Speaker 1 (00:00:00):
Hi everyone. Welcome to Hernia Talk Live. My name is Dr. Shirin Towfigh. I am your hernia specialist every week on Tuesdays on our live sessions for hernia talk. You can follow me on Twitter and Instagram at hernia doc on Facebook. Many of you are joining us live at Dr. Towfigh. Thanks to those of you that are joining via Zoom and at the end of the hour, I’ll make sure you can access to share this session on YouTube. Today’s guest panelist is Dr. Justin Houman, and I hope you enjoy this hour because he’s young and he’s very fun. And the topic is quite interesting for most men who undergo hernia surgery, and that is going to be the discussion about male fertility and hernia surgery. Dr. Houman is a urologist and male sexual health and fertility specialist specialist in Los Angeles. You can follow him on Instagram and on Twitter at Justin Houman MD. So let’s welcome Dr. Houman. Hi there.
Speaker 2 (00:01:05):
Hey, how are you?
Speaker 1 (00:01:06):
Speaker 2 (00:01:08):
Thanks for having me on.
Speaker 1 (00:01:10):
So I know you, because you trained at Cedar Sinai and also did extra training in a, they loved you so much, they brought you back. We’ve had Dr. Joseph in our hernia talk live before you’ve joined his group, and I’m super excited to be able to work with you. So for those of you that know me, know that I do a lot of joint procedures and work with many different specialists. I bring a lot of them onto hernia talk live. Dr. Houman is one of them. He is a urologist. And I feel that because of your specialty, you could add so much to our guests because to our viewers, because I don’t know, when I see patients, they always are worried that how will this affect my fertility? How will this affect my sexual function if I have hernia surgery or Mesh removal? So I hope we can answer some of those questions today.
Speaker 2 (00:02:16):
Absolutely, absolutely. Yeah, we have plenty of good answers for these questions.
Speaker 1 (00:02:21):
So I do have some questions that have been presented before already, and then as they come in through live, I’ll have you answer others. But maybe first you can quickly describe how your training is different than other urologists.
Speaker 2 (00:02:36):
Yeah, so most or so all urologists, the training is you go to medical school, you do a residency anywhere from five to six year residency. Your first year is general surgery, and then you do four or five years of urologic training. And then at that point, so historically decades ago, that’s all urologist ever did. And then you went out into the real world and you practice medicine. You saw all types of urologic issues, kidney stones, prostate cancer, urinary incontinence, and as such. And then now as people get more specialized in training, we have subspecialties within urology. So prostate cancer is Dr. Joseph, he’s a robotic surgeon, deal with prostate cancer. There’s oncologist, pediatric urologist, female urologist. So my field is men’s health. It’s male infertility. So I deal with sexual issues as well as reproductive issues. Very few. There’s, it’s a growing field in urology when I applied, I think there’s only 12 spots in the nation. Wow. Now there’s maybe 20. So it’s growing. It’s growing. Obviously there’s a need for this because men don’t have previous generations of men that were really discussed these men’s health issues and now they are. So we’re filling that niche. So men’s health specialists like myself, were filling that niche.
Speaker 1 (00:03:56):
And you only treat men, right? You don’t, you never see a female in your office?
Speaker 2 (00:04:00):
I do. I see do general urology as well. So I definitely see the bulk of my practice is men’s health, but I see all types of general urology patients as well. So females and
Speaker 1 (00:04:09):
What’s the age group
Speaker 2 (00:04:11 For the men? Yeah. I see patients as young as 18. Some of them have guys have erectile dysfunction all the way to guys who are 97
Speaker 1 (00:04:25):
In Los Angeles with our 20 year old wife.
Speaker 2 (00:04:27):
Yeah, we’re trying to have a kid. So it’s a broad range, but yeah, I see mean there’s a lot of young guys who have erectile dysfunction. So I see ’em young.
Speaker 1 (00:04:36):
Okay. So what is erectile dysfunction? What’s the actual true definition of that?
Speaker 2 (00:04:41):
The true, I mean, so basically, I mean, the layman’s way of saying what it is, is basically if you’re unable to gain, attain or maintain an erection, that leads to satisfying intercourse. So some guys are able to, some guys are able to have a good strong erection, sorry, some guys are able to gain an erection, but then unable to maintain the erection. And ultimately what it comes down to is if you’re not really happy with the length, duration, the whole experience of intercourse, then due to the strength of the erection, then I would say, listen, you should see somebody to address that erectile dysfunction.
Speaker 1 (00:05:23):
And then can hernias cause erectile dysfunction? I get that a lot. They say, oh, I have this hernia and it’s a cause of my erectile dysfunction. But I feel like often what they really mean is they have a hesitancy for erection. Like functionally they can do, it’s just a hesitancy because they maybe have pain from their hernia. Right?
Speaker 2 (00:05:48):
Exactly. Right. Exactly. So no, to have an erection, you need four things. You need good blood flow, you need normal hormone levels, you need a good nervous system. The connection between the brain, the penis, everything has to be connected. And lastly, you can’t have any anxiety or any stress associated with it. So when you’re talking about the things of hernia, I think it comes down to that fourth one, right?
Speaker 1 (00:06:12):
Speaker 2 (00:06:12):
Performance anxiety, the thought in your mind that potentially this is not going to, I’m going to have pain, I’m going to have any type of distress. And the thing is, you can’t have any stress because those hormones are going to crush your ability to have a good erection.
Speaker 1 (00:06:28):
So there’s medications for that, I assume, right? All the, was it the blue pill?
Speaker 2 (00:06:33):
The blue pill, yeah, the blue. There’s the blue pill Viagra, there’s Cialis. Now there’s tons of things out there. And I always say, I promise you some way, somehow if a guy comes in, he has erectile dysfunction, I promise you some way, somehow you’re going to get a good erection. But it all depends on how aggressive you want to be, how invasive you want to be. We have pills, we have injections, and then we have surgery. And along the way, there’s different things that, various new treatment options that are coming out that regenerate the penis that take it back five, 10 years. There’s shockwave therapy, there’s P R P for the penis, all of these things. And in the next five, 10 years, there’s going to be a lot more advances as well. So I promise you, you will be able to have an erection some way somehow if you are experiencing erectile,
Speaker 1 (00:07:18):
So. So if they have a painful hernia and they have erect erectile dysfunction because of it, will Viagra or some medication help with that? Or you have to fix the hernia?
Speaker 2 (00:07:32):
It could. The Viagra, the pills could definitely, it all depends. If your source of the erectile dysfunction is the anxiety and the stress associated with the active intercourse, then the pills could take you to that next level and avoid and make, basically give you a good erection even if you are having some anxiety. But it’s definitely worth a try. I would start off anybody who’s experienced, who has a hernia, who’s experiencing erectile dysfunction, that’s where I would start, for sure.
