Archive for the ‘sexual health’ Category

« Older Entries

Getting There Early or On Time: Which is Better?

Sunday, January 24th, 2010
Is faster better? Not always.

Is faster better? Not always.

What is the most common sexual health problem affecting men? That’s easy, it’s erectile dysfunction, right? Nope. Try premature ejaculation. Hands down more common than erection issues, affecting 25-40% of men in the U.S.

Variably called early ejaculation, or early or rapid climax, it is defined as male ejaculation earlier than the subject or his partner desires. It used to be defined as ejaculation within 2 minutes of sexual intercourse, until it was realized that 75% of men ejaculate within 2 minutes in over half of their sexual encounters. What the definition really implies is that is some element of poor control over ejaculation that is stressful and may result in interpersonal difficulty.

Is this a medical disorder? In some cases, yes. Think of ejaculation as a reflex, like sneezing. There is a point of no return and this is what comes too soon in men with early ejaculation. The problem has two forms: lifelong and recent. The former is believed to result from low levels of the neurotransmitter serotonin (5HT) that normally modulates the ejaculation reflex. The recent form does not have as clear a biological basis, but may occur from psychological stress or from the need to overcome an erection problem.

The good news is that there are treatments available, and more treatments being reviewed by the FDA. Currently, the most effective treatments are pills called SSRIs, which elevate 5-HT levels and include anti-depressants such as Prozac, Zoloft, Celexa, and Lexapro. A newer form of SSRI drug, called Priligy, is now available in nine countries but has still not been FDA approved in the states. Also, a metered-dose aerosol spray has been developed to increase time to ejaculation by numbing the skin on the penis and decreasing sensation. Maybe this will help. Unfortunately, with all drug treatments for this condition, when the drugs are stopped, the issue generally returns.

What I find interesting is that companies are vigorously trying to drum up sympathy and attention for premature ejaculation as a widespread medical disorder, when in many cases it may be only an occasional annoyance that does not need constant treatment. Treatment might be perfect for a few men with debilitating disease, but it appears that they are trying to create and market a whole new category of disease. Good idea: create a “huge unmet need,” an epidemic that is perfect for a blockbuster, quality of life drug. Well what about a pill for shyness, or talking too fast? Where does it end? The larger issue here might be the “medicalization” of our daily lives in which there is a healthy and wide variation of normal.

Do I believe that some men have debilitating early ejaculation? You bet, and I see them every day. Do I think that a pill will treat this issue? Sure, for many, but only while you take it. Will blockbuster pills be the cure-all for early ejaculation? No way. The cure will come with more holistic treatment, by empowering men through behavioral changes that teach them to control and “own” the problem. Works superbly for my patients, pill or no pill.

  • Share/Bookmark

Tags: , , , , , , ,
Posted in men's health, sexual health | 4 Comments »

The Quiet After the The Storm of Cancer

Sunday, January 17th, 2010
Throwing a wrench in the machinery of sperm production...

Throwing a wrench in the machinery of sperm production...

I have to admit, the testis “mapping” procedure that I developed some years ago has truly been a workhorse technique for my male infertility practice. And for the practices of other male reproductive specialists around the world as well. Creating fertility from sterility. I bring it up again because it is gathering more attention in the press as this week we recently published another paper that highlights its utility—this time in cancer survivors.

In a related study from 2002, we published that the majority of men who had been exposed to chemotherapy for cancerous or non-cancerous disease and who were “sterile” afterwards have sperm in the testis that can be safely used for fatherhood with assisted reproduction. Fine needle aspiration (FNA) mapping was employed in this study and its potential to help cancer survivors to conceive was convincingly demonstrated. The recent paper expands that group of men to include those who received not only chemotherapy and radiation therapy but also a relatively extreme treatment for certain cancers termed bone marrow transplantation.

Let’s back up a minute for a biology lesson. How does chemotherapy affect a man’s fertility? Well, the basis of its effectiveness in curing cancer is that chemotherapy preferentially kills rapidly dividing cells more than slowly dividing cells. In general, cancer cells divide more rapidly than do normal body cells. The term for this difference in cell susceptibility is “therapeutic index”. Unfortunately, sperm are also produced very rapidly (about 1200 sperm are made every heartbeat) and therefore sperm precursor cells are also very sensitive to the effects of chemotherapy. Think of sperm production as a rapidly turning set of gears and chemotherapy as a wrench being thrown into them. Ka-chunk! Machine comes to a loud and crashing halt. Sperm production is over, or tremendously slowed down. The same action is true for radiation therapy treatment.

