Acupuncture may help some men overcome infertility problems by improving the quality of their sperm, according to a new study.
Researchers found five weeks of acupuncture treatment reduced the number of structural abnormalities in sperm and increased the overall number of normal sperm in a group of men with infertility problems.
They say the results suggest that acupuncture may complement traditional infertility treatments and help men reach their full reproductive potential.
Acupuncture May Ease Male Infertility
An estimated 10% of men are infertile, and the male partner is a factor in up to 50% of infertile couples, write the researchers. In many cases, the cause of male infertility is unknown.
Previous studies of acupuncture and male infertility have suggested that acupuncture can improve sperm production and motility (a measure of sperm movement).
In this study, researchers looked at the effects of acupuncture on the structural health of sperm in men with infertility of unknown cause. The findings appear in the July issue of Fertility and Sterility.
Twenty-eight infertile men received acupuncture treatments twice a week for five weeks, and 12 received no treatment and served as a comparison group.
Researchers analyzed sperm samples at the beginning and end of the study and found significant improvements in sperm quality in the acupuncture group compared with the other group.
Acupuncture treatment was associated with fewer structural defects in the sperm and an increase in the number of normal sperm in ejaculate.
But other sperm abnormalities, such as immature sperm or sperm death, were unaffected by acupuncture.
The researchers write that acupuncture treatment is a simple, noninvasive method that can improve sperm quality.
Tuesday, March 27, 2007
PSA Screening Fails Says Creator
"My one wish with prostate cancer," says Dr. Thomas Stamey, a veteran researcher at Stanford University, "is that before a doctor does anything aggressive, he would tell his patient that all men will develop the disease eventually." He pauses to let the bad news sink in. "The good news," he wants doctors to add, "is that the rate of dying from prostate cancer is infinitesimal."
Stamey has been in a reflective mood of late because of the growing realization, by him and others, that the screening test he helped discover is far less useful for detecting prostate cancer than many had once believed. In 1987, a team led by Stamey found that high levels of prostate-specific antigen (PSA) circulating in the blood were a strong indication of prostate tumors.
Before then, the only way to detect prostate cancer was with a painful biopsy, and this is still used to confirm the disease. But with a simple PSA test , doctors thought they could weed out men who don't need the more invasive procedure, as well as spot tumors at an earlier, more treatable stage.
The test has proven a powerful draw: about half of all men over the age of 50 get annual PSA tests. Now, Stamey hopes that men will be open to the older means of screening for prostate cancer.
"I don't think PSA adds very much," he says.
The End of the PSA Era?
These second thoughts stem from a troubling variety of evidence that suggests widespread testing is possibly causing more harm than good. Although death rates from prostate cancer are lower than they were before PSA screening, these rates have also declined in countries where this type of testing is not commonly used.
If one were to randomly biopsy men, as Dr. Wael Sakr of Wayne State University did on a group who were accidentally killed on the streets of Detroit, about 8 percent of those in their 20s would have prostate cancer, with the rates steadily increasing as men age. Indeed, about 80 percent will develop the disease by the age of 70.
Some of these tumors are clearly dangerous. But most are slow moving, and many prostate cancer patients can go 20 years without any need for treatment, according to a recent study led by Dr. Peter Albertson. With widespread PSA screening picking up these relatively benign tumors, Stamey fears that the tests are leading to unnecessary treatment and worry.
"I've been as guilty as anyone else," he says.
Not everyone is willing to give up on PSA screening quite yet.
"We know it's not a perfect test," says Jamie Bearse, a spokesperson for National Prostate Cancer Coalition, which advocates annual PSA screening for men 40 years and older. Bearse is hopeful that newer screening tests will prove more discerning. In the meantime, he says, the PSA test is the best early detection option men have. "They would rather know, than not know."
Normal vs. Abnormal PSA
Yet it is increasingly hard to determine even a broad risk prediction from PSA testing. Traditionally, doctors used a PSA measurement of 4 as a key cut off point: lower than 4 nanograms per milliliter (ng/mL) in the blood meant that men were considered cancer free, whereas higher or equal to 4 suggested the need for a biopsy to confirm the disease.
But looking at nearly 5,500 men who had a PSA test and then at least one biopsy, researchers found this cutoff point often missed tumors or implied that men had cancers that weren't in fact really there, according to recent results published in the Journal of the American Medical Association.
Indeed, a PSA level of 4.1 ng/mL accurately predicts only 20 percent of prostate cancers and leads to false alarms about 6 percent of the time. Lowering the threshold will detect more cancers, but at the price of causing men to undergo biopsies for no reason or finding many benign tumors that only need to be monitored. A PSA cutoff of 2.1, for example, would yield false readings more than 85 percent of the time to catch only slightly more than half of all tumors.
The authors of the study, led by Dr. Ian Thompson of the University of Texas Health Science Center in San Antonio, call for a substantial "reeducation" effort on the increasingly murky role of PSA. "It will be a challenge to the medical community to change the long held notion that there is a 'normal' PSA level," the authors write.
Researchers still hold out hope for measuring PSA velocity, the rise of PSA over time that gives an indication if the tumor is growing. As an initial detection tool, Stamey says that doctors should return to looking at increasing age, along with a family history of the disease, as a way of determining who may be at greater risk for prostate cancer and in need of a biopsy to catch tumors early.
Other than that, he adds, "We have as much a way of predicting who will need a biopsy based on looking at someone's eyes." Ongoing studies are continuing to look at whether PSA testing saves lives, and the American Cancer Society and other test supporters urge men to discuss the pros and cons of screening with their doctors. But the creator of the PSA test is calling for the end.
"All men will develop a prostate cancer," says Stamey. "That's a given."
Stamey has been in a reflective mood of late because of the growing realization, by him and others, that the screening test he helped discover is far less useful for detecting prostate cancer than many had once believed. In 1987, a team led by Stamey found that high levels of prostate-specific antigen (PSA) circulating in the blood were a strong indication of prostate tumors.
Before then, the only way to detect prostate cancer was with a painful biopsy, and this is still used to confirm the disease. But with a simple PSA test , doctors thought they could weed out men who don't need the more invasive procedure, as well as spot tumors at an earlier, more treatable stage.
The test has proven a powerful draw: about half of all men over the age of 50 get annual PSA tests. Now, Stamey hopes that men will be open to the older means of screening for prostate cancer.
"I don't think PSA adds very much," he says.
The End of the PSA Era?
These second thoughts stem from a troubling variety of evidence that suggests widespread testing is possibly causing more harm than good. Although death rates from prostate cancer are lower than they were before PSA screening, these rates have also declined in countries where this type of testing is not commonly used.
If one were to randomly biopsy men, as Dr. Wael Sakr of Wayne State University did on a group who were accidentally killed on the streets of Detroit, about 8 percent of those in their 20s would have prostate cancer, with the rates steadily increasing as men age. Indeed, about 80 percent will develop the disease by the age of 70.
Some of these tumors are clearly dangerous. But most are slow moving, and many prostate cancer patients can go 20 years without any need for treatment, according to a recent study led by Dr. Peter Albertson. With widespread PSA screening picking up these relatively benign tumors, Stamey fears that the tests are leading to unnecessary treatment and worry.
"I've been as guilty as anyone else," he says.
Not everyone is willing to give up on PSA screening quite yet.
"We know it's not a perfect test," says Jamie Bearse, a spokesperson for National Prostate Cancer Coalition, which advocates annual PSA screening for men 40 years and older. Bearse is hopeful that newer screening tests will prove more discerning. In the meantime, he says, the PSA test is the best early detection option men have. "They would rather know, than not know."
