you might overheat the testicle and it could affect fertility. Yes.
Speaker 2 (00:27:07):
And repair of hernia could if you have a complication. So if you snag the vast deference and they get a vasectomy at the time, that would be a problem. If they have a Mesh repair that invades a spermatic cord and blocks the vast, then yes they can. That would typically have to be on both sides to work. And we’ve seen that. So yes can. So a hernia repair can affect fertility. So my advice, and I’ve said this to you is if you’re thinking about having kids and you have a hernia, try to do a tissue repair because I think the rate of those injuries is probably less.
Speaker 1 (00:27:49):
And we’ve done that. We’ve had patients that maybe weren’t the best candidate for a tissue repair, but fertility was an issue or they already had, let’s say you reconstructed their va, I don’t put Mesh in those people because I
Speaker 2 (00:28:01):
Don’t want, so we had a guide, like a vasectomy reversal along with a hernia. You try to do it naturally so that you don’t have plastic Mesh that might cause another vasectomy at a different level afterwards, even if it’s a 5% chance. But I don’t know, tissue hernia repairs seem, I hope they come back. I know they’re not as strong and I know if I heard the conversation, which it might not be as permanent, but it may be good for five or 10 years and that’s all you need or whatever.
Speaker 1 (00:28:35):
So another question that’s posed is if a patient has had a hernia repair and now they have testicular pain and erectile dysfunction issues, who should they go to first? Which kind of specialist should they see first? They go to urologists?
Speaker 2 (00:28:49):
I would say anyone who listens.
Speaker 1 (00:28:52):
Yeah,
Speaker 2 (00:28:53):
It’s not about, I mean you and I come up with the same diagnosis from completely different fields because we listen, but
Speaker 1 (00:29:02):
I also see people that go to testicular pain with a urologist who doesn’t treat hernia related problems and don’t understand that hernias and hernia related complication can cause and they’re just focused on the testicle and they do tests and injections and eventually they say, let’s do an orchiectomy, but I can’t promise they’ll get you better. And it never gets them better. Now they have phantom pain.
Speaker 2 (00:29:28):
So I’d say if it’s a hernia, I’d probably start with a hernia specialist because most people aren’t as critical as you and most people don’t want to re-operate on the hernia. And I’d like ’em to just say it’s probably due to the Mesh and it’s a problem and maybe you should go to an expert if they don’t want to do it. But at least acknowledge that it exists and it’s possible. And the patient has some hope. Yeah, that’s the problem. They’re being told, I don’t know or whatever. And that it’s
Speaker 1 (00:29:59):
Just, or it’s on your head. It can’t be like it never happens. I’ve never seen that before.
Speaker 2 (00:30:05):
I’ve never seen it. The classic, never
Speaker 1 (00:30:06):
Seen. That’s actually a joke in our office when my nurse does the intake bell nurse, the
Speaker 2 (00:30:13):
Intake, I was just on the street corner hanging out. <laugh>
Speaker 1 (00:30:16):
Nurse Bell takes intake, she comes back, she’s like never seen this before. But the she gets the intake and the patient says, I went and saw my doctor and they said, they’ve never seen this before or they had surgery, they impacted their surgeon. I’ve never seen this before. And that sometimes is almost like, and therefore it doesn’t exist.
Speaker 2 (00:30:35):
Exactly. And it’s not what it means. It means I haven’t seen it before, but of course my experience is limited and I’m not very good at this. And so maybe you should go to someone else.
Speaker 1 (00:30:43):
I mean everyone chooses what they want to do and my role is a different role than the average general surgeon. So I would say if you have had hernia repair and then since the hernia repair you have new testicular pain or erectile dysfunction, I would see the hernia specialist and the urologist, maybe the hernia specialist first. But you could always have a varicocele or hydroceles or somatic cord cyst
Speaker 2 (00:31:14):
A or something like that. Coincidental condition that bothers
Speaker 1 (00:31:17):
Epidermal cyst. I’m trying to act like I’m a urologist now,
Speaker 2 (00:31:21):
But I’ll tell you this Shirin, I don’t think there’s a duo like us anywhere else in America.
Speaker 1 (00:31:28):
I know a lot of hernia surgeons and yeah, I don’t know anyone who has a duo look like we do. I didn’t even have a duo like us until I met you. I was like wing it with are other urologists. But I mean you’ve completely transformed what I can offer my patients. I’m saying this honestly. Yeah, it’s been a godsend. I really love that there’s someone like you when I was first introduced to you
Speaker 2 (00:31:56):
Another urologist.
