Not Everything is a Nail
The Case of the Month is an actual patient from The Turek Clinic.
He was 33 years old and presented to the Clinic with a 2-year history of infertility. His wife was also 33 years old and she was evaluated early on and cleared by her doctor. He came to me alone, and the first thing he said was “I’ve been to several doctors and no one can figure this out.”
Listen and Learn
“Everything that has been tested has come back normal. My semen analyses and hormones all look good,” he went on to say.
I checked the pile of labs that he brought with him and nodded: “You’re right.”
About half the time, infertility issues are “idiopathic” (med speak) or “unexplained.” This could be very well being the case here. However, I’ve also written exam questions emphasizing the importance of delving deeply into the patient’s story, the so-called “medical history,” to solve infertility problems. So, I began asking some probing questions about his sexual life and habits. Here is what I learned over the next half hour:
- He has a lifelong history of erectile dysfunction. Erections begin fine but cannot be maintained and his confidence and satisfaction with them are low.
- Erections were actually painful for most of his adult life due to tethering of his uncircumcised foreskin. On several occasions, he actually felt pain and bled during sex when the tethered skin had torn. “The sheets were covered with bright red blood!”
- This explained why he had his only surgery, an adult circumcision, and a year prior to his visit with me. This would have eliminated the tethering issue.
- Since the surgery, erections are now pain-free but the erectile dysfunction continues.
- When asked whether he had tried any of the popular erectogenic agents, he responded: “I don’t like to take pills, I should be able to do this on my own.” I respect that.
No Hammer Needed
I am a surgeon. I like to fix things. Anatomy is my parts bin. There is a natural and correct order to the human body that is usually possible to restore in the operating room. But this is no place for a surgeon. This young man had already had restorative surgery, was rid of painful erections, yet still had erectile dysfunction.
Taking off my surgeon’s hat, I concluded that he was “scarred” by years of painful erections, despite having normal ones at this time. Sex has never been much fun for him because it had hurt for so long. In fact, it probably stressed him alot. Not an easy one to get over. I can imagine what he is thinking: “Maybe it will start hurting again, maybe it won’t. Who knows?”
“Put your knife down,” I told myself. This man needs a short, focused round of sex therapy with the best, Melody Lowman in San Francisco. And this what he did.
I just got the call from him this past week, two months to the day after he first saw me: “We’re pregnant!” Fixed. No surgery. No pills. The big lesson here? Although I am a surgeon with a hammer, not everything is a nail.