Speaker 1 (00:08:02):
Wow, okay. As you know, most of what I do is revisional surgery. So they don’t actually come to me with a hernia, but they’ve had a hernia repair and there’s a complication from it. And then they feel that the hernia repair cause erectile dysfunction. Can you explain to our audience that whatever is done during hernia surgery doesn’t actually affect the penis directly, indirectly, maybe because of the anxiety or the pain that may, may cause, but functionally, the blood flow and the nerves and the muscles are not related. That’s correct. Right?
Speaker 2 (00:08:43):
Yeah, that’s right. That’s right. I was a
Speaker 1 (00:08:44):
Speaker 2 (00:08:46):
No, so yeah, that’s exactly right. I mean, the nerves are basically deep in the pelvis. So if you’ve had, they ride along the prostate, so any type of hernia you have, you’re not really in that area. The blood flow is down there as well. So you’re not compromising any blood flow with hernia surgery. But the psychological component, that’s very real. It’s very real. And I would say if functionally you’re having good, strong erections, if everything works, the anatomy works in terms of the blood flow nerves and the hormones, that’s very important. The last thing is the psychological component is the way we’d attack that and address it. And there’s so many good options for that as well.
Speaker 1 (00:09:23):
So therefore, hernia surgery can never physically affect erectile dysfunction?
Speaker 2 (00:09:33):
It should, no, it could be, oh, go ahead. Go ahead.
Speaker 1 (00:09:35):
Complication, such as I do a lot of Mesh removals and the Mesh maybe eroded into the spermatic cord contents that also technically does not affect the penis or any of its components, correct?
Speaker 2 (00:09:51):
No. I mean, it may affect the testicle, right? It may affect the functional disc, but then you have two testicles, right? Yeah. So let’s say you can make the argument, Hey, listen, maybe it’s going to affect the hormone levels, the testosterone production from one testicle, but you have another testicle that compensates for it. So no, in the any hernia surgery should not affect your sexual performance, your sexual drive, your sexual, your erectile function. It shouldn’t touch it at all.
Speaker 1 (00:10:15):
I’m glad we cleared that up because that question comes up on a weekly basis. And I just want to clarify that. That’s very clearly said, and it’s a real concern because everything is so next door nearby, but the origin of the nerves and the blood flow is totally different. And therefore, any hernia surgery, no matter how botched cannot directly permanently affect penal function.
Speaker 2 (00:10:43):
Erectile function, it may, there’s the functional ailments of an erection, it shouldn’t affect it at all.
Speaker 1 (00:10:50):
Right? That’s what I mean. But now there’s other issues. So the components, maybe you can kind of explain the anatomy. So in males, you have a testicle. Actually I have two testicles plus there’s blood flow and nerves and the sperm that’s carried to the prostate. So those components though can be injured at the time of hernia repair. And that’s what I deal with a lot. Actually, we just did one two days last week. We just did one last week where I was a young kid, and the Mesh was impinging on this spermatic cord. And so he had a lot of spermatic cord pain, testicular pain in addition to groin pain. He had pain with intercourse, but an orgasm, but no pain with ejaculation. So there’s a lot that we discuss in my office, which is not typical for a general surgeon to talk about. Right. But maybe you can discuss the components of the spermatic cord, the and the testicle, and how fertility may be affected, if any of those go wrong.
Speaker 2 (00:11:59):
So the spermatic order, there’s a lot of expensive real estate there in the sense of it’s a lot of sensitive and expensive real estate in the sense that it connects to your testicles. And because the testicles do the two things that it does sperm and testosterone by, if you compromise blood flow, if you compromise any blood flow to the testicle, you could potentially compromise sperm and testosterone production. That being said, when it comes to Mesh, the things that could post Mesh complications around the sporadic cord on the outside, you have the true or the spermatic cord muscles, and those are basically, if the Mesh gets around them, you could have some type of SP spermatic cord pain, testicular pain as a result of it. You have the artery and you have the veins. And if those get blood flow gets compromised there, blood flow gets altered there. You could have some testicular issues in terms of pain as well as functionality. Again, sperm and testosterone. But more importantly, you have the vas, the vas deference, and that’s the tube that carries sperm from the testicle out into the prostate, into the urethra, and out into the real world. It’s very thick walled. The VA is very thick walled. Sometimes what happens is, and I’m sure you could talk about this more than I can, it has to get compromised during surgery.
Speaker 2 (00:13:20):
But is that end all be all in terms of fertility down the road? Absolutely not. Absolutely not. First of all, you have two testicles. So you have another testicle that’s going to naturally produce sperm, and all you need is one sperm in order to impregnate somebody. But more importantly, as long as the testicle itself is producing sperm, right, there’s ways in which we could go in there and extract the sperm from the testicle and achieve a good or achieve reproductive the reproductive goals that you’re trying to achieve. So there are options, again, there’s tons of options for this, although there are complications with Mesh, there’s things we could do to address those without questioning.
Speaker 1 (00:13:56):
So the natural way of having a child is you have test, you need to have testosterone, and then the sperm leaves, the testicle goes up, the vast deference, which is like a, it’s like pasta tube.
Speaker 2 (00:14:12):
Yeah, it’s like an all dente pasta. Remember medical school?
Speaker 1 (00:14:16):
Yes. And then it heads over to the prostate, correct?
Speaker 2 (00:14:21):
Yeah, it goes into, yeah, it
Speaker 1 (00:14:22):
Goes. And what’s the function of the prostate?
Speaker 2 (00:14:25):
So the prostate. The prostate and the seminal vesicles, basically they help, they do a couple things. Number one, they create an environment, they provide nutrients to, the prostate basically is involved in producing about 20% of your ejaculate. And within that 20% it’s nutrients as well as it maintains a good, it provides a basic environment for the sperm to survive within the vaginal area, the seminal vesicles, which are close to the prostate, that produces about 80%, 79%, and that produces a lot of same thing. Similar, basically gives a good environment for the sperm. So those three, the vas deference, the seminal vesicles in the prostate basically come together to produce your ejaculate.
Speaker 1 (00:15:09):
So if you have Mesh that’s invaded or eroded into the vast deference, which I see very commonly, it’s possible that that tube is now blocked, right?
Speaker 2 (00:15:23):
Speaker 1 (00:15:24):
Absolutely. That would be the most extreme case. The most extreme case is there’s either inflammation or erosion or some or bending or whatever of that tube to the point where the pathway from the testicle to the prostate and out the penis is blocked at the level of the Mesh repair. But that doesn’t mean you’re infertile if you have one side of hernia, correct?
Speaker 2 (00:15:47):
Definitely not. No, no,
Speaker 1 (00:15:50):
Because you still have the other side.
Speaker 2 (00:15:51):
You still have the other side. And more importantly, I mean, again, you’re, as long as you’re producing sperm from that testicle, you’re not infertile because there’s ways we could go in there and extract that healthy sperm and again, achieve pregnancy.
Speaker 1 (00:16:04):
And that’s in vitro fertilization
Speaker 2 (00:16:06):
Usually. Yeah. I mean, if you’re going into testicle, yeah, you have to do in vitro fertilization. Yeah.