Speaker 1 (00:31:57):
Yes. Who’s lovely maybe I’ll have them on it as a guest. We can talk about all the prostate problems questions that are being asked about the prostate. But I was like, really? That’s awesome. And he’s like, no, this is, you need, he’s number one in the world. He’s like world renowned. This is what he does. And my concern was that I would come to you and you’d be like, yeah, that’s not what I do. That’s too complicated. Because that’s what I see is I go to people that I think would be able to help me in their own specialty and they’re like, I don’t want to deal with That’s too complicated. And you were like, yes, let’s do it. Let’s take care of these patients and figure out these puzzles. And a lot of doctors don’t want to fill out, figure out puzzles. They really
Speaker 2 (00:32:41):
Don’t
Speaker 1 (00:32:42):
Most
Speaker 2 (00:32:44):
So the other
Speaker 1 (00:32:45):
And our healthcare system, I’m sorry, is not made for That’s true. Doctors like us that want to spend the time. No, you’re made part of
Speaker 2 (00:32:51):
The problem. You’re made for an insurance 11 minute visit and get what you can get done. And it’s made for not listening.
Speaker 1 (00:32:58):
Yeah,
Speaker 2 (00:32:58):
Yeah. That’s a problem. So the other thing that’s really unique is, and we had a case like this last week where you saw a patient and you sent over some notes about his history, but you didn’t tell me what you thought. You just said, I have a guy with this. Tell me what you think. And I had to come up with it on my own. And you came up with, and I think we talked and you said, yeah, that’s what I found too. Yeah. So we literally agreed after that. But you don’t leave me on and you don’t tell me what you found. And that’s really unique because that if we come up with the same diagnosis with that approach, it’s got to be right. Yeah, it’s got to be right. I
Speaker 1 (00:33:40):
Agree.
Speaker 2 (00:33:40):
I agree. So that’s really unique. And I can’t imagine there’s another duo in America like this can’t, honestly, I know a lot of general
Speaker 1 (00:33:48):
Surgeon, you’re the wonder twins. We’re like the Wonder twins.
Speaker 2 (00:33:50):
Yeah. So when you say to the fans, if you say to them, go see a general surgeon, then see a urologist, they’re not going to get this.
Speaker 1 (00:34:00):
They’re going to get, I
Speaker 2 (00:34:01):
Know I haven’t seen, but I, I haven’t seen this. You
Speaker 1 (00:34:03):
See every single patient in the world. But I understand people’s limitations I offer. So that’s a good segue because we have a patient a question which is there a doctor on the east coast like Dr. Turek with this type of pain knowledge that can be recommended. Right now it’s hard for those of us on the east coast to come to see you guys. So I offer what’s called online consultation. They call my office. They know this is not going to be a live relationship but I’m here to help because maybe people can’t, even during now COVID, they’re not going to be able to travel as easily as before. So they send me a full packet and it’s like they’re all their images and their reports and their history and we have a questionnaire they fill out. I go through it like a detective and then I type along report to them of how I interpret things and what I think is the next step. And if based on that, okay, now maybe you can help me and I’ll come and see you. But what do you do for your out of
Speaker 2 (00:35:04):
Say, same thing, I do virtual care. It’s called men’s virtual care. So go to the turret clinic.com and you’ll see men’s virtual care. So we do phone calls, but we do zoom visits, all the paperwork, everything I would probably say, you know, could tell them to, okay, I have an opinion of what this is, let’s run it by Turek, do the same thing with Turek and then we could do the same thing. What we’re missing is a physical exam, which yes, ultimately would be important. I think. Very important to do because you can’t complete it. But yeah, you can get a done.
Speaker 1 (00:35:37):
Yeah,
Speaker 2 (00:35:38):
You missed the hernia. No, I’ve been doing second opinions for 20 years and now they’re virtual. And it’s great for patients because you can put ’em on a whole new path.
Speaker 1 (00:35:49):
So they go to the turekclinic.com, that’s your website.
Speaker 2 (00:35:53):
But just contact us and you can see can set up to virtual care and do you call us up? We’ll set it up and it’s not cheap, but you’re going to get fantastic care.
Speaker 1 (00:36:03):
I think it’s cheaper than going to multiple doctors and
Speaker 2 (00:36:06):
Absolutely.
Speaker 1 (00:36:07):
And getting, so
Speaker 2 (00:36:08):
You can just roll out of bed and put your pajama bottoms on and get on and on camera.
Speaker 1 (00:36:14):
Yeah. How is virtual telehealth in your specialty? That must be a little awkward.
Speaker 2 (00:36:20):
No, not at all. I say is, if you’re going to show me your incision, just pull the blinds in your room.
Speaker 1 (00:36:27):
Ah,
Speaker 2 (00:36:28):
<laugh>. Because you’re sneaking up to a computer with your,
Speaker 1 (00:36:31):
I know it’s a little,
Speaker 2 (00:36:32):
So I just say make sure the blinds are closed, that’s all. Yeah.
Speaker 1 (00:36:35):
I mean, I do inguinal hernia surgery, so I’m down there but just
Speaker 2 (00:36:39):
All the time you look, but
Speaker 1 (00:36:41):
I know, but behind a camera it’s different. I don’t know.
