Over 3,200 minimally invasive vasectomies have been performed by our urologist, Dr. James Durward Black, Jr. MD, FACS.

If you have questions, come in to discuss them. It doesn’t matter if it’s for an initial consultation or a second opinion.

If you come in you will ALWAYS see Dr. Black, a board certified urologist, not a nurse and not a general practitioner. A vasectomy consultation is good for one year.

Free 90 day follow up.

Most insurances are accepted and we can check to see if you need a referral or pre-certification.

Vasectomy

Just the thought of surgery in this area is a source of great anxiety for many men. Today’s vasectomy is not the same vasectomy that your father had. The introduction of minimally invasive operations like the percutaneous and the no scalpel vasectomy have revolutionized vasectomies.

A vasectomy is the surgical sterilization procedure for men. This means it is a permanent form of birth control similar to a tubal ligation in women. A vasectomy consists of dividing the vas deferens in two in order to stop the addition of sperm to the rest of the semen. Semen is the combination of fluids from the testicle, the prostate, and the seminal vesicles.

While most men fear that this will affect their masculinity, libido, and erection, this is not the case. Testosterone, the male sex hormone, does not travel up the vas deferens. It is secreted directly into the blood stream. There is no decrease in sex drive or libido. The nerves to the penis are totally separate from those to the testicle and in no way does vasectomy cause ED. As a matter of fact, a significant number of people enjoy sex more often with more spontaneity once their fear of pregnancy is gone.

The vasectomy is carried out most often in the doctor’s office under local anesthesia. Until recently, anesthesia was accomplished by injection of a small amount of numbing medication and used a small, 28-gauge needle. Since August of 2015, I have been doing a “no needle anesthesia”. I use an instrument called a Madajet. This instrument sprays the anesthetic through the skin without using a needle. This is similar to the way some immunizations have been given in the past. Most patients describe the procedure as having the same feeling as a mild thump with a rubber band. I had previously used a small, 28-gauge needle. Diabetic or allergy needles are the same size. Doing this in the office avoids the hospital, its charges, and the antibiotic resistant bacteria that thrive in hospitals.

In years past, this required shaving the lower abdomen, scrotum, and upper thighs. The hair growing back out was almost as bad as the procedure. I currently only shave a small portion of the front of the scrotum at the time of surgery. I do not ask men to shave before the procedure. The shave bumps that appear on many newly shaved men are a staphylococcal infection and are to be avoided. Shaving the site immediately prior to the procedure lowers the risk of infection. Until the late 1980s, two incisions made up to one inch long were required to do a vasectomy. Today, only one, 5mm puncture in the scrotal midline near the base of the penis is required. Previously, the bleeding and infection rate associated with vasectomies was 15-30% in the 1980s. Today, there is only a 1-2% risk of men having any bleeding or getting an infection. Past operations required most men to take up to 30-40 pain pills. Today, they often take nothing but Tylenol or Ibuprofen. A post-procedure prescription of #10-15 tablets of Hydrocodone or rarely Oxycodone is provided upon request.

The missed work depends on how strenuous your job is for you. If you do deskwork, you may miss as little as 2 days. For a job with lifting and straining, 3-5 days of missed work should be enough.

Sterility is not instantaneous as with tubal ligation. After a vasectomy, it takes about 15-20 ejaculations to empty all of the stored sperm (or 3-4 months for all of the remaining sperm to die). While the first few ejaculations may be uncomfortable, this discomfort rapidly diminishes over a few weeks. The epididymal congestion or “blue balls” feeling is usually fully resolved by 3 months, but in most cases, it is minimal by 3 weeks.

The failure rate of vasectomy and tubal ligation are quite similar and are about 1/1,000 to 1/2,000.

Sterility is evaluated by looking at a semen specimen under the microscope. Sterility is noted when no sperm are seen. Two specimens are checked at least one month apart to assure there has not been a failure due to the divided vas deferens ends growing back together.

I have done about 3,000 minimally invasive vasectomies in the last 26 years.

Why I Feel The No-Needle Anesthesia Is a Benefit To You:

Below is a list of reasons why the Madajet is not used by all urologists.

1. Most Urologists don’t do it due to the expense of the equipment.
2. Some Urologists just don’t believe that the injector is a real benefit and is just hype by the manufacturer.
3. Other Urologists just like the tried and true method that they learned long ago and just don’t want to change.
4. Some doctors worry about adding time to the procedure and loss of efficiency.
5. Many medical personnel are so comfortable around needles that they can’t believe men are really afraid of a needle.

 

I started using the Madajet during the summer of 2015. It does take some time to teach the staff how to prepare the instrument, to teach everyone how to properly clean and sterilize the instrument, and begin to use and learn to efficiently use the device.

Just filling a syringe with Lidocaine and Marcaine in a 50/50 mixture and injecting this is a lot easier than learning something new.

My assessment after using this for the first 2-3 months was that placing the 6 Madajet activations (three to each vas deferens) is now as efficient a way to “deaden” the skin and the vas deferens for a vasectomy as was using the 28-gauge needle in the past.

I have found that the Madajet:

1. It uses less medication making it easier to feel the vas deferens during the vasectomy.
2. While most men are mildly needle phobic whether they admit it or not, this benefits all men from the truly needle phobic ones to the very stoic ones. Reduced anxiety makes the vasectomy easier for both the doctor and the patient.
3. Once I learned how to efficiently handle the instrument, the numbing part of the vasectomy actually takes less time, is less painful, and invokes much less anxiety.

 

The anesthesia the Madajet provides is quite good, and it is uncommon to need to use a needle to supplement the anesthesia with any further medication. Additional medication is needed from time to time and a needle is used, but it is passed through skin that has already been deadened with only mild pressure being felt. The Madajet may not fully anesthetize patients with thick scrotal skin. Not all men’s scrotal skin thickness is the same. Thickened skin makes it harder for the Madajet to penetrate as deeply into the tissue around the vas deferens and may require additional anesthesia.

If you are interested, there are multiple YouTube videos of doctors demonstrating the no needle anesthesia during actual vasectomies. You just need to search for the term “no needle vasectomy” or for “Madajet for vasectomy.”

When I am asked if using the Madajet is really better, my response is that I think so. In the big scheme of things, the basics of the vasectomy (cutting the vas deferens and sealing the ends) are not changed. The amount of medicine is less, the anesthesia is as good as the standard injection, the vas deferens are easier to work on due to less volume of medicine, and men are more relaxed knowing there is no needle.

Section 1: The vasectomy pre-op visit

This it the time for you to get to know the person doing your procedure and to ask any questions that may be on your mind. It is used to fully explain the procedure and to allay any fears you may have. On this visit, a complete history will be obtained. This will tell your doctor if there are any special concerns that might affect your procedure.

For example, anyone on blood thinners will be evaluated to see if these can be safely stopped. Aspirin as well as Ibuprofen can be potent blood thinners in some people. Not stopping these can lead to more postoperative bleeding (hematoma formation) or bruising or a delay in recovery.

A complete description of the procedure with visual aids will be completed. This will include both the benefits and risks of the procedure as well as contrast and comparison to tubal ligation. Tubal ligation is the medical term for a woman’s sterilization, also known as “tying her tubes.”

A complete genital examination will tell your doctor if there are any special anatomical concerns such as varicose veins that might increase the risk of bruising. Your doctor will also look for epididymal cysts and any type of testicular sensitivity or pain. Finding this out preoperatively will help to avoid any problems that may cause delays in recovery. This examination will also allow your doctor to show you the vas deferens and where the local anesthetic will be injected.

