CIRCUNCISION."Realidades y Controversias"Parte I(Publicado en quinto Dia)

CIRCUNCISION, “Realidades y Controversias”. PARTE I

Dr. Ricardo Szemat Nikolajenko*

Dr. Ricardo Szemat Daher**

La circuncisión en los varones, implica quitar la porción de piel que normalmente cubre el glande del pene.                                                          La historia nos sugiere que este procedimiento se originó  en Egipto, hace 15.000 años, las momias egipcias y los grabados  en las paredes, descubiertas en el siglo 19, nos ofrecen datos de que la circuncisión, se hizo 6000 años antes de cristo. Cuando Cristóbal Colón arribó al nuevo Mundo, encontró que los nativos ya estaban circuncidados. Muchas culturas históricamente usaron la circuncisión, por razones higiénicas, como marcas culturales, o como ceremonias ofrendadas a Dios. La circuncisión, Ritual en El  Medio Oriente, se ha practicado por lo menos hace 3000 años. A finales del siglo 19 este viejo ritual evolucionó hacia una práctica médica rutinaria, asociándola a  curas milagrosas para: Hernias, parálisis, epilepsia, masturbación, dolores de cabeza, prolapso rectal, hidrocefalia, asma, enuresis y gota. Debido a que la circuncisión en las ultimas 2 décadas, se ha convertido en un caso controversial, LA American Academy Of Pediatrics (AAP) en 1999 afirmó  ”Existen evidencias científicas, demostrando beneficios potenciales  de la circuncisión en el varón  recién nacido, sin embargo estos datos no son suficientes para recomendar la circuncisión neonatal” Como consecuencia de esto, los padres deben ser ilustrados, para que ellos hagan una escogencia,  informada y decidan, cuando,  la circuncisión  es de interés para su hijo. Los grupos que nos oponemos a la circuncisión neonatal, pensamos, que la piel del prepucio tiene nervios especializados que terminan allí, que mejoran el placer sexual y funciones importantes como protección del glande del pene.  La permanente externalización del glande del pene resulta en  desensibilización debido a una queratinización y entierra terminaciones nerviosas dentro de estas estructuras. Muchas familias escogen que sus niños sean circuncidados por razones culturales, religiosas o razones higiénicas, solo pocas razones  médicas son aceptadas y reconocidas. Fimosis, parafimosis, balanitis, postitis, algunas veces se recomiendan en niños menores y mayores, que desarrollan infecciones del tracto urinario y niños que necesitan  pasarles una sonda frecuentemente.                                                                              Fimosis: Es una condición cuando el prepucio distal no se puede retraer por debajo del glande.                                                                        Fimosis severa: A los 3 años solo un 10% de niños son incapaces de retraer su piel, ya en   la adolescencia 98-99%, pueden retraer full su piel. Fimosis adquirida: Ocurre  como resultado de una escasa higiene, balanitis crónica: Cuando se forma un anillo fibrótico en  la apertura del prepucio, que impide la retracción. La fimosis no causa  obstruccion. Aun con una buena higiene los individuos presentan el riesgo de irritaciones de piel, crónicas; infecciones a cándidas (hongos), balanitis (Infección del glande  del pene), postitis (infección de prepucio).                                                                                                                                                              Parafímosis: Es la imposibilidad de regresar de nuevo la piel  retraída al glande del pene, a su posición natural, ésta es una emergencia  Urológica, que si  no se trata a tiempo puede progresar hasta la oclusión  arterial y la posible pérdida de una parte o de todo el glande, la mayoría de las veces el Urólogo con maniobras manuales puede retraer la piel y solucionar el problema, si no puede, debe hacer una incisión en piel hasta que logre su solución y luego en un segundo tiempo, se debe realizar una circuncisión.                                                                                                                             Urólogo Cirujano*                                                                                                                                                  Cirujano. UCV**

http://www.prostataymedicinasexual.com                                                                                          Fuente: Medscape, Carlos A Angel, Enero 20,2011.