Speaker 2 (00:36:45):
Oh, well I just tell ’em it’s up to you. But it’s up to them if they want to do it. Yeah, if they have pain, I say drop ’em, close the blinds drop and show me where it hurts.
Speaker 1 (00:36:56):
Yeah,
Speaker 2 (00:36:57):
It’s not the same as an exam. You need to re-examine it because yeah, my examination is crucial. Right. But yeah, virtual care all the time, day and night. I did five or six patients today virtually from around the world.
Speaker 1 (00:37:11):
So you also do vasectomy reversals, is that right?
Speaker 2 (00:37:14):
That’s my favorite thing.
Speaker 1 (00:37:16):
Is
Speaker 2 (00:37:16):
It? Yeah,
Speaker 1 (00:37:17):
That’s microscopic surgery.
Speaker 2 (00:37:20):
So we have published some of the highest rates in the world of reversing vasectomies. Anywhere from one year old to 40 years old. Not the patient, the vasectomy. And what happens with older vasectomies is the original blockage stimulates a second blockage deeper in the system, which makes it harder to reverse. And so one procedure is a straight connection where you put the ends together. That’s what you think about with reversal. It’s called a vasovasostomy. But if the second blockage exists over time, typically eight, 15 years later and that procedure will fail and you have to do a bigger procedure, that’s even harder. That is very difficult and needs constant experience to be good at which a third of my case is involved. It’s called <inaudible>. So that’s an <inaudible> vasovasostomy. We’re talking 10- 0 11-0, oh suture.
Speaker 1 (00:38:13):
I remember we did one of those together.
Speaker 2 (00:38:15):
Two tubes that are 200 microns big. And you can’t have a tremor if a car goes by the surgery center like a truck, you’ll feel it. That’s how the suture is. The 10th the size of a hair.
Speaker 1 (00:38:29):
Yeah, no, we didn’t want ’em together because there was injury at the groin. And then down there was, he already had epi surgery and
Speaker 2 (00:38:40):
A bunch of No, the second blockage, it was from the first
Speaker 1 (00:38:42):
One. The second blockage.
Speaker 2 (00:38:43):
Yeah, the first one blocked the Vas. The second one was a consequence of that. We fixed them both at the same time. Yeah, I’d never done that before. And it worked.
Speaker 1 (00:38:53):
I mean, he was a young guy too. He really needed your help. So anyway,
Speaker 2 (00:38:58):
I think so those are challenging. And 20% of my vastectomy reversals are redos, like your stuff. So they’ve already had, they have to get the wrong operation done. They needed a different one. So then you have to deal with someone else’s work. It’s like a remodeled kitchen. They just remodeled it, but you don’t like the remodel. You got to do it all over again. And those are fantastically difficult. My third favorite case is, here’s one case from Alaska. A couple comes in, they, they’re really out there. He’s a truck driver. She works at home and they don’t like taking medications. They don’t like anyone else around and they want kids. So they had kids, then he had a vasectomy. Cause that’s the best contraceptive for them. Then he had a reversal, then he had kids and then he had a vasectomy and then he said he wanted a third kid.
Speaker 1 (00:39:52):
Oh my God.
Speaker 2 (00:39:53):
So they’re using vasectomy as a temporary contraceptive, which is their best choice. They love it. And now they come to me after, so three vasectomies, wait, one reversal and two vasectomies. Vasectomy reversal vasectomy. Yeah. And so I’m as fifth procedure and those things, but
Speaker 1 (00:40:13):
Doesn’t the Vas get shorter?
Speaker 2 (00:40:15):
Those are technical. That’s a really technical issue. You can do wonderful things with the testicle and the guy will never know, but you don’t want to tell him. But you can flip ’em upside down, you can turn ’em sideways. You can do lots of things with testicles. The guys will never know. But that guy, the whole problem was his last vasectomy. The guy took a big chunk of the vas out. And so I had to flip the testicle upside down to get it together. But we got it together and it worked.
Speaker 1 (00:40:44):
I mean, they don’t care if the T
Speaker 2 (00:40:45):
Upside mean. That’s like the Olympics of microsurgery is to try to overcome that when no one else would try that.
Speaker 1 (00:40:53):
So I’ve done a couple laparoscopic hernia pairs. The patient wanted a vasectomy and the urologist came in, did a laparoscopic vasectomy. But you can’t reverse those because that’s intra-abdominal.
Speaker 2 (00:41:04):
You can. So the problem with that is the reversal is microscopic. So wherever you do it, you have to put a microscope on it.
Speaker 1 (00:41:15):
So it’s like robotic microscopic.