Normal vs. Abnormal PSA
Yet it is increasingly hard to determine even a broad risk prediction from PSA testing. Traditionally, doctors used a PSA measurement of 4 as a key cut off point: lower than 4 nanograms per milliliter (ng/mL) in the blood meant that men were considered cancer free, whereas higher or equal to 4 suggested the need for a biopsy to confirm the disease.
But looking at nearly 5,500 men who had a PSA test and then at least one biopsy, researchers found this cutoff point often missed tumors or implied that men had cancers that weren't in fact really there, according to recent results published in the Journal of the American Medical Association.
Indeed, a PSA level of 4.1 ng/mL accurately predicts only 20 percent of prostate cancers and leads to false alarms about 6 percent of the time. Lowering the threshold will detect more cancers, but at the price of causing men to undergo biopsies for no reason or finding many benign tumors that only need to be monitored. A PSA cutoff of 2.1, for example, would yield false readings more than 85 percent of the time to catch only slightly more than half of all tumors.
The authors of the study, led by Dr. Ian Thompson of the University of Texas Health Science Center in San Antonio, call for a substantial "reeducation" effort on the increasingly murky role of PSA. "It will be a challenge to the medical community to change the long held notion that there is a 'normal' PSA level," the authors write.
Researchers still hold out hope for measuring PSA velocity, the rise of PSA over time that gives an indication if the tumor is growing. As an initial detection tool, Stamey says that doctors should return to looking at increasing age, along with a family history of the disease, as a way of determining who may be at greater risk for prostate cancer and in need of a biopsy to catch tumors early.
Other than that, he adds, "We have as much a way of predicting who will need a biopsy based on looking at someone's eyes." Ongoing studies are continuing to look at whether PSA testing saves lives, and the American Cancer Society and other test supporters urge men to discuss the pros and cons of screening with their doctors. But the creator of the PSA test is calling for the end.
"All men will develop a prostate cancer," says Stamey. "That's a given."
Jerry Lewis Tells of Four-Decade Battle with Chronic Pain
Comic legend Jerry Lewis showed his serious side when he spoke to a rapt audience in Manhattan this week. In fact, he had something in common with almost everyone who came to see him: life-shattering chronic pain. Lewis had an important message: chronic pain is a horrendous burden, but it can be vanquished with the help of a doctor specializing in pain management and the right treatment. A panel of pain management specialists and patients followed Lewis’ emotional presentation.
Lewis explained that his trademark falls, a stunt that made audiences laugh throughout his career, took a terrible toll on his back. Over the years, it kept getting worse, but the “adrenaline rush” made it possible for him to perform. “From 1965 to two years ago, I had the kind of excruciating pain that drove me one minute away from suicide.” If his daughter hadn’t found him with a gun and stopped him, it would all be over, he said.
Dr. Philip Wagner, a pain management specialist at the Hospital for Special Surgery in Manhattan who was on the panel, says chronic pain is grossly undertreated in the United States. And when people fail to find the right doctor and continue to suffer, many feel suicide is their only escape.
Chronic pain is defined as pain that recurs or persists for at least six months. Experts believe it affects 70 million Americans. “For many, it really is a tragedy,” Wagner says. “Advances in the understanding and treatment of chronic pain can significantly improve quality of life, but many people don’t get the help they need. It is important for them to find a caring physician specializing in pain management.”
Most doctors receive little training in the area of pain control, according to Wagner. Pain management is a licensed medical subspecialty that requires extra training. Wagner is an anesthesiologist and internist with a special credential in pain management.
Of the 150 people who came to the conference, many carried canes to help them walk. Others arrived in wheelchairs. Loved ones attended to get information for family members. There seemed to be a sad solidarity among the people in the audience. Some of those who asked questions of the speakers seemed resigned to their suffering, others had a quiet desperation in their voices.
But Jerry Lewis gave them a message of hope and said he was at the conference “to give something back.” After 37 years of suffering and countless doctors’ visits, he finally found relief in the form of a device called a neurostimulator. Permanently implanted near his spine, the device sends mild electrical impulses to the spinal cord to prevent pain signals from traveling to the brain. Lewis controls the electrical impulses by pressing a button. “My whole body tingles… and it opens my garage door,” he joked.
Fifty-three year-old Susan Herfield of Woodbury, Long Island, also told the audience she was helped by the neurostimulator. But not before six years of suffering, after she tripped on a curb and broke her foot. Herfield has a disease called reflex sympathetic dystrophy or RSD. Most often, it develops after an injury and leads to unrelenting pain. After the initial injury heals, the body plays a cruel trick. Nerves misfire and pain signals go awry, continuing to travel to the brain from the injury site. Herfield says excruciating pain tormented her day and night, bringing her to the brink of suicide. “If I didn’t have a family, I would have killed myself,” she said. “It was raw nerve-ending pain – the worst pain that anyone could ever feel.” She said the neurostimulator gave her life back to her.
Wagner cautioned that although many people are helped by the neurostimulator, not everyone is a candidate. It is generally used to treat pain in the back or limbs. But numerous other treatments are available, including pain medications, nerve blocks and complementary therapies, such as relaxation techniques. “People with chronic pain should find a caring doctor with whom they feel comfortable and who acts as a partner in their care,” he said.
Although chronic pain cannot always be completely eliminated, the idea is to help people become more functional and have the life they want to live, according to Wagner. Unfortunately, misconceptions about chronic pain prevent many people from getting the help they need.
Contrary to popular belief, pain medications are not addictive in appropriate cases and help many people to lead satisfying lives, Wagner says. Other myths about chronic pain can be just as damaging, he says. “Sometimes, if the precise medical cause can’t be found, there’s this erroneous notion that the pain is not real. Any time a doctor tells a patient that the pain is ‘in their head,’ he should look for another physician.” Wagner says anyone who believes chronic pain is something they’ll just have to live with is also mistaken. It is not a sign of weakness to seek treatment, and people should not stop until they find a doctor who helps them. Jerry Lewis would surely agree.
Lewis explained that his trademark falls, a stunt that made audiences laugh throughout his career, took a terrible toll on his back. Over the years, it kept getting worse, but the “adrenaline rush” made it possible for him to perform. “From 1965 to two years ago, I had the kind of excruciating pain that drove me one minute away from suicide.” If his daughter hadn’t found him with a gun and stopped him, it would all be over, he said.
Dr. Philip Wagner, a pain management specialist at the Hospital for Special Surgery in Manhattan who was on the panel, says chronic pain is grossly undertreated in the United States. And when people fail to find the right doctor and continue to suffer, many feel suicide is their only escape.
Chronic pain is defined as pain that recurs or persists for at least six months. Experts believe it affects 70 million Americans. “For many, it really is a tragedy,” Wagner says. “Advances in the understanding and treatment of chronic pain can significantly improve quality of life, but many people don’t get the help they need. It is important for them to find a caring physician specializing in pain management.”
Most doctors receive little training in the area of pain control, according to Wagner. Pain management is a licensed medical subspecialty that requires extra training. Wagner is an anesthesiologist and internist with a special credential in pain management.
Of the 150 people who came to the conference, many carried canes to help them walk. Others arrived in wheelchairs. Loved ones attended to get information for family members. There seemed to be a sad solidarity among the people in the audience. Some of those who asked questions of the speakers seemed resigned to their suffering, others had a quiet desperation in their voices.