Now, imagine not just one small wrench being thrown into the gears, but a huge wrench (or many wrenches) being suddenly thrown into the machine of sperm production. The result? More damage to the sperm-making machinery and a much higher chance of sterility. This is the essential difference between the patients from the 2002 paper on mapping and the most recent one. The cancer survivors in this week’s paper got blasted with the heaviest doses of chemotherapy imaginable, and topped off with a dollop of radiation therapy just to be sure. Hard to believe, but they also had usable pockets of sperm in their testicles. And normal babies as a result.

So, with techniques like FNA sperm mapping, there continues to be hope and good news about fertility after the storm of cancer treatment has passed.

  • Share/Bookmark

Tags: , , , , , , , , , , , , , , ,
Posted in male infertility, men's health, sexual health | 2 Comments »

Weighing Your Options

Sunday, January 10th, 2010
Bacchus is no longer a role model...

Bacchus is no longer a role model...

What you weigh affects how your sperm play. And your fertility. Overweight men tend to have lower semen volumes, less sperm and more oddly shaped sperm. The same is also true for men who are too thin. So, along with the many other health hazards associated with obesity, add poor semen quality to the list.

Obesity in both sexes is known to be associated with heart disease, diabetes, hypertension, and metabolic syndrome among other nasty conditions that can shorten your life. Typically, obesity is measured with BMI or body mass index, which looks at weight in relation to height. Not a perfect measure, but reasonably accurate. Using this tool, the ideal BMI for men (and women) is considered to be 20-25. A Danish study of 1600 men showed that overweight men with a BMI > 25 had a 22% lower sperm concentration compared with healthy weight men. Interestingly, a BMI of <20 was also associated with poor semen quality. For optimal sperm production, then, it helps to be not too fat and not too thin.

But what about fertility? Is it also affected by obesity? Yup. Another recent study showed that for every 20-pound increase in a man’s weight, there is a 10% increase in the chance of infertility. And this remained true when other factors that might influence the results were accounted for, including obesity status of the women, the man’s age, cigarette smoking, alcohol intake, and solvent and pesticide exposure. In addition, obesity was associated with infertility in both older and younger men.

So what is it about weight that influences men’s sperm production and fertility? One theory is that sex hormone metabolism is altered by changes in weight. Sex hormones are the “fuel” for the engine (testis) to make sperm. Obesity increases fat stores and fat converts male hormones (testosterone) into female hormones (estrogens). Too much estrogen in men is bad for sperm production. Another theory posits that normal 2-degree difference in testis temperature relative to the body is lost with obesity, as excessive fat provides too much insulation and results in overheating. On the other hand, when a man is too thin, he may take on a “catabolic” metabolic state. With a body in “starvation mode,” fertility is not the first thing on its mind and sperm production and fertility suffer.

So, is the epidemic of obesity the reason why sperm counts have been falling in Western countries over the last 50 years? Maybe. But this problem is unique in that it is utterly and entirely preventable. Eat well and in moderation, sleep well and treat your body like a temple. You used to it for your own health; now do it for the health of your future family.

  • Share/Bookmark

Tags: , , , , , , , , , , , , ,
Posted in male infertility, men's health, sexual health | 2 Comments »

What Comes After the Pill?

Sunday, 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.

  • Share/Bookmark

Tags: , , , , , , ,
Posted in sexual health | 1 Comment »

Music to Our Ears

Sunday, 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.

  • Share/Bookmark

Tags: , , , ,
Posted in men's health, sexual health | 4 Comments »

Are We Replacing Ourselves?

Tuesday, 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…

  • Share/Bookmark

Tags: , , , , , , ,
Posted in sexual health | 4 Comments »

The Anatomy of an Erection

Monday, August 10th, 2009

Impressive natural rock formations in Cappadocia, Turkey

Impressive natural rock formations in Cappadocia, Turkey

There is a bit of mystery that surrounds the average erection: Where did it come from? How long will it last? Will it be good enough?  They happen when you least expect it (whilst asleep, or in math class). And they happen when you do expect it–hopefully. Biologically, men have less control then they think regarding when or how long they occur. In fact, normal men have at least 3 erections lasting 1 hour every night, while they are asleep, deep asleep. This is the penis “sighing” and relaxing, as it takes more energy to keep a penis flaccid than erect. Believe it or not.

 

The key to an erection lies within the male brain, through visual, auditory, or imagined stimuli, or through manual stimulation. Upon stimulation, the arteries within the penis relax, and blood flows into the penis at more than 20 times the normal rate.  The spongy areas of the penis become firm and engorged with blood, much like filling up a balloon with air. So now that the penis is holding more blood, the veins, which usually drain the penis of blood, are compressed tightly enough that blood cannot exit the penis, in effect tying a knot in the balloon. And now the balloon is ready to go. 

