The infant lamina propria is composed of only one layer, as compared to three in the adult, and there is no vocal ligament. The vocal ligament begins to be present in children at about four years of age. Two layers appear in the lamina propria between the ages of six and twelve, and the mature lamina propria, with the superficial, intermediate and deep layers, is only present by the conclusion of adolescence. As vocal fold vibration is a foundation for vocal formants, this presence or absence of tissue layers influences a difference in the number of formants between the adult and pediatric populations. In females, the voice is three tones lower than the child's and has five to twelve formants, as opposed to the pediatric voice with three to six.
The length of the vocal fold at birth is approximately six to eight millimeters and grows to its adult length of eight to sixteen millimeters by adolescence. The infant vocal fold is half membranous or anterior glottis, and half cartilaginous or posterior glottis. The adult fold is approximately three-fifths membranous and two-fifths cartilaginous.


Puberty  usually lasts from 2 to 5 years, and typically occurs between the ages of 12 and 17. During puberty, voice change is controlled by  sex hormones . In females during puberty, the vocal muscle thickens slightly, but remains very supple and narrow. The squamous mucosa also differentiates into three distinct layers (the lamina propria) on the free edge of the vocal folds. The sub- and supraglottic glandular mucosa becomes hormone-dependent to estrogens and progesterone. For females, the actions of  estrogens  and  progesterone  produce changes in the extravascular spaces by increasing capillary permeability which allows the passage of intracapillary fluids to the interstitial space as well as modification of glandular secretions. Estrogens have a hypertrophic and proliferative effect on mucosa by reducing the desquamating effect on the superficial layers. The  thyroid hormones  also affect dynamic function of the vocal folds; ( Hashimoto's thyroiditis  affects the fluid balance in the vocal folds). Progesterone has an anti-proliferative effect on mucosa and accelerates desquamation. It causes a menstrual-like cycle in the vocal fold epithelium and a drying out of the mucosa with a reduction in secretions of the glandular epithelium. Progesterone has a diuretic effect and decreases capillary permeability, thus trapping the  extracellular fluid  out of the capillaries and causing tissue congestion.


Testosterone , an androgen secreted by the testes, will cause changes in the cartilages and musculature of the larynx for males during puberty, and to a lesser extent to females  assigned at birth  and others such as  intersex  individuals as well as those who are androgen deficient if they are given  masculinizing hormone therapy . In females, androgens are secreted principally by the  adrenal cortex  and the ovaries and can have irreversible masculinizing effects if present in high enough concentration. In males, they are essential to  male sexuality . In muscles, they cause a hypertrophy of striated muscles with a reduction in the fat cells in  skeletal muscles , and a reduction in the whole body fatty mass. Androgens are the most important hormones responsible for the passage of the boy-child voice to adult male voice, and the change is irreversible without  reconstructive surgery  such as  feminization laryngoplasty . The thyroid prominence, which contains the vocal cords appears, the vocal folds lengthen and become rounded, and the epithelium thickens with the formation of  three distinct layers in the lamina propria. [ 8 ]  These changes are also irreversible without surgery, albeit the thyroid/laryngeal prominence, also known as an  Adam's apple  can be potentially diminished via a  tracheal shave  or  feminization laryngoplasty .


Human vocal cords are paired structures located in the larynx, just above the trachea, which vibrate and are brought in contact during phonation. The human vocal cords are roughly 12 – 24 mm in length, and 3–5 mm thick. [ 9 ]  Histologically, the human vocal cords are a laminated structure composed of five different layers. The vocalis muscle, main body of the vocal cords, is covered by the mucosa, which consists of the epithelium and the lamina propria. [ 10 ]  The latter is a pliable layer of connective tissue subdivided into three layers: the superficial layer (SL), the intermediate layer (IL), and the deep layer (DL). [ 11 ]  Layer distinction is either made looking at differential in cell content or  extracellular matrix  (extracellular matrix) content. The most common way being to look at the extracellular matrix content. The SLP has fewer elastic and collagenous fibers than the two other layers, and thus is looser and more pliable. The ILP is mostly composed of elastic fibers, while the DLP has fewer elastic fibers, and more collagenous fibers. [ 10 ]  In those two layers, which form what is known as the vocalis ligament, the elastic and collagenous fibers are densely packed as bundles that run almost parallel to the edge of the vocal fold. [ 10 ]


There is a steady increase in the elastin content of the lamina propria as humans age (elastin is a yellow scleroprotein, the essential constituent of the elastic  connective tissue ) resulting in a decrease in the ability of the lamina propria to expand caused by cross-branching of the elastin fibers. Among other things, this leads to the mature voice being better suited to the rigors of opera. [ citation needed ]


The extracellular matrix of the vocal cord LP is composed of fibrous proteins such as collagen and elastin, and interstitial molecules such as  HA , a non-sulfated  glycosaminoglycan . [ 11 ]  While the SLP is rather poor in elastic and collagenous fibers, the ILP and DLP are mostly composed of it, with the concentration of elastic fibers decreasing and the concentration of collagenous fibers increasing as the vocalis muscle is approached. [ 10 ]  Fibrous proteins and interstitial molecules play different roles within the extracellular matrix. While collagen (mostly type I) provides strength and structural support to the tissue, which are useful to withstanding stress and resisting deformation when subjected to a force, elastin fibers bring elasticity to the tissue, allowing it to return to its original shape after deformation. [ 11 ]  Interstitial proteins, such as HA, plays important biological and mechanical roles in the vocal cord tissue. [ 5 ]  In the vocal cord tissue, hyaluronic acid plays a role of shear-thinner, affecting the tissue viscosity, space-filler, shock absorber, as well as wound healing and cell migration promoter. The distribution of those proteins and interstitial molecules has been proven to be affected by both age and gender, and is maintained by the  fibroblasts . [ 11 ] [ 12 ] [ 5 ] [ 13 ]


Vocal fold structure in adults is quite different from that in newborns. Exactly how the vocal cord mature from an immature monolayer in newborns to a mature three layer tissue in adults is still unknown, however a few studies have investigated the subjects and brought some answers.


Hirano et al. previously found that the newborns did not have a true lamina propria, but instead had cellular regions called maculae flavae, located at the anterior and posterior ends of the loose vocal fold tissue. [ 4 ] [ 14 ]  Boseley and Hartnick examined at the development and maturation of pediatric human vocal fold lamina propria. [ 15 ]  Hartnick was the first one to define each layer by a change in their cellular concentration. [ 16 ]  He also found that the lamina propria monolayer at birth and shortly thereafter was hypercellular, thus confirming Hirano's observations. By 2 months of age, the vocal fold started differentiating into a bilaminar structure of distinct cellular concentration, with the superficial layer being less densely populated than the deeper layer. By 11 months, a three-layered structure starts to be noted in some specimens, again with different cellular population densities. The superficial layer is still hypocellular, followed by an intermediate more hypercellular layer, and a deeper hypercellular layer, just above the vocalis muscle. Even though the vocal cords seem to start organizing, this is not representative of the trilaminar structure seen in adult tissues, where the layer are defined by their differential elastin and collagen fiber compositions. By 7 years of age, all specimens show a three-layered vocal fold structure, based on cellular population densities. At this point, the superficial layer was still hypocellular, the middle layer was the hypercellular one, with also a greater content of elastin and collagen fibers, and the deeper layer was less cellularly populated. Again, the distinction seen between the layers at this stage is not comparable to that seen in the adult tissue. The maturation of the vocal cords did not appear before 13 years of age, where the layers could be defined by their differential fiber composition rather than by their differential cellular population. The pattern now show a hypocellular superficial layer, followed by a middle layer composed predominantly of elastin fiber, and a deeper layer composed predominantly of collagen fibers. This pattern can be seen in older specimens up to 17 years of age, and above. While this study offers a nice way to see the evolution from immature to mature vocal cords, it still does not explain what is the mechanism behind it.


Maculae flavae are located at the anterior and posterior ends of the membranous parts of the vocal cords. [ 17 ]  The histological structure of the macula flava is unique, and Sato and Hirano speculated that it could play an important role in growth, development and aging of the vocal cords. The macula flava is composed of  fibroblasts , ground substances, elastic and collagenous fibers. Fibroblasts were numerous and spindle or stellate-shaped. The fibroblasts have been observed to be in active phase, with some newly released amorphous materials present at their surface. From a biomechanical point of view, the role of the macula flava is very important. Hirano and Sato studies suggested that the macula flava is responsible for the synthesis of the fibrous components of the vocal cords. Fibroblasts have been found mostly aligned in the direction of the vocal ligament, along bundles of fibers. It then was suggested that the mechanical stresses during phonation were stimulating the fibroblasts to synthesize those fibers.


The  viscoelastic  properties of human vocal fold lamina propria are essential for their vibration, and depend on the composition and structure of their  extracellular matrix . Adult vocal cords have a layered structure which is based on the layers differential in extracellular matrix distribution. Newborns on the other hand, do not have this layered structure. Their vocal cords are uniform, and immature, making their viscoelastic properties most likely unsuitable for phonation. Hyaluronic acid plays a very important role in the vocal fold biomechanics. In fact, hyaluronic acid has been described as the extracellular matrix molecule that not only contributes to the maintenance of an optimal tissue viscosity that allows phonation, but also of an optimal tissue stiffness that allows frequency control. [ 6 ]   CD44  is a cell surface receptor for HA. Cells such as  fibroblasts  are responsible for synthesizing extracellular matrix molecules. Cell surface matrix receptors in return, feed back to the cells through cell-matrix interaction, allowing the cell to regulate its metabolism.


Sato et al. [ 18 ]  carried out a histopathologic investigation of unphonated human vocal cords. Vocal fold mucosae, which were unphonated since birth, of three young adults (17, 24, and 28 years old) were looked at using light and electron microscopy. The results show that the vocal fold mucosae were hypoplastic, and rudimentary, and like newborns, did not have any vocal ligament, Reinke's space, or layered structure. Like newborns, the lamina propria appeared as a uniform structure. Some  stellate cells  were present in the macula flava, but started to show some signs of degeneration. The stellate cells synthesized fewer extracellular matrix molecules, and the cytoplasmic processes were shown to be short and shrinking, suggesting a decreased activity. Those results confirm the hypothesis that phonation stimulates stellate cells into producing more extracellular matrix.