Your urologist can discuss how may days off of work you may need, as well as when you may shower and resume intercourse.

Once all your questions have been answered and you are sure that this is the right decision for you, you may then schedule your procedure.

Section 2: The day of the vasectomy

On the day of the procedure, you will usually be at the office for about an hour. The actual vasectomy takes on average about 15-20 minutes. Oral medication for sedation is available on request, but must be arranged before your arrival for the procedure. Intravenous sedation is not available. During the procedure itself, you will be awake and will only be sedated if pre-arranged prior to that day. It is very unusual for most men to require a sedative. The vast majority of men do this under local anesthesia using the Madajet no-needle injector. It is advised that you have someone to drive you home after the procedure.

You will need to undress from the waist down and will be provided a cover up sheet.
Dr. Black will see if you have any new questions that might have come up since the pre-op evaluation. In our office, for your privacy, the doctor does the antiseptic skin prep and places the drapes before the nurse enters the room.

After the local anesthetic is injected using the Madajet needleless injector, a small area at the base of your penis and on the upper scrotum will be shaved and cleaned with antibacterial soap followed by a Betadine, iodine-based, skin prep.

Sterile drapes will be applied, leaving only your scrotum exposed before the nurse enters the room.

The procedure consists of a puncture on the upper scrotum at the base of the penis with exposure of first vas deferens then the opposite one. Each vas deferens has about 3/8 inch or 1 cm removed followed by eletrocautery to heat seal the ends. The surrounding muscular sheath is then closed further separating the two cut ends of the vas deferens.

After the 20-minute procedure, you will be checked for signs of bleeding, the Betadine will be cleaned off, and then bandaged with a sterile 4×4-gauze. You will need your preferred form of scrotal support to use at that time. The scrotal support will be used to hold the bandage in place. This allows the bandage to be held in place without tape. Boxer shorts will not work.

My staff will schedule a 2-month follow-up appointment with you. This is covered with the procedure, so no co-pay is required. We can also schedule a one week post-vasectomy appointment if you feel the need, you just need to call the office and let us know.

Please remember, you will need to continue some form of birth control until you have had 2 negative semen specimens about 1 month apart, starting at the two month appointment.

Section 3: Procedure follow-up after a vasectomy

We will schedule a 2-month appointment with you at the time of your vasectomy. Another appointment can be scheduled at your request for one week post-vasectomy.

The purpose of the 2-month visit is to see if you are having any problems and to evaluate you for sperm granulomas. Granulomas form when sperm leak from the end of the cut vas deferens. These granulomas occasionally cause pain, and large granulomas may increase the failure rate.

You will need to bring in a semen specimen for evaluation of sterility. It is not like a 20-minute old, fertility specimen. The ideal semen specimen is 1-2 hours old. It may be 2-4 hours if 1-2 hours is not convenient. Live sperm continue to swim for about 2 hours; if none are seen, then an older specimen is adequate. If multiple dead sperm are seen, then a fresher specimen may be needed to see if they were alive at 1-2 hours.

If your examination is normal and the semen specimen is devoid of all sperm alive or dead, then a second specimen is required approximately one month later to make sure the vas deferens has not grown back together in a delayed fashion. You do not have to be present for the second semen specimen evaluation, so no appointment is scheduled for this. You or your spouse may drop off your second semen specimen, and we will call you with the results. If a few dead sperm persist, you may need to bring in a third specimen and very rarely, a fourth.

If at that point you are sterile and you have no further questions or concerns, then no further follow-up will be required.

Only after 2 negative semen analyses is it safe to go off birth control.

Section 4: Vasectomy FAQ

[faqs category=’vasectomy’]

Section 5: Woman’s Questions About Vasectomies

[faqs category=’vasectomies-women-questions’]

 

Urinary stone disease (also known as renal stone disease, kidney stone disease, renal calculus disease, Nephrolithiasis, and ureterolithiasis) while found throughout the United States is most commonly found in the “stone belt.” Kidney stones will affect about 1 in 1,000 people. The “stone belt” consists mostly of the southern USA. Kidney stone disease is due to the combination of influences that include diet, heredity, dehydration, and occasionally medication.

Types of Urinary Stones

The most common stones are calcium stones. Calcium stones make up about 70-80% of all kidney stones; however, most people are unaware of the different types of calcium urinary stones that exist. For many years, these were referred to by their mineral or geologic names. These are predominately calcium oxalate dihydrate or weddellite (CaC2O4·2H2O) and calcium oxalate monohydrate or whewellite (CaC2O4·H2O). Others may contain calcium phosphate also known as hydroxyapatite (Ca10(PO4)6(OH)2) or Brushite CaHPO4·2H2O.

Kidney Stones made of Calcium Oxalate Dihydrate

Calcium oxalate dihydrate stones are typically very crystalline in form. Crystalline stones are typically very spiked or rough. If you’ve ever heard anyone refer to their Kidney Stone as a sandspur or cocklebur then they were most likely referring to a calcium oxalate dihydrate stone.

Kidney Stones Made of Calcium Oxalate

Calcium oxalate monohydrate stones on the other hand are usually knobby in shape and have few if any spiked crystals on their surface. The two types of calcium oxalate vary greatly in hardness as well as appearance. The best analogy is that of carbon. While both coal and diamonds are carbon, they exhibit very different chemical and physical properties. Like diamonds, the monohydrate forms are very dense and hard. This hardness must be taken into consideration in choosing a treatment. Calcium dihydrate is much less dense, and the crystalline nature makes them harder to pass but easier to break with Extracorporeal Shock Wave Lithotripsy or ESWL and lasers.

Uric Acid Stone

Uric Acid stone disease is much less common than calcium oxalate stone formation. Uric acid stones make up only 5-10% of all stones. Uric acid causes two different distinct medical conditions. One is stone formation of radiolucent stones. The other condition is gout. Gout is a type of arthritis caused by the crystallization of uric acid crystals in joints. The most commonly affected joints are the big toe and thumb joints. Uric acid stones do not show up on routine radiographs or x-rays such as KUB (Kidney-Ureter-Bladder film) due to their low density. These are characterized to be radiolucent stones. They do show up on CT scan as low density stones in the 400-600 Hounsfield unit range. While they are difficult to localize for ESWL using fluoroscopy, they are very fragile, and when treated, they break very well into multiple small pieces. Pure uric acid stones are usually orange colored stones. Uric acid can also be the nidus or seed crystal that allows calcium stones to form. Once the seed crystal of uric acid forms, calcium is then deposited around this initial uric acid crystal.
Struvite stone disease is most commonly associated with infection within the urinary tract. Struvite stones make up about 10% of all stones. The organisms most likely to cause these stones are urea splitting organisms. As these organisms (germs or bacteria) break down the urea in the urine, the pH of the urine increases from a baseline of pH 5 to a pH of 7, which leads to the precipitation of magnesium ammonium phosphate crystals. The most common bacteria are Proteus mirabilis, Pseudomonas Aeruginosa, Providencia Stuarti, Klebsiella Peumonia, Staphylococcus and Mycoplasma , and Serratia marcescens

Pain From Stones

Passage of a kidney stone or renal calculus is often rated as one of the top 2 pains in humans, which are childbirth and passage of a kidney stone. Women routinely compare passage to labor pains. They often report that labor pains are less intense. The pain is caused by urinary obstruction, not the existence of the stone in the kidney.
Stone disease will affect about 6-9% of all men and until recently 3-4% of women. Recent studies show the gap, between men and women with stones, to be narrowing. The ratio of men to women has changed due to an increased number of stones in women. It has long been noted that the time of first stone formation was after age 18 years. Recently, studies have shown an increase in stones in children as young as 8-10 years old.

