What Comes After the Pill?

November 15th, 2009
Making the world a better place with modern technology.

Making the world a better place with modern technology.

In this forum, I’ve already talked about how erections occur and also about pills used to treat erectile dysfunction in men. But what if they don’t help? What comes after the pill?

There are about 30 million men in the U.S. affected by erectile dysfunction. For 20% or more of men, common prescription therapies – Viagra, Levitra or Cialis – are not effective. For these men, we have many things “up our sleeves” to help. Before reviewing this cornucopia of cures, I really need to emphasize again the idea that erectile dysfunction may be a message that your body is not perfectly healthy. Think of it as a loud noise coming from under the hood of the car. It may run fine if you keep going, but you never know. Similarly, medical conditions such as high blood pressure, heart disease, high cholesterol, diabetes and low testosterone are important “loud sounds” that are associated with erectile dysfunction; they should be treated first and foremost. Often, by treating these illnesses, not only will erections improve, but you might live better and longer too.

Ok, so your cholesterol is fine. How then can erections be improved? Well the answer may be to “go local.” Local therapies attempt to improve erections by going to the source to treat the problem: the penis itself. Help the big guy out without involving the rest of the body. Penile salves, creams and urethral pills are available in many forms and are often compounded by pharmacies. One of these is a pill (MUSE) that is inserted just inside the urethra (the urine tube within the penis) and is absorbed by the penis to stimulate an erection. A little unconventional, but very effective in some men.

Although more difficult to imagine, local therapy can also involve injecting the side of the penis with highly active erectogenic agents such as papaverine, phentolamine and prostaglandins. Not the most palatable way to get an erection, but highly effective for the vast majority of men who fail to respond to pills. A more inviting alternative is based on recent developments in transdermal technology and involves delivering the same three medications in a clear gel into the urethra (TriMix Gel). Rub it in for a minute or two and you are up and running.

Available for 30 years now, penile vacuum pumps will also work in the majority of men. By creating 6 atmospheres of negative suction pressure around the penis, these mechanical devices draw blood directly into the penis. Once filled, a rubber ring is placed around the base of the penis to keep the blood in and away you go. But please don’t keep the ring on too long (more than 45 minutes) as bad things could happen…

In the most resistant cases, surgical implants may be needed to resurrect the erection.  Reliable and realistic, implants are the most invasive kind of local therapy and are effective in virtually all men. They can be rigid but bendable, inflatable, antibiotic coated and can have other neat widgets and gadgets. But they do require surgery, which distinguishes them from other treatments. They are also irreversible in the sense that they permanently alter penile anatomy, rendering ineffective most other treatments discussed here. So, let it be known that “vee have vays” of getting those erections back in case the pill doesn’t work.

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Music to Our Ears

November 8th, 2009

 

Miles and Microsurgery: it doesn't get any better.

Miles and Microsurgery: it doesn't get any better.

For as long we have pounded drums and plucked strings, listening to music has affected people’s sense of well-being, lifting and consoling their spirits, inducing calm and tranquility, or the trance of dance. I have listened to the sounds of classical jazz during microsurgery operations throughout my professional career as a surgeon. Coltrane, Miles, Evans, Djavan, Caetano Veloso and all the greats sweetly waft in the operating suite and overcome the din of devices within the room. Does music in the operating room lead to less wasted and more fluid surgical motion, and therefore faster procedures and better patient outcomes? Who knows. But as the background makes the painting, the music may make the maestro.

 

A recent study suggests that listening to music in surgery may also benefit patients. Maybe this is why oral surgeons and dentists offer earphones and video glasses to their patients. Anything is better than listening to the whine of the drill during a root canal. The effect of music on cortical, limbic or higher brain centers has previously been studied in patients undergoing brain surgery. These centers control feeling, thoughts and memory. In this recent research, a neurosurgeon studied the effect of different kinds of music on deeper portions of the brain, located in the thalamus. This region is responsible for sensation, motor function, consciousness, sleep and alertness. This study of music and Parkinson’s patients is quite different from what Oliver Sacks describes in his book Musicophilia, in which music therapy is used to increase the mobility and responsiveness of Parkinson’s patients.