But Jerry Lewis gave them a message of hope and said he was at the conference “to give something back.” After 37 years of suffering and countless doctors’ visits, he finally found relief in the form of a device called a neurostimulator. Permanently implanted near his spine, the device sends mild electrical impulses to the spinal cord to prevent pain signals from traveling to the brain. Lewis controls the electrical impulses by pressing a button. “My whole body tingles… and it opens my garage door,” he joked.
Fifty-three year-old Susan Herfield of Woodbury, Long Island, also told the audience she was helped by the neurostimulator. But not before six years of suffering, after she tripped on a curb and broke her foot. Herfield has a disease called reflex sympathetic dystrophy or RSD. Most often, it develops after an injury and leads to unrelenting pain. After the initial injury heals, the body plays a cruel trick. Nerves misfire and pain signals go awry, continuing to travel to the brain from the injury site. Herfield says excruciating pain tormented her day and night, bringing her to the brink of suicide. “If I didn’t have a family, I would have killed myself,” she said. “It was raw nerve-ending pain – the worst pain that anyone could ever feel.” She said the neurostimulator gave her life back to her.
Wagner cautioned that although many people are helped by the neurostimulator, not everyone is a candidate. It is generally used to treat pain in the back or limbs. But numerous other treatments are available, including pain medications, nerve blocks and complementary therapies, such as relaxation techniques. “People with chronic pain should find a caring doctor with whom they feel comfortable and who acts as a partner in their care,” he said.
Although chronic pain cannot always be completely eliminated, the idea is to help people become more functional and have the life they want to live, according to Wagner. Unfortunately, misconceptions about chronic pain prevent many people from getting the help they need.
Contrary to popular belief, pain medications are not addictive in appropriate cases and help many people to lead satisfying lives, Wagner says. Other myths about chronic pain can be just as damaging, he says. “Sometimes, if the precise medical cause can’t be found, there’s this erroneous notion that the pain is not real. Any time a doctor tells a patient that the pain is ‘in their head,’ he should look for another physician.” Wagner says anyone who believes chronic pain is something they’ll just have to live with is also mistaken. It is not a sign of weakness to seek treatment, and people should not stop until they find a doctor who helps them. Jerry Lewis would surely agree.
Saturday, March 17, 2007
Peyronie's Disease
Peyronie's disease, a condition of uncertain cause, is characterized by a plaque, or hard lump, that forms on the penis. The plaque develops on the upper or lower side of the penis in layers containing erectile tissue. It begins as a localized inflammation and can develop into a hardened scar.
Peyronie's disease often occurs in a mild form that heals without treatment in 6 to 15 months. But in severe cases, the hardened plaque reduces flexibility, causing pain and forcing the penis to bend or arc during erection.
The plaque itself is benign, or noncancerous. A plaque on the top of the shaft (most common) causes the penis to bend upward; a plaque on the underside causes it to bend downward. In some cases, the plaque develops on both top and bottom, leading to indentation and shortening of the penis. At times, pain, bending, and emotional distress prohibit sexual intercourse.
One study found Peyronie's disease occurring in 1 percent of men. Although the disease occurs mostly in middle-aged men, younger and older men can acquire it. About 30 percent of people with Peyronie's disease develop fibrosis (hardened cells) in other elastic tissues of the body, such as on the hand or foot. A common example is a condition known as Dupuytren's contracture of the hand. In some cases, men who are related by blood tend to develop Peyronie's disease, which suggests that familial factors might make a man vulnerable to the disease.
Men with Peyronie's disease usually seek medical attention because of painful erections and difficulty with intercourse. Since the cause of the disease and its development are not well understood, doctors treat the disease empirically; that is, they prescribe and continue methods that seem to help. The goal of therapy is to keep the Peyronie's patient sexually active. Providing education about the disease and its course often is all that is required. No strong evidence shows that any treatment other than surgery is effective. Experts usually recommend surgery only in long-term cases in which the disease is stabilized and the deformity prevents intercourse.
A French surgeon, François de la Peyronie, first described Peyronie's disease in 1743. The problem was noted in print as early as 1687. Early writers classified it as a form of impotence. Peyronie's disease can be associated with impotence; however, experts now recognize impotence as one factor associated with the disease--a factor that is not always present.
Course of the Disease.
Many researchers believe the plaque of Peyronie's disease develops following trauma (hitting or bending) that causes localized bleeding inside the penis. A chamber (actually two chambers known as the corpora cavernosa) runs the length of the penis. The inner-surface membrane of the chamber is a sheath of elastic fibers. A connecting tissue, called a septum, runs along the center of the chamber and attaches at the top and bottom.
If the penis is abnormally bumped or bent, an area where the septum attaches to the elastic fibers may stretch beyond a limit, injuring the lining of the erectile chamber and, for example, rupturing small blood vessels. As a result of aging, diminished elasticity near the point of attachment of the septum might increase the chances of injury.
The damaged area might heal slowly or abnormally for two reasons: repeated trauma and a minimal amount of blood-flow in the sheath-like fibers. In cases that heal within about a year, the plaque does not advance beyond an initial inflammatory phase. In cases that persist for years, the plaque undergoes fibrosis, or formation of tough fibrous tissue, and even calcification, or formation of calcium deposits.
While trauma might explain acute cases of Peyronie's disease, it does not explain why most cases develop slowly and with no apparent traumatic event. It also does not explain why some cases disappear quickly, and why similar conditions such as Dupuytren's contracture do not seem to result from severe trauma.
Treatment.
Because the plaque of Peyronie's disease often shrinks or disappears without treatment, medical experts suggest waiting 1 to 2 years or longer before attempting to correct it surgically. During that wait, patients often are willing to undergo treatments that have unproven effectiveness.
Some researchers have given men with Peyronie's disease vitamin E orally in small-scale studies and have reported improvements. Yet, no controlled studies have established the effectiveness of vitamin E therapy. Similar inconclusive success has been attributed to oral application of para-aminobenzoate, a substance belonging to the family of B-complex molecules.
Researchers have injected chemical agents such as collagenase, dimethyl sulfoxide, steroids, and calcium channel blockers directly into the plaques. None of these has produced convincing results. Steroids, such as cortisone, have produced unwanted side effects, such as atrophy, or death of healthy tissues. Perhaps the most promising directly injected agent is collagenase, an enzyme that attacks collagen, the major component of Peyronie's plaques.
Radiation therapy, in which high-energy rays are aimed at the plaque, also has been used. Like some of the chemical treatments, radiation appears to reduce pain, yet it has no effect on the plaque itself and can cause unwelcome side effects. Currently, none of the treatments mentioned here has equalled the body's natural ability to eliminate Peyronie's disease. The variety of agents and methods used points to the lack of a proven, effective treatment.
Peyronie's disease has been treated with some success by surgery. The two most common surgical methods are: removal or expansion of the plaque followed by placement of a patch of skin or artificial material, and removal or pinching of tissue from the side of the penis opposite the plaque, which cancels out the bending effect. The first method can involve partial loss of erectile function, especially rigidity. The second method, known as the Nesbit procedure, causes a shortening of the erect penis.
Some men choose to receive an implanted device that increases rigidity of the penis. In some cases, an implant alone will straighten the penis adequately. In other cases, implantation is combined with a technique of incisions and grafting or plication (pinching or folding the skin) if the implant alone does not straighten the penis.
Most types of surgery produce positive results. But because complications can occur, and because many of the phenomena associated with Peyronie's disease (for example, shortening of the penis) are not corrected by surgery, most doctors prefer to perform surgery only on the small number of men with curvature so severe that it prevents sexual intercourse.
