How to use viagra!

In this short video I offer simple strategies to help you get the most out of your Viagra (cialis or levitra). We all know to take it at least 45-60 min before sexual activity. Here’s a few things to try if it’s not working well enough.


Frenuloplasty for Tight Frenulum

It’s only Wednesday, but already this week I have seen three men in clinic for tight penile frenulum. This condition is also known as frenulum breve (short frenulum). Lots of men have it. Most men don’t have a problem, but these three men were having problems. One of them said it felt like a slingshot on tension.

The frenulum is the band of skin that attaches the skin from the penile shaft to the under surface of the glans (penile head). It is usually cut during routine circumcision in boys, so most men with frenulum breve are uncircumcised. The problem usually develops over time, and some men have had problems their entire lives.

The frenulum is like a banjo string, and it can get tight, causing pain or pulling during an erection or during sexual stimulation. Commonly, it can tear, causing more pain, infection or scarring. As it scars, the frenulum becomes shorter, tighter and more painful. It is a vicious cycle of pain, injury, scarring…. rinse and repeat.

What do I recommend to men?

  • pull the foreskin back during urination to decrease irritation which can worsen the pain, inflammation and scarring
  • was under the foreskin daily with soap and water
  • rinse the foreskin with warm water after intercourse
  • wearing a condom with lubrication under the condom works for some men

When this doesn’t work, I usually recommend a steroid ointment for 4-6 weeks. This causes the skin to weaken and can result in stretching of the frenulum.

When all else fails, I perform a frenuloplasty, also known as a frenulotomy. The procedure takes about 10 minutes and is performed in the office with local anesthesia. It involves making a small cut in the middle of the frenulum to release the tight band. This allows me to lengthen the frenulum and the reconstruct it by sewing it closed.

The procedure is not painful. The recovery is easy and men do not require pain medications. I recommend using ibuprofen or similar if there is pain. I tell men that it will get worse and look worse before it gets better. Cleaning the surgical area is critical during recovery to prevent infection. Some men will have tightening of the foreskin for a couple of weeks and not be able to pull it back during that time. Sexual activity must wait for 4 weeks.

Long-term, most men are very happy with the result. In the short-term, men will have some sensitivity, even burning, in the frenulum during sexual activity. This usually resolves. The sensation of the penis, ability to get an erection, achieve orgasm and urinate are remain the same. It is rare to require a reoperation or circumcision if the frenuloplasty fails.


  • most men do not have a problem and need no treatment
  • hygiene can help mild cases
  • steroids work in moderate cases
  • severe cases are treated with frenuloplasty
  • overall frenuloplasty provides men with excellent function with minimal pain or recovery.

Men’s Health Bellevue

Treatment for Men’s Health Issues and Erectile Dysfunction in Bellevue

Bellevue office opens February 2019

I am excited to announce that starting in the new year, my clinic Bellevue, Washington will open.

A first in Bellevue:

A Board-Certified Urologist specializing in Men’s Health, sexual medicine and prosthetics

  • Erectile dysfunction, Peyronie’s disease, low testosterone, sexual dysfunction, infertility and request for vasectomy
  • Pre-existing patients will not have the option to transfer their care to Bellevue, due to the set-up of this space and equipment limitations.
  • Additional testing or surgery will be performed downtown where necessary.

Getting started:

1200 112th Ave NE Suite B-250
Bellevue, WA 98004

ph 206.386.6266
fx 206.622.1052

Learn more about your visit.

Map it on Google!

One Size Does NOT Fit All

I am a novice when it comes to blogging.  One of the things I find interesting when I look at this website’s statistics is the search terms used by people that ultimately lead them to this page.  This post is in response to one of the searches that included “penile implant regret”. I am not sure what regret the person who searched the internet for that topic had, but I will share the details of a case that I recently managed.

Last year, I saw a man and his wife for second opinion.  He had undergone penile implant surgery for erectile dysfunction a couple of months prior.  His point of regret was penis size. He reported that he had lost almost 3 inches of penile length and his girth was significantly reduced.  The penile implant was functioning, but both he and his wife were unsatisfied with the outcome.  Upon examination, it was clear to me that the penile implant that was placed simply wasn’t long enough. The cylinders stopped short of the head of the penis. The reasons for that are many and may include:

  1. Penile abnormalities like scar tissue or Peyronie’s Disease
  2. Unforeseen technical challenges at the time of surgery
  3. Under dilation of the penis
  4. Under measurement of the penis
  5. Surgeon experience (or inexperience) and/or preference

No matter what the cause this man felt short-changed.