Symptoms of Kidney Stones

Symptoms of stone passage include “flank pain”. The flank is the region of your body on your back protected by the last 2 ribs. There may be radiation of the pain around to the lower abdomen on the affected side. Patients frequently experience nausea and occasionally vomiting. As the stone passes out of the kidney into the upper ureter, men may experience testicular pain, and women may have a similar pain in the vagina or groin area. If the stone is very low in the ureter, near the bladder, then there will likely be an onset of frequent urination that can be mistaken for a urinary infection. Bladder infection, cystitis, and UTI are alternate terms for urinary infections. Men may mistake the same symptoms for prostatitis.

Deciding on a Treatment for Kidney Stones

The primary treatment of stones is based on the size and location of the stone. Stones are usually divided, by size, into groups of 1- 4 millimeters (mm), 5-10mm, and stones greater than 10mm. A 6mm stone is about ¼ inch in size. A 12 mm stone is ½ inch in size. There are 25.4 millimeters in one inch. Most stones less than 4 mm will pass and not require surgery. The average time to passage ranges from 3-6 weeks without medical intervention. This can be lessened to as little as 5-10 days with expulsive therapy using alpha blocking medications (Tamsulosin or Flomax, Cardura or Doxazosin, or Hytrin or Terazosin). The alpha blocking medications were first used in medicine as a treatment for hypertension or high blood pressure. These medications lead to dilatation of the ureter and more rapid passage of the stone. Calcium channel blockers such as Procardia (Nifedipine) and steroids such as Prednisone and Methylprednisolone have been used as well.

Surgical Indications for Kidney Stones

Indications for surgical intervention are, having a stone too large to pass, infection behind the stone, intractable pain or vomiting, or complete obstruction of the kidney leading to possible permanent kidney damage. Most of the time, it is acceptable to try to pass the stone if pain and nausea can be controlled and if there is no sign of impending kidney damage.

Risk of Recurrence of Stone Formation

After formation of a stone, there is a 14% risk of having another stone within a year, a 35% risk in the next 2 years, and up to a 52% risk of recurrence at 10 years. This rate of stone recurrence applies if nothing is done to change the patient’s risk. Up to 80-90% of people with a history of stones can modify their risk of recurrent stone formation. One can decrease one’s recurrence rate by change of diet, state of hydration, or by the addition of medications.

Hydration for Prevention

Most people with stones do not drink enough fluids, or what they do drink is high in salt or caffeine. Fluid loss through sweating can also lead to relative dehydration. The goal is to increase your fluid consumption so that there is a 2-liter (2,000-milliliter) or about 2 quarts of output of urine in each 24-hour day. Caffeine is known to be a diuretic and increases urine output. Caffeine also increases the amount of calcium excreted into that urine. This increased calcium excretion leads to more calcium in the urine than can remain in a dissolved form; therefore, crystals begin to form. This initial crystal formation is the beginning of stone formation. The best fluids for stone prevention are lemonade and orange juice. Both juices increase the urinary level of citrate. Citrate has long been known to decrease stone formation. While cranberry juice is widely misused for bladder infections, it can cause stone disease and is not recommended. Water of course is cheap and widely available. In most studies, there appears to be no benefit to bottled water over tap water. It is rare for tap water to contain enough calcium to cause stone formation.

Inheritance of Kidney Stones

Stones commonly occur in families. Most of the time, this history is easily obtainable. Some of your family may have already had a metabolic evaluation, such as a 24-hour urine collection or stone analysis. This information may help other family members as families often make the same type(s) of stones.

Dietary Causes of Kidney Stones

Multiple foods, in excess, have been found to cause stone disease. A partial list is available below.

1. Oxalate containing foods.
   Oxalate is half of a calcium oxalate stone. Foods increasing urinary oxalate include: chocolate; nuts and nut products; vegetables such as grits, okra, spinach (most dark leafy green vegetables); most berries; draft beer; soy protein; and tea.
2. Sodium containing foods.
   Salt or sodium increases the stone formation. Stone formation risk rises as the salt intake rises. Salt, sodium chloride, should be limited to 2,000mg =2grams of sodium per day. Most Americans consume between 12-15 grams per day.
3. Calcium containing foods and medications.
   Calcium should be eaten in moderation as both very high and very low calcium diets can cause stones. Calcium rich foods include dairy products such as milk, cheese, yogurt, and ice cream. Calcium supplements such as Citracal (calcium citrate), TUMS, and Rolaids (calcium carbonate) increase urine levels of calcium. Spinach is high in calcium and usually increases urine levels of calcium. While more expensive, Citracal (calcium citrate) is the best form of calcium supplement in people with a history of stones needing supplements. Your calcium supplement should include Vitamin D to promote deposition of that calcium in the bones. Citracal, not only supplements your calcium, but the citrate tries to prevent stone formation from any calcium excreted in the urine. While milk substitutes such as soy milk and almond milk have less naturally occurring calcium, they are fortified with calcium and often contain more calcium per serving than cow’s milk contains. Drinking low fat milk does not lower the calcium content.
4. Protein containing foods.
   Protein intake increases the risk of stones. Protein is found in all forms of meat (beef, pork, chicken, and fish) and not just red meat as most patients think. Protein supplements for body builders and the elderly may also lead to stone formation. The Atkins Diet popularized a low carbohydrate, high protein diet. People on this diet noted an increase in stone formation. Protein should be limited to a 4-ounce portion per meal. This portion of meat is about the size of a deck of cards.
5. Caffeine containing foods and drinks.
   Caffeine ingested in any form increases stone formation. This includes coffee, tea, chocolate, energy drinks, caffeine tablets, and soft drinks. Decaffeinated soft drinks contain no caffeine. This is not true of coffee. There is no US government standard for low caffeine. I once read that Starbucks’ decaffeinated coffee still has more caffeine per serving than most other brands of regular coffee contains.

If you have been advised to monitor Oxalate intake with your meals, click here for a 2-page diet plan that lets you know which foods are Little or No Oxalate, Moderate Oxalate, or High Oxalate.

· Beverages	· Seafood	· Bread / Starch	· Oils
· Milk	· Vegetables	· Cakes / Snacks
· Meat / Nuts / Protein	· Fruits	· Ingredients