Speaker 2 (00:41:16):
So you could potentially do it robotically. And there’s a couple people in the country who do it, but it’s overkill for the average case. But there’s no series reported on that. So the way you would probably do it, if it’s, so when I do groin surgery, like varicoceles, I always do the vasectomy and the scrotum.
Speaker 1 (00:41:34):
Right. So yeah, that was before I knew you and I think I mentioned to you and you said, oh yeah, reversal’s going to be really difficult with those. Yes. So you have to, maybe not the best idea
Speaker 2 (00:41:45):
If it’s deep laparoscopic, you have to harvest laparoscopically, harvest the vas, push it into the groin and secure it there with a suture or something. And then do your anastomosis in the groin with a microscope traditionally, and then let it go back into the abdomen afterwards. Wow. That that’s the best way.
Speaker 1 (00:42:04):
Yeah. You also deal with people that have had orchiectomy, right? Don’t you?
Speaker 2 (00:42:11):
Yeah. I’m the inventor of the, I’m the inventor of the testes implant.
Speaker 1 (00:42:16):
Okay. You have to explain what that is.
Speaker 2 (00:42:18):
How breasts have been implants and prosthesis, right? Yeah. Well I I’m the guy who invented the artificial testicle, the implant.
Speaker 1 (00:42:25):
So breasts implants come in different sizes. And they’re silicone based. Are water based, sailing based. Yeah. Same with yours.
Speaker 2 (00:42:34):
Yeah.
Speaker 1 (00:42:35):
Different sizes.
Speaker 2 (00:42:37):
They don’t work. Right.
Speaker 1 (00:42:38):
It’s different researcher. We’re
Speaker 2 (00:42:40):
Trying to make sperm from skin. That’s a different artificial testicle. But this one, the story is that for 50 years people were putting rocks and rubber balls and everything in the scrotum to replace missing testicles from cancer or from undefended testicles. And then it all fell apart with the breast implant scare in the eighties because silicone was thought to migrate and caused autoimmune disease and cancer and breasts. And that stopped everything. So everything was pulled off the market. And then there was this period after a wave crashes where nothing is happening. Then a man decided since they’re available for there, there are neuticles available for dogs that he would ask a urologist right. To put a neuticles in that his dog would’ve gotten instead in him. And the FDA heard about it. Instead, you do that doctor and we’re going to shut you down. That’s not approved for men.
Speaker 2 (00:43:37):
And so a big hoopla came out as I was working on replacing the implant with a saline filled silicone shelled implant with mentor in the nineties. And I we’re into this and I went on in the news. I was like, and so the guy said he’s right. I mean this isn’t approved for men. And I told the community, I said, we’re ignoring this population of men. This is something we need to handle and I’m working on it. So we got the first FDA approved testicle implant on a market that definitely showed no cancer and no autoimmune disease and no problems and never did. And it took about 14 centers, including Harvard to do randomized trial over about six years. And they threatened to stop funding it, the company. And I said, you can’t, this is not about, it’s kind of considered a
Speaker 1 (00:44:33):
Cosmetic,
Speaker 2 (00:44:34):
Well what do they call it? It’s a orphan. It’s an orphan product because it’s not a big market. So it’s not like breast implants. It doesn’t make a lot of money. It’s not really worth it for them to study it. They don’t know if they want to do it. And I said, you’ve got to do it for the sake of men because the paper showed that we published on this trial that it’s not simply cosmetic. So men’s quality of life get better. Their self-esteem scores go up, everything improves. It’s not simply cosmetic. Now here’s the kicker. Jane’s Law says that if a woman has the breast cancer, you have to discuss reconstruction or restoring the breast at the same time. Whether they choose to do it or not is separate, but it has to be discussed and offered and insurance covers it. Correct. So if you take the breast out and you put an implant in, they don’t miss a beat, right? Correct. There’s no Jane’s Law for men.
Speaker 1 (00:45:32):
It should be John’s law or don’t.
Speaker 2 (00:45:33):
Well, I have a guy named Bo in San Diego and I said, you are the Jane. You are the bo of Jane’s law. So he now, so I’ve gotten, so that makes
Speaker 1 (00:45:44):
Sense.
Speaker 2 (00:45:45):
Sure. He’s so pissed, that insurance doesn’t cover testicular implants that I said, let’s go to Washington. So I’m a directors board of directors of Men’s Health Network in Boston. They heard about it. He’s really well spoken. And I said, you are the guy, you are the Bo’s law guy. So I think we’re going to get it passed so that it’s covered by insurance at least.
Speaker 1 (00:46:07):
Yeah, no, that totally makes sense. Silly. It totally makes sense. Why would anyone fight that?
Speaker 2 (00:46:11):
It’s a great story. It’s going to take my whole career to get it approved. But it’s worth it. It’s worth it.