Options for management:

  • Do nothing – the implant was functioning well but the placement placed him at risk for thinning of the penile skin
  • Remove the implant – he wanted to remain sexually active
  • Remove the existing penile implant and replace it with a new one, making every effort to place a longer penile implant

Uncertain about his options, it took until this year for him to decide to replace the implant.  Prior to his first surgery he used a vacuum penis pump and after his first consult with me began using it to stretch the penile tissues (even though he had an implant).  Last month we removed the implant.  I was able to place a penile implant that was 5cm (about 2.5 inches) longer than what he already had in place.  My verdict was that he was short changed by a ‘one size suits all’ approach to penile implantation.

What are my thoughts on penile implant size?

  • The best time to get it right is the first time
  • Removal and replacement should be considered only after a discussion about goals and expectations, addressing the benefits but also the shortcomings of revision surgery.  This could be higher rate of infection, falling short of goals or not fixing the problem you set out to treat.
  • Men need to understand that the biggest complaint after implant is that penis will seem shorter than it did before, even when we are doing what we can to optimize implant
  • To optimize the penis length before implant men may use a vacuum erection device to stretch the penile tissues
  • In my opinion, experience matters. The old teaching was to undersize implants. Prosthetic urologists are move adept and getting the sizing correct.  We have a broader skill set that we use even in difficult cases when we encounter unexpected anatomy.

The overall satisfaction rate for penile implant surgery is >90%.  Partners of men with implants report similar satisfaction rates.  Seeking a second opinion at least helps men better understand their surgical options.

penis pump, ED pump, penile implant

Repositioning a Penile Implant Pump

The other day I saw a new patient, who came to see me to discuss problems he was having with his penile implant.  It was placed by another surgeon, a few years ago, before he relocated to Seattle. The problem was not with the mechanics of the penile implant.  He was delighted with how adept he had become inflating and deflating the device.  He was happy with the firmness of the erection and said everything was great except…

He did not like the position of the pump in the scrotum.  He wondered if there was anything we could do to correct this.  I examined him and found the pump to be sitting high up in the scrotum.  It seemed to crowd the under surface of his penis.  He described to me that it commonly got in the way during intercourse.

The Problem

I explained to him the importance of pump positioning and the approach that I take in placing the pump. I try to place it at or slightly above the testicles.  Doing this gets the pump ‘out of the way’.  The goal is to have the pump placed just under the skin, where it is easy to palpate. If the pump is placed too low or too far back it may be difficult for men to function the penile implant.  

Common pump position problems include:

  • high-riding pump under the penis or up into the groin
  • pump placed too deeply making it hard to hold
  • tubing is too long and it coils up or causes pain for the partner
  • pump is too low and is out of reach
  • skin is too thin and I’m worried that it will erode through the skin

My Approach

  • The best time to get it right is the first time.  Care and attention at the time of the initial surgery usually avoids pump position problems.
  • Usually, I spend time troubleshooting the device to look for a solution that does not involve re-operation.
  • If it is early in the recovery phase I instruct men to massage the pump gently several times per day and gently tug and pull the device.  This can improve the final position after healing.
  • Often times, the pump is in a good position, but the problem is ‘too much tissue’. Men who gain weight will sometimes have more difficulty finding their pump.  It gets buried in the extra tissue and losing weight may solve the issue.
  • Surgery is an option if all else fails

Surgery to Reposition a Penile Implant Pump

This is usually performed as an outpatient, and men will go home the same day.  The recovery is much quicker and simpler than it is for the initial surgery to place the penile implant.  Rarely, is it necessary to replace the pump or any of the other components of the implant.

In the pre-op area I mark the skin when the patient is standing.  This indicates the ‘ideal’ final resting place for the pump.  I use the previous incision to open the scrotum and this allows me to free up the pump. The tissues are irrigated with antibiotic solution to reduce infection risk.  The pump is then relocated and secured into place.  If the tubing is too long, I may trim it.  If the tubing is too short, one option is to replace the existing pump with a new pump.

Once the swelling has resolved in 7-14 days, men can resume using the penile implant.