Furthermore, using a specially designed bioreactor, Titze et al. showed that fibroblasts exposed to mechanical stimulation have differing levels of extracellular matrix production from fibroblasts that are not exposed to mechanical stimulation. [ 19 ]  The gene expression levels of extracellular matrix constituents such as fibronectin, MMP1, decorin, fibromodulin, hyaluronic acid synthase 2, and  CD44  were altered. All those genes are involved in extracellular matrix remodeling, thus suggesting that mechanical forces applied to the tissue, alter the expression levels of extracellular matrix related genes, which in turn allow the cells present in the tissue to regulate the extracellular matrix constituent synthesis, thus affecting the tissue's composition, structure, and biomechanical properties. In the end, cell-surface receptors close the loop by giving feedback on the surrounding extracellular matrix to the cells, affecting also their gene expression level.


Other studies suggest that  hormones  play also an important role in vocal fold maturation. Hormones are molecules secreted into the blood stream to be delivered at different targeted sites. They usually promote growth, differentiation and functionality in different organs or tissues. Their effect is due to their ability to bind to intracellular receptors, modulating the gene expression, and subsequently regulating protein synthesis. [ 20 ]  The interaction between the endocrine system and tissues such as breast, brain, testicles, heart, bones, etc., is being extensively studied. It has clearly been seen that the larynx is somewhat affected by hormonal changes, but, very few studies are working on elucidating this relationship. The effect of hormonal changes in voice is clearly seen when hearing male and female voices, or when listening to a teenage voice changing during puberty. Actually, it is believed that the number of hormonal receptors in the pre-pubertal phase is higher than in any other age. [ 20 ]  Menstruation has also been seen to influence the voice. In fact, singers are encouraged by their instructors not to perform during their pre-menstrual period, because of a drop in their voice quality. [ 20 ]


Vocal fold phonatory functions are known to change from birth to old age. The most significant changes occur in development between birth and puberty, and in old age. [ 10 ] [ 21 ]   Hirano et al. previously described several structural changes associated with aging, in the vocal fold tissue. [ 22 ]  Some of those changes are: a shortening of the membranous vocal fold in males, a thickening of the vocal fold mucosa and cover in females, and a development of edema in the superficial lamina propria layer in both sexes. Hammond et al. observed that the hyaluronic acid content in the vocal fold lamina propria was significantly higher in males than in females. [ 12 ]  Although all those studies did show that there are clear structural and functional changes seen in the human vocal cords which are associated with gender and age, none really fully elucidated the underlying cause of those changes. In fact, only a few recent studies started to look at the presence and role of hormone receptors in the vocal cords. Newman et al. found that hormone receptors are indeed present in the vocal cords, and show a statistical distribution difference with respect to age and gender. [ 21 ]  They have identified the presence of  androgen ,  estrogen , and  progesterone  receptors in  epithelial cells ,  granular cells  and  fibroblasts  of the vocal cords, suggesting that some of the structural changes seen in the vocal cords could be due to hormonal influences. [ 21 ]  In this specific study, androgen and progesterone receptors were found more commonly in males than in females. In others studies, it has been suggested that the estrogen/androgen ratio be partly responsible for the voice changes observed at menopause. [ 23 ]  As previously said, Hammond et al. showed than the hyaluronic acid content was higher in male than in female vocal cords. Bentley et al. demonstrated that sex skin swelling seen in monkey was due to an increase in hyaluronic acid content, which was in fact mediated by estrogen receptors in dermal fibroblasts. [ 24 ]  An increase in collagen biosynthesis mediated by the estrogen receptors of dermal fibroblasts was also observed. A connection between hormone levels, and  extracellular matrix  distribution in the vocal cords depending on age and gender could be made. More particularly a connection between higher hormone levels and higher hyaluronic acid content in males could exist in the human vocal fold tissue. Although a relationship between hormone levels and extracellular matrix biosynthesis in vocal fold can be established, the details of this relationship, and the mechanisms of the influence has not been elucidated yet.


There is a thinning in the superficial layer of the lamina propria in old age. In aging, the vocal fold undergoes considerable sex-specific changes. In the female larynx, the vocal fold cover thickens with aging. The superficial layer of the lamina propria loses density as it becomes more edematous. The intermediate layer of the lamina propria tends to atrophy only in men. The deep layer of the lamina propria of the male vocal fold thickens because of increased collagen deposits. The vocalis muscle atrophies in both men and women. However, the majority of elderly patients with voice disorders have disease processes associated with aging rather than physiologic aging alone. [ 25 ] [ 26 ] [ 27 ]


The larynx is a major (but not the only) source of sound in  speech , generating sound through the rhythmic opening and closing of the vocal folds.  To oscillate, the vocal folds are brought near enough together such that air pressure builds up beneath the larynx.  The folds are pushed apart by this increased subglottal pressure, with the inferior part of each fold leading the superior part. Such a wave-like motion causes a transfer of energy from the airflow to the fold tissues. [ 28 ]  Under the correct conditions, the energy transferred to the tissues is large enough to overcome losses by dissipation and the oscillation pattern will sustain itself.  In essence, sound is generated in the larynx by chopping up a steady flow of air into little puffs of sound waves. [ 29 ]


The perceived pitch of a person's voice is determined by a number of different factors, most importantly the  fundamental frequency  of the sound generated by the larynx.  The fundamental frequency is influenced by the length, size, and tension of the vocal folds.  This frequency averages about 125  Hz  in an adult male, 210 Hz in adult females, and over 300 Hz in children.  Depth-kymography [ 30 ]  is an imaging method to visualize the complex horizontal and vertical movements of vocal folds.


The vocal folds generate a sound rich in  harmonics .  The harmonics are produced by collisions of the vocal folds with themselves, by recirculation of some of the air back through the trachea, or both. [ 31 ]  Some singers can isolate some of those harmonics in a way that is perceived as  singing  in more than one pitch at the same time—a technique called  overtone singing  or throat singing such as in the tradition of  Tuvan throat singing .


The majority of vocal fold lesions primarily arise in the cover of the folds. Since the basal lamina secures the epithelium to the superficial layer of the lamina propria with anchoring fibers, this is a common site for injury. If a person has a phonotrauma or habitual vocal hyperfunction, also known as pressed phonation, the proteins in the basal lamina can shear, causing vocal fold injury, usually seen as nodules or polyps, which increase the mass and thickness of the cover. The  squamous cell  epithelium of the anterior glottis are also a frequent site of laryngeal cancer caused by smoking.


A voice pathology called Reinke's edema, swelling due to abnormal accumulation of fluid, occurs in the superficial lamina propria or Reinke's space. This causes the vocal fold mucosa to appear floppy with excessive movement of the cover that has been described as looking like a loose sock. [ 32 ]  The greater mass of the vocal folds due to increased fluid lowers the  fundamental frequency  during phonation.


Wound healing is a natural regeneration process of dermal and epidermal tissue involving a sequence of biochemical events. These events are complex and can be categorized into three stages: inflammation, proliferation and tissue remodeling. [ 33 ]  The study on vocal fold wound healing is not as extensive as that on animal models due to the limited availability of human vocal folds. Vocal fold injuries can have a number of causes including chronic overuse, chemical, thermal and mechanical trauma such as smoking, laryngeal cancer, and surgery. Other benign pathological phenomena like polyps,  vocal fold nodules  and edema will also introduce disordered phonation. [ 34 ]


Any injury to human vocal folds elicits a wound healing process characterized by disorganized collagen deposition and, eventually, formation of scar tissue. [ 35 ] [ 36 ] [ 37 ] [ 38 ]  Verdolini [ 39 ]  and her group sought to detect and describe acute tissue response of injured rabbit vocal cord model. They quantified the expression of two biochemical markers:  interleukin 1  and  prostaglandin E2 , which are associated with acute wound healing. They found the secretions of these inflammatory mediators were significantly elevated when collected from injured vocal cords versus normal vocal cords. This result was consistent with their previous study about the function of IL-1 and PGE-2 in wound healing. [ 39 ] [ 40 ]  Investigation about the temporal and magnitude of inflammatory response in the vocal cords may benefit for elucidating subsequent pathological events in vocal fold wounding, [ 40 ]  which is good for clinician to develop therapeutic targets to minimize scar formation. In the proliferative phase of vocal cord wound healing, if the production of hyaluronic acid and collagen is not balanced, which means the hyaluronic acid level is lower than normal, the fibrosis of collagen cannot be regulated. Consequently, regenerative-type wound healing turns to be the formation of scar. [ 35 ] [ 38 ]  Scarring may lead to the deformity of vocal fold edge, the disruption of lipopolysaccharides viscosity and stiffness. [ 41 ]  Patients suffering from vocal fold scar complain about increased phonatory effort, vocal fatigue, breathlessness, and  dysphonia . [ 35 ]  Vocal fold scar is one of the most challenging problems for otolaryngologists because it is hard to be diagnosed at germinal stage and the function necessity of vocal cords is delicate.


The vocal folds are commonly referred to as  vocal cords , and less commonly as  vocal flaps  or  vocal bands . The term  vocal cords  was coined by the French anatomist  Antoine Ferrein  in 1741. In his violin analogy of the  human voice , he postulated that the moving air acted like a bow on  cordes vocales . [ 42 ]  The alternative spelling in English is  vocal chords , possibly due to the musical connotations or to confusion with the geometrical definition of the word  chord . While both spellings have historical precedents, standard American spelling is  cords . [ 43 ]  According to the  Oxford English Corpus , a database of 21st-century texts that contains everything from academic journal articles to unedited writing and blog entries, contemporary writers opt for the nonstandard  chords  instead of  cords  49% of the time. [ 44 ] [ 45 ]  The  cords  spelling is also standard in the United Kingdom and Australia.


In  phonetics ,  vocal folds  is preferred over  vocal cords , on the grounds that it is more accurate and illustrative. [ 46 ] [ 47 ] [ 48 ]


Xerostomia , also known as  dry mouth , is a subjective complaint of dryness in the  mouth , which may be associated with a change in the composition of  saliva , or reduced salivary flow, or  have no identifiable cause . [ 1 ]


This symptom is very common and is often seen as a  side effect  of many types of medication. It is more common in older people (mostly because this group tend to take several medications) and in people who  breathe through their mouths .  Dehydration ,  radiotherapy  involving the  salivary glands ,  chemotherapy  and several diseases can cause reduced salivation (hyposalivation), or a change in saliva consistency and hence a complaint of xerostomia. Sometimes there is no identifiable cause, and there may sometimes be a  psychogenic  reason for the complaint. [ 1 ]


Xerostomia is the subjective sensation of dry mouth, which is often (but not always) associated with hypofunction of the salivary glands. [ 3 ]  The term is derived from the Greek words ξηρός ( xeros ) meaning "dry" and στόμα ( stoma ) meaning "mouth". [ 4 ] [ 5 ]  A drug or substance that increases the rate of salivary flow is termed a  sialogogue .