Low Oxalate Foods	Mg		Medium Oxalate Foods	Mg		High Oxalate Foods	Mg
Beverages			Beverages			Beverages
< 2mg Per Serving			2-10mg Per Serving			> 10mg Per Serving
Coffee, Decaf	1mg / 8oz		Beer, Light	3mg / can		Hot Chocolate	65mg / 8oz
Coffee, Decaf	2mg / 8oz		Beer, Reg	4mg / can		Ovaltine / Beverage Mixes	35mg / 1oz / 30ml / 2Tbsp
Coke / Pepsi 12oz per day	0mg / 8oz		Brewed Coffee	2-10mg / 3.5oz		Rice Milk	13mg / 8oz
Gatorade but has high salt	0mg / 8oz		Green Tea	2-10mg / 3.5oz		Rose Hip Tea	10-50mg / 3.5oz
Ginger Ale	0-2mg / 3.5oz		Lemon Juice / Bottled	4mg / 8oz		Soy Milk	20mg / 8oz
Koolaid	0mg / 8oz		Liquor	0mg / 1oz		Stevia Sweetner	42mg / 1 packet
Root Beer	0-2mg / 3.5oz		Milk Chocolate Candies	5mg / 1oz		Tea, Black / 2 min Infusion	55mg
Tea, Fennel	0-2mg / 3.5oz		Wine, Red	1mg / 4oz		Tea, Black / 4 min Infusion	72mg
Tea, Lemon Balm	0-2mg / 3.5oz		Wine, White	0mg / 4oz		Tea, Black / 6 min Infusion	78mg
Tea, Oolong	0-2mg / 3.5oz
Tea, Red Raspberry	0-2mg / 3.5oz
Tea, Stinging Nettle	0-2mg / 3.5oz
Milk			Milk			Milk
< 2mg Per Serving			2-10mg Per Serving			> 10mg Per Serving
Butter	0mg / 1 pat		Chocolate Milk	7mg / 8oz
Buttermilk	1mg / 8oz
Cheese / American, Cheddar, Cottage, Mozzarella	0-1mg / 3.5oz
Coffee Creamer	0mg / 15cc
Cream	0mg / 1tsp / 15ml
Cream Cheese	0mg / 1oz
Cream Sauce	3mg / 8oz
Cream Substitute	0mg / 1tsp / 15ml
Low Fat 2% Milk, 2 Cups / 8oz per Cup	1mg / 8oz
Nondairy Cramer	0mg / 15cc
Powdered Mild	3mg / 8oz
Skim Milk 1%	1mg / 8oz
Sour Cream	0mg / 15cc
Vanilla Ice Cream / Light / Nonfat	0mg / 15cc
Whey Fluid, Sweet	1mg / 8oz
Whey, Sweet Dried	0mg / 1tsp / 15ml
Whipped Cream	0mg / 1oz
Whipped Topping	0mg / 1oz
Yogurt / Frozen / Nonfat / Low Fat	1mg / 8oz
Yogurt / Plain	2mg / 8oz
Meat / Nuts / Protein			Meat / Nuts / Protein			Meat / Nuts / Protein
< 2mg Per Serving			2-10mg Per Serving			> 10mg Per Serving
Antelope	0mg / 3oz		Fish Sticks	3mg / 2 sticks		Almonds	122mg / oz
Bacon	0mg / 2 slices		Tuna Salad	6mg / 8oz		Candies with Nuts	38mg / 2oz
Beef, Ground	0mg / 3oz					Cashews	49mg / 1oz
Bologna	0mg / slice					Hazelnut	>50mg / 3.5oz
Buffalo	0mg / 3oz					Liver	10-50mg / 3.5oz serving
Chicken	0mg / 3oz					Macadamia Nuts	21mg / 3.5oz
Chicken Dog	1mg / dog					Mixed Nuts	39mg / 1oz
Chicken Liver	0mg / 3oz					Peanuts	27mg / 1oz
Chicken Nuggets	3mg / 6 nuggets					Pecans	10mg / 1oz
Egg Beaters	0mg / 4oz					Pistachios	14mg / 1oz
Eggs	0 / 1 medium					Pumpkin Seeds	17mg / 8oz
Goat	0mg / 3oz					Sesame Seeds	>50mg / 3.5oz
Ham	0mg / 3oz					Soy Burger	12mg / 3.5oz
Hot Dog	1mg / 1 dog					Soy Nuts	392mg / 1oz
Lamb, Lean	0mg / 3.5oz					Soy Yogurt	113mg / 8oz
Lean Hamburger 75%	0mg / 3oz					Sunflower Seeds	12mg / 8oz
Lean Hamburger 85%	0mg / 3oz					Tofu	13mg / 3.5oz
Lean Hamburger 90%	1mg / 3oz					Trail Mix	15mg / oz
Liver	0mg / 3oz					Veggie Burger	24mg / 1 patty
Meatballs	2mg / 2 balls					Walnuts	31mg / .oz
Moose	0mg / 3oz
Pork	0mg / 3oz
Turkey Dogs	3mg / 1 dog
Turkey Dogs	0mg / 3oz
Wild Game	0mg / 3oz
Seafood			Seafood			Seafood
< 2mg Per Serving			2-10mg Per Serving			2-10mg Per Serving
Blue Fish	1mg / 3oz
Clams, Raw	0mg / 3oz
Cod, Pacific	0mg / 3oz
Flounder	0mg / 3oz
Haddock	0mg / 3oz
Halibut	0mg / 3oz
Herring	1mg / 3oz
King Crab	0mg / 3oz
Mackerel	0mg / 3oz
Oysters	0mg / 3oz
Pollock	0mg / 3oz
Salmon	0mg / 3oz
Sardines	0mg / 3oz
Shrimp	0mg / 3oz
Swordfish	0mg / 3oz
Tuna in Oil or Water	0mg / 3oz
Whiting	0mg / 3oz
Vegetables			Vegetables			Vegetables
< 2mg Per Serving			2-10mg Per Serving			> 10mg Per Serving
Alfalfa Sprouts	0mg / 4oz		Beans, Mung	8mg / 4oz		Bamboo Shoots	35mg / 4oz
Bell Pepper, Red	1mg / 3.5oz		Artichokes	5mg / 1 small		Beans, Fava	20mg / 4oz
Broccoli, Raw	3mg / 3.5oz		Asparagus	6mg / 4 spears		Beans, Navy	76mg / 4oz
Brussel Sprouts	0-2mg / 3.5oz		Beans, Baked, Canned	8mg / 3.5oz		Beans, Red Kidney	15mg / 4oz
Cabbage	1mg / 8oz		Broccoli	6mg / 4oz		Beans, Refried	16mg / 4oz
Cauliflower	1mg / 4oz		Carrots, Cooked	7mg / 4oz sliced		Beet Greens	610mg / 3.5oz
Chinese Cabbage	1mg / 8oz		Corn	5mg / 3.5oz		Beets	675 / 3.5oz
Chives	0mg / 1tsp / 5cc		Cucumber			Brussel Sprouts	17mg / 4oz
Corn	1mg / 4oz		Ginger	2-10mg / 3.5oz		Carrots, Raw	15mg / 1 / 2 lg carrot
Cucumber	1mg / 1 / 4 cucumber		Lima Beans			Celery	20mg / 3.5oz
Cucumber	0-2mg / 3.5oz		Linseed	2-10mg / 3.5oz		Collards	74mg / 3.5oz
Endive	0mg / 4oz		Mushrooms	2-10mg / 3.5oz		Dandelion Greens	24mg3.5 / oz
Fennel Leaves	0-2mg / 3.5oz		Mustard Greens	4mg / cup chopped		Eggplant	18mg / 3.5oz
Green Chives	0-2mg / 3.5oz		Peppers, Chili, Hot	5mg / 4oz		Escarole	31mg / 3.5oz
Iceberg Lettuce	0mg / 8oz		Radish	9mg / 3.5oz		Green Peppers	16mg / 3.5oz
Kale	2mg / 8oz		Red Cabbage	2-10mg / 3.5oz		Kale	13mg / 3.5oz
Kohlrabi	0-2mg / 3.5oz		String Beans / Green Beans	15mg / 4oz		Leeks	89mg / 3.5oz
Mushrooms	0mg / 1 mushroom		Thyme	2-10mg / 3.5oz		Lentils	>50mg / 3.5oz
Onions	0mg / 1 small		Tomato 1 Medium	7mg		Okra	57mg / 4oz
Peas	1mg / 4oz		Yellow Squash	4mg / 4oz		Olives	18mg / 10 pieces
Pickles	0mg / 1 pickle					Olives, Black	18mg / 3.5oz