According to this new study in awake patients undergoing surgery for Parkinson disease, music slowed the neuronal firings deep within the brain. As a consequence, patients became physically more relaxed, calm and even slept during their surgery. And pure melodic music appeared to be the most soothing to most patients.

So music in the operating room may make more sense than we think. In addition to helping the surgeon with his surgery, it may reduce patient anxiety. This in turn, could shorten operative times, reduce the need for anesthetic medication, and lead to quicker patient recovery and shorter hospital stays. In a word, more music, less pills.

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The Bumpy Lives of Teenagers

October 26th, 2009
Teenagers: how about both high-tops and high health?

Teenagers: how about both high-tops and high health?

How seriously do you take the medical symptoms of your teenager? Aren’t the aches and pains, and the bumps and bruises the stuff of the young and the restless? Besides, kids are not supposed to get cancer and other bad things. That’s not fair play by God or Darwin. In any case, a new study reports that teens and young adults are frustrated when others don’t take their medical complaints seriously.

Presented at a European cancer society meeting, the study interviewed a cadre of 16 to 24 year olds who were diagnosed with cancer 2 to 4 months prior. Remarkably, the time between the onset of symptoms and the formal diagnosis of cancer ranged from 8 weeks to 11 years! In addition, the young patients claimed that they were told that it “was normal to feel tired,” or that their symptoms were “due to menstrual problems, fluid on the knee, irritable bowel syndrome, excess weight or lack of exercise” when in fact they had cancer.

Why is it difficult to know whether there are really important medical issues regarding their health when teenagers make that claim? First of all, in many cases, it may not be possible to figure things out any sooner than we do. Medicine is a tremendously complex field. We must deal with diseases like tuberculosis, nicknamed the “great imitator,” as it causes symptoms that can mimic hundreds of other diseases, cancer among them. Next, because it occurs infrequently, cancers are usually low on the list of possible diagnoses for youngsters. Zebras just aren’t that common outside of Africa. Furthermore, kids don’t have that many “risk factors” that alert the medical system to the possibility of cancer. They haven’t smoked cigarettes for 40 years, enough to have every doctor constantly sniffing around them for the 3 or 4 cancers that smoking can cause. In short, kids are different beasts than adults and this makes finding serious diagnoses a little more difficult.

Finally, kids and young adults (especially young men) might not be used to being sick and may not know when their symptoms are medically important. Take for example my study of men with benign cysts of the scrotum, a diagnosis that needs to be evaluated to exclude testis cancer. I found that although most affected men know that there is a mass growing in the scrotum, they do not seek medical attention until it becomes, on average, the size of a normal testicle and causes discomfort. Regardless of why, this is a terrible problem in and of itself.

As medical providers, we really need to better educate teenagers and men in health care prevention and help them to develop a medical “instinct” about their bodies that brings them to care sooner rather than later. It shouldn’t have to hurt or to be life threatening for a man to seek medical attention. And they shouldn’t have to worry that they won’t be taken seriously when they do seek care. Facing issues similar to those of teens seeking care, the Men’s Health movement is equally plagued with the problem of  trying to best serve men’s needs within a relatively unresponsive system. My tasks are clear…

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Sex: Warts and All

October 12th, 2009
Life has its warts, just ask Letterman...

Life has its warts, just ask Letterman...

What is all this news about warts? Although incurable, genital warts (condyloma acuminata for the Greek among us) are the most common sexually-transmitted disease caused by a virus. The human papillomavirus (HPV) to be exact. Not to be confused with HSV that causes genital herpes. Less than 5% of those who have an HPV infection will actually develop visible warts, but either way, they may be infectious. The viral particles penetrate the skin through small abrasions in the genital area that may occur during sexual activity. When visible in men, warts are treated with chemicals such as podophyllin, interferon and trichloroacetic acid when small, and by liquid nitrogen or surgical excision when larger. Since they cannot be cured, the goal of treatment is to remove all visible lesions and theoretically to reduce the chances of transmission.

