Turek On Men's Health » Viagra

Try It, You’ll Like It?

Paul Turek, MD — Mon, 07 May 2012 15:00:09 +0000

The pill that started it all in 1998.

As if it’s not top of mind anyway, here’s an update on the state of erection pills. Another one was just approved by the FDA and will hit the streets soon. Its name: Stendra (avanfil). Who names these drugs anyway?

The PDE5i Drugs

This new pill works similarly to the holy triumvirate of Viagra, Levitra and Cialis; it is a full-fledged member of the phosphodiesterase inhibitor (PDE5i) family. In essence, they are like taking coffee for the penis. Stendra is the first such pill to be approved in the last decade and it will certainly be interesting to see how it fares in this field of household giants.

What These Pills Do for You

You may be curious to try one of these pills, even if you don’t need it. You may even have thought to open that email spam folder that says “Bigger, Better, Badder” for quite some time. What can expect when you take these pills? Well, it depends on why you are taking it.

Goal: Trying it for Kicks

All pharmaceutical grade, FDA-approved pills share benefit and risk. The same is true for the PDE5i’s. If you don’t really need any help with your erection, this is termed “recreational use.” In fact, this is more common than you might think. It is estimated that 1 in 5 men ages 18-30 years have tried one of these erection pills for fun. But we know even more. Men claim that the pills prevent sexual failure and improve sexual performance and stamina. And, these pills tend to be used with other recreational drugs and alcohol that can decrease erections. More concerning however, is the well-defined association between illicit drugs, PDE5is and an increase in unsafe sexual behavior and increased HIV transmission.

In the simplest scenario, when they are taken in isolation by healthy young men, there may be a shorter latency period (“down time”) between ejaculation and the next erection. Others observe that the time to ejaculation can be extended.

But, for the most part, a normal erection is a normal erection and these pills would not be expected to offer much benefit to men who don’t really need them. In such cases, the common side effects of these medications such as headaches, facial flushing, nasal stuffiness, upset stomach may be more evident.

Goal: Trying it for Special Situations

Some men need a little help with erections. They may have normal erections at times but at other times, it’s not quite up to speed. This is termed situational erectile dysfunction. Whether it’s early in the relationship, associated with condom use or because of scheduled sex needed to conceive, the associated stress can be a killjoy. For these men, the PDE5is can be man’s best friend since 90-95% of men will recover normal, on-demand erections. Again, if the PDE5is are not really “needed” the side effect profile of these agents can be bothersome and limit their use.

Goal: Trying it Because You Need it

It is for men with true erectile dysfunction that these pills are intended. For those unable to achieve or maintain an erection, these pills are a holy grail. In fact, from 60-85% of men with erectile dysfunction will respond to the PDE5is as first line therapy, a great achievement for any pill. Unfortunately, men in this category may also have associated medical conditions such as diabetes, cholesterol imbalance or heart disease that make medical supervision of patients mandatory. In addition, other medications, including statins (cholesterol lowering) drugs, diltiazem, Zoloft and protease inhibitors to name a few, can interact with PDE5is and affect drug metabolism and produce, at times, life-threatening side effects. Clearly, doctors need to be involved in determining whether or not a patient should consider PDE5is for erectile dysfunction.

The reason these drugs are so popular is obvious. In the words of the self-help author Wayne Dyer, men fully realize that “miracles come in moments. Be ready and willing.”

Diabetes Mellitus: The Infertility Triple Threat

Paul Turek, MD — Mon, 26 Mar 2012 15:00:55 +0000

Colors as possibility. Feathers in a kite shop, Beijing, China

Based on the feedback received from doctors reading the blog, we are introducing a new feature: Case of the Month. This Case of the Month is an actual patient from The Turek Clinic. It is presented to recognize American Diabetes Association Alert Day.

The Case of Male Infertility

He is a 31-year old who has been trying to conceive with his 28-year old wife for 2 years. During this time, he has noticed a lower sex drive and has had trouble ejaculating. His medical history is negative except for a 6-year history of diabetes mellitus that is well controlled with insulin injections. Exacerbated, he states “I really don’t know what’s happening to me!”

