Within the urology department of Wake Forest School of Medicine, Dr. Ryan Terlecki directs the Men’s Health Clinic. We are a high-volume provider of surgical correction of sexual and urinary health issues including urethral strictures, erectile dysfunction, Peyronie’s disease, and male stress urinary incontinence.
In addition, Dr. Terlecki directs the male fertility program, specializing in hormonal optimization, vasectomy reversals, and sperm extraction for assisted reproduction. We also direct the Prostate Cancer Survivorship Program for men and their loved ones.
What Makes Wake Forest Men’s Health Unique
Unlike many other specialized surgical facilities, we maintain a patient-centered focus that prioritizes patient communication and understanding. Men’s and couples’ wellness is a centerpiece of our practice. We recognize the important role of the partner in any couple.
In addition to optimizing sexual and urinary health, we routinely seek to identify and correct issues related to weight management, tobacco cessation, cardiac risk assessment, diabetic control, and sleep hygiene. As such, we maintain steady and effective collaboration with our supporting services across various departments.
For patients seeking hormonal therapy, we consistently provide a detailed explanation of risks and benefits in view of the most recent published evidence. For men seeking device placement, such as penile implant, artificial urinary sphincter, and male sling, we offer them the confidence that comes with knowing that other surgeons come to us to observe these procedures being performed at an expert level so that they can perform them in similar fashion in their own practice.
When it comes to addressing male health issues, Wake Forest Men’s Health provides the clinical expertise in your own backyard. To learn more about our services or to arrange an appointment with Dr. Terlecki and his skilled team, call us at (336) 716-4131 or request an appointment online.
Some data suggests that the penile prosthesis has the HIGHEST degree of SATISFACTION for both men AND their partners, when compared to other treatments for ED. This may be because men who ultimately elect an implant have had poor success with other therapies. This option is meant to be a permanent solution after a one-time simple outpatient procedure. There are no pills to take or needs to insert. This option allows you to have rigidity on demand, whenever you want and for as long as you want.
Each penile implant is CUSTOM-SIZED to the patient. The length placed at the time of surgery is the length of the chambers within the man's anatomy on stretch. Thus, we seek to place the longest device that the patient's anatomy can accommodate. No portion of the anatomy is removed during the procedure, such that the operation itself does NOT shorten the penis. If a man feels that his erectile length has decreased with age, some implants are designed to expand in both length and girth. Many patients report improvements in size with regular use of their implant upon returning to sexual activity.
The nerves responsible for creating an erection are separate from those that carry the sensory input. This is why men with ED can still enjoy contact, primarily at the head of the penis (called the "glans"). Nearly all of our procedures use an approach involving a small incision on the upper scrotal skin. This avoids the nerves on the top side of the penis. Thus, the sensation at the glans remains intact.
When placing an implant, we aim to develop the necessary space with care to preserve the source of blood flow in the erectile tissue. As such, we have numerous patients that report some fullness to the penis with arousal even before activating their implant for sexual activity. This is despite the fact that the blood flow wasn't adequate for a rigid erection before surgery. We speculate that preserving the arteries and compressing the erectile tissue against the implant allows for the pressure generated by blood flow to be more apparent since it doesn't have to fill the same volume as prior to the procedure.
The penis is simply the portion of the anatomy visible on the outside. The two internal chambers for erectile blood flow (called 'corpora') are inside the penis but also travel into the body and are attached to the public bones. Thus, the implant itself is longer than just the penis, as it occupies the full length of these chambers. The procedure is offered to provide rigidity on demand. For men who feel that the flaccid state is much shorter than the erect state, they may feel that the penis is "longer," but this is a reflection of increased visibility. However, some men who may have lost length due to a prolonged period of infrequent erections (less cycling of well-oxygenated blood) or scarring from prior injection therapies, may be able to stretch their erectile chambers with regular use of the implant.