So that’s the scary part. But what’s new? What’s relatively new is that it has become clear than certain subtypes of HPV cause only benign warts (types 6 and 11) while other subtypes can cause cervical cancer (types 16,18). Of course, any association with cancer thankfully leads to more research and the outcome of research thus far is the development of an HPV “vaccine”. Like many vaccines, this one does not cure HPV but simply prevents it. And, it must be given before exposure to the virus to be effective, ideally before sexual activity begins. To date, the vaccine (Gardasil, Merck & Co) is widely approved for use by young women in many countries including the U.S. and is being widely used to prevent HPV and hopefully cervical cancer.

But what about boys and men with HPV? Similar to women, it would not be expected that an HPV vaccine would have any effect once a man has HPV or warts. But what about vaccinating boys before they begin sexual activity, similar to girls?  Our FDA is considering precisely this question and now has some real information on which to base a decision.The data comes from Britain, where the vaccine has been already been approved for boys.

A very recent study now suggests that although it might be cost-effective to vaccinate girls in Britain, it appears not to be the case for vaccinating boys. This is based on the assumption that all girls would already be vaccinated. So, a “coed” vaccination campaign would double the cost of treatment but is likely not to double the results. Basically, the vaccine can prevent the infection quite well thank you, but it may not be worth the public health investment to offer it to boys. However, if the coverage of girls is low, then it may be worth vaccinating boys.

And so it goes. A story similar to that of contraception: If one partner is well protected, then the other may not need to be protected. So there you have it concerning HPV, warts and all.

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Happy Anniversary to Testis GPS

September 29th, 2009
FNA mapping: testicular "cartography" for male infertility

FNA mapping: testicular "cartography" for male infertility

It’s been 13 years. Certainly a significant amount of time for any recent tech start up, but also impressive for a medical procedure. It’s the 13th anniversary of the invention of fine needle aspiration mapping of the testis for sperm. Nine hundred cases and going strong and many families created along the way.

It all started in 1996. Infertile patients from around the globe asking me if there was anything, absolutely anything, that I could do beyond what was currently available to find sperm so that they could have a child. The in vitro technology was there, if we could just find sperm! Survivors of cancer, war injuries, brutal infections, chronic disease, spinal cord injury, cystic fibrosis and a myriad of other genetic syndromes all had a simple request: the opportunity to be biological fathers. They refused to accept what a simple testicular biopsy was telling them, that there was no sperm being produced in the factory and no chance of having their own sons and daughters.

Its times like these, pushed against the wall, when creativity surges and opportunity frees us from the restraints of the routine. For me, it came as a simple revelation: not all branches of an apple tree have apples. Or, in my field, not all prostate biopsies show cancer and not all testis biopsies show sperm. A single biopsy of a testicle in a man with no sperm in the ejaculate is simply not enough to say that he does not have any sperm and that he cannot become a father. We must look harder. And so out of this revelation, testis fine needle aspiration “mapping” was born, 13 years ago and going strong.

The details of the mapping procedure don’t matter except to say that it’s all a matter of sampling enough to reduce sampling error and, while doing so, being kind to patients. Too many biopsies can destroy a testis, but non-surgical, fine needle sampling is a kinder, gentler, and more informative way to learn more and to find sperm. Think of it as “GPS” for the testis or, as one patient put it, “testicular cartography.” And, once sperm are found, the world becomes our oyster in a reproductive sense.

Telling a leukemia survivor who was too young to bank sperm before he was hit with a wall of chemotherapy, radiation therapy or a bone marrow transplantation to just stay alive that he can now be a father because of some small pocket of sperm still alive in his mapped testis is a profoundly satisfying and motivating experience. Motivating enough for me to be thinking about the next new thing…

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A Short History of the Y Chromosome

September 22nd, 2009
The Y chromosome: diminutive but cool.