Radishes	0mg / 10 count					Parsley	100mg / 3.5oz / 100gram
Romaine Lettuce	0mg / 8oz					Parsnips	15mg / 4oz
Sauerkraut	0mg / 4oz					Peas, Snow	30mg / 3.5oz
Scallions	0mg					Peas, Sugar Snap	60mg / 3.5oz
Squash / Acorn	0mg / 4oz					Poke Greens	>50mg / 3.5oz
Water Chestnuts	0mg, 4 chestnuts					Rhubarb	541mg / 4oz
Zucchini	1mg / 4oz					Rutabagas	31mg / 4oz
						Soybeans	96mg / 8oz
						Spinach	600mg / 3.5oz
						Spinach, Cooked	755mg / 3.5oz
						Spinach, Raw	750mg / 3.5oz
						Summer Squash	22mg / 3.5oz
						Swiss Chard	645mg / 3.5oz
						Tempeh	10-50mg / 3.5oz
						Tomato Juice	22mg / 3.5oz
						Tomato Juice	14mg / 8oz
						Turnips	30mg / 4oz
						V8	18mg / 8oz
						Watercress	10mg / 3.5oz
						Yams	40mg / 4oz
Fruits			Fruit			Fruits
< 2mg Per Serving			2-10mg Per Serving			> 10mg Per Serving
Apple Juice	2mg / 6oz		Apples, Green	2-10mg / 3.5oz		Avocado	19mg / 1 fruit
Apple, Red	1mg / 3.5oz		Apricots	2-10mg / 3.5oz		Black Berries	18mg / 4oz
Apples, Dried	2mg / 8oz		Bananas	2-10mg / 3.5oz		Blue Berries	15mg / 4oz
Apricot Juice	2mg / 8oz		Cherry, Sweet	2-10mg / 3.5oz		Carrot Juice	27mg / 8oz
Apricots	0-2mg / 3.5oz		Huckleberry	2-10mg / 3.5oz		Concord Grapes	25mg / 1oz
Apricots, Dried	3mg / 8oz		Kumquat	2-10mg / 3.5oz		Cranberry Juice	25mg / 4oz
Bananas	3mg		Mandarin Orange	2-10mg / 3.5oz		Currents, Red	19mg / 1oz
Bilberries	2-10mg / 3.5oz		Peaches	2-10mg / 3.5oz		Currents, Red	19mg / 1oz
Cantaloupe	1mg / 1 / 2 melon		Pears	2-10mg / 3.5oz		Dates	24mg / date
Casaba			Pineapple Juice	3mg / 8oz		Dewberries	10-50mg / 3.5oz
Cherries, Bing	3mg / 8oz		Prune Juice	7mg / 8oz		Elderberry	>50mg / 3.5oz
Cherries, Bing Sour	2-10mg / 3.5oz		Prunes, Italian	5.8mg / 3.5oz		Figs	>50mg / 3.5oz
Cherries, Canned	7mg / 4oz					Figs, Dried	24mg / 5 figs
Coconut	2-10mg / 3.5oz					Gooseberries, Red	10-50mg / 3.5oz
Cranberries, Dried	1mg / 4oz					Gooseberries / Kiwi Fruit	88mg / 3.5oz
Cranberry Juice Cocktail	1mg / 3.5oz					Grape Juice	24mg / 4oz
Currants, Black						Grapefruit	12mg / half
Figs	9mg / 1 med					Lemon Peel	83mg / 3.5oz
Fruit Cocktail	0-1mg / 4oz					Lemonade, From Concentrate	15mg / 8oz
Grape Juice	1mg / 8oz					Lime Peel	110mg / 3.5oz
Grapefruit Juice	1mg / 8oz					marmalade	10mg / 3.5oz
Grapes	1mg / 8oz					Orange Peel
Honey Dew	1mg / 8oz					Oranges	29mg / fruit
Lemon Wedge	1mg					Pineapple, Canned	24mg / 4oz
Lemonade, Diet	1mg / 8oz					Pineapple, Dried	30mg / 4oz
Lime	3mg / half fruit					Plums, Damson	10mg / 3.5oz
Mango Juice	1mg / 8oz					Prunes, Dried
Mango	1mg / fruit					Raspberries	48mg / 8oz
Melons, All Types	2-10mg / 3.5oz					Raspberries, Black	53mg / 3.5oz
Nectarines	0mg / fruit					Raspberries, Red	15mg / 3.5oz
Nectarines	2-10mg / 3.5oz					Rhubarb	600mg / 3.5oz
Orange Juice	2mg / 8oz					Star Fruit	>50mg / 3.5oz
Papaya	1mg / med fruit					Strawberries	10mg / 3.5oz
Passion Fruit	2-10mg / 3.5oz					Tamarillo	10-50mg / 3.5oz
Peaches	0mg / fruit					Tangerine	10mg / fruit
Pear	2mg / 1 fruit
Plantain	0mg / med fruit
Plums	0mg / 1 fruit
Plums, Green and Yellow	2-10mg / 3.5oz
Raisins	3mg / 4oz
Red Current Juice	2-10mg / 3.5oz
Watermelon	0-1mg / slice
Bread / Starch			Bread / Starch			Bread / Starch
< 2 mg Per Serving			2-10 mg Per Serving			> 10 mg Per Serving
Corn Bran	0mg / 8oz		Bagel, Plain	9mg / 1		All Purpose Flour	17mg / 8oz
Corn Flakes	2mg / 3.5oz		Biscuit	6mg / 1		Amaranth	>50mg / 3.5oz
Corn Starch	3mg / 4oz		Corn Flour	3mg / 8oz		Bagel, New York	40mg
Flaxseed	0mg / 15cc		Cornbread	4mg / 1 slice		Barley Flour	41mg / 8oz
Flour, Barley Malt	0mg / 8oz		Cracker, Triscuit	1mg / cracker		Bread, French	11mg / 3.5oz
Oat Bran, Raw	0mg / 3oz		Cracker, Wheat Thins	1mg / cracker		Bread, Pita	18mg / 3.5oz
Oat Flour	0mg / 8oz		Crackers, Graham	2mg / rectangle		Bread, Pumpernickel	22mg / 3.5oz
Rice, Wild	0-2mg / 3.5oz		Crackers, Ritz	3mg / 5crackers		Bread, Rye	14mg / 3.5oz
			Crackers, Saltines	1mg / cracker		Bread, White	21mg / 3.5oz
			English Muffin, Multi Grain	8mg / 1		Bread, Whole Wheat	27mg / 3.5oz
			English Muffin, Wheat	7mg / 1		Brown Rice	24mg / 8oz
			Flour, White Corn	3mg / 8oz		Brown Rice Flour	65mg / 8oz
			Hummus	4mg / 15ml		Buckwheat	>50mg / 3.5oz
			Macaroni and Cheese	4mg / 8oz		Buckwheat Groats	133mg / 8oz
			Macaroni, Boiled	7mg / 3.5oz		Bulgar, Cooked	86mg / 8oz
			Muffin, Blueberry	9mg / 1		Bun, Hot Dog	11mg / 3.5oz
			Muffin, Bran	5mg / 1		Cornmeal	64mg / 8oz
			Muffin, Low Fat	5mg / 1		Couscous	15mg / 8oz
			Oat Bran Bread	4mg / 1 slice		English Muffin	12mg
			Oatmeal Bread	4mg / 1 slice		French fries	51mg / 4oz
			Rye Bread	7mg / 1 slice		French toast	13mg / 2 slices
			Sponge Cake	7.5 / 3.5oz		Fruit Cake	12mg / 3.5oz
			Tortillas, Flour	8mg / 1		Grits, Corn	97mg / 8oz
			Tortillas, Corn	7mg / 1		Lasagna	23mg / 4oz
			Vanilla Wafer	8mg / 3.5oz		Millet, Cooked	62mg / 8oz
			Wheat Bran Bread	7mg / 1 slice		Miso	40mg / 8oz
			Wheat Bread	5mg / 1 slice		Pancakes	11mg / 4 cakes
			White Bread	5mg / 1 slice		Potato Flakes, Instant	82mg / 3.5oz