Speaker 1 (00:16:11):
Okay. So just to clarify, the natural way is for the testicle, just to produce a sperm for it to come out through ejaculate. But if you can’t do that because it’s blocked for whatever reason, some people have vasectomy, right? And that’s why it’s, it’s blocked on purpose. Others functionally have a vasectomy because of Mesh erosion or inflammation from surgery, you still have the sperm. So the sperm can be extracted directly from the testicle bio surgeon. Is that something you do, or are there other doctors that do that part of it?
Speaker 2 (00:16:46):
No. So that’s what I specialize in as male fertility specialists. I mean, when we could do vasectomy reversals where we reattach the two portions of the vas, that’s, that’s more in a situation where you have a vasectomy, not in a situation with Mesh Mesh erosion, just given the location. But the sperm extraction, the testicular sperm extraction, that’s what we specialize in. Yeah, absolutely. Oh,
Speaker 1 (00:17:08):
Wow. Yeah. So we know that one of the major complications, I can’t say complication because it, well, I’ll call it a complication. One of the major side effects of doing hernia repair is you can get what’s called testicular atrophy, which means the testicle shrinks down. Is that because it was an aggressive surgeon and the blood flow to the testicle has been compromised? Or why do people get so much test testicular atrophy after, especially with open surgery, I don’t see as much with laparoscopic, but it’s usually an open surgery operation. The testicle becomes smaller and softer.
Speaker 2 (00:17:52):
I would say typically in a typical situation, the way you’re describing it’s because of blood flow, right? Basically you’re compromising. Typically it’s the arterial blood flow. Essentially. It’s not getting the blood that it needs, the testicle’s not getting it. And the way biology works, if you’re not getting nutrients or if you’re not getting blood and what you need to survive, you’re doing atrophy. So that test school atrophy as a result of that. I don’t know. I mean, I can’t speak on how aggressive or what, open versus laparoscopic, but yeah, it’s usually because you’re not, blood is compromised. That’s the idea.
Speaker 1 (00:18:27):
So if you have testicular atrophy, does that affect your fertility
Speaker 2 (00:18:31):
Bilaterally? Potentially? Unilaterally? No. Okay. The beauty is we have two testicles and there’s a lot of, I mean, we see it with pediatric urology. Sometimes what happens is an undescended testicle, if it doesn’t drop all the way into the scrotum as a child either at test, usually you have to take it out if it’s too high up. But anyways, a lot of people survive, have long, healthy sexual quality of life. Their testosterone levels are normal. Their reproductive potentials normal with one testicle their whole lives. So the other testicle generally compensates as a result of it losing the other one.
Speaker 1 (00:19:10):
And part of what you do, you also give testosterone to males, right? I feel like in Los Angeles it’s the trend like Sylvester Stallone’s always bragging about the testosterone that he takes. Is that a thing?
Speaker 2 (00:19:24):
It’s testosterone for men. Yeah. Oh yeah. I’m a big believer in testosterone for men,
Speaker 1 (00:19:28):
For sure. Tell me more about that
Speaker 2 (00:19:30):
Mean. So testosterone is so important, and this is the problem with the idea of testosterone for men, is this, it’s in the nineties, there was a study that came out that basically said testosterone for men is not good because of risk of heart attack and strokes, right? And that was the first day that ever came out. Ever since then, there’s been a black box warning on testosterone. It’s a controlled substance. And ever since then, ever since, I believe there’s been like 20 studies since then, and essentially every single one of those has disproven that initial study. And then when they looked at that initial study, they found out that there’s a lot of messed up. There’s women in the study. There was a lot of misinterpreted data. But ultimately, this is what we know about testosterone. Now, if you look at a 65 year old guy, or any say 50 year old guy who has normal testosterone levels, you look at the same exact 50 year old guy who has a low testosterone level, that guy who has low testosterone levels, he’s at increased risk of dying from heart attack, stroke, and overall mortality.
Speaker 2 (00:20:28):
He’s going to live a shorter life as a result of having low T for a number of reasons, because testosterone gives you energy, it gives you stamina, gives you libido, it gives you the drive to go out there and exercise, to have a social life, to spend time with people, all the good things and more important. And also, it’s good for endothelial function, right? It’s good for your body’s ability to function. So I’m a huge believer in testosterone. I think it’s important to get guys to normal levels, not to bodybuilder levels. It just gets you to a normal level. And I do it for a lot of patients, and they love it. They absolutely love.
Speaker 1 (00:21:00):
What if your testosterone level is normal? Would you give that to an elderly patient?
Speaker 2 (00:21:05):
So it’s a good question. So this is a problem, but this is an issue here with testosterone too. So we say the normal range is 300 to a thousand, and which is a huge range. My testosterone requirement is different than the guy next to me, and it’s different than an N F L player, for example. Everyone has different testosterone requirements. So the number is important, the number is important, but more importantly, the symptoms, when you have to, some guys will come in there, they’re big guys. They’re 6 5, 250, and their testosterone’s at 500, and they still complain of low tea.
Speaker 1 (00:21:35):
Are they’re what? They’re fatigued and kind of like overall.
Speaker 2 (00:21:38):
Yeah, fatigue. They’re fatigued, they’re not sleeping well. They’re depressed. They used to exercise so much better than they are now. Now that when they start to exercise, they can’t stand. They’re not there for more than 15 minutes. Mood issues, erectile dysfunction, libido, those types of things. It’s incredibly important. Testosterone’s so important.
Speaker 1 (00:21:58):
So I recently sent you a patient, he was young. Why was he, yeah, testosterone.
Speaker 2 (00:22:04):
So someone put him on testosterone. Yeah, someone else put ’em on testosterone. So for him, he,
Speaker 1 (00:22:13):
And he wanted me off of it, right?
Speaker 2 (00:22:15):
Yeah. I took him off that testosterone, put him on something that would stimulate natural testosterone production. Oh, okay. You could met young guys, because this is the thing about testosterone also, would these clinics, a lot of clinics, they don’t tell patients this. It’s if a guy wants to have a child, a young guy wants to have a child at some point in his life, you have to understand going on exogenous testosterone, whether it’s the gels, the injections, pellets, whatever it is, yeah. You’re essentially, you’re going to be sterile, right? You’re killing your body’s ability to produce sperm. And so a lot of guys will come in, they’re like, look, I have no sperm. Are you on testosterone? I’m like, yeah, I’ve been on it for five years. No one ever told me that I can’t be on it. So you have to take them off the testosterone. You have to put on some medications that essentially stimulate natural testosterone production. And natural testosterone production is good for sperm. So in doing so, you switch ’em off one and put ’em on another, and then they’re able to do well.
Speaker 1 (00:23:11):
So we have a question. What stimulates natural testosterone? What are you offering these people?