Peyronie's disease often occurs in a mild form that heals without treatment in 6 to 15 months. But in severe cases, the hardened plaque reduces flexibility, causing pain and forcing the penis to bend or arc during erection.
The plaque itself is benign, or noncancerous. A plaque on the top of the shaft (most common) causes the penis to bend upward; a plaque on the underside causes it to bend downward. In some cases, the plaque develops on both top and bottom, leading to indentation and shortening of the penis. At times, pain, bending, and emotional distress prohibit sexual intercourse.
One study found Peyronie's disease occurring in 1 percent of men. Although the disease occurs mostly in middle-aged men, younger and older men can acquire it. About 30 percent of people with Peyronie's disease develop fibrosis (hardened cells) in other elastic tissues of the body, such as on the hand or foot. A common example is a condition known as Dupuytren's contracture of the hand. In some cases, men who are related by blood tend to develop Peyronie's disease, which suggests that familial factors might make a man vulnerable to the disease.
Men with Peyronie's disease usually seek medical attention because of painful erections and difficulty with intercourse. Since the cause of the disease and its development are not well understood, doctors treat the disease empirically; that is, they prescribe and continue methods that seem to help. The goal of therapy is to keep the Peyronie's patient sexually active. Providing education about the disease and its course often is all that is required. No strong evidence shows that any treatment other than surgery is effective. Experts usually recommend surgery only in long-term cases in which the disease is stabilized and the deformity prevents intercourse.
A French surgeon, François de la Peyronie, first described Peyronie's disease in 1743. The problem was noted in print as early as 1687. Early writers classified it as a form of impotence. Peyronie's disease can be associated with impotence; however, experts now recognize impotence as one factor associated with the disease--a factor that is not always present.
Course of the Disease.
Many researchers believe the plaque of Peyronie's disease develops following trauma (hitting or bending) that causes localized bleeding inside the penis. A chamber (actually two chambers known as the corpora cavernosa) runs the length of the penis. The inner-surface membrane of the chamber is a sheath of elastic fibers. A connecting tissue, called a septum, runs along the center of the chamber and attaches at the top and bottom.
If the penis is abnormally bumped or bent, an area where the septum attaches to the elastic fibers may stretch beyond a limit, injuring the lining of the erectile chamber and, for example, rupturing small blood vessels. As a result of aging, diminished elasticity near the point of attachment of the septum might increase the chances of injury.
The damaged area might heal slowly or abnormally for two reasons: repeated trauma and a minimal amount of blood-flow in the sheath-like fibers. In cases that heal within about a year, the plaque does not advance beyond an initial inflammatory phase. In cases that persist for years, the plaque undergoes fibrosis, or formation of tough fibrous tissue, and even calcification, or formation of calcium deposits.
While trauma might explain acute cases of Peyronie's disease, it does not explain why most cases develop slowly and with no apparent traumatic event. It also does not explain why some cases disappear quickly, and why similar conditions such as Dupuytren's contracture do not seem to result from severe trauma.
Treatment.
Because the plaque of Peyronie's disease often shrinks or disappears without treatment, medical experts suggest waiting 1 to 2 years or longer before attempting to correct it surgically. During that wait, patients often are willing to undergo treatments that have unproven effectiveness.
Some researchers have given men with Peyronie's disease vitamin E orally in small-scale studies and have reported improvements. Yet, no controlled studies have established the effectiveness of vitamin E therapy. Similar inconclusive success has been attributed to oral application of para-aminobenzoate, a substance belonging to the family of B-complex molecules.
Researchers have injected chemical agents such as collagenase, dimethyl sulfoxide, steroids, and calcium channel blockers directly into the plaques. None of these has produced convincing results. Steroids, such as cortisone, have produced unwanted side effects, such as atrophy, or death of healthy tissues. Perhaps the most promising directly injected agent is collagenase, an enzyme that attacks collagen, the major component of Peyronie's plaques.
Radiation therapy, in which high-energy rays are aimed at the plaque, also has been used. Like some of the chemical treatments, radiation appears to reduce pain, yet it has no effect on the plaque itself and can cause unwelcome side effects. Currently, none of the treatments mentioned here has equalled the body's natural ability to eliminate Peyronie's disease. The variety of agents and methods used points to the lack of a proven, effective treatment.
Peyronie's disease has been treated with some success by surgery. The two most common surgical methods are: removal or expansion of the plaque followed by placement of a patch of skin or artificial material, and removal or pinching of tissue from the side of the penis opposite the plaque, which cancels out the bending effect. The first method can involve partial loss of erectile function, especially rigidity. The second method, known as the Nesbit procedure, causes a shortening of the erect penis.
Some men choose to receive an implanted device that increases rigidity of the penis. In some cases, an implant alone will straighten the penis adequately. In other cases, implantation is combined with a technique of incisions and grafting or plication (pinching or folding the skin) if the implant alone does not straighten the penis.
Most types of surgery produce positive results. But because complications can occur, and because many of the phenomena associated with Peyronie's disease (for example, shortening of the penis) are not corrected by surgery, most doctors prefer to perform surgery only on the small number of men with curvature so severe that it prevents sexual intercourse.
Circumcision. A Barbaric Practice, A Human Rights Violation
I'm going to raise an issue a lot of women and men would rather not think about. Circumcision (also known as male genital mutilation, or "MGM"). I think there are several reasons it's difficult to talk about. First of all, it involves male genitals, which we don't usually like to discuss in polite society. Secondly, it involves a very painful operation done to children, and we would probably rather not think too much about that. Finally, I think many of us aren't quite sure why we do it, and feel the easier option is just not to discuss it. But I think it's important to look at because in many ways it's revealing about the differences between how we view women and men in this culture, differences which in varying ways harm and limit all of us. Male circumcision is closely connected with is closely connected with other forms of male oppression and has much to teach us about our condition. The simple fact that circumcision can happen in this country is astounding. When we are days old, doctors cut off the most sensitive part of our body without anesthesia. The operation is very violent, performed without anesthesia, and unspeakably painful to the infant. The screams, shaking, and frantic attempt by the newborn to escape this unexpected and unbearable pain can be truly horrible to watch, let alone experience. Concrete medical evidence demonstrates that relative to an adult, the circumcision experience is significantly MORE traumatizing to an infant, who has not yet developed methods to cope with pain and whose neurological pathways are not yet fully developed. Researchers found that circumcised boys exhibited, 4-6 months after their circumcisions, heightened physiological pain responses to inoculation shots as compared to girls and boys who had not had the experience of circumcision. The procedure also can cause a broad range of traumas including serious harm to infant neurological development and memory capability, learned helplessness, weakening of the ego, disturbance of sexual identification, disruption of maternal bonding, distrust, suppression of pain and empathy, damage caused by memories of the procedure, and later damage to self-esteem and body image as well as post-traumatic stress disorders. While societies tend to be blind to the horrors they create themselves, anyone must concede that this is brutal and an act of mutilation. This pain in turn causes permanent and irreversible changes in the developing brain, altering portions of the brain responsible for perceiving pain. Developmental neuro-psychologist James Prescott found that domestic levels of violent crime, particularly violent sex-related crimes such as rape, grew in direct proportion to the rise in the number of sexually active circumcised males in American society.