Speaker 1 (00:46:17):
I want to read this. This is a comment that’s made by one of our frequent online people, but it just kind of goes to show what’s going on. So hello doctors. This one is right up my alley. This one is right up my alley and I cannot miss it. I need to just get in my RV here in Columbus and drive out Route 66 and see you both. Oh,
Speaker 2 (00:46:36):
Sweet. That’s the way to go,
Speaker 1 (00:46:37):
Right?
Speaker 2 (00:46:38):
That is the way to do it. I love Route 66,
Speaker 1 (00:46:41):
Not knowing what is causing the aching pain in my left testicle is driving me a little batty. And I agree with Dr. Turek. He hit that on the head. I just hope it doesn’t last my whole life. It’s not awful. Just worrisome, annoying and occasionally startling.
Speaker 2 (00:46:55):
The bother
Speaker 1 (00:46:56):
What?
Speaker 2 (00:46:57):
The bother score?
Speaker 1 (00:46:58):
Yeah. I was doing the ridiculous adductor exercises when I felt it happened like a squirt feeling. It hurts directly on the left side of the testicle. And a little as the cord exits higher up with pressure, mostly not really much otherwise. So it’s bearable. Sometimes just brushing, it hurts. But usually the more pressure, the more pain. But only on the left side. For instance, when I sit and the inseam of the pants compress on it, that can be pretty starling. Maybe it will go away eventually. Maybe I should not think about it. I just have no idea. Wish I were there. Hence I might drive up.
Speaker 2 (00:47:34):
Wish I were you. I’d love to see it. Send a postcard. I’d love to see the Route 66 trip. So that sounds to me like either epididymitis, a hernia, or varicocele. I don’t know if he had a hernia repair or not. I don’t know what the story is, but it’s a classic varicocele. So I would ask him if you lie down.
Speaker 1 (00:47:57):
Sorry, you said this is a classic varicocele
Speaker 2 (00:47:59):
Or a hernia or epididymitis. Yeah. Okay, got it. So I have a pain tool I give everybody and I can usually read the pain tool and figure it out. But I would say this, if he’s not, say if 10, 10 is the worst pain you’ve ever had, one, if it’s running one to three discomfort, pressure localized, never gets worse, never goes anywhere else. And it goes away in the morning before you wake up. When you lie down, then it’s a varicocele. Very treatable. 95% chance you get rid of it. So, so varicoceles a gravitational pain. So while you’re standing or with activity, it’ll hurt sort of like a hernia, but you can’t reproduce it like a hernia. If you push on it, sometimes hernias hurt. You can’t reproduce it, then it’s probably, and it goes away in the morning when gravity goes away all night, then it’s a classic varicocele.
Speaker 1 (00:48:53):
Okay. So there’s been no hernia repair on that side. Now doesn’t an ultrasound just rule out varicocele? Isn’t that the
Speaker 2 (00:48:58):
No ultrasound are terrible. It depends on the user.
Speaker 1 (00:49:01):
Oh really?
Speaker 2 (00:49:02):
No, they don’t know how to pick up varicocele.
Speaker 1 (00:49:04):
Really? Yep. So how do you diagnose a varicocele?
Speaker 2 (00:49:08):
So varicocele mean there’s reverse flow of blood in the system
Speaker 2 (00:49:13):
And so you have to show that. And an exam can show it if you have them bare down. But typically the ultrasound will say there’s veins there. The veins have to be three millimeters or more in size. They have to measure ’em and then they put the Doppler on it and they have the guy bare down. And if the blood flow in that vein is going north to the testicle and alters direction and starts going south, then you have a varicocele. So it’s a demonstration of reverse flow through a venous system. That is the last definition. And you can do it when I do ultrasounds. That’s what I do. But I have to do them. I can’t train a radiologist to take 20, 30 minutes to do this very particular reverse flow thing.
Speaker 1 (00:49:56):
Yeah, well
Speaker 2 (00:49:57):
I see. So I’ll say what radiologists like is they want to make sure it’s not twisted or there’s a mass in it. And that’s all I really care about. Other than that,
Speaker 1 (00:50:07):
With a patient laying flat,
Speaker 2 (00:50:09):
You can do it flat. If you have them bare down, you got to teach them how to bear down and push down. It’s called Valsalva and not move too much. So I have to train them for five minutes. I’m going to do this when I say 3- 1, 2, 3, I want you to bear down slowly and I’ll watch the vein and I’ll show the flow.
Speaker 1 (00:50:27):
And if you order a testicular ultrasound, usually the tech just does it with you flat with no bear down. Is that correct?
Speaker 2 (00:50:33):
Right. They don’t know how to do that.
Speaker 1 (00:50:35):
That’s the problem. Because
Speaker 2 (00:50:36):
Same with the
Speaker 1 (00:50:36):
Hernia,
Speaker 2 (00:50:37):
It’s time to teach the patient to do it. Right?
Speaker 1 (00:50:39):
Yeah. So he said he did get an ultrasound and it killed him. It was so painful for days. Is that a clue?