Experiencia de las parejas sexuales de las personas con Cáncer

Discussion

This study examined changes to sexuality after the diagnosis and treatment of cancer for informal carers who were the partner of a person with cancer. Most participants reported that the cancer experience had impacted on their sexual relationship, resulting in a cessation or reduction of sexual activity, with only a minority renegotiating sexual intimacy after cancer. This supports previous research demonstrating that the impact of cancer and cancer treatment extends beyond the person with cancer,^[3-5,7,30] reinforcing the need for acknowledgment of the sexual and intimate needs of partners and of people with cancer. Rather than restricting our sample to partners caring for a person with cancer affecting the reproductive areas of the body, we examined changes to sexuality after cancer across a range of cancer types. Most participants who were providing support to a person with prostate, breast, or gynecologic cancer cited an impact, confirming previous research.^[4,13,14] However, the finding that a high proportion of partners of a person with nonreproductive cancer also reported changes highlights the pressing need to acknowledge and attend to the sexual concerns and needs of all partners who care for a person with cancer.

There were some gender differences in the accounts of the nature of changes to the sexual relationship after cancer. Reports of complete cessation of sex were more common for women than for men, and very few women gave accounts of developing alternative sexual practices if intercourse was no longer possible. This could be attributed to women being more likely to assume that they should subordinate their own needs to the needs of their partner^[31] and to cultural constructions of normative heterosexuality, which expect men to initiate sex.^[32]Previous research has found that partners are reluctant to initiate sexual intimacy if the person with cancer does not initiate^[4] and that heterosexual women partners do not wish to initiate sex or discuss alternatives to coital sex for fear of emasculating their partner if he cannot "perform" through sexual intercourse.^[33] This is consistent with research that has demonstrated that sexual performance is positioned as central to heterosexual constructions of "manhood," with failure having negative consequences in terms of a man's sense of self.^[34] Equally, the "male sex drive discourse," which positions men as "needing" sex,^[35,36] may result in the sexual needs of male partners being classified by either or both members of the couple as being "important enough" for sex to continue after cancer or for alternative sexual practices to be developed, in contrast with women partners, who were more likely to report that renegotiated intimacy was nonsexual. The phallocentric bias evident in the research and clinical literature on cancer and sexuality,^[37] which serves to reinforce the notion that "normal" sex equals coitus and emphasizes sexual "functioning" with little attention to alternative practices, needs to be challenged, as this potentially plays a significant role in the construction of truths about sexuality, which people with cancer and their partners take up, limiting their exploration of alternatives to coitus after cancer. However, in the present study, 4 of the 6 lesbian partners all reported complete cessation of sex, suggesting that even couples positioned outside of a heterosexual matrix^[38] can experience changes to sexuality after cancer.

Although previous research has attributed changes in sexuality and intimacy after cancer to the physiological effects of cancer or cancer treatment, a finding confirmed by many of the accounts in the present study, our findings also showed that the caring role had an impact on the sexual relationship. Participants associated sexual changes with stress, fatigue and exhaustion, revised prioritization centered on coping and survival, and a redefined status as a carer rather than as a lover. Past research that has explored carers' experiences of stress and exhaustion primarily focuses on the impact upon carers' general health and well-being. For example, Brown and Stetz^{[39] (p186)} found that the initial period of "becoming a caregiver" is particularly stressful, as carers not only are focused on their new role but also have to "face the present," negotiate their choice/or lack thereof to care, develop competency around their caring tasks, and evaluate their future. It is important to further investigate how the stresses involved in being a caregiver impact upon a carer's sexuality and how this may in turn impact on quality of life.

The impact of the repositioning of the person with cancer as patient or "child," rather than as "lover," is an important issue that requires further investigation. The finding that the physical symptoms of cancer or the physical tasks associated with cancer caring make it difficult for many carers to continue to see their partner as a sexual person confirms patterns found in other spheres of healthcare.^[17] This assignment of individuals with cancer with a "sick" or "childlike" identity, which is antithetical to an identity as a person with sexual desires and needs, can significantly impact on the sexual and intimate relationship of a couple facing cancer.^[40] Sex can be positioned as "inappropriate" or as a "frivolous activity,"^[41] resulting in carers experiencing guilt in the face of their own sexual needs or desires and the avoidance of any discussion or renegotiation of sexual practices, as was reported in the present study. This could be seen as one aspect of a broader practice of self-silencing in cancer carers, where the needs of the carer are repressed because the person with cancer has to be put first.^[42] However, it is also associated with cultural discourses that position people with cancer as having limited sexual needs or as asexual,^[19,43] resulting in a different set of norms being applied to what is an acceptable behavior.^[44] The finding that male partners were more likely to report an impact of repositioning the person with cancer as a patient may result from the role of carer being a more unfamiliar position for men to take up, given the congruence between femininity and the caring role.^[31] It may thus be more difficult for men to eroticize a partner with cancer who is in need of care. This matter is worthy of further investigation in future research.