It is worth remembering that the two developed countries in which circumcision is most widely practiced, Israel and the United States, have what many consider to be two of the most violent governments in the world. On a criminal level, we are probably the most violent developed country. Research has suggested that these facts are connected and not simple coincidence. Psychobiological studies support this theory. Circumcision dates from an age when babies were believed not to feel pain. We now know that this is utter nonsense. Concrete medical evidence demonstrates that relative to an adult, the circumcision experience is significantly more traumatizing to an infant, who has not yet developed methods to cope with pain and whose neurological pathways are not yet fully developed. The harm circumcision causes to babies by the severe levels of pain has been repeatedly documented. As developmental neuro-psychologist James Prescott has documented, the rise in violence in our country, particular sex-related violence such as rape, has occurred in proportion to the increase in the number of sexually active circumcised males in American society. As discussed below, the brutality of the early circumcision strongly appears to be one of many factors affecting men who grow up and eventually give this violence back to society. Research also suggests that circumcision causes behavioral changes and that some reported gender differences may actually be a result of circumcision. As is clear from statements by doctors from that period, circumcision of non-Jews started in this country around 100 years ago as a technique to stop young boys from masturbating by reducing our ability to feel. The pain of the operation was explicitly cited by doctors as one "positive" byproduct of the operation. John Harvey Kellogg, creator of Kellogg's Corn Flakes, originally developed as another measure to stop masturbation (!), said of circumcision, "The operation should be performed without anesthetic, as the pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment." By Reducing masturbation, circumcision would supposedly cure a range of diseases including seizures, hip trouble, imbecility, paralysis, epilepsy, etc. As time went on, whenever any new disease would become a subject of social concern, circumcision would be proposed as a cure. Penile cancer, urinary tract infections, venereal disease, AIDS, even uterine cancer in women having sexual relations with men--there was no limit to what this procedure could supposedly cure. Under standard medical practice, amputation is of course the treatment of last resort, only appropriate when other, more conservative measures have failed to correct an actual disease which threatens survival of the organ or the patient. We should be guided by the sort of abhorrence we would have to a suggestion that, for example, a woman's breasts be lopped off due to the high incidence of breast cancer. The foreskin should not receive any less protection under this principle than is enjoyed by every other organ and tissue of our bodies. In order to examine our society's form of childhood genital cutting, we must know what it is that circumcision actually does. American beliefs that circumcision destroys little tissue, and that the tissue lost is of no particular value, are not confirmed by medical research. Medical researchers recently documented that the average circumcision removes over half the genital tissue and many specialized nerve endings, thereby substantially curtailing sexual sensitivity. We should not forget that circumcision, like any medical procedure, also has complications. These occur at a rate of 2-10% depending on the definition of "complication." At least dozens of baby boys needlessly die in the United States every year due to this procedure. This number cannot be precisely determined due to the medical community's practice of attributing circumcision-caused deaths to other reasons such as "hemorrhage."
Circumcision thus causes harm and carries risks. However, unlike other medical procedures, it does not offer any genuine health benefits. All suggested justifications for routine circumcision throughout its 100-year history in the US have failed, including prevention of alcoholism, epilepsy, plague, paralysis, rheumatism, polio, lunacy, tuberculosis, syphilis, cancer, urinary tract infections, and AIDS. The British Medical Association, Canadian Paediatric Society, Australian College of Paediatrics, and even the American Academy of Pediatrics have stated that there is no justification for routine circumcision. Science has thus begun to turn its attention to male circumcision and has corrected many prior misconceptions which are holdovers from the Nineteenth and early Twentieth Centuries. The procedure causes serious harm and lacks medical justification; it should not be tolerated in any civilized society. But it is a money-making operation here and continues despite many doctors' personal disapproval of the procedure. As medical student Franc Garcia has discussed, male circumcision destroys a male's capacity for certain sexual sensations and dulls other sensations. Doctors and medical students have documented the "triple whammy" of lost sexual sensitivity resulting from circumcision. 1. Loss of the foreskin nerves. The inner foreskin possesses a greater density of nerve endings and is probably more erogenous than even the glans. This tremendous amount of sensitivity is lost completely when the foreskin is amputated. Also, the most sensitive part of the penis, the frenulum of the foreskin, is removed in most infant circumcisions. The frenulum is the continuation of the inner foreskin which attaches to the underside of the glans. Thus, circumcision robs us of a large percentage, if not the majority, of erogenous nerve endings to the penis. 2. Damage to the glans. The erogenous sensitivity that remains after circumcision is primarily in the glans. This is further reduced by the removal of the protective foreskin which leaves the glans permanently exposed. The penis head developed over millions of years of evolution as an internal organ, meant to be safely enclosed by the prepuce. The skin covering of the glans IS the foreskin. The glans becomes artificially keratinized (dry, hardened, discolored, and wrinkled) as a result of permanent exposure, and thus significantly less sensitive. 3. Loss of skin mobility. The nerve endings in the glans are best stimulated by a rolling massage action. Direct friction tends to fire off pain receptors causing irritation and also causes further keratinization of the glans. With the skin system of the penis significantly reduced by circumcision, the mobility is essentially gone and now the penis is a static mass with no dynamic self stimulation mechanism. Direct friction is now the primary form of stimulation. So circumcision further reduces erogenous sensitivity in the penis by reducing skin mobility and thus the ability to use the foreskin to massage the glans. Men circumcised in adulthood have summed up the overall difference in sensation as similar to the contrast between seeing in color and seeing in black and white. There is reason to think the loss may be even greater for men circumcised as infants, as most of us were. Sexual pleasure continues to be reduced as circumcised men age until, in many cases, we are left with relatively little sensation. Like many men in their late thirties or early forties, every day I rediscover firsthand the horror of this procedure. I have noticed a dramatic and heartbreaking loss of sensitivity over the last couple of years. This is due to the continual buildup of layers of keratin over the mucous membrane which remains on our penises after the foreskin is removed. Such damage to the penis as described above has a profound impact on a man's well-being and sense of self. Some men who feel mutilated by their circumcisions have reported feeling depressed to the point of suicidality. Some men who understand themselves to be harmed by their circumcisions report deep rage at their parents and/or physicians. Men experiencing these profound feelings of loss and anger generally have little social support, since circumcision is viewed as benign by most American. Some men, upon revealing their distress at having lost a body part they value, have received cruel responses from counselors. Male and societal denial regarding harm does not negate the harm. There are at least two reasons we have not heard a great deal from men angry about or physically damaged by their circumcision. First, the millions of circumcised men who hate what was done to them do not speak out for fear of ridicule. The second reason is that most men are unaware of what they lost. It is important to remember that not only the male victims but society as a whole is denying the existence of harm, a problem which does not, for example, face incest victims. While there is no intent to compare the incest trauma with the trauma of circumcision, at least as a society we have come to recognize the horror of the former. In societies that cut girls' genitals, there are very few women who object to the cutting. Widespread ignorance of the value and function of the destroyed genital parts, combined with culturally conditioned abhorrence of natural genitalia, perpetuate women's silence. Parallel psychosocial dynamics keep men silent in our culture. Circumcision is one more form of institutionalized violence against men. It is, of course, a myth that violence against women is tolerated while violence against men is opposed by society. If anything, the opposite is true; our legislature has passed the astoundingly sexist Violence Against Women Act. When is the last time you heard a politician proposing legislation to stop violence against men? When did you last hear anyone in power even acknowledge that most violence happens to men? Domestic violence occurs roughly equally between the sexes, and yet the disparities in available support are shocking. When you raise these issues, as I have done in my