Speaker 2 (00:50:48):
No, that’s strange. Okay. Unless they had a hammer at the end of the ultrasound or something.
Speaker 1 (00:50:55):
<laugh> terrible.
Speaker 2 (00:50:57):
No, I mean to me that would be mean that it’s a sunburn. That would mean that might be epididymitis like something right on the
Speaker 1 (00:51:07):
Yeah. Where you’re very tender and inflamed.
Speaker 2 (00:51:09):
Right. Something inflammatory component. And it’s directly there where you’re touching it.
Speaker 1 (00:51:14):
Does a varicocele have an inflammatory component to it?
Speaker 2 (00:51:17):
Not like that, no. Oh, okay. It’s more congestive.
Speaker 1 (00:51:21):
Yeah. So you have a very popular blog on men’s health. Is it really
Speaker 2 (00:51:31):
Five or six national awards? Yeah.
Speaker 1 (00:51:33):
Well I read it every so often because I’m just amazed that with everything you do, you have the time to do pretty nice blog on a very regular basis.
Speaker 2 (00:51:44):
There’s 600 posts that’s been 12 years We Wow. Was weekly for 11 years. And I wrote every single one of them. Well except for some guest blogs.
Speaker 1 (00:51:54):
And maybe tell the audience how they can get involved in your blog.
Speaker 2 (00:52:00):
So you can go to Turek on men’s health.com and just sign up for it and they’ll get sent to you.
Speaker 1 (00:52:06):
It’s free.
Speaker 2 (00:52:07):
Yeah. Yeah, it’s free.
Speaker 1 (00:52:08):
Yeah. And what kind of things do you discuss on your blog? So
Speaker 2 (00:52:12):
Anything men’s health related men will learn more about themselves in this blog than anywhere else in the world. It’s about typical male behavior. It’s about celebrating men. It tends to be very upbeat about men. I think men are getting beat up right now. The Me Too
Speaker 1 (00:52:30):
Movement. Yeah. Are a little bit, yeah, sorry to
Speaker 2 (00:52:31):
Say. And this has always been, you
Speaker 1 (00:52:33):
Got to stop abusing women. That’s why
Speaker 2 (00:52:35):
<laugh>. Okay. Alright. Guess I guess we’ll do
Speaker 1 (00:52:38):
That. <laugh>, I’m just kidding.
Speaker 2 (00:52:41):
But I think it’s always been very celebratory. You learn something about yourself in four minutes. And I’ll put the primary literature in there. For instance, the recent one is I’m now convinced that pot use is a risk factor for testis cancer. So we blocked about it 10 years ago. Cause I’m a very good reader of literature as a professor and I’ve written 200 papers. So I under, I’m on editor editorial boards of 20 journals. So I know how to read a paper and I know if it’s real or not, and I know if it’s going to be real. So the blog tends to be truth. I tend to write about the truth. I don’t like fashion. So I wrote about my worry about pot use and testis cancer risk 10 years ago. And then a nice epidemiology study confirmed it for me. So one question is, when does fact become fact? When does theory become fact? But that’s a recent one on test cancer that I’m finally convinced and I’m going to stick with it. I betcha in 10 years that’ll be true. That that’s, that’s what the blog goes after. It’s the truth behind everything. Wow. Yeah. So it’s fun.
Speaker 1 (00:53:51):
Yeah, I love it. I think it’s great what you do. We’re almost running out of time, but we have one really long but relevant questions. So I’d like to be able to answer this for our viewer. So this patient’s been dealing with top side and backside testicular paint on the left for 20 years.
Speaker 2 (00:54:10):
Top side and back
Speaker 1 (00:54:12):
The backside of the testicle. Okay.
Speaker 2 (00:54:13):
Sounds like a varicocele
Speaker 1 (00:54:14):
The past
Speaker 2 (00:54:15):
history.
Speaker 1 (00:54:16):
Okay. The past history is tissue repair on the left side exploratory surgery a year later for a potential nerve injury where they found an ileal nerve was cut in a aroma during the second surgery they put more Mesh, they put Mesh in as a Onlay patch. So that’s a typical victim scene. Sounds like on top of a McVay. About three years ago I saw a year. I
Speaker 2 (00:54:43):
Love you by the way. I love it when you use big words like that. <laugh> typical.
Speaker 1 (00:54:50):
About three years ago I saw urology that’s X who recommended a denervation. He did a spermatic cord block to test to see if it would be, I would be a good candidate for the denervation procedure. I had a 30% relief since blocking my testicular, my testicular pain seems to have increased a bit. And I’ve been experiencing constant aching penile pain, locating and underside the penis and shaft, which I didn’t have before the block. So now he has penile pain.
Speaker 2 (00:55:19):
So it’s probably spermatic cord block left lateral shaft pain.
Speaker 1 (00:55:23):
Okay.