Speaker 2 (00:23:16):
So it’s the drug. There’s a couple drugs, but essentially you’re stimulating, the most common one that we use is something called Clomid. It’s a fertility drug used for women, but we use it off-label in men, very, very well tolerated. I have patients who have been on it for decades who do great, who do great. It stimulates, it stimulates your brain to stimulate the testicles to produce testosterone.
Speaker 1 (00:23:41):
That’s pretty cool. Can surgery affect your testosterone level?
Speaker 2 (00:23:47):
Yeah. You mean like hernia surgery?
Speaker 1 (00:23:49):
Yeah. Some men come to me and they feel like, after my surgery, I have dysfunction. I don’t lose lost libido. I’m like, it’s not from the surgery, but that should I be sending ’em to you and check checking, having you check testosterone levels or stimulating their natural testosterone?
Speaker 2 (00:24:09):
Yeah. So after surgery, for sure, guys will lose their testosterone goes down after surgery, definitely. Oh, okay. To what extent? It depends on the guy, and obviously it depends on the surgery, but if it drops off, but most times it picks back up, sometimes it takes months. Sometimes it takes, I dunno, 12 to 18 months, but eventually it should get back to normal. So yeah, to answer your question, definitely people do have low testosterone as a result of surgery. The more major the surgery, the lower the T,
Speaker 1 (00:24:39):
The testosterone. Yeah. We just don’t think of these things. And then I talk to you, and then now I’m thinking of all these.
Speaker 2 (00:24:45):
Yeah, yeah, you could send them my way.
Speaker 1 (00:24:48):
Okay. Let’s go back to infertility and hernia surgery. So what do you know about hernia repair and actual infertility? Let’s assume we’re talking bilateral now, left and right at the same time, because we already discussed that having one side of surgery can affect it. I’ll tell you historically we didn’t know. And then there was one or two studies that said, men that are men that undergo hernia repair. And this was during a tissue repair time, I think. And then maybe the Mesh repair afterwards. Their sperm counts are lower after hernia repair. And then that became one of the thing you have to tell everyone that there’s a risk of infertility after hernia surgery. Then a larger population study was done, and they said, no, there’s actually no difference in sperm count. Or actually, I think no difference in the ability to have children among those who’ve had hernia repair and those who haven’t. And that seems to be the consensus. Currently. In your group, in your community of male health specialists, what do you say about, do they teach you anything about hernia repair and as a cause of infertility?
Speaker 2 (00:26:12):
I mean, we do know there’s some things that we discuss about, it’s not a big topic, but to answer your question about that first study versus this one, I’d say the, I bet you if you look at immediately after a couple months after hernia repair, that vas, that vas deference that tube, there may be a little bit of inflammation around it causing even a mild obstruction to that, to the vas causing decreased sperm counts. Now, the key thing here is this, and like you mentioned, it is at the end of the day, decreased sperm counts are one thing, but what’s the goal? The goal is having successful pregnancy. So if you’re able to say that after hernia repair you’re able to have normal, or it’s comparable rates of successful pregnancy, then there’s no difference then that you’re good. That’s the ultimate goal. So decrease sperm counts, I’d say depending on when you’re checking it early, like a couple weeks after surgery versus a couple months versus a year, my sense is it shouldn’t affect it at all long term. It shouldn’t have any effect on sperm counts.
Speaker 1 (00:27:15):
I was sitting at the American Hernia Society meeting, this is maybe 10 or 15 years ago, 15 years ago, early on in my career. And this surgeon came up, and I think he was in SA from South America, and he presented, he took half the patients and did a typical Lichtenstein, Mesh based open inguinal hernia repair. And the other half, he did the same operation, but he took the hernia sac, which is peritoneum, and he wrapped the spermatic cord with the hernia sac, hernia
Speaker 2 (00:27:49):
Speaker 1 (00:27:50):
And then he checked sperm counts afterwards, and the sperm count was lower in the pure Mesh patients and higher than those in the those, it was like the spermatic cord is somewhat protected from the Mesh. So I think you’re right. I think it’s the inflammation, at least in the short term, exactly, can affect it. Okay. So it’s a short term problem,
Speaker 2 (00:28:13):
I think. Yeah, it shouldn’t, long term, it shouldn’t have any impact. Yeah, if done, done appropriately, right, if done surgery’s done well, then it shouldn’t have any impact. Yeah.
Speaker 1 (00:28:21):
Yeah. We had this question, which I think you answered already, which was, would Mesh cause erectile dysfunction and the inability to maintain an erection if the Mesh erodes or shifts somehow? Yeah. So if you have erosion besides the pain, I guess the pain may would affect the erectile dysfunction.
Speaker 2 (00:28:41):
It, I mean, the pain, the pain, and then the pain associated with knowing that you’re going to experience pain during sex, during intercourse, during that may. As a result, that may lead to erectile dysfunction. But again, functionally it has no effect on the anatomy and the BL and the important components to have an erection, no impact.
Speaker 1 (00:29:02):
And then if there is damage to the spermatic cord in, by damage I mean erosion, let’s say, is that a reversible problem?
Speaker 2 (00:29:15):
So it depends what part of the spermatic cord. So let’s say the Mesh erodes into the outer portion, so let’s say erodes into the spermatic cord peripherally right on the outer portion into the muscle fibers, and that leads to some level of testicular pain. Now, it may not be reversible, but if that’s leading to pain, there’s things that we could do, stop and to prevent that. It’s called the, we do a spermatic cord denervation. So we look under a microscope, I identify all the portions of the spermatic cord, and we’re able to essentially isolate the parts of the spermatic cord that could be leading to pain. We burn those areas. We make sure that those nerve fibers are no longer conducting and causing pain. So in that sense, it’s reversible in terms of pain. Now, let’s say an artery is compromised at that point, there’s not, there’s very little you could do, especially after surgery in terms of revascularizing, that testicle, if we talked about the vas, if the vas deference is compromised, whether it’s blood flow compromised, where it’s actually cut that high up is very literally you could do in terms of reversibility of it, and then the veins.
Speaker 2 (00:30:30):
I mean, even if you compromise some of the veins, you may get a varicocele seal, you may get varicose veins of the testicles. Yes. Yeah. You may potentially get that. And there’s things micro surgically, we’re able to go in there and address that as well, really. So yeah, in some ways there are, it, reversible isn’t the right way of saying it, but it’s more solutions to it. If there is a problem caused, caused by it, we have some options available.
Speaker 1 (00:30:56):
So there is this gentleman that’s been following me for years. He’s seen, I would say 10 or 15 surgeons. They’re all on the east coast. For some reason, he’s not asking to be seen by anyone on the west coast, which means I haven’t been able to help him, but he’s seen many of the experts that I’ve put on hernia attack live. So here’s his issue. He had, I don’t know if it got, I think his nerve got cut, the genital branch of the genital form, nerve got cut. We know that that gives sensation to the squirrel skin, but it also is the nerve that feeds the cremasteric muscle. So as a result, he has kind of like a low lying testicle. What, is there a treatment for that?
Speaker 2 (00:31:51):
I mean, his testicle, essentially, it’s hanging much lower than the other one.