Upon further questioning, the sex drive issue started even before they were trying to conceive. Regarding ejaculation, the patient states that his erections are not very strong and, although he has the sensation of climax, nothing comes out of the penis with ejaculation. In fact, he is concerned that things might be “backing up” in his body with these symptoms.

A Short Review of Diabetes

First identified as a disease of “sweet urine” in ancient times, diabetes mellitus a metabolic disease characterized by high blood sugar (glucose) levels. It is one of the most common medical diseases in the U.S., affecting 26 million adults and children or about 8% of the population. Among those affected, about 15 million are people of reproductive age.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. When the blood glucose rises, say after eating food, insulin is released to decrease the glucose level. In patients with diabetes, there is low or no production of insulin and therefore blood sugar levels are elevated. The sugars spill into the urine, hence the term “sweet urine.” Diabetes is currently a chronic medical condition that is not curable.

Can Diabetes Cause Infertility?

You bet. Diabetes causes male infertility in three ways:

Causes erectile dysfunction-by affecting the health of small blood vessels and lowering testosterone levels
Lowers sex drive-by lowering testosterone levels
Reduces ejaculate volume-by affecting the small nerves that control ejaculation and by lowering testosterone levels

Indeed, this patient had all three issues at the same time along with a low testosterone level. Fortunately, these symptoms are fairly easy to correct with oral medications:

Erectile dysfunction- Viagra, Cialis or Levitra can restore erections
Sex drive and low testosterone-Selective estrogen receptor modulators (i.e. off label use of clomiphene citrate) can correct testosterone deficiency
Ejaculate volume is low because it is emptying backwards into the bladder instead of forward into the penis. This can be treated with over the counter cold medication (alpha agonists) to restore the normal direction of ejaculate flow.

Sure enough, with this combination of pills, the infertility “hat trick” induced by diabetes was overcome and the patient was able to conceive naturally after several months. Another family holiday card on its way to The Turek Clinic this year!

Remember that about 1/3 of infertility is male driven. And diabetes is both a common and quite treatable cause of infertility. So, do yourself and your future family a favor and take the Diabetes Risk Test today.

On Matters of Size

Paul Turek, MD — Sat, 21 May 2011 06:39:35 +0000

Priapus, the Greek God who weighed his member against gold.

I know that you have been waiting for this post for a good 2 years. Men are constantly reminded that women think that size matters, which plays beautifully into their fear of inadequacy. Well, here is the real skinny on size.

A Study of Penile Length

My colleagues at UCSF performed a nice study to address this issue about 15 years ago. They were seeing many patients who had disastrous surgical attempts at penile “augmentation” or enlargement and felt the need to define what was “normal” to give some frame of reference to the issue.

The study examined penile length, both flaccid and erect, in 80 adult men of different ages and ethnicities. The authors were careful to account for the thickness of the pubic fat pad above the penis that can often “bury” the base of the penis as men age or gain weight. They measured the top of the penis from the skin where the penis joins the body, down to the tip of the penis (urethra).

Putting a little science behind the sex was quite revealing. The average length of a flaccid (limp) penis was a little less than 3.5 inches (8.8 cm). Likewise, the average length of an erect penis was 5 inches (12.9 cm). Notably, they found that the length of the flaccid penis did not accurately predict the length of the penis when erect. In fact, in many cases, smaller flaccid penises tended to increase much more in size with erection than longer ones. Lastly, they defined a short penis as that having a flaccid length of <1.6 inches (4 cm) and an erect length of <2.9 inches (7.5 cm). Interestingly, the authors also observed that “the anxiety regarding phallic size ha[d] little relationship to true penile length.”

So, go ahead, grab a tape measure and assess your own trouser trout. I’d bet you 100 to 1 that you fall into the normal range. And, if you can hang a towel off of it or use it as a kickstand while sleeping on your side, more power to you.

Six More Truths About the Male Member

In humans, most penis growth occurs between infancy and age 5 years, and again 5 years after puberty starts.
Assuming puberty is complete, age does not correlate with penis size.
The human penis is both longer and thicker than that of any other primate relative to the size of the rest of the body.
There is no demonstrated relationship between penis size and race or ethnicity.
Flaccid penis length is a poor estimate of erect length.
Many men who believe that their penis is of inadequate size actually have average-sized penises.