			White Rice, Cooked	4mg / 8oz		Potato Salad	17-21mg / 3oz
			Whole Oat Bread	5mg / 1 slice		Potato, Baked	97mg / 1 medium
						Potato, Chips	17mg / 1oz
						Potato, Mashed	29mg / 8oz
						Potato, Sweet	28mg / 8oz
						Rice Bran	281mg / 8oz
						Rice Flower, White	11mg / 8oz
						Soy Flour	94mg / 8oz
						Spaghetti, Cooked	11mg / 8oz
						Stuffing	36mg / 8oz
						Wheat Bran	130mg / 3.5oz
						Wheat Flour	29mg / 8oz
						Wheat Germ	269mg / oz
Cakes / Snacks			Cakes / Snacks			Cakes / Snacks
< 2mg Per Serving			2-10mg Per Serving			> 10mg Per Serving
Fruit Rollup	2mg / roll		Cheese Puffs	5mg / 3.5oz		Brownies	31mg / 1oz / 1 / 2 brownie
			Chocolate Pudding	4mg / serving		Cake, Homemade	16mg / serving
			Cookie, Chocolate Chip Low Fat	7mg / cookie		Cake, Store Brand	15mg / serving
			Custard	1mg / 8oz		Chocolate Chip Cookies	10mg / cookie
			Fig Bars	4mg / bar		Cookie, Oreo	97mg / 3.5oz
			Jello	1mg / 8oz		Cookies, Store	10mg / cookie
			Oatmeal Cookies, Homemade	2mg / cookie		Cracker, Wheat Thins	20mg / 3.5oz
			Oatmeal Cookies, Store	4mg / cookie		Fudge Sauce	28mg / 1oz
			Pie, Apple	5mg / serving
			Pies, Home Made	5mg / serving
			Popsicle	0mg / 1
			Popcorn	5mg / 8oz
			Pretzels, Hard, Salted	5mg / oz
			Pudding Popsicle	5mg / 1
			Rice Cake	4mg / cookie
			Rice Krispy Treat	1mg / bar
			Rice Pudding	2mg / 4oz
			Sherbet	0mg / 4oz
			Snack Cakes, Crème Filled	3mg / cake
			Tapioca	0mg / 4oz
			Tortilla Chips	7mg / oz
			Vanilla Pudding	1mg / 8oz
			Vanilla Wafer	8mg / 3.5oz
Ingredients			Ingredients			Ingredients
< 2mg Per Serving			2-10mg Per Serving			> 10mg Per Serving
Apple Butter	0mg		Chili Powder	7mg / 1Tbs / 15ml		Black Pepper	419mg / 1oz
Basil	0-2mg / 1Tbs / 15ml		Cream Sauce	3mg / 8oz		Chocolate Syrup	38mg / 1oz
Brown Sugar	1mg / 8oz		Gravy	4mg / 8oz		Cinnamon	2-10mg / 3.5oz
Bullion Cube	1mg / 1cube		Ranch Dressing	4mg / 3.5oz		Cocoa Powder	67mg / 4tsp / 20cc
Catsup / Ketchup	0mg / 1tsp / 15ml		Soy Sauce	3mg / 1Tbs / 15ml		Coffee Beans	42mg / 3.5oz
Corn Syrup	1mg / 1tsp / 15ml					Fudge Sauce	28mg / 1oz
Dill	0-2mg / 1Tbs / 15ml
Garlic Powder	0mg / 1tsp / 15ml
Gelatin	0mg / 1tsp / 5ml
Honey	0mg / 1tsp / 15ml
Horseradish	0mg / 15ml
Italian Dressing	0mg / 1tsp / 15ml
Jam / Jelly	1mg / 1Tbs / 15ml
Lard	0mg / 1tsp / 15ml
Lemon Balm	0-2mg / 1Tbs / 15ml
Mayonnaise	0mg / 1tsp / 15ml
Molasses	0mg / 1tsp / 15ml
Nutmeg	0-2mg / 3.5oz
Olive Oil and Vinegar	2mg / 1oz
Oregano	0-2mg / 3.5oz
Pancake Syrup	0mg / 1tsp / 15ml
Peppermint	0-2mg / 1Tbs / 15ml
Sage	0-2mg / 1Tbs / 15ml
Salsa	1mg / 1tsp / 15ml
Savory	0-2mg / 1Tbs / 15ml
Vinegar	0-2mg / 3.5oz
White Pepper	0-2mg / 1Tbs / 15ml
Yellow Mustard	1mg / 1tsp / 15ml
Cereal			Cereal			Cereal
< 2mg Per Serving			2-10mg Per Serving			> 10mg Per Serving
Corn Pops	1mg / 8oz		Apple Cinnamon Cheerios	5mg / 6oz		100% Bran	25mg / 3oz
Cornflakes	1mg / 8oz		Cheerios	8mg / 8oz		40% Bran	36mg / 6oz
Crispix	1mg / 8oz		Cinnamon Toast Crunch	5mg / 6oz		All Bran	26mg / 4oz
Fruit Loops	2mg / 8oz		Complete Oat Bran Flakes	5mg / 6oz		All Bran Extra Fiber	11mg / 4oz
Frosted Flakes	1mg / 6oz		Corn Chex	5mg / 8oz		Apple Jacks	12mg / 3.5oz
Fruity Pebbles	2mg / 6oz		Frosted Cheerios	6mg / 8oz		Basic 4	17mg / 8oz
Honey Bunches of Oats, Honey Roasted	3mg / 6oz		Golden Grahams	9mg / 6oz		Bran Flakes	173mg / 3.5oz
Honey Bunches of Oats, with Almonds	2mg / 6oz		Healthy Choice Multi Grain Flakes	7mg / 6oz		Chex Multi Grain	38mg / 3.5oz
Honeycomb	1mg / 10oz		Honey Corn Flakes	3mg / 6oz		Cocoa Krispies	28mg / 8oz
Kix	2mg / 11oz		Honey Nut Cheerios	7mg / 8oz		Cracklin Oat Bran	15mg / 6oz
Oats, Quick	2mg / 3.5oz		Kashi Heart to Heart	8mg / 6oz		Fiber One	13mg / 4oz
Product 19	1mg / 8oz		Lucky Charms	5mg.8oz		Frosted Cheerios	20mg / 3.5oz
Trix	0mg / 8oz		Oats, Instant	6mg / 3.5oz		Frosted Mini Wheats	53mg / 3.5oz
Waffle Crisp	1mg / 8oz		Rice Chex	4mg / 10oz		Fruit ‘n’ Fiber Dates, Raisins, & Walnuts	41mg / 8oz
			Rice Krispies	4mg / 10oz		Granola with Raisins	16mg / 4oz
			Smacks	3mg / 6oz		Grapenuts	14mg / 4oz
			Special K	3mg / 3.5oz		Great Grains Crunchy Pecan	17mg / 6oz
			Special K, low calorie	35mg / 4oz		Great Grains Raisins, Dates, and Pecans	17mg / 6oz
			Special K, red berry	2mg / 8oz		Honey Nut Cluster	23mg / 8oz
			Total corn flakes	5mg / 11oz		Kashi GoLean	14mg / 4oz
			Wheat Chex	7mg / 8oz		Kashi Good Friend	10mg / 6oz
			Wheaties	8mg / 8oz		Mueslix	17mg / 6oz
						Multigrain Chex	36mg / 8oz
						Muslix Apple and Almond Crunch	20mg / 6oz
						Nature Valley Cinnamon Raisin Granola	13mg / 6oz
						Oatmeal Crisp with Almonds	42mg / 8oz
						Oatmeal Raisin Crips	13mg / 8oz
						Original Shredded Wheat and Bran	53mg / 10oz
						Puffed Kashi	13mg / 8oz
						Raisin Bran	46mg / 8oz
						Raisin Bran Crunch	27mg / 8oz
						Raisin Nut Bran	24mg / 8oz
						Shredded Wheat	100mg / 3.5oz
						Smart Start	15mg / 8oz
						Spoonsize Shredded Wheat	45mg / 8oz
						Total Raisin Bran	31mg / 8oz
						Wheaties Raisin Bran	11mg / 8oz
Oils
all vegetable oils are low oxalate	0-1mg