As most partners positioned these changes to their sexual relationship as problematic, confirming previous research,^{[10,12,15,45]} this suggests that education and information about sexuality after cancer, which challenges myths and provides a framework for renegotiation of sexual relationships, need to be included in advice and supportive interventions for partner carers. However, although it has been recognized that healthcare professionals need to discuss issues of sexuality and intimacy with patients in cancer and palliative care^[46] and can play a vital role in providing "permission" for sexual intimacy between couples after the onset of cancer by legitimating such discussions,^[47] the findings of the present study confirm previous research that found that these discussions are not taking place for most people with cancer or their partners,^[48] particularly for those outside the sphere of prostate cancer. Even when sexuality was discussed, this was not at a level that was satisfactory to most participants in the present study. This confirms recent Australian research that reported mismatched expectations and unmet needs in relation to communication about sexuality between healthcare professionals and individuals with cancer,^[49,50] suggesting that further education and training of healthcare professionals are required so that they will be able to advise couples affected by cancer on issues of sexuality and intimacy and address their unmet needs in this arena.^[51] Although specific interventions have been developed to address sexuality issues in relation to cancer,^[52] models of intervention that have been developed for persons with disability^[53,54] or individuals who are older aged^[55,56] can also be used to facilitate communication about sexuality between couples facing cancer so that they will understand and feel confident about trying "alternative" modes of sexual behavior, such as intimate touching or oral sex, without feelings of guilt or inadequacy. More specifically, couples can benefit from encouragement and permission to raise concerns about sexual functioning, allowing them to ask for and be provided with information within a supportive environment that fosters open communication with healthcare professionals.^[52] Strategies that can be used include using normalizing statements to show that discussing sexual issues comprises standard and routine care, adopting a positive attitude toward such discussions, embedding individualized information in other aspects of care, and eliciting basic understanding of concerns and of the individual's motivation to address the issue to offer specific suggestions.^[52]

A number of methodological issues need to be considered when evaluating the findings of this research. First, the issue of selection bias must be examined. The present study used self-selection in response to advertisement or information sheets distributed by cancer organizations or clinics and thus may not have tapped a representative sample of informal cancer carers. However, there was a good distribution across cancer type, stage, gender, and age group, in contrast with many previous studies of cancer and sexuality that focused solely on cancers affecting the reproductive organs. Equally, as the participants were recruited for a general study on cancer caring, answering questions on sexuality as part of a broader questionnaire or interview, it could be argued that we have recruited individuals who would not usually respond to requests to take part in a research study on sexuality and thus have obtained a broader sample for our research. Second, this study did not use standardized measures of sexual functioning or sexual or relationship satisfaction but rather focused on subjective reports through open-ended questionnaire items or interview. Future mixed-method research in this field could usefully adopt these standardized measures alongside qualitative measures to allow for greater triangulation of data in evaluating the extent and impact of changes to sexuality after cancer. Third, the cross-sectional design meant that all assessments of change were retrospective. A longitudinal design would more effectively allow for the evaluation of changes to sexuality across cancer stage and allow precancer and postcancer treatment changes to be evaluated more thoroughly.