Speaker 1 (00:31:54):
Speaker 2 (00:31:58):
I mean, is there a proven, I mean, you could go in there and figure something out, right? You could let me, before I actually
Speaker 1 (00:32:05):
do a creamasteric pull up.
Speaker 2 (00:32:08):
No, because once those, so that muscle fiber is denervated, the nerves that muscle are gone, there’s very little to do. There’s very, very little you could do to stimulate that muscle to go back up. Now, the problem is that the testicles, the thing about the testicles is they’re very temperature sensitive for them to function, for them to do produce sperm for them to produce testosterone, they live within this very narrow temperature range. And that’s the whole point of the scrotum, right? The scrotum, when it gets too hot, your scrotum relaxes and it takes it away from the body. When it’s cold, your body pulls ’em ’em up because it wants to stay again within this narrow temperature range. So if you mess with that, now, if you mess with that, by attacking ’em too high up, you’re going to decrease testicular function because you’re too close to the body, it’s going to be warm. So no, there’s no real good option for it. No, there’s not. So
Speaker 1 (00:33:00):
I’m telling you, the Shouldice Clinic, which is a hospital in Toronto, outside Toronto and Canada, they do hernia surgeries only. Almost all of it is inguinal and it’s tissue based. So based on the Shouldice technique, they routinely transect the cremasteric muscle. They do it because they’ve found that by doing that, they reduce their recurrence rate, and as a result, the testicle can drop. So as part of their repair, at the same time as cutting the cremasteric muscle, they sew it up to the pubic bone,
Speaker 2 (00:33:38):
They sew the cremasteric muscle to the pubic bone,
Speaker 1 (00:33:40):
Speaker 2 (00:33:40):
Bone, and just let it kind of hang from there. Hang
Speaker 1 (00:33:43):
There. Does that sound like a good idea? I would say leave it, leave good enough alone. I don’t know. I don’t, yeah,
Speaker 2 (00:33:53):
Mean, so look, when we do it, when do the cremasteric, when the denervation, we’re releasing it, all the cremasterics, and we’re just letting it hang, right? Yes. We’re not really attaching it to anything but to attach it. I’ll say if they haven’t had any problems, I don’t think it’s a bad idea. I don’t think it’s a bad idea, especially if they’re not having problems. But I wouldn’t necessarily do it. It’s an extra step. It could create problems. Yeah. There’s nothing wrong with just letting it hang, right? There’s absolutely nothing wrong with that.
Speaker 1 (00:34:22):
But then won’t it hang too low or no?
Speaker 2 (00:34:25):
Yeah, but you screwing ’em. Your screwing ’em supports it.
Speaker 1 (00:34:28):
Speaker 2 (00:34:28):
See. Your screw ’em supports it. Yeah.
Speaker 1 (00:34:30):
But I’ve seen men that have kind of like,
Speaker 2 (00:34:33):
I know I have two
Speaker 1 (00:34:34):
Preservation of the creamer muscle from the, and then one testicle super low,
Speaker 2 (00:34:39):
Right? And I have two, and some guy, most guys are okay with it, but some guys complain. Some guys complain. Yeah. And there’s things, again, there’s things you could do. We could call it, you could p the testicle a little bit higher. Okay. It’s more of a cosmetic procedure. No, me, the aesthetics of it are usually with the reason why guys are bothered by it. But yeah, there’s things you could do for it. There’s things
Speaker 1 (00:35:01):
You could, if you have cream hysteric dysfunction, can that cause testicular pain?
Speaker 2 (00:35:06):
Speaker 1 (00:35:07):
I think that’s what this guy has then,
Speaker 2 (00:35:09):
Yeah, definitely. That when that cream master is hyperactive, sometimes it’s,
Speaker 1 (00:35:13):
Speaker 2 (00:35:14):
It’s moving way too high or it’s hanging too low, right? Just that movement, that friction could cause pain.
Speaker 1 (00:35:21):
And what’s the treatment for that?
Speaker 2 (00:35:23):
I’d start with the spermatic cord block.
Speaker 1 (00:35:25):
Okay. Yeah. And see if any of the nerves are involved.
Speaker 2 (00:35:29):
Yeah. And if the spermatic cord block works, then denervations are great for these guys with cremasteric dysfunction.
Speaker 1 (00:35:37):
Yeah. See, I’m sending you so many difficult questions. No, these are not questions that you could read in a book or in a journal. These are not questions that come up routinely. And then these poor patients, they’re kind of left out there. And I feel that a lot of doctors are, they have a hesitancy to commit to an answer, and then the patient is at a loss.
Speaker 2 (00:36:05):
Right. There’s not a lot of, there’s no textbook to this stuff. Not at all. Not at all. Yeah.
Speaker 1 (00:36:14):
Okay. Couple questions. Quick one here. Six months ago, I had al hernia surgery with Mesh. I noticed a, this is laparoscopic, by the way, laparoscopic bilateral AL hernia repair with Mesh, which I must say has a lower risk of vascular, like blood vessel injury to the testicle than open surgery. I noticed a change in my urine smell. It almost smells ammonia. Like I’ve gotten urine tests, which are normal. Is there any chance the Mesh or the operation could cause a change in my urine odor?
Speaker 2 (00:36:55):
Hey, when was the surgery? How many months ago? Six
Speaker 1 (00:36:57):
Speaker 2 (00:36:58):
Huh, interesting. And as long as,
Speaker 1 (00:37:03):
Why would urine smell like ammonia?
Speaker 2 (00:37:06):
I mean, I’d say the smell of urine. A lot of it, it’s diet and hydration dependent. If the diet has changed in the last six months potentially, and the hydration status, but as long as the U, so we do something called the urinalysis, and it looks like it looks at a few of the important things of urine. As long as that’s fine. I wouldn’t be worried. I wouldn’t necessarily be worried.
Speaker 1 (00:37:31):
Could antibiotics. So if you give antibiotics during surgery, we give one dose antibiotic. There’s this thing called C. We had his whole hour with Dr. Treyzon, a gastroenterologist about SIBO, which is small intestinal bacterial overgrowth. So you give antibiotics, it changes the bacterial flora in your colon, some bacterial killed, and then the other ones therefore survive and become much more popular. And that increase in population of that bacteria can cause bloating and gas. A lot of problems. Can that happen with urine? Can it change the, I mean, urine is sterile, but is it possible that back antibiotics can change the pH of urine? I don’t know. I’m making these things
Speaker 2 (00:38:19):
Up. No, no, it’s a good question. So about a year ago, I read something about this where, so less so like SIBO, obviously, you know, have a ton of bacteria in your GI tract. But the bladder itself, there’s something called interstitial cystitis. Yes. Where there’s a bacteria, realizing there’s a bacterial component to it. There’s good bacteria, there’s good healthy bacteria that just keep the bladder wall healthy. So taking antibiotics, definitely. Basically, patients who have recurrent UTIs, they’re more prone to interstitial cystitis or bladder pain because that good bacteria is always being destroyed. So being taking one dose of intraoperative antibiotics and a few days of antibiotics after surgery shouldn’t C. Cause. Yeah, it shouldn’t cause anything that long-term to the bladder wall. But yeah, chronically antibiotics could definitely cause that.