Hyposalivation  is a clinical diagnosis that is made based on the history and examination, [ 1 ]  but reduced salivary flow rates have been given objective definitions. Salivary gland hypofunction has been defined as any objectively demonstrable reduction in whole and/or individual gland flow rates. [ 6 ]  An unstimulated whole saliva flow rate in a normal person is 0.3–0.4 ml per minute, [ 7 ]  and below 0.1 ml per minute is significantly abnormal. A stimulated saliva flow rate less than 0.5 ml per gland in 5 minutes or less than 1 ml per gland in 10 minutes is decreased. [ 1 ]  The term subjective xerostomia is sometimes used to describe the symptom in the absence of any clinical evidence of dryness. [ 8 ]  Xerostomia may also result from a change in composition of saliva (from serous to mucous). [ 6 ]   Salivary gland dysfunction  is an  umbrella term  for the presence of xerostomia, salivary gland hyposalivation, [ 6 ]  and  hypersalivation . [ citation needed ]


Hyposalivation may give the following signs and symptoms:


However, sometimes the clinical findings do not correlate with the symptoms experienced. [ 9 ]  For example, a person with signs of hyposalivation may not complain of xerostomia. Conversely a person who reports experiencing xerostomia may not show signs of reduced salivary secretions (subjective xerostomia). [ 8 ]  In the latter scenario, there are often other oral symptoms suggestive of  oral dysesthesia  ("burning mouth syndrome"). [ 3 ]  Some symptoms outside the mouth may occur together with xerostomia.


These include:


There may also be other systemic signs and symptoms if there is an underlying cause such as  Sjögren's syndrome , [ 1 ]  for example, joint pain due to associated  rheumatoid arthritis .


The differential of hyposalivation significantly overlaps with that of xerostomia. A reduction in saliva production to about 50% of the normal unstimulated level will usually result in the sensation of dry mouth. [ 8 ]  Altered saliva composition may also be responsible for xerostomia. [ 8 ]


Salivary flow rate is decreased during sleep, which may lead to a transient sensation of dry mouth upon waking. This disappears with eating or drinking or with oral hygiene. When associated with halitosis, this is sometimes termed "morning breath". Dry mouth is also a common sensation during periods of anxiety, probably owing to enhanced  sympathetic  drive. [ 11 ]  During periods of stress, our body responds in a ‘fight or flight’ state that will interfere with the saliva flow in the mouth. [ 12 ]  Dehydration is known to cause hyposalivation, [ 1 ]  the result of the body trying to conserve fluid. Physiologic age-related changes in salivary gland tissues may lead to a modest reduction in salivary output and partially explain the increased prevalence of xerostomia in older people. [ 1 ]  However,  polypharmacy  is thought to be the major cause in this group, with no significant decreases in salivary flow rate being likely to occur through aging alone. [ 9 ] [ 13 ]


Aside from physiological causes of xerostomia,  iatrogenic  effects of medications are the most common cause. [ 1 ]  A medication which is known to cause xerostomia may be termed  xerogenic . [ 3 ]  Over 400 medications are associated with xerostomia. [ 8 ]  Although drug induced xerostomia is commonly reversible, the conditions for which these medications are prescribed are frequently chronic. [ 8 ]  The likelihood of xerostomia increases in relation to the total number of medications taken, whether the individual medications are xerogenic or not. [ 9 ]  The sensation of dryness usually starts shortly after starting the offending medication or after increasing the dose. [ 1 ]   Anticholinergic ,  sympathomimetic , or  diuretic  drugs are usually responsible. [ 1 ]


Xerostomia may be caused by autoimmune conditions which damage saliva-producing cells. [ 8 ]  Sjögren's syndrome is one such disease, and it is associated with symptoms including fatigue,  myalgia  and  arthralgia . [ 8 ]  The disease is characterised by inflammatory changes in the moisture-producing glands throughout the body, leading to reduced secretions from glands that produce saliva, tears and other secretions throughout the body. [ 8 ]  Primary Sjögren's syndrome is the combination of dry eyes and xerostomia. Secondary Sjögren's syndrome is identical to primary form but with the addition of a combination of other connective tissue disorders such as  systemic lupus erythematosus  or  rheumatoid arthritis . [ 8 ]


Xerostomia may be the only symptom of celiac disease, especially in adults, who often have no obvious digestive symptoms. [ 14 ]


Radiation therapy for  cancers of the head and neck  (including  brachytherapy  for  thyroid cancers ) where the salivary glands are close to or within the field irradiated is another major cause of xerostomia. [ 8 ]  A radiation dose of 52 Gy is sufficient to cause severe salivary dysfunction. Radiotherapy for oral cancers usually involves up to 70 Gy of radiation, often given along with chemotherapy which may also have a damaging effect on saliva production. [ 8 ]  This side effect is a result of radiation damage of the parasympathetic nerves. Formation of salivary gland ducts depends on the secretion of a  neuropeptide  from the parasympathetic nerves, while development of the end buds of the salivary gland depends on  acetylcholine  from the parasympathetic nerves. [ 15 ]


"Sicca" simply means dryness. Sicca syndrome is not a specific condition, and there are varying definitions, but the term can describe oral and eye dryness that is not caused by autoimmune diseases (e.g., Sjögren syndrome).


Oral dryness may also be caused by mouth breathing, [ 3 ]  usually caused by partial obstruction of the  upper respiratory tract . Examples include  hemorrhage ,  vomiting ,  diarrhea , and  fever . [ 1 ] [ 9 ]


Alcohol may be involved in the cause of salivary gland disease, liver disease, or dehydration. [ 3 ]


Smoking is another possible cause. [ 9 ]  Other recreational drugs such as  methamphetamine , [ 16 ]   cannabis , [ 17 ]   hallucinogens , [ 18 ]  or  heroin , [ 19 ]  may be implicated.


Hormonal disorders, such as poorly controlled diabetes, chronic graft versus host disease or low fluid intake in people undergoing  hemodialysis  for renal impairment may also result in xerostomia, due to dehydration. [ 8 ]


Nerve damage can be a cause of oral dryness. An injury to the face or surgery can cause nerve damage to the head and neck area which can effect the nerves that are associated with the salivary flow. [ 20 ]


Xerostomia may be a consequence of infection with hepatitis C virus (HCV) and a rare cause of salivary gland dysfunction may be  sarcoidosis . [ 8 ]


Infection with Human Immunodeficiency Virus/Acquired immunodeficiency Syndrome (AIDS) can cause a related salivary gland disease known as Diffuse Infiltrative Lymphocytosis Syndrome (DILS). [ 8 ]


Similar to taste dysfunction, xerostomia is one of the most prevalent and persistent oral symptoms associated with COVID-19. Despite a close association with COVID-19, xerostomia, dry mouth and hyposalivation tend to be overlooked in COVID-19 patients and survivors, unlike ageusia, dysgeusia and hypogeusia. [ 21 ]


A diagnosis of hyposalivation is based predominantly on the clinical signs and symptoms. [ 1 ]  The  Challacombe scale  maybe used to classify the extent of dryness. [ 22 ] [ 23 ]  The rate of the salivary flow in an individual's mouth can also be measured. [ 24 ]  There is little correlation between symptoms and objective tests of salivary flow, [ 25 ]  such as  sialometry . This test is simple and noninvasive, and involves measurement of all the saliva a patient can produce during a certain time, achieved by dribbling into a container. Sialometery can yield measures of stimulated salivary flow or unstimulated salivary flow. Stimulated salivary flow rate is calculated using a stimulant such as 10%  citric acid  dropped onto the tongue, and collection of all the saliva that flows from one of the  parotid papillae  over five or ten minutes. Unstimulated whole saliva flow rate more closely correlates with symptoms of xerostomia than stimulated salivary flow rate. [ 1 ]   Sialography  involves introduction of  radio-opaque  dye such as  iodine  into the duct of a salivary gland. [ 1 ]  It may show blockage of a duct due to a calculus. Salivary  scintiscanning  using  technetium  is rarely used. Other medical imaging that may be involved in the investigation include  chest x-ray  (to exclude sarcoidosis),  ultrasonography  and  magnetic resonance imaging  (to exclude Sjögren's syndrome or neoplasia). [ 1 ]  A minor salivary gland  biopsy , usually taken from the lip, [ 26 ]  may be carried out if there is a suspicion of  organic disease  of the salivary glands. [ 1 ]   Blood tests  and  urinalysis  may be involved to exclude a number of possible causes. [ 1 ]  To investigate xerophthalmia, the Schirmer test of lacrimal flow may be indicated. [ 1 ]   Slit-lamp examination  may also be carried out. [ 1 ]


The successful treatment of xerostomia is difficult to achieve and often unsatisfactory. [ 9 ]  This involves finding any correctable cause and removing it if possible, but in many cases it is not possible to correct the xerostomia itself, and treatment is  symptomatic , and also focuses on  preventing tooth decay through improving  oral hygiene . Where the symptom is caused by hyposalivation secondary to underlying chronic disease, xerostomia can be considered permanent or even progressive. [ 8 ]  The management of salivary gland dysfunction may involve the use of saliva substitutes and/or saliva stimulants:


Saliva substitutes can improve xerostomia, but tend not to improve the other problems associated with salivary gland dysfunction. [ citation needed ]  Parasympathomimetic drugs (saliva stimulants) such as pilocarpine may improve xerostomia symptoms and other problems associated with salivary gland dysfunction, but the evidence for treatment of radiation-induced xerostomia is limited. [ 27 ]  Both stimulants and substitutes relieve symptoms to some extent. [ 28 ]   Salivary stimulants are probably only useful in people with some remaining detectable salivary function. [ 3 ]  A systematic review compromising of 36  randomised controlled trials  for the treatment of dry mouth found that there was no strong evidence to suggest that a specific  topical  therapy is effective. [ 8 ]  This review also states that topical therapies can be expected to provide only short-term effects, which are reversible. [ 8 ]  The review reported limited evidence that oxygenated glycerol triester spray was more effective than electrolyte sprays. [ 8 ]  Sugar free  chewing gum  increases saliva production but there is no strong evidence that it improves symptoms. [ 8 ]   Plus, there is no clear evidence to suggest whether chewing gum is more or less effective as a treatment. [ 8 ]  There is a suggestion that intraoral devices and integrated mouthcare systems may be effective in reducing symptoms, but there was a lack of strong evidence. [ 8 ]  A systematic review of the management of radiotherapy-induced xerostomia with parasympathomimetic drugs found that there was limited evidence to support the use of pilocarpine in the treatment of radiation-induced salivary gland dysfunction. [ 6 ]  It was suggested that, barring any  contraindications , a trial of the drug be offered in the above group (at a dose of five mg three times per day to minimize side effects). [ 6 ]  Improvements can take up to twelve weeks. [ 6 ]  However, pilocarpine is not always successful in improving xerostomia symptoms. [ 6 ]  The review also concluded that there was little evidence to support the use of other parasympathomimetics in this group. [ 6 ]  Another systematic review showed, that there is some low-quality evidence to suggest that amifostine prevents the feeling of dry mouth or reduce the risk of moderate to severe xerostomia in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short- (end of radiotherapy) to medium-term (three months postradiotherapy). But, it is less clear whether or not this effect is sustained to 12 months postradiotherapy. [ 29 ]


A 2013 review looking at non-pharmacological interventions reported a lack of evidence to support the effects of electrostimulation devices, or acupuncture, on symptoms of dry mouth. [ 30 ]


Xerostomia is a very common symptom. A conservative estimate of prevalence is about 20% in the general population, with increased prevalences in females (up to 30%) and the elderly (up to 50%). [ 8 ]  Estimates of the prevalence of persistent dry mouth vary between 10 and 50%. [ 8 ]


Xerostomia has been used as a test to detect lies, which relied on emotional inhibition of salivary secretions to indicate possible incrimination. [ 31 ]


The  zygomatic branches of the facial nerve  ( malar branches ) are  nerves  of the  face . They run across the  zygomatic bone  to the lateral angle of the  orbit . Here, they supply the  orbicularis oculi muscle , and join with filaments from the  lacrimal nerve  and the  zygomaticofacial branch  of the  maxillary nerve  (CN V 2 ).


