Day -2

Today Dr. Baum called me with answers to my questions. He only performs preputioplasty with one dorsal incision. I guess this is my second best option because studies show that two incisions leave a slightly better cosmetic result and avoid a cleft in the foreskin on the top of the penis. I also wonder if two incisions make the foreskin wider than one incision. He gave me no reply to my question about BXO. I am still going to stick with the plan.

At the same time, I find more sources that say preputioplasty is not an option if BXO is present because the continuing inflammatory process results in recurrent stenosis of the preputial orifice. I am still going to try preputioplasty for two reasons. If I do have BXO indeed, it is of the slightest form (my penis is not nearly as scary as some penises on pictures of BXO). Also, I can always undergo circumcision if preputioplasty does not help, but not vice versa.

More information: http://www.ispub.com/journal/the-internet-journal-of-surgery/volume-18-number-1/bilateral-lateral-slit-preputial-plasty-a-technique-preferred-over-circumcision-in-primary-phimosis.html

http://urologycentre.com.sg/bxo_treatment.html

http://www.google.com/url?sa=t&rct=j&q=prepuce%3A%20phimosis%2C%20paraphimosis%2C%20and%20circumcision&source=web&cd=4&ved=0CDkQFjAD&url=http%3A%2F%2Fdownloads.tswj.com%2F2011%2F405910.pdf&ei=in1yT7fLEcPi2gWU-OGCDw&usg=AFQjCNE0otITK0wYPDmAFxqaInJrj714Ug

Day -4, BXO

Today I think I found the answer to my question about the link between white patches and tight foreskin (see the very first post of this blog here). Lichen sclerosus. Thought to be the most common cause of phimosis, lichen sclerosus is a dermatological condition manifesting as white patches on the foreskin and glans; often a hard, white ring of tissue develops, which may prevent retraction. What causes lichen sclerosus is not certain, although theories range from bacterial or viral infection (especially with HPV – human papilloma virus) to autoimmune diseases. Lichen sclerosus is also called balanitis xerotica obliterans (BXO).

Here are more links to information about BXO:

http://www.dermaamin.com/site/atlas-of-dermatology/2-b/147-balanitis-xerotica-obliterans-.html

http://en.wikipedia.org/wiki/Balanitis_xerotica_obliterans

http://www.centerforreconstructiveurology.org/urethral-stricture/lichen-sclerosis-bxo.htm

I guess it is good that I found some explanation to my problem. Also, it seems like this finding does not change my treatment as most studies recommend circumcision/preputioplasty for BXO. Except for this study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC539601/

I also see different techniques describing preputioplasty in different sources. Some recommend one incision, others recommend two or more.

Definitely now I have more questions to ask Dr. Baum.

I am still puzzled why it is I who searches for answers and then presents them to doctors, and not vice versa.

Day -7, Pre-Op

Today I had two pre-op visits. One with the nurse of Dr. Baum, and another one with the Surgery Center personnel. The procedure will be performed at the Ambulatory Surgery Center of Touro. Preputioplasty and frenulotomy are considered outpatient surgeries. Both nurses said that the whole time I will spend at the Center on the day of the surgery should be between four and five hours. I got two prescriptions, one for pain medication after the surgery, and one for antibiotics to start one day before the procedure. The rest was basically signing papers and consents.

I know that a lot of people wonder how expensive this procedure is. The total price that Dr. Baum’s office charges is around $1500. The official diagnosis is phimosis, and my insurance covers it. So, in total, I paid out-of-pocket around $200 to Dr. Baum. I will post how much the bill from the Ambulatory Surgery Center of Touro is.

First Visit to Dr. Baum

Today was my first visit to Dr. Neil Baum. First of all, it was at least a thirty minute conversation. He carefully looked at my penis and realized what the problem was. Also, he wanted to see the condition when the penis is erect, so he asked me to take pictures of my penis while erected and send them over to him. Here is an example of what I sent:

Dr. Baum presented me with my options: do nothing (since I still can open the head), full circumcision, and preputioplasty. Frenulotomy will still help, he said. When I told him that I like my foreskin, he replied that then there is no reason to part with it. I showed him the same articles I showed Dr. Prats, and he replied that he is aware of them. He also briefly explained how preputioplasty is done.