The implant can be placed through various approaches. We use a penoscrotal technique. This involves a tiny incision that is hidden in the folds of the scrotal skin. In very rare situations, we would consider an infrapubic approach if necessary, as in patients with extensive pelvic mesh, prior bladder removal, or significant radiation and/or surgical trauma within the pelvis. The penoscrotal approach is preferred for a number of reasons. The scar is typically not seen by patients or partners. Additionally, there appears to be less pain for patients and presumably less risk of hemotomas. Providers who perform a high volume of infrapubic device placements often apply sandbags or other forms of pressure dressings after surgery, and often use drains to collect blood that would otherwise build up and potentially cause problems. We have never had to apply pressure dressings or drains. Perhaps the biggest advantage to our preferred technique is positioning of the "pump" within the scrotum, as we are able to easily place this in the desired location without issues of future ascent. With the infrapubic technique, there is a risk that the pump will "ride up" superiorly such that it can be uncomfortable, unsightly, and potentially difficult to use.
Most men prefer 3-piece inflatable devices. The three components include the reservoir that holds the fluid (saline), the fluid transfer mechanism (the "pump"), and the chambers within the erectile bodies. This type of implant provides the most feeling outcome and allows the penis to be back in a comfortable position when sexual activity is completed. Also, one of the device types within the 3-piece category is designed to expand in both length and girth, which is not available in other device types. For men with severe pelvic trauma from prior accidents or surgery, a 2-piece device may be considered. For men with extremely poor manual dexterity, there is a simplistic option known as a "malleable" or "semirigid" device. This does not involve fluid at all since the implant consists only of two bendable rods within the penis.
For men involved with female partners, we find it essential to optimize HER experience. Giving a man a rigid penis on demand doesn't necessarily make him the best lover. The average age of menopause in the U.S. is approximately 51.5 years, although some women may experience these changes sooner or later for various reasons. As estrogen levels fall, the blood flow to the vaginal tissue may change and becomes dry and/or sensitive. As such, we educate our male patients and couples on optimal lubrication and the importance of foreplay prior to intercourse (including massage and other intimate activities with which most adults are typically familiar). We go over specific products available and how to use them most effectively. Men are informed that they can take all the time they need in the bedroom to accommodate their partners because they won't have to worry about the erection fading, since it will stay up for as long as they need and/or want. Female partners tend to prefer the implant based on the ability to be spontaneous.
Once a man has an implant, there is no fear of not being able to perform. There is no need to take a pill with the debate about when he ate/drank last so as to optimize chances the medication will work. there are no more trips to the pharmacy with out-of-pocket payments for medications. There are no more episodes of facial flushing, headache, or sinus congestion from the medication. There is no fear of increased risk of visual issues or skin cancer, as has been reported with some oral medication. There is no need to interrupt sexual activity to perform a needle injection into the penis. There is no need for cumbersome vacuum erection devices and constriction bands. There is no need for worrying about traveling with items that would be found in carry-on luggage and potentially cause embarrassment.
The implant will NOT set off metal detectors at the airport.
An MRI can be performed in men with an implant based on the type of MRI coil being used. The device is listed as MRI-conditional and full details are available through the manufacturer.
The device can be removed if necessary, similar to other medical devices (e.g. pacemakers, neurostimulators). We've encountered situations with patients undergoing pelvic cancer surgery with an indwelling implant placed 10-20 years ago such that the device had to be removed to allow for the cancer surgery. Several of these patients had device replacement once recovered from their cancer operations.
In our experience, the risk for infection is less than 1%. We have published these results within the medical literature. Similarly, the rate of device malfunction in our series is also less than 1%.
For most patients, the device will last them the rest of their lives without need for revision or replacement. Prior studies have verified this in the overwhelming majority of patients when contacted 15 years after implant placement.
The inflatable implant currently in use has been available in some form since the early 1970s.
Dr. Terlecki has been extensively trained in penile implant surgery. He was trained in Michigan by Dr. Dhabuwala and was involved with hundreds of cases before going on to high-volume practices in both Colorado and Texas for two separate fellowships involving prosthetic urology. At present, we perform between 100-200 prosthetic cases each year.