Medications Associated With Kidney Stone Formation

The new onset of stones can occasionally be linked to medications. The most common medications are calcium supplements. Studies vary in how much calcium is safe in supplement form. These estimates range from 1,000 to 1,500mg to 2,000mg per day for the prevention of osteoporosis. I usually recommend 1,500mg Calcium citrate with Vitamin D 400-500 IU per day in patients needing supplements.

The commonly used medication Topamax (Topiramate) causes about 1-2% of patients to begin forming stones. Current uses of this medication are for seizure disorders and prevention of migraine headaches. This medication is usually associated with the new onset of metabolic acidosis. This metabolic acidosis in turn lowers urinary citrate levels.
Zonegran (Zonisamide), a medication for control of partial seizures, may also cause 1-2% of patients to begin forming stones. The mechanism is felt to be similar to Topamax by inducing metabolic acidosis.

Vitamin C was popularized by Dr. Linus Pauling, a biochemist not a medical doctor, for the prevention of colds. He recommended 2,000 mg to 5,000mg or more per day. While this has been found not to be useful in preventing colds, it does cause stones at doses above 1,000-2,000mg per day. The excess Vitamin C is converted to oxalate and excreted in the urine. This may lead to stone formation.

Tests For Kidney Stone Recurrence Preventions

1. Stone analysis.
   Stone analysis breaks down the most common stone’s contents into percentage of the most common minerals in each stone.
2. 24-Hour urine collection.
   A 24-hour urine collection is used to measure the chemicals in the urine to determine which of the above dietary restrictions needs to be applied to you.
3. Parathyroid hormone measurement.
   A parathyroid hormone blood test will test for parathyroid gland over activity. Parathyroid glands are 4 button-sized glands on the surface of the thyroid. These glands regulate calcium in the blood stream and deposition of calcium in bones. If one or more is overactive, the result is breakdown of bone with an increase in urine and blood calcium levels.
4. Blood chemistry.
   Routine serum chemistries are also evaluated to look for illnesses that may be associated with stone formation.

Medications Used for Prevention of Kidney Stones

Urocit-K and Polycitra-K (Potassium citrate) are available in tablet form and can raise urinary levels of citrate enough to decrease the risk of stone formation in many people. While some insurance companies want to substitute cheaper Sodium citrate and Potassium chloride (KCL) for this medication, these are not appropriate substitutes.

Hydrochlorothiazide (HCTZ), a common diuretic used in hypertension, at a dose starting at 25 mg per day, increases urine output while at the same time lowering the calcium content of the urine.

Pyridoxine or Vitamin B6 has been used in the past but with lesser results and has a side effect of neurotoxicity at higher doses.

Magnesium supplementation, Magnesium oxide 400mg per day, may help some patients lower their risk of repeat stone formation.

Allopurinol 300mg per day and Potassium citrate combined with a decrease in protein intake generally makes uric acid stones smaller and less frequent. Uric acid stone disease can usually be more easily controlled than calcium stone disease.

Surgery For Kidney Stones

If medical management fails, then surgery becomes a treatment option. The surgical procedure recommended for you depends on multiple factors including size of the stone, location within the ureter, whether the stone is infected or not, stone density, history of previous surgical results, and history of passage of previous stones.

Open Removal of Kidney Stones

Open surgical removal of ureteral and renal stones, also called ureterolithotomy and nephrolithotomy, is still rarely needed. Starting in the 1980s, newer options greatly reduced the need for this type of surgery.

Extracorporeal Shock Wave Lithotripsy of Kidney Stones

ESWL or Extracorporeal Shock Wave Lithotripsy utilizes a percussion wave generated in water to break the stone. This technology was introduced from Germany in 1985. While the initial procedure submersed the patient in a large tub of water, this machine is rarely used today. Current second and third generation machines push a small self-contained tank of water up against the patient’s side, and the stone is localized in 2 different axes with either x-ray or ultrasound. The same percussion wave technology is then used to fragment or crush the stones into small enough pieces to pass.

Stone Fragments after ESWL

About 80-85% of people will require only one ESWL treatment. If fragments larger than 5 mm remain after lithotripsy, a second treatment may be needed. The shock wave is not an electrical shock but is a percussion wave. Examples of percussion waves most people are familiar with include bomb blasts and depth charges. Think about a bomb blast or a high speed wind blowing out windows or a depth charge cracking the metal in a submarine.

When the lithotripter created percussion wave hits the stone, the stone absorbs the energy and pieces of the stone break off. The more crystalline dihydrate stones are easiest to break. The monohydrate stones are much harder to break. Stone densities can be measured on a CT scan in Hounsfield units. The range of stone density for kidney stones is between 400-1,400HFU. As the density of the stone approaches 1,000HFU, the stone becomes harder to break and may require 2 treatments.

Percutaneous Removal of Renal Stones

Percutaneous stone removal was popularized in the 1980s as a way to avoid incisional or open stone removal. Percutaneous stone removal is used for large stones within the kidney. Usually, these stone are 25 mm or greater in diameter. One inch in maximum diameter equals 25.4 millimeters. The density of the stone also influences the choice of surgery. Denser stones that do not break well with ESWL will respond to mechanical lithotrites (Gyrus, CyberWand, and Microvasive Lithoclast Ultra). These devices use ultrasound to drive a burr or use pneumatic technology to fragment the stone while suctioning out the pieces at the same time.

For this procedure, a small needle is guided through the skin into the kidney through the flank under x-ray guidance. Dilators then enlarge the opening from 2 mm to 10 mm or about 3/8 inches. This avoids the 10-12 inch incision of an open removal. A temporary, plastic sheath is inserted into the newly established access. A telescope is guided down this tract, the stone is broken, and the pieces are removed. A drainage tube or nephrostomy tube may be left in the tract in the flank. This nephrostomy tube is removed after 2-5 days. This procedure is usually used for large stones that might have previously taken multiple ESWL procedures to fragment.