performance pieces, many people rush to "justify" them since men supposedly commit most of the violence. Such blaming of the victim would scarcely be tolerated in a discussion of violence among blacks or poor people, for example. Why is such victim-blaming more acceptable when its target is men? Astoundingly, talk show hosts like Oprah Winfrey can decry female circumcision while somehow believing that male circumcision is all right. I recently lunched with a well-known human rights attorney and law professor in her fifties who had never considered the fact that male circumcision might also be a human rights violation. The denial of male pain and male feelings cuts that deep. Any violation of a woman's genital integrity is recognized as unconscionable violence. How can it possibly be defended as any less reprehensible when carried out against a man? While feminists rightly ask for our support and cooperation in their struggles to stop female circumcision and other abuses, they should correspondingly make common cause with us here to stop mutilation of our bodies. We should demand this minimal support. Many laws against female genital mutilation (FGM) exist around the world, while no law anywhere forbids MGM. Statutes forbidding FGM have become law in California, Delaware, Minnesota, North Dakota, Rhode Island, Tennessee, Wisconsin, Egypt (by decree), Kenya, New Zealand, the Sudan, Sweden, the United Kingdom, New South Wales, Quebec, and Ontario. Recently both this country and Canada passed national legislation criminalizing FGM. These laws are clearly unconstitutional under principles of equal protection enshrined in international human rights law as well as the national law of the United States. Our state and federal laws against female genital mutilation, and the discriminatory failure to outlaw and vilify male genital mutilation, violate equal protection under both international human rights law and the American Constitution. The double-think at play here is breathtaking. Human rights treaties forbid FGM and MGM alike based on such important principles as the rights of the child, the right to freedom of religion, the right to the highest attainable standard of health, and the right to protection against torture. Activists who oppose the horrors of FGM are correct when they introduce absolutist, human rights principles that any violation of genital integrity is a crime and morally indefensible. Human rights principles are indeed absolute ones not subject to a balancing in the scales of international justice relative to other violations. And yet somehow it is still permissible when we do it to boys. The real reason for this double standard lies deep in our different socializations and genetic heritages from thousands of years ago. Men and women are hard-wired to serve different functions. Men have greater upper-body strength and endurance to enable us to serve as hunters and protectors of our people, while women have more connections between the spheres of the brain to link their emotional and thinking sides and facilitate their caring for the young, protecting the hearth and gathering food. Evolution is not destiny, but we are still influenced by this genetic legacy even though in modern society, it no longer serves us well. In addition, certain forms of violence against men are tolerated and even structurally incorporated into our society. Men around the world are systematically compelled to give our bodies and our lives in armed conflict. We are also economically compelled to give our bodies and our lives in the workplace; 94% of all American workplace deaths occur to men. The numbness in our penises resulting from circumcision here in the US parallels the emotional numbness which those in power need for us to have so we will continue to fulfill our roles as producers. If we all get in touch with our feelings and discover our own strength and desires, we may not want to keep working at our often unsatisfying, low-paying and hazardous jobs to produce more profits for those at the top. Circumcision is one of many societal factors helping to keep us disempowered and out of touch with our sexuality and our own great potential. I believe a complementarity of men's and women's oppressions exists, both sides of the same coin impeding us from becoming full beings. As men, we are encouraged to be emotionally and physically numb. We must make war, must not cry or express feelings at work, and are not supposed to be househusbands or even custodial fathers.
We are so accustomed to men being the disposable sex that it has become an invisible cultural assumption. "Women and children first." Women's pain is simply viewed as more important than men's pain, and so we can tolerate a cultural practice of cutting baby boy's genitals. Or of drafting men and not women for war. It is no accident that the same gender which must fight the wars is the one which suffers a childhood slash to the genitals. Historians have documented that in primitive societies circumcision served the explicit goal of preparing young boys to grow up and sacrifice their bodies in battle. In some cultures, boys are forced to cut their penis themselves and must not even grimace as the knife slices through the flesh. Cross-cultural studies demonstrate that the earlier and more violently the circumcision ritual occurs, the more violent is the society. Cultural blindness frequently colors perceptions of human rights issues. Throughout history a broad range of body mutilation practices have been accepted, including footbinding, placing growing children in vases so their bones would be bent to the shape of the vase, and many other forms of genital mutilation of both sexes. As with infant male circumcision, all these practices were carried out without the victim's consent. Circumcision may be facilitated by our culture's myths about men and masculinity. Like women, men grow up in a culture which holds a set of degrading myths about them. We may uncover embedded in American beliefs about circumcision these "original myths" about males: 1) Males are inherently pathological, requiring correction at birth. 2) Male genitalia are not worthy of preservation. 3) Natural male genitalia are a health hazard. 4) Natural male genitalia are inherently unclean. 5) Males do not experience pain; they require no anesthesia.
6) It is better to cut away part of a boy's penis than to give a parent the task of cleaning it. 7) A male's body does not belong to him, but to some social group (religion or medicine) which acts "for his own good." 8) Restraining a male and cutting his genitals is good for him. Feminists have uncovered and worked to correct damaging mythology regarding women's bodies. They also have gathered together libraries of evidence and information regarding women's unique needs from clinicians based on their gender needs and their needs as survivors of female-specific traumas. This feminist work has deeply impacted society at large and clinical practice particularly, resulting in women receiving much more respectful and appropriate therapy. Men suffer a dramatically less recognized, but no less insidious and damaging set of denigrations and false beliefs regarding their bodies and their roles in society. If we listen carefully and heartfully to men's stories, we may discover the destructive impact on male mental health of circumcision and other myths which degrade men. As societal and personal denial about circumcision fades, men may evoke a more compassionate response from their brothers and sisters. Some of us are working to stop this act of violence against our male children. Four organizations in the Bay Area are concerned with circumcision. NOHARMM is a men's awareness and activism organization (PO Box 460795, San Francisco, CA 94146). NORM works to support men who are seeking to restore their foreskin nonsurgically (3205 Northwood Drive #109, Concord, CA 94520, 510- 827-4077). A nurse who was fired years ago for refusing to perform the operation has started a very successful informational and organizing organization, NOCIRC (PO Box 2512, San Anselmo, CA 94979, 415-488-9883). The author recently founded Attorneys for the Rights of the Child (2961 Ashby Avenue, Berkeley, CA 94705, 510-848-4437) to coordinate attorneys around the world in developing legal approaches to stopping circumcision and all other forms of childhood genital mutilation. Other organizations exist around the country. Others of us are using slow skin stretching techniques to "restore" our foreskins. Actually this process only partially heals one of the three harmful effects of circumcision discussed above, namely the loss of covering of the glans. Nevertheless, successful restoring men report significantly improved sensitivity of their glans. Jim Bigelow's excellent book "The Joy of Uncircumcising" (available at bookstores) discusses foreskin restoration techniques and also documents the problems caused by this barbaric practice, as do other books such as Ronald Goldman's ("Circumcision: The Hidden Trauma, $21.95 postpaid from Vanguard Publications, 888-445- 5199), Billy Ray Boyd's ("Circumcision: What it Does," $6.95 plus postage to C. Olson, Box 5100-CB, Santa Cruz, CA 95063-5100) and a poll conducted by the activist organization NOHARMM (Awakenings: A Preliminary Poll of Circumcised Men"; $25 to NOHARMM, PO Box 460795, San Francisco, CA 94146).
Steven Svoboda is a 38-year-old attorney who has reorganized his work life to devote the majority of his time to men's work. He is founder and director of Attorneys for the Rights of the Child, an organization devoted to developing legal approaches to stopping circumcision. He cofounded and serves as Secretary/Treasurer of the Northern California Chapter of the Coalition of Free Men, as well as Archivist and Board Member for the national parent organization. He is writing a book as well as regular articles and letters about men's issues, writing and performing solo theater pieces illustrating men's issues, and doing legal and human rights work on behalf of men.