Insurance coverage is verified by our office prior to surgery. Medicare offers coverage for nearly all patients, but Medicaid does not. Many commercial plans will provide coverage; however, some will have exclusions. For patients denied coverage or for those that have no insurance, affordable cash-based options are available.
Our procedure falls under the outpatient classification. Typically, this is listed as a "23-hour" stay. In most cases, the procedure takes less than 60 minutes (often as little as 30-40 minutes) of operative time. At the end of the procedure, the device is left fully inflated until the following morning. As such, we send the patient to a private room until that time. Men are typically surprised by their level of comfort immediately after surgery and are allowed to eat/drink when ready. The device is placed back to a resting position in the morning and patients are discharged home after breakfast. Patients are walking after surgery and may resume driving 24 hours after returning home. We ask them to resume showering 48 hours after surgery, but to avoid underwater activities (e.g. baths, hot tubs, pools) for 4-6 weeks. Additionally, we ask that they limit strenuous lifting to 25 lbs. at a time for the same duration.
The device is activated at 6 weeks after surgery during an office visit where instructions are provided. After that visit, patients are able to resume intercourse.
The head of the penis (known as the "glans") is actually connected to the urethra (tubular structure carrying urine out of the body from the bladder). With natural erections, the glans often enlarges (becomes engorged) because there are blood vessels that connect the erectile chambers (the "corpora") to the urethra. If blood flow through the corpora is less due to ED, or with an implant, there may be less enlargement of the glans during arousal and sexual activity. This is not an issue of concern for most patients. However, should a man desire greater engorgement of the glans at time of intercourse, some of the medications that may not have been effective enough to produce a rigid erection (e.g. Viagra, MUSE) may be just enough to offer that engorgement that meets their desired state.
The implant is not a biological product. So, unlike with an organ transplant recipient, there is NO need for anti-rejection medications.
There are NO oral medications FDA-approved to treat Peyronie's disease.
Xiaflex is an enzyme produced by bacteria that degrades collagen, which is found in numerous types of connective tissue. It was initially used in a condition called Dupuytren's contracture (also called "trigger finger") to try and degrade the scar-like tissue within the hand. It is used in some men with repeat injections and episodes of bending the penis opposite the degree of curvature in order to improve trajectory. In the clinical trials leading to FDA approval, the medication worked better than simply injecting saline into the plaques (the scars causing the curvature). However, the saline injection patients also saw improvement. The degree of improvement, however, is of debatable clinical significance. For the largest trials performed, men had around 50 degrees of dorsal curvature (on average) prior to treatment. After a year of treatment and numerous injections, they still had over 30 degrees of curvature (on average). Traditionally, experts in the field have used 30 degrees to indicate an erection requiring intervention. Thus, one can argue that, on average, the treatment failed to "solve" the problem in those studies. Additionally, the enzyme can digest healthy tissue such that the erectile tissue chambers can rupture. This is well reported in the medical literature. Thus, while this option can be considered, men need to be fully informed.
Shockwave therapy does not have a viable role for treatment of Peyronie's disease. However, it has been well-studied for men with ED. It is believed to create a mild injury such that the body's response is to increase the density of vascular tissue through stimulation of new blood vessel formation. The results appear promising. In fact, this is now listed among options in European guidelines for treating ED. In the U.S., however, certain societies (e.g. the Sexual Medicine Society of North America) still view this as experimental. We are able to offer this treatment for interested patients. Platelet rich plasma (PRP) involves extracting the platelet portion of a patient's blood and then injecting it into a target location. The hope is that this enhances tissue healing, which is why it is used following orthopedic injuries in athletes. It has also been used as a tissue filler/expander within the plastic surgery field. After an internist injected his own penis and then his partner's clitoris, interest has expanded about its use in sexual medicine. However, since there is no long-term data showing efficacy against placebo, the treatment is still viewed as experimental. For men who are interested and well-informed, we have the ability to offer this treatment as well.