It is my hope that through this little biology lesson, I help put things into perspective here. My advice: stop worrying about the size of your bat and focus on the way you swing it.

Freud’s Vasectomy

Paul Turek, MD — Mon, 26 Jul 2010 03:06:14 +0000

A man looking for his mojo.

Do you know why Sigmund Freud, esteemed psychoanalyst, had a vasectomy when he was 67 years old? How about William Butler Yeats, the famed writer, having his vasectomy at 69 years of age. Were they that sexually active and worried about conceiving? God bless them if this is true!

Hardly. Believe it or not, vasectomies were done in the roaring twenties and thirties in Austria by an endocrinologist named Steinach for physical and mental rejuvenation. “It revived my creative power,” wrote Yeats in 1937. This may be true as Yeats wrote a crop of poems during this period that rank with his best work. At that time, a vasectomy was considered the “holy grail” of perpetual youth. Steinach felt that by blocking sperm flow, male hormone production in the testis would improve.

The idea of hormonal rejuvenation really started in earnest with an acclaimed endocrinologist named Brown-Sequard who in 1889 injected himself with testicular extracts from rats and dogs. This led to the trend of “organotherapy” in which all sorts of animal organs were injected for every conceivable human illness. Sound familiar at all? It also led to serious and productive experimental research on the function of glands in the body.

The rejuvenating vasectomy was not an isolated claim to fame by Eugen Steinach from Vienna. He was nominated for a Nobel Prize six times for innovative studies that showed that male or female development depended almost entirely on the sex glands and their secretions. Give this theory a pinch of salt to incorporate modern genetics and is it true enough today.

What went wrong with Steinbach’s vasectomy idea was that he believed that narrow biologic principles could be used to treat the wide and complex condition of human sexuality. The funny thing is, almost 100 years later, we are still trying to figure out how to stay young forever.

Synthetic Cells: The Latest Vinyl?

Paul Turek, MD — Mon, 24 May 2010 05:16:26 +0000

Synthetic cells: true science or fashion vinyl?

Believe it or not, science has now claimed to have made “synthetic life.” Life created from non-living substances. J Craig Venter and colleagues, after a decade of work, produced a man-made version of the entire DNA content (genome) of a bacteria (adding in a couple of harmless “watermarks” to track it) and inserted it into the shell of another bacteria after removing its DNA. And, lo and behold, the artificial genome starting making proteins and the man-made bacteria began to replicate.

You may remember Craig Venter as the man in corporate biotech a decade back who challenged the U.S. government in a race to completely encode the entire human genome. The Human Genome Project was completed in 2003 and jointly announced. This is a beautiful thing but Venter wanted to “own” and patent the human genome and charge others for using it as a resource whereas the U.S. government insisted that it be made publicly available, which it is.

Is this really synthetic life? No. Essentially, Venter performed the equivalent of gutting a computer and then entirely reprogramming it. Is this an important scientific achievement? Absolutely, a tour de force, since technology has been limiting this work for years. Recently, however, there has been a 100-fold increase in the length of genetic material that can be manufactured from raw chemicals in the lab. Without a doubt, science has been dreaming about this kind of work for three decades and recombinant DNA technology is an early product of this movement.

So, an entirely “artificial cell” was not produced by Venter, as the control station was man-made, but the rest of the cell was not. My only hope is that this is not just another “pleather” (plastic and leather) product in our lives. As Lily Tomlin said: “[even] vinyl leopard skin is becoming an endangered synthetic.” On the contrary, this work may have advance science sufficiently to begin the manufacture of designer cells, good or bad, that can clean up oil spills, dynamite and waste water, dispose of nuclear waste and deliver antibiotics, chemotherapy, testosterone or Viagra to hard to reach but important areas of the body.

What Comes After the Pill?

Paul Turek, MD — Sun, 15 Nov 2009 22:52:57 +0000

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.

The Agents of Erection

Paul Turek, MD — Mon, 24 Aug 2009 16:04:12 +0000

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.

Sexual Health Pop Quiz #2

Paul Turek, MD — Mon, 20 Jul 2009 15:25:46 +0000

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.