The zygomatic branches of the facial nerve are branches of the  facial nerve  (CN VII). [ 1 ]  They run across the  zygomatic bone  to the lateral angle of the  orbit . This is deep to  zygomaticus major muscle . [ 1 ]  They send fibres to orbicularis oculi muscle.


The zygomatic branches of the facial nerve have many nerve connections. Along their course, there may be connections with the  buccal branches of the facial nerve . [ 2 ]  They join with filaments from the  lacrimal nerve  and the  zygomaticofacial nerve  from the  maxillary nerve  (CN V 2 ). [ 3 ]  They also join with the  inferior palpebral nerve  and the  superior labial nerve , both from the  infraorbital nerve . [ 3 ]


The zygomatic branches of the facial nerve supply part of the  orbicularis oculi muscle . [ 2 ]  This is used to close the eyelid. [ 2 ]


To test the zygomatic branches of the facial nerve, a patient is asked to close their eyes tightly. [ citation needed ]  This uses  orbicularis oculi muscle . [ 2 ]  The zygomatic branches of the facial nerve may be recorded and stimulated with an  electrode . [ 4 ]


Rarely, the zygomatic branches of the facial nerve may be damaged during surgery on the  temporomandibular joint  (TMJ). [ 5 ]


A  cystoprostatectomy  is a  surgical procedure  in which the urinary  bladder  and  prostate  gland are removed. The procedure combines a  cystectomy  and a  prostatectomy . [ 1 ] [ 2 ]


A  cystourethrectomy  or  cysto-urethrectomy  is a  surgical procedure  in which the  urinary bladder  and  urethra  are removed. [ 1 ]   The procedure combines a  cystectomy  and a  urethrectomy . [ citation needed ]


Emasculation  is the removal of the external  male sex organs , which includes both the  penis  and the  scrotum , the latter of which contains the  testicles . It is distinct from  castration , where only the testicles are removed. Although the terms are sometimes used interchangeably, the potential  medical consequences  of emasculation are more extensive due to the complications arising from the removal of the penis. [ 1 ]  There are a range of religious, cultural, punitive, and personal reasons why someone may choose to emasculate themselves or another person.


The term  emasculation  may be used in a  metaphorical  sense, referring to the perceived loss of attributes traditionally associated with  masculinity , such as strength, power, or autonomy.


There are several different methods of emasculation. Both the penis and testicles may be removed simultaneously using a sharp instrument, such as a knife or razor or swords. [ 2 ] [ 3 ]  Non-crushing vascular clamps may also be used in medical surgery to cut off blood circulation and reduce bleeding. [ 4 ]


Alternatively, the penis and testicles may be removed during a series of stages. Medical surgeons use this method when performing surgery on  trans women  who want their genitals removed over multiple  sex reassignment surgeries (male-to-female) , rather than in a single operation. [ 5 ]  In these surgeries, the tissue is used and re-shaped into the neo-vagina and vulva.


Short-term consequences of emasculation include  bleeding [ 6 ]  and infection. [ 7 ]  Historically, death was also a potential complication, although the prevalence is disputed. [ 8 ]


Long term complications include incontinence, [ 9 ]   urethral stricture , [ 10 ]  urine retention, [ 11 ]   urinary tract infection , [ 12 ]   urine extravasation [ 7 ]  and  bladder stones . [ 13 ]  Some studies have found that emasculation may cause a range of physiological changes, such as a shortened torso, [ 14 ]  widened stomach and hips, [ 15 ]  increased height, bowed legs, [ 14 ]  and an elongated skull. [ 14 ]  Additionally, emasculates typically have less or no facial and body hair, [ 16 ]  increased fatty tissue or  gynecomastia , [ 16 ]  and a feminine fat pattern distribution. [ 17 ]  The physiological effects of emasculation are more severe for people who undergo the procedure before the onset of puberty. [ 18 ]


Emasculation was performed in China on men to create palace  eunuchs  for the imperial court. [ 19 ]  The practice dates back to the  Shang dynasty  (1600–1046 BC) [ 20 ]  and continued up until 1924, [ 21 ]  when the eunuch system was abolished by the last emperor of China,  Puyi . [ 22 ]  The last living palace eunuch,  Sun Yaoting , died in 1996. [ 23 ]


Originally, palace eunuchs were prisoners who were involuntarily emasculated. In the  Qing dynasty , men began volunteering to undergo the procedure in order to gain employment, although instances of forced emasculation still occurred. [ 24 ]  One reason why recipients willingly underwent emasculation is that they saw employment as a palace eunuch as a way to acquire wealth and power. Alternatively, poverty was a reason why fathers forced their sons to undergo emasculation, and the desire for financial benefit motivated human traffickers to force emasculation on their victims. [ 25 ]


There were several reasons why the Imperial court required its civil servants to be emasculated. Emasculation was thought to ensure a recipient's undivided loyalty to the emperor, as it severs the recipient's existing familial or social bonds and destroys their ability to produce future heirs. [ 26 ]  The choice to hire emasculated eunuchs also ensured the legitimacy of the emperor's lineage. [ 27 ]  The choice to emasculate, rather than merely castrate, was motivated by a desire to protect the chastity of women in the court, as emasculation rendered a recipient physically incapable of having sex. [ 28 ]  While emasculation was a pre-requisite for gaining employment as a palace eunuch, it did not guarantee employment. [ 29 ]


The emasculation procedure was typically performed by a trained 'knifer', or 'knife expert'. [ 30 ]  To prepare for the operation, the recipient was bathed in cold water to numb his senses and, in some instances, his genitals were twisted to reduce blood flow. [ 31 ]  The recipient was then asked if he consented to the procedure, and if he answered yes the knifer excised the genitals with a single cut. [ 32 ]   Styptic powder  was then applied to the wound to stop bleeding, and a  pewter  needle or spigot was inserted into the urethra to prevent stenosis (narrowing). [ 33 ]


Some Chinese emasculates were the great historian  Sima Qian ,  Cao Teng , the foster grandfather of  Cao Cao ,  Zheng He , a  Ming dynasty  admiral of the imperial navy who sailed to Africa, and the surviving sons and grandson of rebel  Yaqub Beg . [ 34 ]


To create eunuchs for the  Arab slave trade , young black boys from South East Africa typically had their penis and scrotum amputated. [ 35 ]  White boys, by comparison, were usually only castrated. [ 35 ]


Emasculation was one form of genital mutilation practiced by the Skoptsy, a Russian Christian sect. For males, the other form of mutilation available was castration. Females could remove their nipples, breasts,  labia majora ,  labia minora  or  clitoris . [ 36 ]  These practices may have begun sometime during the 1760s, after the sect was founded by Kondratii Selivanov, although they were only discovered by the broader community in 1772. [ 37 ]  They continued up until the 1930s, when the sect was destroyed and its members sentenced. [ 38 ]


The Skoptsy practiced genital mutilation because they believed the genitals were the source of original sin, and that by removing them, they could attain salvation. [ 39 ]  The aim of removing the offending genitalia was to purify the body. [ 40 ]  Their belief was based on a literal reading of the verse of  Matthew 19:12 , which states: "There are some eunuchs, which were so born from their mother's womb: and there are some eunuchs, which were made eunuchs of men: and there be eunuchs, which have made themselves eunuchs for the kingdom of heaven's sake." [ 41 ]  In addition, the verses of  Matthew 18 :8,9 and  Luke 23 :29 were also cited as support. [ 42 ]  Of the two types of genital mutilation available to men, emasculation was called the Greater Seal. Castration, by comparison, was called the Lesser Seal. [ 43 ]  Emasculation was preferable because it rendered a recipient physically incapable of engaging in sinful sexual conduct, allowing them to attain a higher level of purity.