The chances of Peyronie's disease completely resolving simultaneously are less than 5%, although some patients may notice decreased curvature with time. This, however, may be due to less rigid erections making the degree of curvature simply seem less.
Surgical options involve plication, grafting, or implant placement. Plication is a short outpatient procedure whereby internal sutures are used to correct curvature but folding tissue on the side opposite the plaque (scar causing the curve). Grafting involves incising and possibly excising the plaque and then placing a patch in the same area to allow the erection to straighten. Penile implants can be used for men who have both ED and Peyronie's to result in a straighter and function erection.
When the erect penis shows curvature (typically upwards, but can also be sideways or down), the convex side is longer than the concave side. The depth of penetration, however, if often the length of the concave side or even less based on the patient's body shape and size. With plication, technically you have changed the side opposite the plaque to be similar to the side with the plaque, but this typically does not change the depth of penetration. From a practical perspective, if the curvature is precluding use of the erection, its functional length is zero.
Based on published literature, the risk of ED of any degree subsequent to a grafting procedure is approximately 20%.
For men with Peyronie's disease who have significant ED as well (e.g. cannot maintain a rigid erection to allow for intercourse even with pharmacologic therapies) are likely reasonable candidates for an implant with straightening performed at the same time.
At the time of surgery, we aim to reduce curvature to less than 30 degrees to allow for satisfactory intercourse for men and their partners. In many cases, the final trajectory may approach a perfectly straight penis, but we feel that the natural anatomy often favors a slight upward tilt that facilitates intercourse, especially in heterosexual situations.
Procedures for Peyronie's disease are outpatient. Plication and grafting patients are discharged home immediately after the procedure. Implant patients stay overnight until the morning as part of a "23-hour" stay that is still considered outpatient. Patients can shower 48 hours after surgery and remove any dressings that have been placed. Most patients return to work at that time, if applicable. We ask patients to wait 6 weeks before resuming sexual activity involving the penis.
Penile ultrasounds with injection are not necessary prior to treatment. We often ask patients to produce photos of their curvature in the erect state prior to surgery and we can use saline at the time of procedure to demonstrate the extend of disease requiring repair.
Male Stress Incontinence
Most patients recover urinary control after radical prostatectomy (surgery to remove the prostate for cancer), but individual patients heal differently. We typically wait 1 year after prostatectomy to observe for full recovery of urinary control if patients continue to have steady improvement over time. In select cases, men with severe issues that have not improved by 6 months after surgery may be considered for procedural intervention at that time.
For men considering procedural interventions for stress incontinence, the main options include the urethral sling and the artificial sphincter (AUS). Both procedures are outpatient ("23-hour" classification involving overnight stay). The sling is better suited for milder degrees of incontinence (typically 2 pads or less per day by our selection criteria) and the AUS is the "gold standard" for higher degrees of incontinence. If a man requires 2 pads or less per 24 hours when doing his normal full degree of activity, can voluntarily interrupt his stream and close his sphincter with effort (confirmed by in-office endoscopy), has no significant scarring at the bladder neck (also known as a bladder neck contracture), and is willing to accept at least 50% improvement in incontinence as "success," he is an appropriate sling candidate in our practice. The data suggests that men with prior radiation have lower success rates with urethral slings, but they can still be considered if they meet the other criteria. Men with more significant incontinence are generally considered for the AUS. They still need to be evaluated to make sure they lack bladder neck contractures from their prior prostatectomy. For both procedures, as with most of our other surgical cases, patients need to be able to safely discontinue blood thinning medications (e.g. aspirin, Plavix, coumadin, etc.) in advance. Patients also need to demonstrate absence of urinary tract infection prior to surgery.
Most men who have had surgical correction of incontinence can be considered for a penile implant. The exception would be those men who have had a "transcorporal" AUS. This is a specialized operation for men who have had prior urethral issues requiring more tissue protection around the urethra.