In conclusion, sexuality and intimacy are central aspects of quality of life that have often been neglected in examinations of the well-being of partners of a person with cancer, particularly for nonreproductive cancers. The findings of the present study add further support to the suggestion that sex should not be positioned as inappropriate or "trivial" in the context of cancer care but rather be recognized as an aspect of couple relationships, which is associated with well-being.^[57] Having healthcare professionals legitimate sexuality by "giving permission" for couples to be sexually active or physically intimate when undergoing and recovering from treatment for cancer is one of the key strategies that could assist in this repositioning.^[47] The positive consequences of this may include increased feelings of well-being on the part of the partner carer and closeness between the couple, which will have positive consequences for the physical and psychological well-being of the person with cancer,^[1] the central aim of professional cancer care. There is thus no justification for sexuality and intimacy being ignored or dismissed; partner cancer carers are telling us that it is important, it is time for healthcare professionals to recognize this need and to act accordingly.

pene curvo(enfermedad de Peyronie)Parte I

Pene Curvo (Enfermedad de Peyronie) PARTE I
D
Dr. Ricardo Szemat Nikolajenko*
Dr. Ricardo Szemat Daher**
Francois Gigtot de Peyronie es el primero que describe una curvatura peneana en 1743, conocida ahora como Enfermedad de Peyronie (EP).
La EP es una curvatura del pene, particularmente durante las erecciones, que se asocia usualmente con áreas de fibrosis palpable en la túnica albugínea (envoltura de los cuerpos cavernosos) es precedida de erecciones dolorosas y puede asociarse con Disfunción eréctil. El área fibrotica conocida como placa puede variar en firmeza y algunas veces puede estar calcificada, esta condición no está asociada con un organismo infectante y no se transmite de una persona a otra.
Hay una prevalencia de 3,2% en la aparición de una nueva placa, Prevalencia por edades: 1.5%, a los 30-39 años; 3%, a los 40-49 años; 3%, a los 50-59; 4%, a los 60-69 años; 6,5% de 70 años en adelante. 84% Asociado con placa , 47% reportan erecciones dolorosas, 32% reportan la triada(placa, angulación y dolor), 41% reportan disfunción eréctil.

2
La EP está reportada entre 0,39-3%, sin embargo se piensa que esta sub-reportada, debido a lo penoso que resulta para ciertos hombres esta condición, en el 2004, Mulhall y colaboradores encontraron una prevalencia de 8,9% en hombres que asistieron a una pesquisa de Cáncer de Próstata en USA, ellos encontraron una significante proporción de hombres con EP que también tenían hipertensión y Diabetes.
Por qué se produce? EP, está asociada a deficiencia de vitamina E, ingestión de agentes beta bloqueantes y elevación de los niveles de serotonina, la EP, está asociada a la contractura de Dupuytren y con HLA_B7, implicando lazos genéticos a su etiología. Más recientemente La EP se piensa que es el resultado de trauma vascular o injuria al pene, esta ruptura, puede ser leve y toca solo vasos microscópicos y tejido. USTA y colaboradores investigaron enfermedades como: Diabetes, hiperlipidemia, hipercolesterolemia o hipertensión y no encontraron correlación estadística entre la severidad de la curvatura del pene en el hombre con EP. El-Sakka en 2006, encontró en estudio de 1440 hombres con disfunción eréctil, un 8%, EP, basado en placas en el pene.
En análisis sociodemográficos, se identificaron asociaciones importantes entre EP y los factores de riesgo para disfunción eréctil: Edad, Obesidad, fumar (duración y numero de cigarrillos por día), Duración prolongada y aumento de severidad de la Disfunción eréctil, Diabetes Mellitus, Dislipidemia (alteración de las grasas, lípidos) y desordenes psicológicos. No se encontró una asociación

3
Significativa entre EP e Hipertensión o enfermedad cardiaca isquémica en este estudio.
Bjekic y colaboradores 2006, identificaron factores de riesgo en 82 hombres que tenían una EP, basados en su historia y en una placa en el pene bien definida y los compararon con 264 hombres que no tenían ni historia ni signos de EP y encontraron lo siguiente como factores de riesgo: 1) predisposición genética en asociación con historia familiar de contractura de Dupuytrem, 2) trauma vascular menor en pene ya sea incidental o iatrogénico post cistoscopia o una resección transuretral de próstata, 3) enfermedad vascular sistémica incluyendo: Diabetes mellitus, Hipertensión e hiperlipidemia (grasas altas), 4) fumar y consumo de alcohol. El uso de propanolol (agente beta bloqueador) y una historia de uretritis no gonocócica también es un riesgo para EP. Como estos factores contribuyen a la iniciación de EP, permanece sin explicación.
Agrawal y col en 2008, reportaron que los pacientes con EP tienen evidencia de daño sistémico arterial que es dependiente –endotelial. Los autores creen que estas anormalidades sistémicas tienen una relevancia clínica para el desarrollo de EP. Como verán diferentes hallazgos, sin ningún resultado definitivo, evaluaciones a futuro son necesarias para confirmar estos interesantes hallazgos.
*Urólogo cirujano. **cirujano UCV.
http://prostataymedicinasexual.com