The Y chromosome: diminutive but cool.

Among the many chromosomes in a man’s body, the smallest one with the largest personality has to be the Y chromosome. With it, you are a male; without it, you are a female, with few exceptions. More than any other chromosome, it really defines who you are.

The Y chromosome controls other traits as well: hairy ears, tooth enamel, and stature to name a few. But for the longest time, the Y chromosome was also considered home to a lot of “junk DNA” that we thought had no purpose. We now know that much of this DNA has a purpose and that the Y is the home of many important male fertility genes.

Before its association with male fertility, the Y chromosome was widely considered a genetic black hole, a chromosome that evolved as a broken remnant of the X chromosome. We knew that the “maleness” gene was on the Y and a few other genes. However, since the Y chromosome has been fully undressed as a result of the human genome project, we now know that it is very unique, even special, and that it evolves in its own special way to keep men men.

The Y chromosome, and its neighbor the X chromosome, evolved into “sex” chromosomes hundreds of millions of years ago. This is important because many species do not have a chromosome for each sex like we do. Some species become male or female based simply on the environment in which they find themselves. Imagine that! A boy in the Artic but a girl in the Caribbean. At first, the original sex chromosomes probably evolved as a pair of two X chromosomes. Then, 150 million years ago, the Y chromosome made its break from the X chromosome. Basically, it stopped associating with it and this led to our current X-Y system of sex determination. I guess this is when men really became men.

As it works now, the single Y chromosome has no partner with which to swap genes when sperm are made (at a normal rate of 1200 sperm/heartbeat!) This “swap meet” of genes that occurs when new sperm are formed is an important repair process for the 22 other chromosomes and is absolutely critical for our evolution as a species. In fact, this is the source of our evolution. So, now that the Y chromosome has become isolated and less of a team player, is it doomed to extinction? More importantly, are men are doomed to extinction?  

So how does the Y chromosome survive and repair itself, living alone in isolation while the world is changing around it? Well, we now know that it manages very well on its own, thank you. And this has probably been true for about 5 million years. Although it no longer swaps genes with the X chromosome, from which it came, the human Y chromosome is able to swap genes with itself to discard bad genes. It’s called gene conversion and no other chromosome does it. Just the Y. How uniquely male.

Basically, essential Y chromosome genes are arranged in a series of eight “palindromes,” or mirror image sequences, each of which folds like a hairpin in which its two arms come together. Then the “DNA checkers” compare the two arms for any differences and convert a mutation back to the correct sequence, thus saving the Y’s genes from mutational decay. So, the older “junk DNA” thought to exist on the Y chromosome is now known to represent DNA that it critical for its survival. One man’s junk is another man’s treasure. And so it goes, the Y lives on, and men do too.

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Are We Replacing Ourselves?

September 8th, 2009
Where are you? Green means high and red means low.

Where are you? Green means high and red means low.

When a couple decides to have children, they rarely, if ever, contemplate the effect this has on the nation. But population scientists do. The effect that birth rates have on society is critical—as basic as knowing whether a nation is sustaining their population or not. But, trying to figure out if birth rates are going up or down is also complex, not unlike taking our temperature by feeling our foreheads.

A good barometer of birth rate assesses the average number of births per woman, and is generally noted by country. For a country to sustain its population in the future, the replacement rate is 2.1, or 2.1 births to every woman. What has occupied the minds of population scientists over the past 20 years is the fact that birth rates have dropped around the world, especially in Europe, but also in China and Japan. Interestingly, many countries in Africa do not have this problem, with birth rates well above 4. 