Originally, the emasculation procedure was performed by burning the testicles off with an iron. [ 44 ]  Later, the genitals were tied at the base and removed using a knife or razor blade. The wound was then cauterised, or a salve was applied, to prevent bleeding. Many Skoptsy were peasants and were familiar with animal husbandry, which meant their emasculation procedures were often performed with "surgical precision." [ 45 ]  In some instances, members of the Skoptsy would perform the emasculation on themselves, in an act of  self-surgery , though it was more typical for the procedure to be performed by an elder during a ceremony. [ 36 ]


Throughout the  Indian subcontinent tradition , including India, Bangladesh and Pakistan, some members of the  Hijra  community reportedly undergo emasculation, or  nirvan. [ 46 ]


Traditionally, emasculation was a  rite of passage  into the Hijra community. [ 47 ]  Today it remains an important ritual, though is not mandatory or universally practiced. [ 48 ]  When it is performed, it typically occurs several years after an individual has already participated within the Hijra community. While some Hijra are emasculated, others are intersex, undeveloped in puberty or impotent. [ 49 ]


Whether or not a Hijra undergoes emasculation is influenced by a range of considerations. Some people are not emasculated because they are fearful of surgical complications, are under financial constraints, or merely as a matter of personal choice. [ 50 ]  For Muslim Hijra, emasculation may be avoided due to the belief that genital mutilation goes against Allah's will. [ 51 ]
Others see emasculation as necessary in order to be 'reborn' as a Hijra. In this view, emasculated Hijra are seen as more 'real' than those who are not. [ 52 ]  The decision to be emasculated may also be motivated by personal beliefs about whether a Hijra can have spiritual powers without undergoing the procedure. Amongst members of the Hijra community, this issue is subject to considerable debate. [ 51 ]


In the past, the emasculation procedure was performed by barbers or by the individual themselves (i.e. self-emasculation). [ 53 ]  Nowadays, the operation is performed by a Hijra elder, also called a  dai ma  (midwife). [ 54 ]  They have no medical training, but believe they operate with the power of the patron goddess,  Bahuchara Mata . [ 55 ]  The operation takes place early in the morning, around 3   a.m. or 4   a.m. [ 55 ]  Anesthesia is not administered.   [ 56 ]  The penis and testes are tied together with a string, and the elder then makes two diagonal cuts with a sharp surgical knife to completely excise the organs. [ 57 ]  The elder allows the blood to gush from the wound, which is considered necessary to completely cleanse the recipient of their male parts. This is one reason why the procedure is performed by an elder rather than a medical professional, who might try to stop the haemorrhage, thus interfering with the ritual's cleansing effect. [ 58 ]  Afterwards, no stitches are taken and the wound is left exposed, although a small stick is inserted into the urethra to prevent  urethral stricture . [ 59 ]


Emasculation was one of the Five Punishments used in ancient  China . [ 60 ]  It was the prescribed punishment for people who engaged in licentious conduct, such as infidelity or rape. [ 61 ]  The first evidence of its use dates to the  Shang dynasty  (1700–1100 BC), when the characters for a knife and male genitalia were carved into oracle bones. It continued up until the  Sui dynasty  (581–618 CE), when it was formally abolished. [ 62 ]


There are reports of self-emasculation cases resulting from  mental disorder . Some academics claim that a majority of self-emasculations are a result of psychosis, [ 63 ]  although this finding has been challenged. [ 64 ]  Nonetheless, there are several reported cases of people with  schizophrenia  engaging in self-emasculation.  [ 65 ]


It has been linked to other mental disorders such as dissociative identity disorder. [ 66 ]


Klingsor syndrome, sometimes known as Skotpic syndrome is a condition where people mutilate their genitals as a result of psychotic  religious delusions .  [ 67 ]  For example, in one case a person is reported to have mutilated his genitals after experiencing  auditory hallucinations  telling him he would only be allowed into the  kingdom of heaven  if he emasculated himself. [ 68 ]


Body integrity dysphoria , or xenomelia, is another mental disorder that may drive a person to seek emasculation. [ 69 ]  People with this disorder are distressed by the presence of a limb that they do not identify as part of their body, including the genitals. Emasculation in this context alleviates their distress, enabling them to become 'whole'. [ 70 ]  However, the amputation of healthy limbs by medical professionals is highly controversial. The inability to acquire medically administered emasculation has driven some to self-emasculation. [ 71 ]


Occasionally, self-emasculation is practiced by those suffering from gender dysphoria. [ 72 ]  When compared with the general population, transgender persons are at a higher risk of engaging in acts of genital self-mutilation, including self-emasculation. [ 73 ]


In some cases, a person with a mental illness has emasculated other people. [ 74 ]


Emasculation occurs voluntarily within the  transgender  community as a form of  gender reassignment surgery , allowing recipients to renounce their masculine characteristics and bring their body into closer alignment with their identified gender. It may be sought by trans women (those assigned male at birth who identify as female), who wish to assume their femininity, or by non-binary transgender individuals (those assigned male at birth who identify as neither male nor female), who want to locate themselves outside of traditional gender categories. [ 75 ]


For trans women, emasculation surgery may be performed with or without the creation of a vagina. When a vagina is created, the procedure is called a  vaginoplasty , [ 76 ]  and where it is not, the procedure is called a  vulvoplasty . [ 77 ]


For  non-binary  transgender people, the purpose of emasculation is to make the body less congruent with one's assigned sex without the subsequent assumption of femininity.  [ 78 ]  These individuals may identify as non-binary, a third-sex, eunuch, or another gender. Some adopt the term ' nullo ', meaning someone whose gender has been nullified. [ 79 ]


In some circumstances, a person may be emasculated involuntarily as the result of an accident, [ 80 ]  as part of a ritual attack, [ 81 ]  or due to poor circumcision practice. [ 82 ]


In these cases, the objective of medical treatment is different than for cases of voluntary emasculation. The goals of treatment are to either reattach the severed genitals or to reconstruct an artificial penis and testes. [ 83 ]


From 1960 to 2000, involuntarily emasculated infants were surgically reassigned female, similar to the treatment received by  David Reimer  after his penis was burnt off during a  circumcision  procedure. It is now understood from cases like Reimer's that gender reassignment surgery in infancy can interfere with gender identity formation. Therefore, gender reassignment is no longer the standard practice for involuntarily emasculated infants. [ 84 ]


By extension, the word  emasculation  has also come to mean rendering a male less  masculine , including by humiliation. It can also mean to deprive anything of vigour or effectiveness. This figurative usage has become more common than the literal meaning. For example: " William Lewis Hughes  voted for Folkestone's amendment to Curwen's emasculated reform  bill , 12 June 1809 ... " [ 85 ]


In  horticulture , the removal of male (pollen) parts of a plant, largely for controlled pollination and breeding purposes, is also called emasculation. [ 86 ]


A  frenuloplasty of prepuce of penis  (also known as a  release of frenulum ) is a  frenuloplasty  of the  frenulum of prepuce of penis .


An abnormally short or sensitive  frenulum  of the  penis  can make some types of sexual activity uncomfortable or even painful.  This may be a complication of circumcision or a naturally occurring event.  When it is a naturally occurring event, a short frenulum can restrict normal retraction of the  foreskin  during  erection  (a condition known as  frenulum breve ). The goal of treatment is to allow normal retraction of the foreskin.  Circumcision may relieve this condition but is not indicated solely for treating frenulum breve. [ citation needed ]


The procedure usually involves the removal of the frenulum or the creation of an incision in the frenulum that is then stretched to lengthen it and stitched closed. The incision can be z-shaped, y-shaped or a single horizontal cut. Once healed, the procedure effectively elongates the frenulum, allowing normal function. Under normal circumstances the incision heals completely in around six to eight weeks, after which time normal sexual activity can resume. Other methods of treatment include horizontal stitches in the frenulum which over the course of a week cut through the tight skin, elongating it. This is generally more painful than the standard procedure, but heals faster. [ 1 ]


Another reason for the treatment is to correct a rare complication of a frenulum breve which presents as scars on the frenulum, these scars cause  pain  and make normal sex very difficult and are caused by the rubbing of the frenulum whilst engaging in sexual activity. These scars only affect those with frenulum breve. The frenuloplasty can be conducted under both general or local anesthesia. [ 2 ]


One study suggests around 15–20% of men require additional circumcision after a frenuloplasty, because not all symptoms indicating the surgery improved. [ 3 ]  The British Association of Urological Surgeons (BAUS) estimates this number to be lower at 2–10%. [ 4 ]   Frenuloplasty might avoid the need for circumcision even when a clinician felt circumcision to be indicated at presentation. [ 3 ]


A swelling of the penis occurs in 10–50% of patients after operation, usually lasting a few days. Reduced sensation in the  glans  penis is reported in 2–10% of patients. Below 2% of patients experience an infection of the incision requiring antibiotics or further treatment. [ 4 ]


GreenLight Laser Therapy  is a medical procedure for treating  benign prostatic hyperplasia . [ 1 ]  It uses a  laser  beam to remove prostate tissue. The laser treatment is delivered through a thin and flexible fiber, which is inserted into the urethra through a  cystoscope .


GreenLight Laser Therapy has been increasingly performed as an alternative to  transurethral resection of the prostate  in order to treat benign prostatic hyperplasia, with several studies demonstrating comparable results with fewer side effects and complications. Typically, it is an outpatient procedure which provides immediate relief of lower urinary tract symptoms.  It is a virtually bloodless procedure and may be suitable for patients who cannot undergo traditional surgery. GreenLight has well-documented safety and success data since 1997 and has treated more than 500,000 patients worldwide. Cost analyses have shown GreenLight to be less costly than traditional surgery.


Inguinal orchiectomy  (also named  orchidectomy ) is a specific method of  orchiectomy  whereby one or both  testicles  and the full  spermatic cord  are  surgically removed [ 1 ]  through an incision in the lower lateral  abdomen  (the "inguinal region"). The procedure is generally performed by a  urologist , typically if  testicular cancer  is suspected. Often it is performed as same-day surgery, with the patient returning home within hours of the procedure. Some patients elect to have a prosthetic testicle inserted into their  scrotum . Depending on whether or not a prosthetic testicle is put in place of the original one, operating times run on average from three to six hours.


A 4–6 cm incision is made above the  pubic bone  on the side corresponding to the testicle to be removed.  This incision runs obliquely midway between the  pubic tubercle  and the  anterior superior iliac spine .  The incision is extended down through the fat until the  external oblique   fascia  is encountered.  It is incised along its fibres and the spermatic cord is identified and isolated.  From there, the testicle is pulled into the field through the  inguinal canal .  The  spermatic cord  is clamped off in two places and cut between the clamps.  Long permanent sutures, usually silk or  polypropylene , are left on the stump of the spermatic cord as a marker in case it needs to be removed in the future during a  retroperitoneal lymph node dissection  (RPLND).


The inguinal orchiectomy is a necessary procedure if  testicular cancer  is suspected.  While it is possible to remove a testicle through an incision in the scrotum, this is not done when cancer is suspected because it disrupts the natural  lymphatic drainage patterns .  Testicular cancer usually spreads into the lymph nodes inside the abdomen in a predictable manner.  Cutting the skin in the scrotum may disrupt this and cancer may spread to the  inguinal lymph nodes , making surveillance and subsequent operations more difficult.


Complications from this procedure include bleeding and infection. The  ilioinguinal nerve  which runs anterior to the spermatic cord may be damaged during the operation and cause numbness over the inner thigh or chronic groin and scrotal pain. Other symptoms also include intermittent and chronic back pain and sudden loss of mobility in the lower back.


If the orchiectomy is performed to diagnose cancer, the testicle and spermatic cord are then sent to a  pathologist  to determine the makeup of the  tumor , and the extent of spread within the testicle and cord.
The pathology report, along with pre-surgical imaging studies and  tumor markers , will determine the course of treatment.