It is worth remembering that the two developed countries in which circumcision is most widely practiced, Israel and the United States, have what many consider to be two of the most violent governments in the world. On a criminal level, we are probably the most violent developed country. Research has suggested that these facts are connected and not simple coincidence. Psychobiological studies support this theory. Circumcision dates from an age when babies were believed not to feel pain. We now know that this is utter nonsense. Concrete medical evidence demonstrates that relative to an adult, the circumcision experience is significantly more traumatizing to an infant, who has not yet developed methods to cope with pain and whose neurological pathways are not yet fully developed. The harm circumcision causes to babies by the severe levels of pain has been repeatedly documented. As developmental neuro-psychologist James Prescott has documented, the rise in violence in our country, particular sex-related violence such as rape, has occurred in proportion to the increase in the number of sexually active circumcised males in American society. As discussed below, the brutality of the early circumcision strongly appears to be one of many factors affecting men who grow up and eventually give this violence back to society. Research also suggests that circumcision causes behavioral changes and that some reported gender differences may actually be a result of circumcision. As is clear from statements by doctors from that period, circumcision of non-Jews started in this country around 100 years ago as a technique to stop young boys from masturbating by reducing our ability to feel. The pain of the operation was explicitly cited by doctors as one "positive" byproduct of the operation. John Harvey Kellogg, creator of Kellogg's Corn Flakes, originally developed as another measure to stop masturbation (!), said of circumcision, "The operation should be performed without anesthetic, as the pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment." By Reducing masturbation, circumcision would supposedly cure a range of diseases including seizures, hip trouble, imbecility, paralysis, epilepsy, etc. As time went on, whenever any new disease would become a subject of social concern, circumcision would be proposed as a cure. Penile cancer, urinary tract infections, venereal disease, AIDS, even uterine cancer in women having sexual relations with men--there was no limit to what this procedure could supposedly cure. Under standard medical practice, amputation is of course the treatment of last resort, only appropriate when other, more conservative measures have failed to correct an actual disease which threatens survival of the organ or the patient. We should be guided by the sort of abhorrence we would have to a suggestion that, for example, a woman's breasts be lopped off due to the high incidence of breast cancer. The foreskin should not receive any less protection under this principle than is enjoyed by every other organ and tissue of our bodies. In order to examine our society's form of childhood genital cutting, we must know what it is that circumcision actually does. American beliefs that circumcision destroys little tissue, and that the tissue lost is of no particular value, are not confirmed by medical research. Medical researchers recently documented that the average circumcision removes over half the genital tissue and many specialized nerve endings, thereby substantially curtailing sexual sensitivity. We should not forget that circumcision, like any medical procedure, also has complications. These occur at a rate of 2-10% depending on the definition of "complication." At least dozens of baby boys needlessly die in the United States every year due to this procedure. This number cannot be precisely determined due to the medical community's practice of attributing circumcision-caused deaths to other reasons such as "hemorrhage."
Circumcision thus causes harm and carries risks. However, unlike other medical procedures, it does not offer any genuine health benefits. All suggested justifications for routine circumcision throughout its 100-year history in the US have failed, including prevention of alcoholism, epilepsy, plague, paralysis, rheumatism, polio, lunacy, tuberculosis, syphilis, cancer, urinary tract infections, and AIDS. The British Medical Association, Canadian Paediatric Society, Australian College of Paediatrics, and even the American Academy of Pediatrics have stated that there is no justification for routine circumcision. Science has thus begun to turn its attention to male circumcision and has corrected many prior misconceptions which are holdovers from the Nineteenth and early Twentieth Centuries. The procedure causes serious harm and lacks medical justification; it should not be tolerated in any civilized society. But it is a money-making operation here and continues despite many doctors' personal disapproval of the procedure. As medical student Franc Garcia has discussed, male circumcision destroys a male's capacity for certain sexual sensations and dulls other sensations. Doctors and medical students have documented the "triple whammy" of lost sexual sensitivity resulting from circumcision. 1. Loss of the foreskin nerves. The inner foreskin possesses a greater density of nerve endings and is probably more erogenous than even the glans. This tremendous amount of sensitivity is lost completely when the foreskin is amputated. Also, the most sensitive part of the penis, the frenulum of the foreskin, is removed in most infant circumcisions. The frenulum is the continuation of the inner foreskin which attaches to the underside of the glans. Thus, circumcision robs us of a large percentage, if not the majority, of erogenous nerve endings to the penis. 2. Damage to the glans. The erogenous sensitivity that remains after circumcision is primarily in the glans. This is further reduced by the removal of the protective foreskin which leaves the glans permanently exposed. The penis head developed over millions of years of evolution as an internal organ, meant to be safely enclosed by the prepuce. The skin covering of the glans IS the foreskin. The glans becomes artificially keratinized (dry, hardened, discolored, and wrinkled) as a result of permanent exposure, and thus significantly less sensitive. 3. Loss of skin mobility. The nerve endings in the glans are best stimulated by a rolling massage action. Direct friction tends to fire off pain receptors causing irritation and also causes further keratinization of the glans. With the skin system of the penis significantly reduced by circumcision, the mobility is essentially gone and now the penis is a static mass with no dynamic self stimulation mechanism. Direct friction is now the primary form of stimulation. So circumcision further reduces erogenous sensitivity in the penis by reducing skin mobility and thus the ability to use the foreskin to massage the glans. Men circumcised in adulthood have summed up the overall difference in sensation as similar to the contrast between seeing in color and seeing in black and white. There is reason to think the loss may be even greater for men circumcised as infants, as most of us were. Sexual pleasure continues to be reduced as circumcised men age until, in many cases, we are left with relatively little sensation. Like many men in their late thirties or early forties, every day I rediscover firsthand the horror of this procedure. I have noticed a dramatic and heartbreaking loss of sensitivity over the last couple of years. This is due to the continual buildup of layers of keratin over the mucous membrane which remains on our penises after the foreskin is removed. Such damage to the penis as described above has a profound impact on a man's well-being and sense of self. Some men who feel mutilated by their circumcisions have reported feeling depressed to the point of suicidality. Some men who understand themselves to be harmed by their circumcisions report deep rage at their parents and/or physicians. Men experiencing these profound feelings of loss and anger generally have little social support, since circumcision is viewed as benign by most American. Some men, upon revealing their distress at having lost a body part they value, have received cruel responses from counselors. Male and societal denial regarding harm does not negate the harm. There are at least two reasons we have not heard a great deal from men angry about or physically damaged by their circumcision. First, the millions of circumcised men who hate what was done to them do not speak out for fear of ridicule. The second reason is that most men are unaware of what they lost. It is important to remember that not only the male victims but society as a whole is denying the existence of harm, a problem which does not, for example, face incest victims. While there is no intent to compare the incest trauma with the trauma of circumcision, at least as a society we have come to recognize the horror of the former. In societies that cut girls' genitals, there are very few women who object to the cutting. Widespread ignorance of the value and function of the destroyed genital parts, combined with culturally conditioned abhorrence of natural genitalia, perpetuate women's silence. Parallel psychosocial dynamics keep men silent in our culture. Circumcision is one more form of institutionalized violence against men. It is, of course, a myth that violence against women is tolerated while violence against men is opposed by society. If anything, the opposite is true; our legislature has passed the astoundingly sexist Violence Against Women