Also notable is the fact that in the past 20 years, the population of the world has dropped, falling an average of 1% per year. You can imagine how much this issue has occupied the minds of population scientists who seek to explain the phenomenon. Contributing factors include changing attitudes about family size, the cost of raising a child and the wider availability of contraceptives. The birth rate may also be dropping because child mortality on the whole has dropped. Or, because women who choose to have children later create a temporary lull in the birth rate. One concern with population drops is that countries whose populations become too small may not be able to afford to support its infrastructure, causing economic decline. So, on the one hand, it’s expensive to raise a child. On the other, it’s also expensive not to.

A recent study however, does show a change in these trends. Fertility rates now show a recent increase in developed nations. For years it has been thought that for some reason, developed nations, including most of Europe, have steadily dwindling populations. But this may not actually be the case. For example, in the 1970s, the US fertility rate was at a low of 1.74; lately it’s been relatively stable at 2.05. It appears that children are still wanted in a modernized world.

It’s quite hard to see these trends in my daily medical practice, as I perform as many vasectomies as I do vasectomy reversals. It’s even harder to render an opinion when the information is so diffuse and generational. So, to population scientist, I am a professionally “neutral contributor” to fertility rates. Like to think I do more good than that though…

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Autumn in California

August 31st, 2009
Ending a sunset surf session in Santa Cruz

Ending a sunset surf session in Santa Cruz

Autumn is approaching, and San Francisco is sweltering in an Indian summer.  In the city where I live and practice my profession, September is our most California-like month. The air goes still and briny as the breeze wanes, and drapes itself heavily on the roofs and hills. The clouds dance with delight in a painterly way. Our Junes and Julys are gloomy, to many a tourist’s surprise, as if the fog has gathered from afar, and migrated here for the summer. As the tourists begin to leave, the city glows with a diffuse, cottony, almost silky light. Swimsuits replace wetsuits as the sea is warm before the winter chill, and the beaches are dotted with surfers. That’s fall in my City by the Bay.

Autumn in San Francisco is when balmy nights lead to blissful, restful sleep, and to a focus regained. As school starts, the sweaters and scarves emerge. Productivity surges, along with traffic, as minds return from all corners of the earth to think everyday thoughts, and perform everyday rituals. Budgets tighten as memories of Bora Bora fade gracefully like an ancient memory. Gone are the lazy afternoons, the nectarines and peaches left uneaten, and late afternoon naps that fuel the evening flurry. The change in countenance of the city’s many faces replaces the colorful foliage of the New England autumn.

Why not remember to play when the wind sweeps all the warmth away? Why not take a moment to breath, to just stand and watch the golden light as the days fail sooner, as the birds steer gracefully south? Perhaps playing is exactly what is needed as autumn sets in. Instead of filling the mind’s nooks with obligations, meetings, health care, politics, PTA, financials and homework, take a brief moment to play and delight, like a child with a bright new toy. A perfect time to take play a little more seriously.

Autumn, with its tremendous force of change, its leaves going up in flame by slow degrees, its rush of wind and its earth fertile with pumpkins, is ripe for a little lightness of being. We should taste the last of the blackberries, play a little football, tell stories by campfire, toast to friendship and find other ways to keep summer alive. The waves will soon rise powerfully in the sea near my home, replacing the dead surf of summer. I’ll be swimming into them, negotiating a ride when I can, and letting them carry me back to shore.

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The Agents of Erection

August 24th, 2009
The biochemistry is complex; the result is simple.

The biochemistry is complex; the result is simple.

Subtle, efficient, and powerful, Viagra is a first-line agent of erection, along with its accomplices, Cialis and Levitra. True, there are other agents out there, such as penile implants and injections, but these three, the triumvirate of pills, are the go-to agents, because they work so well for so many people.

Viagra wasn’t so much invented as happened upon. Its ability to restore erections was discovered as a side effect of a clinical trial targeted towards treating heart disease. Viagra was supposed to reduce anginal chest pain by increasing blood flow to the heart. It turned out that Viagra did increase blood flow, but to a different organ. After the trial, when the company asked the test subjects to return the extra pills, the patients refused because their erections were so much better. And so the agents of erection were born.