Speaker 1 (00:39:20):
Are there other tests besides a routine urinalysis that can analyze content in your urine?
Speaker 2 (00:39:28):
Yeah. Yeah. I mean, there’s things we could do to, we have advanced tests now with pcr, using pcr, where we’re able to identify even the smallest amounts of various bacteria within your urine, within your prostate. So yeah, there is, but usually if you’re having an issue where bad bacteria are living in your urinary system, yeah, you have pain, right? It’s the simplest thing is pain if you’re having pain with urination. But if it’s just the smell, it’s no pain, it’s, I’d say it’s okay. I’d say it’s, but if it is bothersome that we could do advanced PCR tests to figure that out
Speaker 1 (00:40:09):
During laparoscopic surgery I and many other surgeons, we place foley catheters and that can introduce bacteria, not anything to cause an infection necessarily. But bacterial prostatitis or some type of prostatitis is a side effect, right? Of foley catheterization. Is that true
Speaker 2 (00:40:30):
Long? Yeah. If the catheter sits there for long term, A little bit, yeah. If it sits there,
Speaker 1 (00:40:35):
You can’t get prostatitis from just on in and out.
Speaker 2 (00:40:38):
No. I mean, you may get a uti, you may get a urinary tract infection, but prostatitis usually comes after that.
Speaker 1 (00:40:45):
I was wondering if that was the cause, if it’s a prostatitis issue, I guess not trying to figure out this poor guys
Speaker 2 (00:40:52):
Probably doing the pcr. I think doing that PCR test could probably help him at least this evening. Maybe there is a bacterial source to this.
Speaker 1 (00:40:59):
Yeah. So we have Tracy Sheer, who’s a great pelvic floor physical therapist. She writes, I’m a big fan of pelvic floor pt, manual therapy, and Bulbo, sorry, at Bulbospongiosus, spermatic cord and that whole area before blocks and denervation. What are your thoughts about that?
Speaker 2 (00:41:18):
I’m a huge fan of pelvic floor physical therapy. I think it’s incredibly important, that whole area. I think she’s right in the cremasteric. So that patient that you were talking about, who I may have cremasteric overactivity you, a lot of times it’s that pelvic floor. Cause it’s essentially attached to the pelvic floor. It’s the thick, thick pelvic floor muscles. And people don’t appreciate the pelvic floor muscles. Some of it’s voluntary. These are the muscles that we use to stop our urinary stream, for example, when we’re urinating. But they’re involved in urination, defecation, ejaculation, and they’re very, very strong muscles. So if there’s ever any dysrhythmia to them, yeah, it could cause problems. So the cremasteric, that patient for cremasteric issues, yeah, if they are pelvic floor physical therapy could definitely relax that pelvic floor to the extent of releasing that trimester. I don’t know. But yeah, it’s a great idea. A hundred percent.
Speaker 1 (00:42:16):
For men. Pelvic floor pt, does that involve rectal when
Speaker 2 (00:42:19):
It Yeah, it’s all rectal. It’s all rectal,
Speaker 1 (00:42:22):
Speaker 2 (00:42:23):
The patients love it. Patients love it.
Speaker 1 (00:42:27):
It’s a little odd. No,
Speaker 2 (00:42:29):
Speaker 1 (00:42:30):
Just to initiate pelvic floor PT for men. I feel like women, it’s transvaginal for women, so it’s a little bit more tolerated. I don’t know. What are your thoughts on that?
Speaker 2 (00:42:42):
So I’ve sent many patients to pelvic floor, and none of ’em actually have come back and been like, I don’t like that. Oh, okay, good. They get good results. Pelvic floor PTs. Very underrated. Very underrated. It’s wonderful.
Speaker 1 (00:42:56):
Good to know. Okay, another question is, what is more important in determining what is more important in determining how high or low the testicle lies, the scrotum supporting it or the hysteric muscle function?
Speaker 2 (00:43:12):
That’s a good question. They work, work hand in hand. They work in harmony, right? It’s not like the cremasteric is going to release and then the scrotums going to pull up. But what I would say, I think that the stronger component is the, it’s the scrotum because the scrotal scrotum muscles are definitely thicker. So when we operate down to the testicle, when we go through the scrotal muscles, yeah, they’re definitely thicker. I mean, it’s markedly different, thicker than the cremasteric of the testicle. So I would say the scrotum is the bigger component.
Speaker 1 (00:43:49):
Yeah, very cool. Tracy said that when she does the pelvic four PT for men, it can be extra too. And 60% of our patients are men for pain. Wow. So Tracy, 60% of your population are men? That seems discorded. I would’ve assumed. Mostly it’ll be women or I don’t know. Do you find that P four PT for men is being more commonly prescribed now than before?
Speaker 2 (00:44:15):
Yeah, because So what happens is a lot of these guys, they’ll get prostatitis and they’ll sit on it and pro they won’t do anything about it. Or it lingers on, yeah, the prostate sits right in the middle of that pelvic floor, so that inflammation, once it spreads the pelvic floor area, those muscles are going to, they’re going to be firing and causing a lot of pain.
Speaker 1 (00:44:36):
The pelvic, I had to learn more about the pelvic floor because I kept hearing that my patients would present with these occult, small hernias, little angle hernias. But their main complaint was they urinate 10 times a day. They wake up at night multiple times a day, and it just seems that that was just odd that it fixed their hernia. And then the urination went fine. So we kind of decided that pelvic floor spasm is one of the side effects of having a hernia, especially the smaller ones for some reason. And so rectal pain, tenesmus urinary frequency, and sometimes incomplete bladder ting. But usually the frequency and urgency is part of the questions that I ask my patients just to get a better understanding of how the pelvic floor is involved. And however, pelvic floor pt though, it can help the spasm in patients with hernias tends to hurt more.
Speaker 1 (00:45:39):
And then I feel like that’s one of the deciding factors in determining if the hernia is the cause or not, is they don’t tolerate pelvic floor PT as well. If it’s a hernia and then they tolerate it much better, oh, Tracy’s giving us some more information. So she specializes in complex pelvic pain, pal, testicular, et cetera, which of course can affect the men. She also makes the comment that prostatitis get diagnosed, but then often it’s actually related to pelvic four issues at any level and gets missed often. So that’s essentially a label, but not the underlying issue. I would agree. I feel that male chronic pelvic pain equals prostatitis in so many people’s charts
Speaker 2 (00:46:29):
And pelvic floor.
Speaker 1 (00:46:31):
It’s not necessarily that. Right?
Speaker 2 (00:46:35):
For sure. Yeah. Yeah. Pelvic, I mean, I’m a huge, huge fan of pelvic floor physical therapy. Yeah, it’s great. A lot of good outcomes.