Ureteroscopy for Ureteral Stone Removal

This requires the introduction of a long, thin telescope (both metal and flexible ureteroscopes are available) through the urethra into the bladder and up the ureter to the level of the stone. A quartz, holmium, laser fiber is then typically used to fragment the stone for removal or passage. A ureteral stent, a hollow plastic tube, is then temporarily inserted to prevent swelling that may close the ureter thus causing stone like pain. The ureteral stent is usually removed after 3-5 days depending on each patient’s surgical findings. Unlike metal, vascular stents, ureteral stents must be removed. If left in place for long periods, ureteral stents can encrust with stone crystals and be difficult to remove.

Conclusion

Most people will benefit from a urologic consultation even if they pass their stone. Together, you and your urologist can decide what tests and dietary changes are right for you.

Erectile dysfunction, also known as ED or impotence, is a very common problem among men. It has been estimated that ED affects about 40% of 40 year old men and about 70% of 70 year old men. It is estimated that complete impotence affects 5% of 40 year old men and 15% of 70 year old men. Most men are embarrassed to bring up the subject to their Doctor. It is even more difficult to make an appointment. Most receptionists are women so men frequently make an appointment for a different medical problem only to want to talk about ED. Often times the office has not set aside enough time to discuss the problem in full because of the inaccurate reason given when making the appointment. These medical receptionists do not require a detailed description of the problem. Just tell them you would like to discuss ED and then there will be enough time set aside for your real problem.

Getting an erection is a complex system of events. There is no one cause of ED. In fact, it is usually several factors taking place all at once. It is easiest to use the analogy of a mechanical system involving an operator, a computer, a pump, pipes, hydraulic fluid and an electrical circuit. For this system to work properly, each of the individual components has to work. Just one component not working defeats the whole system. For example, it the electricity is off, no action. The same is true of the pump or any other component.

Now let’s talk about the anatomical equivalents of this mechanical system.
You are the Operator = you + libido + testosterone + testicles + sex drive

Brain	Computer
Heart	Pump
Arteries	Pipes
Blood	Hydraulic Fluid
Nervous System	Electrical System

If any of the above anatomical components malfunction, the result is Erectile dysfunction (or ED).

The brain is susceptible to stress which leads to performance anxiety and loss of erection. Medications affecting the hormones produced in the brain may have the same effect.

The nervous system is composed of the brain and the nerves. Damage to the nerves as occurs with diabetes, is a common cause of ED. Reversible causes include medications affecting the nerves ability to function normally. Most of these drugs are for more serious psychiatric disorders.

Arteries are the source of the increased blood flow into the penis resulting in an erection. If there is a decrease in flow, as occurs with atherosclerosis or hardening of the arteries, then the penis is unable to fill with blood, resulting in either partial erection or no erection at all. If a patient has a history of coronary artery disease, peripheral vascular disease or carotid disease there is an increased chance of blockage of the penile arteries. Smoking cessation, good diabetes control, control of cholesterol, and weight loss are the most common patient-controllable ways to avoid of atherosclerotic vascular disease.

If you continue to use the analogy of flow in pipes, the penile arteries the smallest of the pipes. If you were to compare a ¼ inch copper pipe to a ½ copper pipe and put a 1/8 inch layer of corrosion in each, then the ¼ pipe would be nearly blocked and the ½ inch pipe would be decease to a ¼ inch luminal size (or internal diameter) size.

The heart is the pump within this mechanical system. An increase in heart rate usually increases cardiac output of blood during the initial excitement phase of erection. If any medical condition slows the heart rate or if congestive heart failure weakens the pump, there will be a change in the ability to get and maintain an erection.

Testosterone is the male hormone responsible for puberty, onset of secondary sexual characteristics such as hair growth, voice change and increase in libido. A decline in testosterone occurs naturally as men age. The problem becomes one of defining the age at which testosterone decreases. Just as women go through menopause anywhere between 40 and 55 years of age, men too have a wide range of years at which time the testosterone might be low. I have found 27 year olds with very low testosterone levels and 75-80 year old men with very high testosterone levels. Anabolic Steroid use, as is common in body builders and athletes, causes the testes to essentially quit functioning. If usage of steroids stop, the testes may resume normal output of testosterone if the period of usage was short, but most of the time the testes do not resume normal function. The loss of one testicle on childhood rarely causes low testosterone. The loss of a testicle usually occurs with mumps orchitis, resulting in one testis being small, undescended testis or childhood hernia surgery. Common medications such as Tagamet (Cimetadine) have been found to suppress testosterone production. Weight gain and loss can temporarily cause changes in testosterone levels.

Medications, such as beta blockers, are typically used after heart attacks to control your heart rate. This rate control decreases cardiac output and may be associated with ED. Do not stop your beta blocker without your cardiologist’s permission. If you are on a beta blocker for blood pressure control, speak to you primary care physician (PCP) about changing you medication.

Treatment of Erectile Dysfunction

The primary treatment of ED has become oral medications such as Viagra, Levitra, and Cialis. While these work well for most men, they do have side effects such as headache, indigestion, muscle pain, flushing of the skin, and temporary blue vision as well as a very small risk of blindness and hearing loss. In addition, their costs are usually not covered by insurance and range in price from $20 to $28 per pill. It is better to look at the whole system and try to optimize each component.

Men that stop smoking will see an improvement in erections in as little as 2-3 months after smoking cessation. Men that exercise, lose weight, and change their life style see improvement as well. Weight loss results in better hypertension control, a decrease in diabetes risks, and in the loss of adipose tissue resulting in improved erections. Fat cells actually produce estrogen that counteracts the testosterone. Switching from cimetidine to other indigestion or reflux medications usually results in normalization of testosterone levels. Asking your doctors to work together to adjust or switch any medications affecting ED is also effective.

If you have stopped smoking, maximized your diabetes control, lost weight, and adjusted your medications and still have ED, then it is time to try oral medications such as Viagra. This is not the only class of medications available. It is, however, the cheapest and easiest route to improvement. If these medications fail, options include evaluation of your hormone levels of testosterone, thyroid, prolactin, FSH, and LH and occasionally checking your cortisol levels.

If no problem is found or if the testosterone is replaced and you still have problems, other options still exist.
Muse is a urethral suppository inserted about ½ inch down the urethra and is absorbed into the penis stimulating an erection. The active ingredient is prostaglandin E1. Dosage ranges from a 250mg to 500mg to 1,000mg suppository. The size of this suppository is about 1/16 inch in diameter by 1/4 inch in length.

Intracorporeal injection is the direct injection of a vasoactive medication directly into the side of the penis. This is done by inserting a small, diabetic type needle directly into the side of the penis. Brand names include Caverject and Edex. Both are alprostadil or prostaglandin E1. Mixing pharmacies make combinations of a 3-drug mix containing phentolamine, papaverine and prostaglandin E1 called Trimix. This combination may be effective if other medications do not work for you.

Vacuum devices have been available for decades. While they do produce a partial erection adequate for penetration, they are far from normal erections. Do not waste your money on one until you have fully discussed this with your doctor. The cylinder is placed over the penis, then a vacuum pump removes the air from the cylinder. The vacuum causes the penis to fill with blood. A rubber band like device is deployed off of the cylinder onto the penis and stops blood loss from the penis. The problem with this is that the penis rapidly becomes cold and blue. The penis is anchored well beyond the rubber band posteriorly, and this results in a floppy erection.

The last resort is insertion of a penile prosthesis. This is an implantable, pump-up device surgically placed inside your penis. This is beyond the scope of this article, but your urologist can discuss the benefits and risks of a penile prosthesis with you if all other methods have been tried and have not been successful.