Viagra, Cialis, and Levitra all work the same way–sort of like coffee for the penis. Similar to coffee, which works by preventing the breakdown of the energy molecule ATP, thus increasing metabolic energy, these agents inhibit an enzyme that breaks down a different energy molecule (cGMP) that is found in the penis. This energy molecule causes the arteries of the penis to dilate which is how erections begin. Because cGMP is not being broken down, more cGMP is available, and for a longer period of time. More cGMP equals more blood to the penis. Cue the Love Boat theme.

These medications, as a class called PDE5 inhibitors, are not aphrodisiacs and are no replacement for sexual stimulation. In other words, the traditional rules of engagement still apply. They can take up to one hour to start working, during which time foreplay and intimacy is important for a good experience. All three medications work equally well, with Cialis having the longest effect. Aside from the usual side effects from most pills that include headaches and upset stomach, the major concern with these medications is that they can have dire consequences if one is also taking certain heart or blood pressure medications, namely nitrate-containing medications and alpha-blockers. Dangerously low drops in blood pressure can result, leading to strokes and heart attacks.

These first-line agents of erection are intended for mild to moderate cases of erectile dysfunction. Because this disease is frequently a harbinger of other medical problems such as diabetes and heart disease that you should really know about, a thorough evaluation by a doctor should be performed before it is prescribed. So for health’s sake, please resist the temptation to purchase them from your email spam folder and see a doctor; although embarrassing at first, you’ll be happier in the long run.

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Baby Making Tips

August 19th, 2009
The most fun he ever had without laughing

The most fun he ever had without laughing

You might have “practiced” the art of baby making for quite a while. But have you actually tried to make a real baby? What does it mean when a couple says they’re “trying”, besides jettisoning the condoms, scheduling free time, and practicing your “sore throat” voice for calling in sick to work. No one teaches you the nitty gritty of baby making in sixth grade sex ed classes. So, here are some of the finer points.

First of all, your chances of conceiving decrease if the two of you are under stress. Frequent travelling, major life changes, a long sickness, being vetted for the Supreme Court, running a start up with a gazillion hours weekly, are terrible for getting one “in the mood.” If the body is under stress, it’s in the primitive “fight or flight” response, and it’s not exactly in the mood to reproduce. So to improve your chances, decrease your stress level by eating well, sleeping well, staying healthy and relaxed, and treating your body right. If you are chronically overworked, you may consider decreasing or delegating your responsibilities. If this isn’t possible, force your body to relax with exercise, yoga, massage or acupuncture. Also, quit smoking, drink no more than two glasses of alcohol daily and avoid hot tubs and hot baths (showers are fine).

Like many things in life, timing is everything. Eighty percent of pregnancies occur when sex takes place before or during ovulation, which is the time when a woman’s ovary releases an egg for fertilization. But how to tell when ovulation is occurring? The most accurate way would be with an “ovulation predictor kit” purchased at any drugstore. Like a pregnancy test, it uses urine to determine if ovulation is about to occur. The old-fashioned method, which also works well, would be to pay attention to her basal body temperature. To do this, she should take her temperature first thing in the morning, for a string of consecutive days during the middle of her monthly cycle. There should be a dip in her temperature, followed by a rise. This indicates ovulation.

Once you know that the egg is on its way, intercourse is best performed every other day. Men need time between ejaculations to “reload”, and daily intercourse may not give a man enough time to do so (sorry guys). As for the act itself, studies have shown that no particular position is best. Research is suggesting that the two of you can bend yourselves into pretzels, if desired, with no effect on your chances of conceiving or on the gender of the child.

Baby making is a special experience. And, it’s fun! As Woody Allen said in the movie Annie Hall, ”…sex is the most fun I ever had without laughing.” If you think about it, what I am suggesting is that you and your partner make it a habit to take the best care of yourselves, just as you are going to take the best care of your child. Set the example for the new family and enjoy the ride!

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