Final Word

  • Pump position matters and attention at the time of implantation can avoid problems.
  • Issues with pump position are actually uncommon and many men do not require re-operation.
  • Surgical reposition is a straight forward procedure and yields a high rate of satisfaction
Prostate cancer erectile dysfunction and recovery

Road to Recovery after Prostate Cancer Surgery

For several years we have prescribed Viagra, Cialis and Levitra to men recovering from prostate surgery.  Before that, we recommended regular use of penile injections or a vacuum erection device.  We call this approach ‘penile rehabilitation’.  The goal is to keep the blood vessels in the penis ‘limber’.  By doing this, the hope was that men would be left with better erections after the treatment and healing period.  It is not so clear and some studies show and improvement.  Other studies suggest there is no benefit.  So what is a man recovering from prostate supposed to do?

A recent article in the Journal of Sexual Medicine, sheds some light on issue.  It is not a study but an article called a meta-analysis.  This type of article reports the findings of many existing studies.  After very careful selection of the better studies  the data is analyzed.

In a nutshell it’s a bit confusing but here’s my read:

  1. In terms of erectile function / recovery:  penile rehab does not improve the degree / amount of recovery. Men who are on penile rehab do not fare better at the end of recovery with medications like viagra.
  2. Men who used medications, injections or vacuum for rehab however experienced better sexual function during the period of rehab.  They had better erections as they recovered.  I deduce that this is probably a happier patient.

My opinion:

  1. Penile rehab helps in the psychological recovery of men who wish to be sexually active. It allows them to experience better erections during recovery.  I think it gives them more confidence.
  2. Even though the end function is not improved, there are benefits to the vascular tissue of the penis. As a result of rehab less stiffness in the blood vessels develops, compared to not doing it…. use it or lose it.

Last word:

In summary, I think that penile rehab is a good idea for a man who is recovering from prostate removal surgery, if he wants to be sexually active during the recovery.  His erections will be better than the guy who wants to be active but isn’t on rehab.  And probably as important is that for men who aren’t interested in being sexually active during the recovery, they are not missing an opportunity if they aren’t treated with penile rehab.  There are various approaches, but usually it involves taking a low dose of the erectile function medications on a daily basis.

Penile implant for men with Peyronie's disease.

Penile Implant for Peyronie’s Disease

This weekend, I received an email from a man, who described a history of prostate cancer, impotence / erectile dysfunction (as a result of prostate surgery) and penile curvature (Peyronie’s disease).  At the present time he is no longer responding to medications for erectile dysfunction.  He has already seen another urologist who suggested that he undergo surgery to place a penile implant for his condition.  His question for me was about my approach.  Here is a snippet of how I replied:

  •  In general, men with erectile dysfunction and Peyronie’s disease (curvature) are best treated with a penile implant, which can correct 20-30 degrees of curvature just by placing the device. This will recover some of the lost length that comes with Peyronie’s disease. Additional sutures are sometimes placed to further straighten the penis, but have the risk of some shortening of the penis.  More invasive reconstruction is an option, and it involves incising the scarred area on the penis then placing the graft.  It restores some of the lost length but has the added risk of temporary numbness because usually we will have to elevate the nerves that give sensation to the penis to place the graft.  Permanent numbness is rare, however.
Further questions

He then asked about which implant I use and why:

  • In my practice, I only use Boston Scientific penile implants because they feel more natural and have antibiotic coating, lowering the risk of infection.  Specifically, in men with curvature I will only use the CX700, because use of the LGX700 will result in an erection, but it won’t be firm enough because of the scar tissue in the shaft of the penis where the scar originates.

Finally, he asked about sex drive (libido) and insurance coverage:

  • Libido is a separate function and is not affected by penile implant.  Similarly, men will still orgasm.
  • Many insurances cover penile implant and Peyronie’s surgery, and Medicare covers both.  We obtain authorization at the time of scheduling surgery to confirm.



Preparation for Implant Surgery

Having implant surgery for incontinence with an artificial sphincter or undergo penile implant is an important decision.  Preparation in the days and weeks before surgery is also critical.  Achieving a good outcome starts before you arrive at the hospital and it is my primary goal for men.