 

Erections last, on average, between fifteen and thirty minutes, and can cause the penis to rise to a fairly stiff angle. They can also curve upward or downward, to the right or to the left. This is why upscale clothiers in London ask men who are ordering custom tailored suits: “To what side do you dress, sir?” Right before ejaculation, a reflex is triggered (bulbocavernosus) which causes the muscles that surround the penis to forcefully compress the penis, such that the blood pressure within the penis reaches levels far higher than normal blood pressure. The penis falls when there are no more energy molecules available, in effect “running out of gas”. Viagra and other erectile drugs work by supplying more “gas” to the penis. Erections also fall from nervous system discharge during ejaculation. This discharge results in a latency period or “down time” during which it is difficult to achieve another erection. Once the nervous system has recovered, then an erection is again possible.

 

One can see what might cause the balloon to wilt (erectile dysfunction). There could be a problem with circulation (not enough pressure), a problem with venous leakage (the balloon has a hole in it) or nerve damage or hormonal issues (no one is blowing up the balloon) which could inhibit penile filling or emptying or the ability to feel sexual stimulation. Drugs, toxins, and conditions such as heart disease and diabetes are all culprits. This is why good health is so important for a healthy sex life.

You may never have ultimate control over something so willful as an erection, but it may be helpful to understand how it occurs. Because, with a finer understanding, hopefully, comes finer appreciation and enjoyment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  • Share/Bookmark

Tags: , , , ,
Posted in sexual health | 6 Comments »

Pulling Out is In

Thursday, July 30th, 2009
Barrier contraception faces stiff competition...

Barrier contraception faces stiff competition...

Hold on now. Wait a minute. Don’t get too excited. If you thought “pulling out” was a feeble and ineffective method of contraception for the reckless and unprepared, well it is. At least at first glance. But given that at least 38 million couples use it worldwide, coitus interruptus warrants a second look. 

Coitus interruptus, with its ancient yet undistinguished history, is very easily dismissed as an effective contraceptive because of the widely accepted belief that the pre-ejaculate contains sperm. There is actually no conclusive evidence that this is the case. No one has actually found sperm in pre-ejaculatory fluid. In addition, it is all-natural, organic, hormone- and side effect-free, and affordable. It needs no tool that nature hasn’t already given us, except rigorous and unerring self-control. Well, in fact this is the big downside. Who has rigorous and unerring self-control? We are men, not robots. Pulling out doesn’t protect you from sexually transmitted diseases, either.

That said, a recently published study has shown for the first time in the modern era that withdrawal is more effective a contraceptive than one might think. Maybe we should look at the pull-out with a little more respect. The withdrawal method, when used with perfect technique, has a 4% failure rate. This falls behind vasectomy (0.1%), birth control pills (0.3%), IUDs (0.6%), and condoms (2%), but not by much. The actual (real life) failure rate is likely somewhere between 15-25%, which is really not far behind the actual failure rate of condoms, at 10-18%.  So withdrawal is not that bad after all, only a little less effective than condoms. Perhaps men deserve a pat on the back for this. Well done. 

However, if this were a contraceptive pill, a 15% failure rate would send its inventors back to the drawing board. For coitus interruptus is inherently flawed, and women who seek more control over whether or not they become pregnant are more likely to reject this method over the long term. One study revealed that women of higher economic status and education are more likely to insist upon a more surefire method of contraception. It appears that women simply don’t trust men’s timing, their control, and perhaps even the male sense of responsibility when it comes to contraception. They want more control in the matter. What does this mean for a male contraceptive pill? More on that next week.

  • Share/Bookmark

Tags: , , , , , , ,
Posted in sexual health | 15 Comments »

Sexual Health Pop Quiz #2

Monday, July 20th, 2009
Remember computer test bubble sheets? Get out the #2 pencils...

Remember computer test bubble sheets? Get out the #2 pencils...

You may call me a stern and demanding taskmaster, but because the last one was so much fun, it’s time for another pop quiz on men’s sexual health. This one is based on real-life, case-based questions.

1. In anticipation of a romantic encounter with his partner, and to help him be the best that he can be, a man takes Viagra. His next move should be:

A. Watch Law and Order, a stirring drama to stir the loins.
B. Go to the post office and renew his passport.
C. Eat tacos and drink beer.
D. Play strip poker with his romantic encounter.

Answer: D. Viagra and the other erection pills do not provide an instantaneous erection. They may take from 20-60 minutes to work. In addition, they won’t give you an erection unless you want it to occur. Engaging in stimulation and foreplay is an excellent way to spend your time waiting for the pill to kick in.

2. Good sex ALWAYS involves:

A. Multiple orgasms from your partner.
B. Whatever looks really freaky in the last pornographic film you saw.
C. Kinky stuff.
D. Leather of one sort or another
E. None of the above.

Answer: E. In our society, exceptions to any rule fascinate us. Here, extreme sex performance acts, characteristic of pornography, are the exception. Sex was designed by Mother Nature to be satisfying when undertaken in many different ways, and takes many different forms, all of which can be intimate and pleasurable without having to go to extremes.