Speaker 1 (00:46:42):
And we’re lucky in Los Angeles, we have great pelvic four pt, but
Speaker 2 (00:46:45):
Speaker 1 (00:46:45):
Like your specialty, it’s one of those specialties within physical therapy that is growing, but there aren’t that many people around it that do them. Another question for you. I had ascension of my testicle following tissue open repair. So this is Inguinal hernia repair without Mesh and was checked both on exam and by MRI with no evidence of recurrence. Is there anything urological other than recurrence that could cause elevation of my testicle? I can have the edge to that.
Speaker 2 (00:47:19):
So they had an open repair and
Speaker 1 (00:47:24):
Speaker 2 (00:47:26):
What I would think of just off the cuff, I would say it’s one of two things. Maybe the cord was potentially sutured or placed a little bit higher when they were closing the hernia area. Or what could happen is sometimes scar formation, right? Yeah. That scar formation, that healing area of the hernia will, if it’s scars down, higher up on the cord than it’s going to sit higher.
Speaker 1 (00:47:49):
Yeah, I agree. So whatever we do, inguinal hernia repair, I always make sure the testicles at the end of the operation testicles pulled down into well into the scrotum, because no matter what operation you do, there will be scar tissue and you don’t want the testicle to scar in an elevated position. The clarification on the last question, the high writing testicle is only during ejaculation. Why is that?
Speaker 2 (00:48:15):
So what happens is, as Tracy alluded to it, with the pelvic floor, so it’s all kind of connected. The pelvic floor and the trimesters, they’re all in some way connected. So what could happen is, and it shouldn’t usually happen, but it does sometimes when that pelvic floor, as I mentioned, the pelvic floor is responsible for orgasm and ejaculation. When that pelvic floor is contracting in order to admit, in order to ejaculate, sometimes that’s transmitting to the cremasteric, and when they contract, they pull up. Okay. So that would explain it.
Speaker 1 (00:48:48):
Speaker 2 (00:48:51):
To a certain extent. To a certain
Speaker 1 (00:48:52):
Speaker 2 (00:48:54):
Well, I think a lot of guys don’t pay attention to it. They’re not paying attention to it to know whether or not if it’s happening or not. But I would say it’s, if it’s bo…it’s normal to a certain extent, for sure. But if you’re having pain with it, then there’s things we could do. But as long as there’s no pain, it’s completely, it’s fine. I wouldn’t worry about very
Speaker 1 (00:49:13):
Normal. But why would it happen after surgery? Is it just they’re more aware or
Speaker 2 (00:49:21):
That area? That’s a good question. I’d say say just that area is just hyperactive. Sometimes because of scarring, because of the healing, sometimes those nerves to that area are just a little bit more active, A little bit more reactive.
Speaker 1 (00:49:36):
Yeah. In fact, with, well, so with ejaculation comes orgasm, and that does kind of cause extreme kind of contraction. I wonder if, could you have kind of a hyperactivity of a gentle nerve because it’s being impinged on?
Speaker 2 (00:49:55):
Yeah, too. That’s a good, yeah, it’s a point actually. It could be a nerve issue that’s causing that. Yeah. Yeah. Hyperactive nerve could basically simulate
Speaker 1 (00:50:03):
That. Let me read this for you. I had anal hernia repair bilateral almost six weeks ago. My last operation was in my last operation prior to that was in 2012. I had an Inguinal hernia recurrence. This time, the same operation had to be done. Now the third time for inguinal hernia repair only that I had on the right side an inguinal hernia as well. But now after surgery, after being in bilateral chronic pain for two years, I have great pain of a lumbar upper abdomen and the right radius to my right leg and my right epididymitis. So sounds like a left groin pain is gone, but my body still suffers on the right. There’s something I can do. Maybe we can talk about Epididymitis and Epididymitis. Can you explain what the epididymitis is and
Speaker 2 (00:50:55):
Speaker 1 (00:50:56):
Speaker 2 (00:50:58):
The Epididymitis, it’s underappreciated. So the testicle, there’s two structures within, I mean, the testicle isn’t just by itself posterior laterally, like behind and a little bit to, on the outside. There’s this structure that basically rides along the whole thing from the top to the bottom. And it’s very important because what happens is it’s the connection, it’s the in between the testicle and the vas deference that we talked about. So what happens is the testicle produces sperm. The sperm going to this Epididymitis, and they work their way. So the testicle sperm goes up and all the way to back down through the Epididymitis is when they mature. That’s when they become adult forms and ready to go out there and procreate. And they sit in the epidermis. And when you’re ready to ejaculate, all that comes up through the VA deference and into the outside world, the Epididymitis. And that usually takes 71 days, right? We say about 70 days for sperm from the day of production to the day of ejaculations, about 70 days. So the Epididymitis is, it’s important and there has issues with it. Sometimes there’s bacterial issues with it where you get bacterial inflammation of it. Sometimes it’s overuse inflammation you get like you use it too much and causes pain and you get inflammation as a result of it.
Speaker 2 (00:52:11):
Those are the two main ones. Now I think she’s referring to a nerve issue associated with it. Right.
Speaker 1 (00:52:16):
Well, let me tell you this. I get patients where they have an obstruction at the hernia repair, but that’s not, there’s no pain up there. What they actually have is epididymitis or very swollen epididymitis and also spermatic seal. Maybe you can explain why that happens. Because I feel that they go to urologists, urologists keep giving them antibiotics for their epididymitis. What they really have is engorged, epididymitis and even leakage, because there’s an obstruction higher up at the level of the hernia repair.
Speaker 2 (00:52:54):
Interesting. They’ll get spermatic seals after hernia surgery. Really?
Speaker 1 (00:52:58):
Speaker 2 (00:52:59):
That’s interesting. Because look, the thing is, the reason why I say it’s so interesting is because we do the vasectomy, right? Yes. And we’re doing it much closer to the testicle. Yes. You would think that the obstruction would be even more severe.
Speaker 1 (00:53:12):
Yeah. I never understood why vasectomy doesn’t cause obstruction. Side effects, but erosion, maybe it’s not completely obstruct closed.
Speaker 2 (00:53:23):
It’s a different type of, I think
Speaker 1 (00:53:24):
Speaker 2 (00:53:25):
It’s more than just the vas that’s being affected
Speaker 2 (00:53:29):
During the hernia. So what, to answer your question about the spermatic, it’s the spermatic. It’s basically, it’s a cyst. It’s a cyst of the epididymitis where those tubules, those tubules that basically carry the sperm. Sometimes they get an outpouching and the sperm will sit in that, grow in that. So what is usually something small will slowly grow in size? Is it bad? Absolutely not. Does it affect fertility? Definitely not. Sometimes guys are bothered by that, the growth and the size of it. So at that point you can go in there and surgically remove it, but it’s generally benign and it’s have any long-term issues with it. But that’s very interesting that you get these, the spermatic seals when you’re that high up.