Laparoscopic radical prostatectomy  (LRP) is a form of radical  prostatectomy , an operation for  prostate cancer . Contrasted with the original open form of the  surgery , it does not make a large incision but instead uses  fiber optics  and miniaturization. [ citation needed ]


The  laparoscopic  and open forms of radical prostatectomy physically remove the entire  prostate  and reconstruct the  urethra  directly to the bladder. Laparoscopic radical prostatectomy and open radical prostatectomy differ in how they access the deep pelvis and generate operative views. In contrast to open radical prostatectomy, the laparoscopic radical prostatectomy makes no use of  retractors  and does not require that the  abdominal wall  be parted and stretched for the duration of the operation.


A few good studies exist looking at open versus laparoscopic versus laparoscopic and robotic radical prostatectomy in cancer as of 2011. [ 1 ]


There is a robotic and non robotic version. [ 2 ]  These two versions have unclear differences in cancer related outcomes [ 2 ]


The  American Cancer Society  states that success with laparoscopic technique is determined by surgeon experience and focus. There is a long learning curve for the robotic procedure. It is estimated that about 60 cases need to be performed by a surgeon to be comfortable with the procedure and about 250 cases to be an expert.


The procedure takes at least five hours and as long as eight hours for the average urologist, without a bilateral lymph node dissection, compared to 2.5–3 hours when done by an open technique with an incision, with a completed lymph node dissection.


There is a greater risk of accidentally incising into the prostate, resulting in "margin positivity," i.e. leaving cancer within the patient, in otherwise organ confined disease, even in the hands of experts. This is presumed to happen as a result of the lack of tactile sensation.  Margin positivity is strongly correlated with  PSA  recurrences and a fourfold annual increase in cancer recurrence compared to men with negative surgical margins.
There was a recent study from the University of Michigan by Hollenbeck et al. (Urology 2007; 70: 96-100) after their first 200 cases that they were able to eliminate extensive positive margins (12% in their first 15 cases versus 2% after performing 81 cases) but they continued to have a positive surgical margin rate of 22%.  Their conclusion was "It seems that cumulative surgeon volume beyond that which can be obtained in the typical urology practice may be needed to obtain ideal margin rates with this new technology."Patrick C. Walsh M.D in an editorial comment in the Journal of Urology, commenting on this article, compared his own experience at Johns Hopkins with organ confined disease with a positive surgical margin rate of only 1.8%.


Another problem in higher-risk cases is that many surgeons using the robotic technique do not perform a lymph node dissection, as it is difficult to perform this adequately, robotically. The rationale usually given is that patient selection is such that most patients with  Gleason score  6 on pathology do not need a  lymphadenectomy . However, a small number of patients with Gleason 6 adenocarcinoma of the prostate are upgraded to Gleason 7 on final pathology. Any  micrometastases  in  lymph nodes  would not be detected, not be removed and would increase the risk of recurrences.


There has not been any evidence in the urologic literature showing a benefit in regard to  continence ,  potency  or cure rates with the robotic procedure. Interest in the procedure is often patient driven, by patients who have been led to believe by the extensive advertising, that there are significant benefits to be obtained from the procedure.
The open radical prostatectomy is still the "gold standard." [ citation needed ]


There was a study in the Journal of Clinical Oncology from Harvard [ 3 ]  using a national random sample of Medicare patients, showing that patients who had a laparoscopic/robotic radical prostatectomy underwent hormonal therapy in more than 25% of cases after the procedure compared to an open radical prostatectomy [this is usually not necessary with open radical prostatectomy if all the cancer has been removed and is usually less than 10% of cases], with a high risk of secondary procedures for bladder neck contracture [40% greater risk] which can result in poorer continence.


In an accompanying editorial in the journal commenting on this article [ 4 ]  (Note: over 9 years ago) Michael L.Blute, M.D. of the Mayo Clinic wrote that "Patient interest in robotic assisted radical prostatectomy has been the result of a highly successful marketing campaign with the resultant consumer demand. Patients have been led to believe that hospital and recovery times are shorter and outcomes are better, a study has shown this expectation not to be the case."
He also wrote "Currently, open technique is the state-of-the-art procedure in experienced hands, as the long-term results for laparoscopic/robotic assisted radical prostatectomy do not exist. The published literature fails to answer the question whether these procedures meet 'quality standards.


No-scalpel vasectomy  (also called  non-scalpel vasectomy ,  keyhole vasectomy  or  NSV ) is a type of  vasectomy  procedure in which a specifically designed ringed clamp and dissecting  hemostat  is used to puncture the  scrotum [ 1 ]  to access the  vas deferens . This is different from a conventional or incisional vasectomy where the scrotal opening is made with a  scalpel . The NSV approach offers several benefits, including lower risk for bleeding, bruising, infection, and pain. [ 1 ]  The NSV approach also has a shorter procedure time than the conventional scalpel incision technique. [ 1 ]  Both approaches to vasectomy are equally effective. Because of the inherent simplicity of the procedure it affords itself to be used in  public health  programs worldwide. This method is used in over 40 countries for  male sterilisation . [ 2 ]


No-scalpel vasectomy was developed and first performed in China by Dr. Li Shunqiang with the aim of reducing men's fear related to the incision and increasing vasectomy use in China. [ 3 ]  In 1985, a team created by  EngenderHealth  visited his centre to learn the technique. [ 3 ]  One of the team members, Dr. Phaitun Gojaseni, introduced the no-scalpel technique in Thailand upon his return, while another member of the team, Dr.  Marc Goldstein , introduced the technique to the United States at the  NewYork–Presbyterian Hospital . Over time, the technique gained popularity and it is now a preferred method of male sterilization in many countries. [ 3 ]


No-scalpel vasectomy was introduced in India in 1998. A team of Indian surgeons led by Dr RCM Kaza travelled to Chengdu, China, to learn the technique under the aegis of EngenderHealth and the  UN . They then introduced the procedure in India, under the  National Rural Health Mission . The  Government of India  then proceeded to introduce the procedure in every district of India as an alternative to  tubal ligation  offered to women. [ citation needed ]


World Vasectomy Day  is celebrated on 7 November in India. [ 4 ]


No-scalpel vasectomy is a day case ( outpatient ) procedure and the patient is fit to go home the same day. [ 5 ]


The eligibility criteria for the no-scalpel vasectomy and the conventional vasectomy procedure are the same, although may vary from clinic to clinic.


No-scalpel vasectomy is performed under  local anaesthesia . Usually  lidocaine  2 percent is infiltrated into the  vas deferens  and the puncture site on the scrotum. This makes the procedure pain free. Some patients may prefer to receive  regional anaesthesia . [ citation needed ]


The vas deferens is isolated by three-finger technique on both sides. The ideal entry point for the needle is midway between the top of the  testes  and the base of the  penis . Usually, 100 mg  lidocaine  (without  epinephrine ) is injected to create a wheal. The no-scalpel vasectomy uses two specific instruments designed by Dr. Li Shunqiang. One is a ringed clamp and the other is a dissecting forceps. The ringed clamp is used to isolate and encircle the vas. The dissecting forceps is used to puncture the scrotal skin, spread tissues, and pierce the vas deferens to deliver it outside the scrotum. The vas deferens is then occluded. [ 3 ]


The most commonly used methods to occlude the vas deferens include: [ 6 ]


The American Urological Association recommends occlusion by one of the following methods to achieve highest efficacy: [ 6 ]


No-scalpel vasectomy has less pain, bleeding and infection than conventional vasectomy. [ 1 ]  No-scalpel vasectomy can also be done in less time and the individual is able to return to sexual activity sooner than traditional vasectomy surgery. [ 1 ]  However,  sperm  may still be present for 10–20 ejaculations, and some doctors may schedule a follow-up visit to confirm the success of the procedure. Additionally, there is approximately a 1 in 2,000 chance of pregnancy following a vasectomy, as some sperm may be able to cross the severed vas deferens. [ 5 ]


Complications are rare and can include: [ 7 ]


Orchiectomy  (also named  orchidectomy ) is a  surgical procedure  in which one or both  testicles  are removed. The surgery can be performed for various reasons: [ 1 ] [ 2 ] [ 3 ]


Less frequently, orchiectomy may be performed following a trauma, or due to wasting away of one or more testicles. [ 5 ]


A simple orchiectomy is commonly performed as part of  gender-affirming surgery  for  transgender women , or as  palliative treatment  for advanced cases of  prostate cancer . A simple orchiectomy may also be required in the event of  testicular torsion . [ 5 ]


For the procedure, the person lies flat on an operating table with the  penis  taped against the  abdomen . The nurse shaves a small area for the incision. After anesthetic has been administered, the surgeon makes an incision in the midpoint of the  scrotum  and cuts through the underlying tissue. The surgeon removes the testicles and parts of the  spermatic cord  through the incision. The incision is closed with two layers of  sutures  and is covered with a  surgical dressing . If desired,  prosthetic testicles  can be inserted before the incision is closed to present an outward appearance of a pre-surgical scrotum. [ 6 ]


A subcapsular orchiectomy is also commonly performed for treatment of prostate cancer. The operation is similar to that of a simple orchiectomy, with the exception that the  glandular tissue  that surrounds each testicle is removed rather than the entire testis itself. This type of orchiectomy is performed to remove testosterone-producing glandular tissue while maintaining the appearance of an ordinary scrotum. [ 6 ] [ 4 ]


Inguinal orchiectomy  (named from the Latin  inguen  for "groin", and also called  radical orchiectomy ) is performed when an onset of  testicular cancer  is suspected, in order to prevent a possible spread of cancer from the spermatic cord into the lymph nodes near the kidneys. [ 6 ]


An inguinal orchiectomy can be either unilateral (one testicle) or bilateral (both testicles). The surgeon makes an incision in the groin area (in contrast to an incision in the scrotum, as is done in both simple and subcapsular orchiectomies). The entire  spermatic cord  is removed, as well as the testicle(s). A long, non-absorbable suture may be left in the stump of the spermatic cord in case later surgery is deemed necessary. [ 6 ]  After the cord and testicle(s) have been removed, the surgeon washes the area with saline solution and closes the layers of tissues and skin with sutures. The wound is then covered with sterile gauze and bandaged. [ 6 ]


Partial orchiectomy is an option for individuals with testicular masses that want to preserve their testes and their function. During surgery, the testis is exposed in a similar way to inguinal orchiectomy. Once the testis is exposed and the spermatic cord is clamped, there is a current debate as to whether surgeons should deliver  cold ischaemia  which means submitting the organ, in this case the testis, into a cold/freezing environment. Whether or not it is submerged and frozen, the next step is to cut the  tunica vaginalis  and an ultrasound is used to find the tumor. After, the tumor is scraped away from the testis in a process called  enucleation . Following enucleation, biopsies are taken of the tissues surrounding the testicle where the mass once was. Afterwards, each layer or tunica of the testis is sutured up and the testis is placed back in the scrotum. The skin layers are also closed up with sutures. [ 7 ]