Speaker 2 (00:55:24):
I mean that’s the sounds of it. And one side only on the side of the
Speaker 1 (00:55:28):
Hernia. Correct. Underside of the penis at which, okay. Also worth noting is I have a unilocular cyst in the head of the epididymitis, small cyst in the body of the epididymitis, trace hydrocele, small varicocele, all the urologists have said none of these could be causing my pain. And I’ve been to countless doctors with no luck finding answers. So two hernia repairs, one with Mesh, an ilio angle nerve that was cut and top side and backside testicular pain for 20 years since the original hernia repair, the tissue repair could the,
Speaker 2 (00:56:05):
So the new pain on
Speaker 1 (00:56:07):
You’ve been injured
Speaker 2 (00:56:10):
Plus
Speaker 1 (00:56:11):
New pain of the penis.
Speaker 2 (00:56:12):
So the penile pain, let’s talk about that nerve distribution. Yeah. Is that a cutaneous branch of one of those nerves?
Speaker 1 (00:56:21):
No, the ilio only goes to the penile shaft. Penile base
Speaker 2 (00:56:25):
Base,
Speaker 1 (00:56:25):
Not the shaft.
Speaker 2 (00:56:26):
Okay. So that’s going to be an inferior, probably scrotal nerve coming up, which is not Right. So that’s not one of the classic cord nerves distribution.
Speaker 1 (00:56:36):
Correct? Correct.
Speaker 2 (00:56:37):
It’s not the ileal branch or the inguinal branch of the ileal nerve.
Speaker 1 (00:56:41):
No.
Speaker 2 (00:56:43):
So I don’t know about that. I don’t know how to explain because it sounds like it’s when you see the distribution of pain increase like that, you think you go north, right? You go north for some common bundle of nerve that might be affected. But my question is, if they cut his in inguinal nerve, why wouldn’t he have a patch of numbness?
Speaker 1 (00:57:04):
He should have numbness at kind of the base of the penis and maybe
Speaker 2 (00:57:07):
Inner thigh, like the external inguinal ring area should be numb. So maybe that’s what he’s talking about. Maybe that’s the penile pain or something. But it may feel like pin the needles, not pain, but pins and needles so
Speaker 1 (00:57:21):
That he does have the numbness. He confirms he does have the numbness. So that’s appropriate numbness. But what I’m wondering is if this all happened at the time of a tissue repair with the McVay, just with any surgery in that area, they could have injured the vasal nerve.
Speaker 2 (00:57:41):
Yeah, right.
Speaker 1 (00:57:43):
They already injured the ilio nerve that wasn’t appropriate for a tissue repair and they had a aroma. So that made me a clue that this was just a very aggressively handled tissue. And there’s injuries
Speaker 2 (00:57:54):
And the basal nerves are a web-like and spider, spider web-like they’re very thin and then
Speaker 1 (00:58:01):
They did a cord block. So if the court block, court
Speaker 2 (00:58:04):
Block should do it,
Speaker 1 (00:58:05):
Well they got 30% relief. So I wonder if the cord block block was done too low. I do it way up at the groin crease.
Speaker 2 (00:58:12):
So I would say the fact that he got any relief for the cord block in implies some nerve involvement. And it could just been an inadequate block. I mean it could have been a poor poorly done block and correct.
Speaker 1 (00:58:23):
So I would recommend repeating the cord block. Yes. Higher up closer the hernia repair.
Speaker 2 (00:58:27):
Maybe add some steroids to it.
Speaker 1 (00:58:29):
Okay. It says the block was done high at the site of the incision and low. Yeah, low would make sense. At the site of the incision is also too high because you don’t know where the cord is in relation.
Speaker 2 (00:58:39):
You have to do a i inguinal block at the crest. The crest area are really formal. One Yes. Above and below the fascia, right? Yes. So you got to That’s that’s highly expert. I do those, but yeah, those are hard to do. I hard to do. Yeah. I iliac crest block
Speaker 1 (00:58:58):
And then this spermatic cord de like the other question I would want to know is did the pain get go, the testicular pain change after the Mesh was put in? And if not, then this is just like a, oh, the other thing that can happen, let me tell you, with tissue repairs, this is another reason why tissue repair is not perfect either. Obviously with this patient, he’s got all these problems since a tissue repair, right? It’s not necessarily superior to Mesh repair. Sometimes when they do these tissue repairs, they change the angle of the Vas. So the Vas kind of does one of these things. Instead of going straight, they actually, it curves because you change the ring through which you change the position of the ring through which the cord goes through the
Speaker 2 (00:59:48):
Trajectory.
Speaker 1 (00:59:49):
Right. The trajectory. Thank you. So if it’s curved,
Speaker 2 (00:59:52):
You like big words too.