Overall, I am satisfied with the visit and am eager to hear from him once he receives my pictures.

On the Phone

I decided to somewhat change my strategy. I googled for all urologists within a 50 mile radius from my location. For the last two days I have been calling their offices with just one question, ‘Does your doctor perform preputioplasty?’ By midday today I became pretty sad as every single office replied with a no. I was ready to increase the radius for my search options when I received a phone call from Dr. Neil Baum’s office.

‘Yes, I can do that,’ the doctor said. ‘Would you like to set up an appointment?’

‘Sure!’ I replied.

My first meeting with him is scheduled on February 24, 2012.

Second Visit to Dr. Prats and What I Think About Doctors

Today was my second visit to Dr. Prats. I had printouts from Wikipedia and scientific journals about preputioplasty with me. Still, that was another five minute meeting. I asked Dr. Prats what he thinks about preputioplasty. From his expression (What?!), I could tell that was the first time he heard of it. Without even looking at the studies, he told me that for him it is ‘an excuse to charge more money’ and that he does not believe in preputioplasty (he could not repeat the word, of course, since he had never heard it before). End of conversation.

…Wait a minute. You either don’t know what it is and therefore have no opinion, or you know what it is and disapprove.

Doctors are scientists. I am a scientist myself. The are supposed to know research related to their area of expertise. They are supposed to be on a constant watch for new treatments and methods. I understand that it is impossible for them to know everything. But then at least they shouldn’t be blind to new knowledge and in no way should they ignore it in front of their patients. They may get themselves familiar with it and disapprove or not use in their practice. But they should not ignore it!

A lot of medical problems stem from the fact that people are afraid to share their concerns with anyone, sometimes including doctors. This is especially common in urology. ‘Don’t be ashamed. Talk to your doctor’ seems to be the most common piece of advice everywhere. No matter what a medical condition is, every source recommends first consulting with a doctor. Doctors seem to be like angels that help people in most desperate situations, they are remedies to most complicated conditions, and solutions to seemingly unresolvable problems. They are viewed by many patients as the last resort and the last hope. Doctors always care about their patients, doctors always think about them, doctors always understand their problems, and constantly try to do the best to help them. You may be afraid to tell your family about your delicate problem, your friends may be indifferent, but doctors will always understand.  I am pretty sure that in the vast majority of cases doctors are indeed like that. We all share so much respect to them and are so much thankful for everything they have done.

But then it hurts even more when you realize that this particular doctor turned out to be ignorant to your problem. This particular doctor made you feel stupid when you were most vulnerable. This particular doctor showed that your delicate problem is unimportant to him. This happened to me with Dr. Prats. I understand that he treats patients with terminal illnesses on a daily basis. I know that people are in constant urgent need of his help. These are people who have problems with urinating, pain, urinary tract infections, prostate cancers and erectile dysfunctions. Compared to their problems, my problem seems unimportant. But it is important to me!

I was brave enough to come, to talk about my symptoms to at least five people of his staff, and to drop my pants in front of him. I have been searching on-line for days to see my options (this is part of his job, actually). And all that so that he can tell me, ‘I don’t believe in per..put…whatever it is’? Preputioplasty is not a god to believe in it. Can you tell me why? Why exactly do you disagree with these studies? Why do you think I brought these printouts to you? I may be one thousand times wrong about preputioplasty but I do deserve an explanation why you think so!

At least Dr. Prats openly told me that he does not perform the procedure and he only performs full circumcisions and frenulotomies. I guess that was the real reason why the conversation was so short. It is simply easier to stick with what you know.

I changed my mind about having frenulotomy with Dr. Prats, cancelled, and left the office.