Guidelines state that fertility counseling should be offered to all patients undergoing inguinal orchiectomy, as there is a risk of reduced fertility or infertility. Testicular germ cell tumors (TGCT) accounts for 95% of cases of testicular cancer in young men. [ 7 ]  TGCT is associated with abnormal semen parameters. [ 8 ]  Because testicular cancer is commonly diagnosed in young, fertile men, it is critical that these individuals be educated on preserving their semen through freezing ( cryopreservation ) and complete a fertility assessment prior to surgery. In addition, testicular prosthesis placement counseling and education is encouraged to be given before an individual undergoes orchiectomy or before inguinal exploration with possibility of orchiectomy. This is an elective surgery which can be done at the time of orchiectomy. Testicular prosthesic placement has known psychological benefits (see below). Although risks for complications with prosthesis is low, individuals should also be informed of the possibility of infection, rotation, and replacement of prosthesis. [ 7 ]


Following orchiectomy, those who have undergone the procedure are advised to avoid bathing, swimming, and heavy lifting for at least one month. If an individual had previously been taking hormone and/or hormone-blocking medications, modifications to their medication would be needed after the procedure. Any androgen-blocking medications, such as  spironolactone  or  cyproterone , are stopped, and estrogen hormones can be resumed at the doctor's discretion. Post-operative pain management includes icing the surgical site, wearing supportive underwear, and the use of pain relief medications ( analgesics ) such as acetaminophen or ibuprofen; for more severe pain,  narcotic analgesics  may be needed. A follow-up appointment to monitor recovery and healing is routine. [ 1 ]


Risks and complications should be discussed with an individual pre-operatively. Risks and complications for inguinal orchiectomy include scrotal hematoma (accumulation of blood in the scrotum), infection, post-operative pain (60% initially, 1.8% one year after), phantom testis syndrome (pain in the kidney as a result from trauma from the testicle), reduced fertility, and with the more rare complications being inguinal hernia, ilioinguinal nerve injury, tumor spillage, and hypogonadism. [ 7 ]


Unilateral orchiectomy results in decreased sperm count but does not reduce testosterone levels. [ 9 ] [ 4 ]   Bilateral orchiectomy  causes infertility and greatly reduced testosterone levels. This can lead to side effects including loss of sexual interest,  erectile dysfunction , hot flashes, breast enlargement ( gynecomastia ), weight gain, loss of muscle mass, and  osteoporosis . [ 4 ]  It has been discovered that some individuals with a history of prostate cancer who had bilateral orchiectomy had effects on their new bone production, resulting in increased risk of bone fractures due to testosterone deficiency after the procedure. [ 10 ]


Bilateral orchiectomy also reduces the use of exogenous medications for transgender women; the reduction in testosterone eliminates the need for testosterone-blocking medications and can contribute to feminizing features such as breast enlargement. [ 1 ] [ 11 ] [ 12 ]


The loss of one or both testicles from orchiectomy can have severe implications in a male's identity and self-image surrounding masculinity, such that it can lead to an individual having thoughts of hopelessness, inadequacy, and loss. Among testicular cancer survivors who have lost a testicle, there are feelings of shame and loss, which are more evident in young and single men than older and non-single men. [ 13 ]  As many as one third of individuals who will undergo orchiectomy are not offered the option of having a testicular prosthesis. Data shows that simply offering testicular prosthesis to individuals undergoing orchioectomy is psychologically beneficial. While some individuals do not mind losing a testicle, studies have shown that there is a change in body image in testicular cancer survivors who have undergone orchiectomy and an improvement in body image in 50–60% of individuals who undergo testicular prosthesis placement. One year after testicular prosthesis placement, there are reports of increase in self-esteem and psychological well-being during sexual activity in a study that followed up on post-orchiectomy individuals including adolescents. [ 14 ]  On the other hand, there is a current debate whether children undergoing orchiectomy should be offered testicular prosthesis to be inserted at the time of orchiectomy procedure. [ 5 ] [ 15 ]


Bilateral simple orchiectomy is one option of  gender-affirming surgery  for transgender women. [ 1 ]  It may be performed as a standalone procedure or at the same time as a  vaginoplasty . [ 1 ]  Bilateral orchiectomy is considered first before undergoing vaginoplasty. Vaginoplasty can still be administered after undergoing bilateral orchiectomy, as the orchiectomy preserves the penoscrotal skin that can later be transformed into a skin flap. Additionally, it is an option for those who are unable to undergo vaginoplasty due to the risk of complications. [ 11 ]


In addition to alleviating  gender dysphoria , the procedure allows trans women to stop taking testosterone-blocking medications, which may cause unwanted side effects. [ 1 ]  Some common testosterone-blocking medications that most use before undergoing orchiectomy are  spironolactone  and  cyproterone . Common side effects caused by spironolactone are drowsiness, confusion, headache, fatigue, nausea/vomiting,  gastritis ,  polyuria ,  polydipsia , and electrolyte imbalance ( hyperkalemia ). Cyproterone can cause side effects such as fatigue, low mood, and  fulminant hepatitis . Orchiectomy allows individuals to stop taking these medications and avoid these adverse effects. [ 1 ]  It is also an alternative for trans women who have contraindications to antiandrogens and is a minimally invasive procedure to eliminate testosterone levels. [ 11 ]


Criteria from the World Professional Association for Transgender Health (WPATH) are used as a framework to guide health care professionals in approving or denying an orchiectomy. When a transgender individual wants to complete an orchiectomy, they are in a state of gender incongruence and they must meet the criteria before having the procedure done. The criteria are as follows: [ 1 ]


(i) persistent, documented gender dysphoria,


(ii) capacity to make informed decisions and consent to treatment,


(iii) well-controlled medical or mental health comorbidities, and


(iv) the use of hormone therapy for 12 months.


Additionally, persons wishing to go through with the procedure are required to obtain referrals from two independent qualified mental health professionals. This referral should include "the individual's demographic information, psychosocial assessment results, duration of the therapeutic relationship, type of evaluation and therapy performed, if the criteria for surgery have been met and if informed consent has been obtained from the patient." [ 1 ]


An individual seeking to undergo orchiectomy is evaluated by a healthcare provider to ensure that the procedure is safe. Many candidates for orchiectomy are on estrogen therapy before the operation, which increases risk of intraoperative  venous thromboembolism  (VTE); thus, the provider must take this risk into account and determine whether  prophylaxis  (prevention) is necessary. [ 11 ]  Current smokers, individuals with limited mobility, individuals older than the age of 40, and individuals who have a medical history of  thrombolytic disorder  are at higher risk of developing VTE. For these high-risk populations, the use of sequential compression devices during the operation is recommended to prevent VTE complications. [ 11 ]


Testicular cancer most commonly occurs in males ages 15 to 34. In 2017, there were 8,850 new cases and 410 deaths in the United States. [ 16 ]


The American Urological Association (AUA) and European Association of Urology (EAU) 2019 guidelines recommend imaging with testicular ultrasound in any individual suspected of having testicular cancer following a physical examination. The ultrasound aids in differentiating diagnoses so that the individual may avoid the need of the surgical approach of inguinal orchiectomy. Inguinal orchiectomy is the gold standard treatment approach for those with confirmed malignancy of testicular cancer. Thus, it is imperative to diagnose the individual as having benign tumor vs. malignant tumor. Benign tumors are cancerous masses typically outside the testicle or surrounding it (extratesticular), whereas the malignant tumors typically lie within/inside the testicle (intratesticular). [ 7 ]


An orchiectomy is used not only as a treatment option, but also as a diagnostic tool for testicular cancer. Before an orchiectomy is deemed necessary, liver function tests, tumor markers, and various blood panels are taken to confirm the presence of testicular cancer. Tumor markers that may be checked include  beta human chorionic gonadotropin ,  lactate dehydrogenase , and  alpha fetoprotein . These markers are rechecked after orchiectomy to stage the testicular cancer. [ 16 ] [ 7 ]  Imaging, including  chest radiography  and an  abdominal/pelvic CT (computed tomography)  are also performed after orchiectomy to evaluate for  metastasis . [ 16 ]  An inguinal orchiectomy is the primary treatment for any cancerous tumor that is found in the testicles; however, in cases where tumors are small, testis- or testes-sparing surgery may be performed instead. [ 16 ]


Partial orchiectomy, also known as testis-sparing surgery, is another treatment option for smaller testicular masses which is becoming widely popular in recent years. This treatment option is an alternative to remove testicular cancer masses which are <20 mm, have a high probability of being benign, and with negative serum tumor markers. Its benefits include preserving fertility and normal hormone function. [ 7 ]


About half of testicular cancer germ cell tumors are  seminomas . Individuals with seminomas are 80-85% likely to have a stage 1 diagnosis and the individual must undergo surveillance every 3–6 months in the first year following their orchiectomy, with an abdominal/pelvic CT at 3, 6 and 12 months. Additional treatment such as chemotherapy may be given if they have risk factors for a relapse. Men with stage 1 seminoma after orchiectomy have been shown to be free from a relapse for five years following orchiectomy. [ 16 ]


Among children and adolescents diagnosed with  testicular torsion , the orchiectomy rate is as high as 42%. [ 3 ]  Though the goal during surgery is to correct the twist of the spermatic cord, orchiectomy is performed if the testicle is examined during the surgery to have dead tissue ( necrosis ) and suspected to no longer be a functioning testicle (no fertility). [ 3 ]  Delays in diagnosis and treatment increase the risk of orchiectomy, with diagnosis in the first four to eight hours of symptoms being critical to prevent permanent  ischemic damage , decreased fertility, and need for orchiectomy. [ 3 ] [ 17 ] [ 18 ]


Prostate cancer, if non-metastatic, is commonly treated with radical prostatectomy or radiation therapy. Less often, orchiectomy is used to treat prostate cancer. Prostate cancer grows in the presence of testosterone. When testosterone is present, " it is metabolized and converted into  dihydrotestosterone  (DHT) which stimulates the growth of prostate cells. This leads to normal prostate growth in adolescents but contributes to abnormal cell growth in older men." [ 19 ]  Reducing the amount of testosterone in a person is one way in which prostate cancer is treated. If the prostate cancer is in fact metastatic, then orchiectomy may be used "...to abolish the stimulation of cancer cells by inhibiting testicular testosterone production and thereby reducing androgen levels in the blood: so-called androgen deprivation therapy (ADT)." [ 20 ]  Castration or orchiectomy is a suitable option for androgen deprivation therapy, and it should be used if a very quick reduction in testosterone levels is needed. However, in recent years, orchiectomy is not commonly used since medical castration is a viable option. [ 20 ]  Medical castration means that drugs or medications are used to suppress the production of androgens such as testosterone. Some examples of medications used in medical castration include, euprolide, goserelin (Zoladex), buserelin, and triptorelin (Trelstar). [ 21 ]  Some of the side effects of these medications include but are not limited to "Reduced sexual desire and libido, Impotence, reduced size of testes and penis, hot flashes, growth of breast tissue (gynaecomastia) and pain across the breasts, thinning of the bones or osteoporosis and risk of fracture, anemia, loss of muscle mass, weight gain, fatigue and memory problems, and depression." [ 19 ]