Should a patient who has previously received an AUS require a urethral catheter (e.g. unconscious from a motor vehicle accident, undergoing elective surgery for other reasons, etc.), a urologist should be called to deactivate the AUS and to use a small catheter (e.g., 12 French). Should a patient need a catheter beyond 48-72 hours, we advise a temporary suprapublic catheter to avoid having a catheter in the urethra. We can arrange for medical alert bracelets for patients with an AUS.
Most patients will never require revision or replacement of their AUS. However, should the tissue under the cuff become encapsulated or the device pressure decrease over time, a new unit can typically be placed.
The artificial urinary sphincter (AUS) consists of a cuff that is wrapped around the urethra. This cuff fills with saline to compress the urethra closed to a pressure regulated by a small balloon (called a pressure regulating balloon). A small olive-sized pump is hidden within the scrotum. When this unit is gently pressed, the fluid in the cuff will travel towards the balloon to allow the urethra to "open" with urination. The fluid will travel back into the cuff within about 60 seconds to close the urethra once again.
The AUS does not set off metal detectors. The unit allows for an MRI with either a 1.5T or 3.0T coil, and is listed as MRI-conditional by the manufacturer.
Although infection is possible with any operation, we have not had a primary infection of a sling or an AUS in our experience. Thus, we explain that the rate of infection is less than 1%.
The AUS can be deactivated using a small button located at the top of the pump.
There is NO externalized components with an AUS.
With strictures (scars) within the urethra that narrow the space for passing urine, dilation offers only a temporary solution in most cases. If a patient has had a prior dilation or internal incision of a stricture and had recurrence, future dilations or endoscopic incisions have not been shown to provide durable correction. Such patients are considered for definitive repair (urethroplasty) when referred. However, if patients are not healthy enough to have a urethroplasty, dilation may be a necessary form of management.
If possible, it is advantageous to repair a urethra by removing the diseased segment containing the stricture and simply suturing the healthy ends of the urethra to one another. This is easiest if the strictures are short and in the portion of the urethra closest to the bladder. However, if strictures are longer, within the penis, or if patients have already had prior urethral surgery, use of a graft may be necessary.
Success rates of urethroplasty are approximately 90%.
Most patients will have a temporary urethral catheter after urethroplasty. The typical duration depends on the type of repair and ranges from 1-3 weeks.
Depending on the type of repair, some patients will have an X-ray to determine if they have adequately healed to allow catheter removal. Afterwards, they will be asked to urinate in the office to determine the flow rate and degree of bladder emptying.
Most patients do not see any detriment to sexual function following urethroplasty, but we list it as a "possible" risk on the informed consent.
Men who present with symptoms such as decreased libido, worsened energy, ED, etc. and who have two morning blood draws showing total testosterone values below 300 can be considered for testosterone replacement unless contraindications (e.g., male breast cancer, untreated aggressive prostate cancer) exist.
The symptoms of low testosterone are often non-specific. Similar symptoms can be seen with aging, weight gain, hypothyroidism (underactive thyroid), low vitamin B12 levels, anemia, sleep apnea, and depression.
Testosterone can be increased in some cases through exercise and weight loss.
Most of a man's testosterone is produced by the testicles, with a small portion also being made by the adrenal glands. The stimulation of testosterone production stems from the pituitary gland, which is stimulated by a hormone from the brain. The signals coming from the pituitary gland can be "turned off" by rises in testosterone and/or estrogen. This "turning off" phenomenon can be blocked to a degree using an oral medication named clomiphene (marketed as Clomid). Additionally, fat tissue (also called adipose tissue) contains an enzyme that converts testosterone to estrogen. This enzyme can be blocked by a different oral medication called anastrozole (marketed as Arimidex). If the pituitary isn't sending the appropriate signals to the testicle to produce testosterone and.or stimulate maturation of sperm, there are injectable medications that mimic the pituitary hormones, HCG (human chorionic gonadotropin) acts like LH (luteinizing hormone) to encourage the testicle to produce testosterone. HMG (human menopausal gonadotropin) acts like FSH (follicle stimulating hormone) to encourage maturation of sperm.