Speaker 1 (00:54:13):
Speaker 2 (00:54:15):
I have to think about that. I wonder what causes that.
Speaker 1 (00:54:18):
I don’t know. And then they get a, what is it called? They get amo
Speaker 2 (00:54:24):
Speaker 1 (00:54:26):
No, what is it? When you do the bypass, you kind of connect it over
Speaker 2 (00:54:32):
Speaker 1 (00:54:33):
What is it?
Speaker 2 (00:54:35):
Speaker 1 (00:54:36):
Speaker 2 (00:54:37):
Vaso. They’ll get one of those.
Speaker 1 (00:54:38):
Yeah. And it cures
Speaker 2 (00:54:43):
Really? Yeah. Well, I mean, look, the cure part, that makes sense. No, the cure part. Cause it’s obstruction. No, no, no. To answer your, I get the cure part, but to connect those from, to make that connection, that’s a pretty good a length that you’re, you’re traversing. Yeah. But it’s an obstructive process. Yeah.
Speaker 1 (00:55:00):
Yeah. Okay. Does varicocele affect fertility?
Speaker 2 (00:55:05):
Definitely. Yeah. Definitely. So the way to think about seal is, like I said, it’s varicose veins. So what happens is blood pools around the testicle. Blood is generally very warm. Testicle likes to live in a very narrow temperature range. So when it’s blood is pooling, warm blood is pooling around it, that testicle’s not going to function the way it’s supposed to. Yeah. So it does cause decrease sperm parameters. Typically you get varicocele on the left. They’re much more common on the left versus the right. Very common varicocele are very common. I do a lot of these surgeries micro surgically. We go in there and we ligate those veins, we tie off those veins and prevent that back cooling. And usually you see a recovering sperm in about four months.
Speaker 1 (00:55:48):
Does spermatic effect fertility?
Speaker 2 (00:55:51):
No, it shouldn’t. It really shouldn’t. If addressed appropriately, if you tie it off, if you basically find it at its base, you’re able to reestablish the natural connection, the natural flow of sperm.
Speaker 1 (00:56:05):
Okay. Another question. Do you advise follow up after hernia surgery with dopplers or testicular ultrasonography? That’s not routine.
Speaker 2 (00:56:15):
Yeah. Well, if you’re not having pain, no. There’s no reason to.
Speaker 1 (00:56:18):
No. Yeah, it’s definitely not routine to do any imaging after your hernia
Speaker 2 (00:56:22):
Speaker 1 (00:56:23):
But if you do have testicular pain, the first step is examination and always include a testicular ultrasound because there’s a lot of things that can go wrong regardless of the hernia surgery. Exactly. Unrelated to the hernia surgery. But I think things that higher up within the testicle, which is the hernia repair, definitely should be looked at. And I feel that a lot of times patients have had a hernia repair and because all their symptoms are not in the groin where the hernia repair was, but down lower in the testicle, people forget that the origin can be up higher in the groin region.
Speaker 2 (00:57:01):
Speaker 1 (00:57:03):
Let’s see. Do injured or cut nerves heal with time? I had an Inguinal hernia pair with Mesh removed five months, but it’s hardened inside me. Ileal nerve was sacrificed when Mesh was implemented, was implanted. Yeah. Nerves do heal, but sometimes the heal abnormally about 5% of the time, like a neuroma. So you got to be careful anytime you cut nerve. Sometimes we have to cut it, but not What about Mesh migration in the body? I don’t know what the question is about. Mesh doesn’t usually migrate. It’s usually gets stuck immediately where it is. Plugs have been shown to migrate sometimes, but Mesh doesn’t usually migrate.
Speaker 2 (00:57:47):
It sits there.
Speaker 1 (00:57:47):
Secure. Misconconceptual. Okay. Well, I know that you and your group are the esteemed group of urologists in Los Angeles. That’s why I work with you all. And so I do appreciate all the work that you provide for the care of my patients. If someone wants to see you in consultation, should they just go on social media and DM you or because you’re young hip been happening, or what do they do? Do you have an email address? Website?
Speaker 2 (00:58:22):
Yeah. So I mean, couple ways you could do it. You could either call the office and schedule a consultation. You could look me up on Google. I have a Google page. Justin Houman, H O U M A N, MD. And then I have a social media presence where I talk about a lot of men’s health issues from low testosterone or erectile dysfunction, fertility issues, low libido. But across any of those, whether you look me up on Google call, the office, or even the social media, you want to slide it, you want ’em send a message through the direct message on Instagram or Twitter, what have you. I’m happy to respond.
Speaker 1 (00:58:55):
So lot of thank yous out here. Thank you. For your time and expertise. Are patients that are out of town, would they benefit from seeing you? Like let’s say they need fertility help. Is that something that works? If they come and fly in to see you, how
Speaker 2 (00:59:11):
Do you Absolutely. Absolutely. I mean, I do telemedicine for a lot of out-of-town, out-of-state patients. Yeah. Depends on what it is. You can’t do a vasectomy if you’re out of state, tell you can’t do a vasectomy obviously over telemedicine. But fertility issues, hormone issues, and erectile dysfunction, we find ways in which to coordinate. Most of the time we easily do it through telemedicine, but sometimes we do need to do an in-person consultation.
Speaker 1 (00:59:35):
Actually, that’s a good point about vasectomy. They can travel and don’t, do you as a specialist recommend that vasectomy be done by someone like you rather than a general urologist? Would they have less risk of let’s say, post vasectomy chronic pain?
Speaker 2 (00:59:53):
I would say, obviously my answer come to a men’s health specialist, but in general, the idea is vasectomy. All urologists are very well versed in, or most urologists are very well versed in doing a vasectomy. And if you have a
Speaker 1 (01:00:07):
Surgeons and doing hernia repairs,
Speaker 2 (01:00:09):
There you go. There you go. Right. Yeah. So most people are very well versed in and they do a good job with it. Yeah. So yeah, you can go anywhere really.
Speaker 1 (01:00:18):
All right. Well, thank you very much Dr. Houman, for spending your evening with us. This is the end of Hernia talk Live. Please do follow Dr. Justin Houman, MD on Twitter and Instagram. I’m at Hernia Doc on Twitter and Instagram. Thank you for all of your questions through Facebook Live at Dr. Towfigh. And for all of you joining us on Zoom, I will post the link to this talk on from my YouTube channel and hopefully you can like it and share it and watch it over and over again. And I feel like more men need to watch this and see how complicated it can be, but when you see urologists or specialists that only do this kind of work, it really makes it much more likely that you’ll get excellent care. So thank you Dr. Houman, and I’ll see you at the hospital.
Speaker 2 (01:01:08):
Sounds good. Hey, thank you. I really appreciate the opportunity.
Speaker 1 (01:01:10):
Thanks a lots. They’ve been very happy and hope you have a good rest of your evening.
Speaker 2 (01:01:14):
Likewise, likewise. Bye. Thank you. Take care. Bye.