masa Escrotal-testicular

 

riñon sano

 

La Cirugia minimamente Invasiva ,causa mas incontinencia y mas disfuncion erectil que la Prostatectomia abierta retropubica?

Un nuevo articulo publicado en Jama 2009:302(14)1557, nos dice que la prostatectomia minimamente invasiva (Robotica)causa mas incontinencia y mas disfuncion erectil que la cirugia abierta retropubica,.Esperamos que este articulo contribuya para esclarecer lo que se esta discutiendo en todos los ambitos urologicos del mundo,.
Cual sera la realidad?
Pronto tenedremos los numeros necesarios para aclarar esta controversia.
Lo que si es cierto en nuestras manos ,que solo hacemos Prostatectomia Abierta retropubica y en la cual tenemos una experiencia en el pais abundante,podemos decir que nuestro tiempo de operacion es corto(una hora hora y media)incontinencia,en nuestros primeros pacientes muy leve y los costos son mucho menores que las otra cirugias y la radioterapia,con resultados a 12 años muy buenos.
Disfuncion erectil: esperando a los 5 meses,tenemos que el 75% se recuperan y nos queda un 25% que no se recupera,pasarian a beneficiarse de uan protesis peneana.
DR.Ricardo Szemat Nikolajenko.Urologo.04142570173

Varicocele combinado con fumar empeora la motilidad y la morfologia

By Will Boggs, MD

NEW YORK (Reuters Health) Oct 26 - Smoking combines with varicocele to worsen sperm motility and morphology, say researchers from Italy in the October Urology.

"The present study indicates a negative synergic effect of cigarette smoking and varicocele: another strong reason to stop smoking," Dr. Elena Moretti from the University of Siena told Reuters Health. "The main message of the present research should be to implement effective interventions targeted to encourage men to quit smoking in order to improve general health and also their fertility potential."

Dr. Moretti and colleagues investigated whether smoking increases the adverse effects of varicocele on sperm morphology and function in a study of 121 smokers and 158 nonsmokers with varicocele.

Progressive sperm motility was lower in both groups compared to World Health Organization values, the authors report, but the difference between smokers and nonsmokers was not significant.

Similarly, the percentage of immaturity, necrosis, and apoptosis were significantly lower than reference values in men with varicocele, but the values did not differ significantly between smokers and nonsmokers.

When the smokers were categorized according to their daily cigarette usage, however, sperm concentration, progressive motility, apoptosis, immaturity, and necrosis were all significantly worse among heavy and moderate smokers than among mild smokers.

"I believe that the most important point to be stressed is to persuade males to quit smoking as soon as possible, as it has been reported that reduced fecundity associated with smoking may in great part be reversed within a year of smoking cessation," Dr. Moretti said.

"The study of the relationship between smoking and varicocele, which we have shown to affect sperm characteristics, is the first step in the research we have undertaken to discover the determinants of sperm injury," Dr. Moretti added. "It should be of pivotal interest to consider other putative mechanisms of damage, in addition to free oxygen species release due to smoking and the presence of varicocele (widely reported in the literature)

Urology 2009;74:794-800.
Comentario RSZN; El dr moretti piensa que esta es la primera etapa en esa investigacion para descubrir las determinantes en la injuria del espermatozoide y buscar otros mecanismos de daño,aparte de la liberacion de " especies oxigeno libre" debido al fumar y la presencia de Varicocele.

DR Ricardo Szemat Nikolajenko;urologo.