Testosterone can be replaced topically through gels or patches applied to the skin, via direct injections in liquid form, by use of a nasal spray, or by implantable pellets. There is also an oral patch that can be applied to the gums, but patients generally avoid this.
Daily topical gels most closely mimic natural production since the body typically provides a burst of testosterone in the morning (for people with a normal sleep cycle) that fades throughout the day.
Testosterone has NOT been shown to cause cancer. However, testosterone can impact the growth rate of cells in aggressive forms of prostate cancer.
Testosterone therapy often results in an increase in red blood cell production from the bone marrow. This is typically a positive change, but if the value climbs too high, there is a theoretical increased risk of stroke or other vascular issues. We generally refer to the blood becoming too viscous or "thick," and the risk is drawn indirectly from a study that was not specific to men using testosterone. Although rare, men can also develop breast cancer. Such individuals with untreated disease should not be given testosterone. There is concern of using testosterone replacement in patients with significant liver disease and/or fluid retention. The cardiac risk is somewhat controversial, but a prior study did show an accelerated rate of coronary artery plaque development associated with testosterone use.
If a man is looking to maintain sperm production, he should generally AVOID use of testosterone-containing products. Giving testosterone alone has the potential to reduce sperm production to ZERO. Some data has shown that men taking testosterone AND HCG may maintain sperm production. However, whether or not the level of sperm production is as optimal as it would be without use of testosterone in those men is not well established.
If a man was started on testosterone therapy without an adequate workup to diagnose the condition and to rule out an important list of causes, we will typically consider a 90-day weaning protocol whereby we use medication to try and accelerate testicular recovery using a combination of oral and injectable medication.
For men who elect testosterone replacement therapy, we typically follow their red blood cell counts and symptoms closely at specified intervals throughout the first year. Once the protocol has been established and clinical goals are achieved, we continue to have the men followed (in urology or by their primary care provider) at least once per year with appropriate blood work and clinical exam.
Supplements in Men's Health
As of 1994, the Dietary Health and Education Act reclassified supplements under the category of foods. As such, the role of the FDA was significantly reduced in terms of monitoring both efficacy and safety. Without quality data to attest to these factors, we cannot recommend that patients use these products.
Some supplements marketed for male sexual health have been found to actually contain elements of prescription drugs. In many cases, the content of these adulterated products is actually higher than the maximum approved dose for prescription strength. Thus, while marketed as ‘natural’ products, they are actually the opposite. These drugs can potentially place patients at risk, especially if combined with other drugs used for heart disease or hypertension. Additionally, some products have the potential to disrupt the male hormonal axis, even to the point of compromising fertility in some patients.
Although some lab research has shown some positive changes in animal models, data from human trials is less impressive. Numerous supplements have been promoted for the potential to increase nitric oxide, including red ginseng. This supplement was reported to have some potential benefit based on review of multiple low-quality clinical trials. However, side effects were few and generally mild, but diabetics should use caution as red ginseng may cause low blood sugar.
While some animal data suggested a potential to increase testosterone, multiple trials in humans have failed to show this same effect and there was no benefit in sexual function. There are a few reports of significant toxicity.
True vitamin deficiencies are relatively rare in the United States. Thus, use of a multivitamin may amount to an unnecessary expenditure for most of our patients. However, there may be a role in select instances if levels are found to be low. We often check Vitamin D and B12 levels as part of our men’s health lab panel.
Some data in rats suggested that the drug may improve penile blood flow, but no human trials have validated this effect and there are reports of toxicity.
A small study initially suggested a benefit in erectile function. However, subsequent well-designed trials showed that blood flow into the erectile tissue was no different than placebo. The supplement, however, was generally well tolerated with only mild side effects.
Based on a study done by Morales and colleagues, DHEA supplements do NOT improve testosterone levels.
This drug has been studied multiple times for ED in men taking medications to treat depression known as SSRIs (selective serotonin reuptake inhibitors). Two well designed studies showed no improvement from this supplement and toxicities that included major bleeding, seizures, and death.