Speaker 1 (00:59:53):
I love that big word. I mean that just made my night,
Speaker 2 (00:59:57):
I normally say path, but
Speaker 1 (01:00:00):
Right, but trajectories. Right. Could that cause testicular pain?
Speaker 2 (01:00:05):
Not usually. There has to be some compression of the vas, the nerves, the perivasal nerves and yes. And it would be typically the back of the testicle along with the Vas along the back end sometimes. And this is a condition I described that nobody seems to know about. You can have vasitis.
Speaker 1 (01:00:26):
Yes. That’s a very rare but
Speaker 2 (01:00:29):
Good. So we described the first clinical paper. It was inflammation of the Vas and it’s, and here’s take credit for this, but no one ever names it or anything after me that I invent. So I decided to do it.
Speaker 1 (01:00:41):
The turek vasitis, the Turek sign. Oh no. If you want to be known
Speaker 2 (01:00:44):
For Turek sign, you grab the testicle and you pull on it, you tug on it, compare it to the other one. And a thick in inflamed VA will be uncomfortable.
Speaker 1 (01:00:54):
Yeah.
Speaker 2 (01:00:54):
Will you pull on a testicle? It doesn’t hurt. It’ll be firmer. And then if you examine them, the VA is like a pencil, not like a thick piano wire. Yes. A lead of a pencil. It’s as thick as a pencil. Yes. And that is months of anti-inflammatories. And that’s how you treat it. So look
Speaker 1 (01:01:12):
Up. Well that’s what happens up north when not up north, higher up. It’s more higher up. When they do laparoscopic Mesh, you get like a vasitis. That’s really what it, yeah.
Speaker 2 (01:01:21):
And Vasitis spreads throughout the whole length of the vas from the testicle through the pelvis into behind the bladder and shooting pain. And you have that feeling of it going up, right? Yeah. But I, so I picked up a couple cases in the last month. It was virtual and I said, I need to see you. I examined ’em within 10 minutes after an hour this virtually came in. I said, you’ve got it. And the guy, I treated him for it virtually. And then he came in and he was 30% better when he hit the door.
Speaker 1 (01:01:55):
Nice. So he also has pain post ejaculation. I wonder if they injured his vas. Can you have an obstruction?
Speaker 2 (01:02:01):
No, that’s vasitis.
Speaker 1 (01:02:02):
Oh, that’s vasitis.
Speaker 2 (01:02:04):
V A S I T I S.
Speaker 1 (01:02:06):
What’s the treatment for that? Steroids.
Speaker 2 (01:02:08):
Read the paper. Oh, search Turek,
Speaker 1 (01:02:11):
Please search Turek sign
Speaker 2 (01:02:13):
Turek and vasitis. The largest clinical paper published.
Speaker 1 (01:02:17):
Is it medically or is it or surgical?
Speaker 2 (01:02:20):
Well, before I wrote the paper, which was about 10 years ago, the treatment was to excise the entire vast deferens from the scrotum into the groin, to the pelvis, to the sum of sle. That’s major surgery. Yeah. So my treatment was different. I said, let’s do long-term low dose anti-inflammatories and not no non-steroidals like ibuprofen, Motrin. And if they aren’t completely responding, add steroidal anti-inflammatories. And the risk factors are some kind of manipulation of the Vas vastectomy, inguinal hernia, something is rubbing against it and it’s pot of autoimmune and it just spreads throughout the length of the tube and it’s painful. It’s like having a pipe in there.
Speaker 1 (01:03:07):
Okay, well you heard it from the original, the owner, Turek owner of vasitis. That’s pretty cool. Yeah, if that’s, you know what? I would love it if whoever wrote this reaches out to you and me to either get it treated or to at least let us know if they’re able to get that diagnosis confirmed and treated successfully. Because that’s really lovely. If we could, we’re able to help this patient on hernia attack
Speaker 2 (01:03:37):
Life, it’s called a tele-cure. We could do our first tele-cure. When I’m a fertility doctor and I do the telehealth, I often, I have tele-pregnancies. They say they work doctor, they never even saw me. And those count, count. Of course this is a Telecare. Of
Speaker 1 (01:03:52):
Course. Well, on that note, I would like to thank you very much for your time. Yes. And I hope you have a good evening. I know you worked all day chasing patients. This will stay on Facebook and I will also post it on YouTube for anyone to watch, download, rewatch share, et cetera. Thank you to Dr. Turek. You’ve been awesome. I, what did you say? Yeah. And I look forward to working with you. I know we have at least one patient coming up together. Yeah, it’s great. And you can follow Dr. Turek and he’s at the Turek clinic.com. Yeah.
Speaker 2 (01:04:29):
I’m a mile from your office now. Brand new space. I know. It is a man cave. You want to, yeah. You want to see this space <laugh>.
Speaker 1 (01:04:37):
All right everyone, thank you and help you all Stay safe until, take care next time. Care.