  • You will be notified if your urine culture or nose swab is positive for MRSA bacteria, in which case you will need to have this cleared before surgery.
  • Skin care / preparation
    • Do not shave or clip the hairs in the groin or around the penis for 2 weeks prior to surgery;  I will do this at the time of the operation
    • Purchase the skin cleanser, Hibiclens.  
    • Starting 3-4 days before your surgery you will use the cleanser daily.  In the shower, lather up the soap from the naval / belly button to the top of the thighs and include the penis and scrotum.  Leave on the skin for 5 minutes then rinse.
    • If you develop open sores, rash or cuts in the skin leading up to surgery please let us know.  This will need to be examined.  Rarely, surgery is postponed until these things resolve.
  • Please read all of the paperwork provided by the surgery scheduler.  This is where your surgery time, arrival time and preop information will be found.
    • You will be instructed to call the hospital preoperative program (or attend the appointment if it was required).  They will instruct you on which medications to take and which to stop.
    • If you have a pacemaker or defibrillator, take blood thinners or have a history of heart problems, it is best to get clearance from your cardiologist or primary doctor.  This is elective surgery and we want to ensure that you are healthy at the time of the operation.
  • Good blood sugar control, for diabetics, facilitates better healing and less risk of infection after surgery.
  • If you use a C-PAP device, bring this to the hospital on the day of surgery.
  • Likely you will spend the night in hospital, and you may be sent home with a catheter.
  • Please contact us for clarification or if you have further questions about the preparation.

Consider reading my blog post on Recovering from Penile Implant Surgery.


Anti-depressants and sex

Treatment is an important step for those suffering from depression–but treatment can also present an additional host of unexpected and uncomfortable circumstances for patients. Regardless of the side effects, treating depression is critical to maintaining optimal mental and physical health, and the benefits certainly outweigh the consequences. It can be frustrating, however, when treatment interferes with a patient’s sexual health. Commonly prescribed antidepressants can have a negative impact on libido and/or orgasm–but there are solutions that mean you won’t have to sacrifice your sex life to maintain your mental health.


Depression and sex

Anyone that has suffered from depression knows that it can have a significant impact on your overall physical well being. Oftentimes, this means a decrease in energy. Coupled with lower self-esteem and feelings of inadequacy, depression is a recipe for a sex drive disaster. From this perspective, there’s generally no place to go but up in dealing with depression; but patients undergoing treatment are often surprised to find that while other areas of their life are improving, their sex drive remains low and they may experience decreased sensitivity during intercourse.


Sexual side effects

Approximately 30-70% of patients taking an antidepressant experience some form of sexual dysfunction as a side effect of their medication. Typically men may experience a lower than normal sex drive or that it’s hard to achieve an orgasm during intercourse. While side effects can certainly contribute to sexual issues, low self-esteem or self-image may also be a factor. These negative thoughts can persist even after depression has been treated. Feeling bad about your body or yourself can be equally as damaging to a healthy sex life as the chemical impact of medications.


Reduce the impact

A study from the American Academy of Family Physicians found that “Decreased libido disproportionately affects patients with depression. The relationship between depression and decreased libido may be blurred, but treating one condition frequently improves the other.”


In addition to taking prescribed medication, therapy can help patients break out of negative thought patterns. Therapists can teach patients healthy coping methods to deal with the depressive thoughts and low-self esteem that impact sexual performance. Couples therapy can also be a good way to open the lines of communication between a patient and their partner.


If you’re still experiencing lowered libido, talk to your doctor about other options available to you. They’ll help you identify whether or not it’s your SSRI or some other factor that’s impacting your sex life. Under the direction of your doctor, you may be able to switch or reduce your medication, experiment with the time of day you take your prescription, add erectile dysfunction medication, or take a doctor-supervised “drug holiday,” a temporary break from your medication. There’s no reason to suffer.


Photo credit

My Movember Mustache in support of testicular cancer

12-yr Testicular Cancer Free Anniversary!

This past weekend I received a text from mother, wishing me a ‘happy anniversary’!  Each year it takes me a moment to remember that she is referring to my surgery for testicular cancer 12 years ago.  It seems so long ago.  Mothers have a way of remembering 🙂

It is unusual for me to discuss an issue like this in my workplace, but occasionally, I have found it very helpful to disclose to men upon hearing that they have cancer.  Your world changes when you’re told you have cancer, even in the ‘best’ case scenarios, where the problem is lower risk (as mine was).  I understand how my world changed, and when I receive the annual anniversary text from mother, I give pause and am grateful to be healthy.  I found my cancer doing a Testicular Self-Examination, and since I’m a urologist I knew what I was feeling and I found it early.

This month is MOVEMBER  Men grow a mustache as a symbol of awareness to men’s health and cancer issues.  I’m not doing it this year, but have done it in the past.  It’s about men taking action about their own health, receiving screening and routine medical care.   Sooner is better than later, as it was in my case!

Here’s my MOvember pic from a few years back…  No captions please!