3. The problem with porn on the Internet is that:

A. There is no problem! It’s good fun and free!
B. The video is fuzzy and far too pixilated.
C. I can’t watch it at work without getting caught.
D. I can get too used to it, and sex with my own partner could become unsatisfying.

Answer: D. With the increasing availability of porn, a serious problem is arising. Men who are without partners become accustomed to that kind of sexual stimulation and then end up needing that same kind of stimulation to become aroused with a partner. So, when they find themselves face to face with an honest-to-goodness, flesh-and-blood woman, they may have trouble performing. This is an increasingly common issue for sex therapists.

4. TRUE or FALSE: You and your partner have a night in together. You turn off the television, go upstairs, and tenderly give each other long, leisurely massages with body oil in a room lit only by candles. You have a great time. This constitutes a satisfying sexual experience.

Answer: True. “Sex” does not have to involve sexual intercourse and climax and orgasm. The point is to feel satisfaction and closeness with your partner. Of course sex can involve pure carnal pleasure, but that definition should be broadened to include other emotional and physical intimacy.

5. TRUE or FALSE: Since the advent of free love, we’ve become liberated from the sexual taboos of our mothers and  fathers.

Answer: Profoundly False. Although we’d like to think so, sex therapists still see tales of embarrassment and lack of communication between couples, now more than ever. Being able to express our needs, both emotional and physical, without embarrassment or shame, is a problem of the ages.

  • Share/Bookmark

Tags: , , , , , , , ,
Posted in sexual health | No Comments »

The Prostate: All You Ever Wanted to Know

Monday, June 1st, 2009

One famous fountain: the mannequin pis in Belgium

One famous fountain: the mannequin pis in Belgium

As a man ages, he is more likely to look at travel experiences as a series of restroom stops. He might begin navigating his way to the grocery store, the gas station or to a friend’s house for poker based on whether or not there’s a restroom conveniently located nearby. This may sound like the end of the world, but it’s not. It may be the end of long road trips. It is also the start of the realization that, similar to needing reading glasses, he is not immortal but actually a simple human being.

The prostate is a gland the size of a walnut at the base of the penis. It wraps around the urethra (the tube that urine comes from). A prostate is essential for normal male fertility, as it is responsible for making fluid that protects and nourishes sperm. Everything is shipshape until a man gets older, when two problems can arise. One is benign prostatic hypertrophy (BPH), which is a fancy way of saying enlargement of the prostate. This occurs in about half of all men in their sixties. For reasons still unclear, the prostate continues to grow as a man gets older. It is usually symptomatic – men have urinary urgency, dribbling, weak stream and may have to get up at night to urinate. The other problem is prostate cancer. Most commonly, cancer has no symptoms.

BPH is not preventable, but prostate cancer may be. Following a heart-healthy, low-fat, low carbohydrate diet is key to the prevention strategy, as are exercise, weight management and stress reduction. Concentrate on fruits and vegetables, which are high in antioxidants that protect the cells of your body from becoming cancerous. Soy and green tea may also protect the prostate. Sugar intake should also be limited, as it often ends up stored in your body as fat, and obesity is linked to prostate cancer.

That said it may surprise you to know that prostate cancer doesn’t always kill. Cancer is no one’s friend, but prostate cancer is not as deadly as lung cancer, colon cancer or breast cancer. It is much more slow-growing than these other cancers, doubling in size every 2-3 years instead of every 4-6 months. As such, a man is eight to ten times more likely to die of heart disease than prostate cancer. Even more interesting, some believe that prostate cancer is really a disease of age in men, as the likelihood of having small amounts of cancer in the prostate goes up with age. That means that about 80% of 90 year old men will have prostate cancer, and may never know it. They will likely die of unrelated causes. It also means that there are many prostate cancers occurring in men that are “clinically insignificant,” a rare term in cancer medicine. So, many prostate “cancers” actually don’t act as such.

Although diseases of the prostate are rarely lethal, they can affect your quality of life…and your road trips. Men over forty should start to have the prostate checked regularly, although most men would rather spend quality time with the dentist’s drill than go in for that exam. Blood tests for a substance called PSA, can also help detect cancer. The symptoms of prostatic enlargement can treated with pills; if these don’t work, various, safe but indescribable procedures can remove the symptom-causing prostatic tissue. Some of the FDA approved pills to treat BPH also prevent prostate cancer. Now that’s a pill that men might want to swallow. So, for all kinds of reasons, don’t ignore the prostate. Try to attend to it before it disrupts the flow of your daily life.

  • Share/Bookmark

Tags: , , , , , , ,
Posted in Prostate, sexual health | 1 Comment »

« Older Entries