Until the mid-1980s, pediatric testis tumors were managed in accordance with adult guidelines where the standard therapy was radical inguinal orchiectomy. It was later discovered that this procedure was being overused in the pediatric population, particularly those in pre-puberty, because it was assumed that the tumor was malignant. [ 22 ]  It was discovered that the majority of the pediatric tumor registries over reported malignant tumors and had biased reporting. It has now been found that most tumors are benign lesions and the majority are cases of  teratoma  which act benign in pre-puberty pediatric individuals along with other benign tumors that have been reported such as:  Sertolic cell tumor ,  Leydig cell tumor  and  juvenile granulosa cell tumors . Most malignant tumors found in pre-pubertal individuals are pure yolk sac tumors. [ 22 ]  There is a difference in pre-pubertal, post-pubertal, and adult testis tumors in their histology and their level of malignancy with malignant tumors being rare in the pre-pubertal pediatric population. [ 23 ] [ 24 ]  There has been a consideration to switch to testes sparing surgery (TSS) such as partial orchiectomy specifically for the pre-puberty pediatric populations who lack signs of malignant tumors. [ 22 ]  Partial orchiectomy allows the ability to preserve hormone function and the possibility of reproduction in the future. [ 23 ] [ 24 ]  It has also been found to increase the quality of life. In the case that an individual is pediatric (<18 years of age) and is a post-pubertal with a malignant testes tumor, they must follow the adult recommended standard guidelines and proceed with radical inguinal orchiectomy. [ 22 ]


The post-pubertal pediatric population and adults are at higher risk of malignant tumors and usually have a histology of a mixed germ cell tumor. Their first line of treatment is radical orchiectomy; however, they may be candidates for testis-sparing surgery such as partial orchiectomy, if there is a presence of a benign tumor. Although partial orchiectomy is controversial for this group of individuals, it has been found to be a successful procedure for benign masses such as stromal tumors, epidermoid cysts, and fibrous pseudotumors. [ 22 ]  There is greater use of partial orchiectomy with individuals who have small, benign testicular mass usually < 2 cm which indicate the tumors being benign. There is limited data on the size of tumors of the pediatric population, therefore, size cannot be used as a predictor of a tumor being benign. [ 22 ]


Orchiopexy  (or  orchidopexy ) is a  surgery  to move and/or permanently fix a  testicle  into the  scrotum . While orchiopexy typically describes the operation to surgically correct an undescended testicle, it is also used to resolve  testicular torsion .


Undescended testicles affect 1% of males and are 10% bilateral. The cause is unknown, with a small percentage associated with developmental abnormalities or chromosomal aberrations. [ citation needed ]


Early orchiopexy reduces the risks for cancer and sterility in males with  cryptorchidism , or undescended testes. [ citation needed ]


Cryptorchidism is definitively diagnosed after 1 year of age, as testicular descent may occur after birth. Surgical placement into the scrotum is recommended by 18 months to decrease the likelihood of testicular cancer, testicular atrophy, and sterility.


Cryptorchidism is associated with tubular atrophy and sterility. In addition, cryptorchid testes carry a three to five times higher risk for  testicular cancer  (germ cell neoplasia in situ within the atrophic tubules). Patients are at increased risk for the development of cancer and atrophy in the contralateral, normally descended testes as well.


There are multiple different orchiopexy techniques used to correct an undescended testicle due to the large variation in location where the testes may present. The procedures have a high overall success rate. [ 1 ]


Orchiopexy is performed in the event of  testicular torsion , a urologic emergency presenting with intense pain and often without inciting injury. [ citation needed ]


While neonatal torsion occurs with no anatomic defect to account for its occurrence (occurring in utero or shortly after birth), adult torsion results from a bilateral congenital anomaly often called a " bell-clapper deformity ", where the testis is abnormally anchored in the scrotal sac, leading to increased mobility. [ 1 ]


Twisting of the spermatic cord results in obstruction of the testicular venous drainage. Intense vascular engorgement and infarction may lead to testicular injury and sterility. If the cord is manually untwisted within approximately six hours the testis has a high chance of remaining viable. One in three cases results in dead testes, requiring  orchiectomy . [ 2 ]


Surgical fixation in the form of orchiopexy is indicated to prevent the reoccurrence of torsion, and is usually performed bilaterally, even if only one testicle is affected by torsion. The procedure has a high success rate in preventing reoccurrence. [ 1 ]


For the management of palpable undescended testes (over 80% of undescended testes) the standard inguinal approach is the appropriate procedure. [ 3 ]


Approximately 50% of non-palpable testis are high in the  inguinal canal  or abdominal, while the other 50% are atrophic, and usually located in the scrotum. Diagnostic  laparoscopy  is often advised to determine the location of non-palpable testis. [ 4 ]


Two distinct techniques used for surgical fixation are the sutured point-fixation and Jaboulay tunica plication. Multiple studies have shown that both are effective techniques for fixation with limited evidence favoring either in acute torsion. [ 2 ]


Sutured fixation  may be performed using either absorbable or non-absorbable sutures, with 3 point fixation sites being preferred. There are concerns regarding potential complications arising from suture fixation (and required breach of the  tunica albuginea ) like infarction and abscess formation, however this is not supported by data. [ citation needed ]


The  Jaboulay procedure  was developed later as a non-suture fixation method that avoids trans-parenchymal sutures and instead utilizes eversion, loose plication, and adhesion formation. this technique is criticized for potential security inadequacy. [ citation needed ]


Overall, there is considerable variation in surgical practice for testicular fixation for testicular torsion, with no significant difference in effectiveness between sutured and Jaboulay fixation in emergency re-presentations, post-operative complications, or returns to operation. [ 8 ]


The first attempts at surgical correction of cryptorchidism began in the early 1800s. Before this, inguinal testis were managed with the use of  truss  or  castration , if at all.


The theory of orchiopexy is attributed to the observations of Baron Albrecht von Haller and  John Hunter  in the 1700s, who began to elucidate the anatomy and mechanism of testicular descent.


The first recorded attempt for surgical correction of an undescended testis was performed by James Adams in the London Hospital in 1871, although there are reports of attempts by several German doctors (J. F. Rosenmerkel in 1820 and M.J. von Chelius in 1837). The patient died due to infectious complications of the procedure.


Thomas Annandale  completed the first successful orchiopexy in 1887 on a three-year-old boy. He discussed the care of this patient in  The British Medical Journal,  crediting Thomas Curling (who had worked with James Adams) with the idea of anchoring the testis to the bottom of the scrotum. Notably, Annandale was a close acquaintance of  Joseph Lister , and practiced antiseptic techniques that had been absent from previous attempts by other physicians. The postoperative course was reported to be “satisfactory in every way”.


Max Schüller, Arthur Dean Bevan, and  John K. Lattimer  further contributed to the current techniques for orchiopexy between the late 1800s and early 1900s, with the steps for standard orchiopexy being established before the 1960s. At this point, the standard orchiopexy applied to most undescended testes had a high success rate ranging from 89% to 92%- Attention was then turned to the treatment of high undescended testes, which the standard orchiopexy did not adequately treat.


In 1979, Jones and Bagley suggested a high inguinal incision for high canalicular or intra-abdominal testes. Fowler and Stephens devised a means to preserve the blood supply of high undescended testes through collateral circulation. Their technique was modified into a two-staged operation. Later, one-stage laparoscopic orchiopexy was reported first to reveal the location of non-palpable testes and then as a therapeutic treatment. [ 9 ]


Penectomy  is  penis removal  through  surgery , generally for medical or personal reasons.


Cancer , for example, sometimes necessitates removal of part or all of the penis. [ 1 ]  The amount of penis removed depends on the severity of the cancer. Some men have only the tip of their penis removed. For others with more advanced cancer, the entire penis must be removed. [ 2 ]


In rare instances, a botched  circumcision  can also result in a full or partial penectomy, as with  David Reimer . [ 3 ]


Fournier gangrene  can also be a reason for penectomy and/or  orchiectomy .


Because of the rarity of cancers which require the partial or total removal of the penis, support from people who have had the penis removed can be difficult to find locally. Website support networks are available. [ 2 ]  For instance, the American Cancer Society's Cancer Survivors Network website provides information for finding support networks. [ 4 ]   Phalloplasty  is also an option for surgical reconstruction of a penis.


Patients who have undergone a partial penectomy as a result of a penile cancer diagnosis have reported similar sexual outcomes as prior to surgery. [ 5 ]  Sexual support therapists and specialists are available nationally in the United States and can be accessed through the specialist cancer services. [ 2 ]  Many surgeons or hospitals will also provide this information postoperatively. Local government health services departments may be able to provide advice, names, and contact numbers. [ tone ]


Frenulectomy of the penis  is a surgical procedure for cutting and removal of the  penile frenulum , to correct a condition known as  frenulum breve . This condition prevents the full retraction of the foreskin with or without an erection. [ 1 ]


It is a simple and normally painless procedure that is performed in a urologist's office. First the physician applies a local anesthetic, such as  lidocaine/prilocaine  cream on the frenulum and surrounding area. If the patient retains any feeling there after the anesthetic has had time to take effect, the physician may recommend that the procedure be performed in a hospital, with stronger anesthesia.


Once the frenulum is cut, the physician applies stitches to close the wound. The patient may be given a prescription for pain killers to take in case there is pain afterwards, but usually the only discomfort is from the pricking of the stitches on the foreskin. Once the stitches are removed, in about seven days, normal sexual activity can resume.


A  penile implant  is an  implanted device  intended for the treatment of  erectile dysfunction ,  Peyronie's disease , ischemic  priapism , deformity and any traumatic injury of the penis, and for  phalloplasty  or  metoidioplasty , including in gender-affirming surgery. Men also opt for penile implants for aesthetic purposes. Men's satisfaction and sexual function is influenced by discomfort over genital size, which leads some to seek surgical and non-surgical solutions for penis alteration. [ 1 ]  Although there are many distinct types of implants, most fall into one of two categories: malleable and inflatable transplants. [ 2 ]