Act. When is the last time you heard a politician proposing legislation to stop violence against men? When did you last hear anyone in power even acknowledge that most violence happens to men? Domestic violence occurs roughly equally between the sexes, and yet the disparities in available support are shocking. When you raise these issues, as I have done in my performance pieces, many people rush to "justify" them since men supposedly commit most of the violence. Such blaming of the victim would scarcely be tolerated in a discussion of violence among blacks or poor people, for example. Why is such victim-blaming more acceptable when its target is men? Astoundingly, talk show hosts like Oprah Winfrey can decry female circumcision while somehow believing that male circumcision is all right. I recently lunched with a well-known human rights attorney and law professor in her fifties who had never considered the fact that male circumcision might also be a human rights violation. The denial of male pain and male feelings cuts that deep. Any violation of a woman's genital integrity is recognized as unconscionable violence. How can it possibly be defended as any less reprehensible when carried out against a man? While feminists rightly ask for our support and cooperation in their struggles to stop female circumcision and other abuses, they should correspondingly make common cause with us here to stop mutilation of our bodies. We should demand this minimal support. Many laws against female genital mutilation (FGM) exist around the world, while no law anywhere forbids MGM. Statutes forbidding FGM have become law in California, Delaware, Minnesota, North Dakota, Rhode Island, Tennessee, Wisconsin, Egypt (by decree), Kenya, New Zealand, the Sudan, Sweden, the United Kingdom, New South Wales, Quebec, and Ontario. Recently both this country and Canada passed national legislation criminalizing FGM. These laws are clearly unconstitutional under principles of equal protection enshrined in international human rights law as well as the national law of the United States. Our state and federal laws against female genital mutilation, and the discriminatory failure to outlaw and vilify male genital mutilation, violate equal protection under both international human rights law and the American Constitution. The double-think at play here is breathtaking. Human rights treaties forbid FGM and MGM alike based on such important principles as the rights of the child, the right to freedom of religion, the right to the highest attainable standard of health, and the right to protection against torture. Activists who oppose the horrors of FGM are correct when they introduce absolutist, human rights principles that any violation of genital integrity is a crime and morally indefensible. Human rights principles are indeed absolute ones not subject to a balancing in the scales of international justice relative to other violations. And yet somehow it is still permissible when we do it to boys. The real reason for this double standard lies deep in our different socializations and genetic heritages from thousands of years ago. Men and women are hard-wired to serve different functions. Men have greater upper-body strength and endurance to enable us to serve as hunters and protectors of our people, while women have more connections between the spheres of the brain to link their emotional and thinking sides and facilitate their caring for the young, protecting the hearth and gathering food. Evolution is not destiny, but we are still influenced by this genetic legacy even though in modern society, it no longer serves us well. In addition, certain forms of violence against men are tolerated and even structurally incorporated into our society. Men around the world are systematically compelled to give our bodies and our lives in armed conflict. We are also economically compelled to give our bodies and our lives in the workplace; 94% of all American workplace deaths occur to men. The numbness in our penises resulting from circumcision here in the US parallels the emotional numbness which those in power need for us to have so we will continue to fulfill our roles as producers. If we all get in touch with our feelings and discover our own strength and desires, we may not want to keep working at our often unsatisfying, low-paying and hazardous jobs to produce more profits for those at the top. Circumcision is one of many societal factors helping to keep us disempowered and out of touch with our sexuality and our own great potential. I believe a complementarity of men's and women's oppressions exists, both sides of the same coin impeding us from becoming full beings. As men, we are encouraged to be emotionally and physically numb. We must make war, must not cry or express feelings at work, and are not supposed to be househusbands or even custodial fathers.
We are so accustomed to men being the disposable sex that it has become an invisible cultural assumption. "Women and children first." Women's pain is simply viewed as more important than men's pain, and so we can tolerate a cultural practice of cutting baby boy's genitals. Or of drafting men and not women for war. It is no accident that the same gender which must fight the wars is the one which suffers a childhood slash to the genitals. Historians have documented that in primitive societies circumcision served the explicit goal of preparing young boys to grow up and sacrifice their bodies in battle. In some cultures, boys are forced to cut their penis themselves and must not even grimace as the knife slices through the flesh. Cross-cultural studies demonstrate that the earlier and more violently the circumcision ritual occurs, the more violent is the society. Cultural blindness frequently colors perceptions of human rights issues. Throughout history a broad range of body mutilation practices have been accepted, including footbinding, placing growing children in vases so their bones would be bent to the shape of the vase, and many other forms of genital mutilation of both sexes. As with infant male circumcision, all these practices were carried out without the victim's consent. Circumcision may be facilitated by our culture's myths about men and masculinity. Like women, men grow up in a culture which holds a set of degrading myths about them. We may uncover embedded in American beliefs about circumcision these "original myths" about males: 1) Males are inherently pathological, requiring correction at birth. 2) Male genitalia are not worthy of preservation. 3) Natural male genitalia are a health hazard. 4) Natural male genitalia are inherently unclean. 5) Males do not experience pain; they require no anesthesia.
6) It is better to cut away part of a boy's penis than to give a parent the task of cleaning it. 7) A male's body does not belong to him, but to some social group (religion or medicine) which acts "for his own good." 8) Restraining a male and cutting his genitals is good for him. Feminists have uncovered and worked to correct damaging mythology regarding women's bodies. They also have gathered together libraries of evidence and information regarding women's unique needs from clinicians based on their gender needs and their needs as survivors of female-specific traumas. This feminist work has deeply impacted society at large and clinical practice particularly, resulting in women receiving much more respectful and appropriate therapy. Men suffer a dramatically less recognized, but no less insidious and damaging set of denigrations and false beliefs regarding their bodies and their roles in society. If we listen carefully and heartfully to men's stories, we may discover the destructive impact on male mental health of circumcision and other myths which degrade men. As societal and personal denial about circumcision fades, men may evoke a more compassionate response from their brothers and sisters. Some of us are working to stop this act of violence against our male children. Four organizations in the Bay Area are concerned with circumcision. NOHARMM is a men's awareness and activism organization (PO Box 460795, San Francisco, CA 94146). NORM works to support men who are seeking to restore their foreskin nonsurgically (3205 Northwood Drive #109, Concord, CA 94520, 510- 827-4077). A nurse who was fired years ago for refusing to perform the operation has started a very successful informational and organizing organization, NOCIRC (PO Box 2512, San Anselmo, CA 94979, 415-488-9883). The author recently founded Attorneys for the Rights of the Child (2961 Ashby Avenue, Berkeley, CA 94705, 510-848-4437) to coordinate attorneys around the world in developing legal approaches to stopping circumcision and all other forms of childhood genital mutilation. Other organizations exist around the country. Others of us are using slow skin stretching techniques to "restore" our foreskins. Actually this process only partially heals one of the three harmful effects of circumcision discussed above, namely the loss of covering of the glans. Nevertheless, successful restoring men report significantly improved sensitivity of their glans. Jim Bigelow's excellent book "The Joy of Uncircumcising" (available at bookstores) discusses foreskin restoration techniques and also documents the problems caused by this barbaric practice, as do other books such as Ronald Goldman's ("Circumcision: The Hidden Trauma, $21.95 postpaid from Vanguard Publications, 888-445- 5199), Billy Ray Boyd's ("Circumcision: What it Does," $6.95 plus postage to C. Olson, Box 5100-CB, Santa Cruz, CA 95063-5100) and a poll conducted by the activist organization NOHARMM (Awakenings: A Preliminary Poll of Circumcised Men"; $25 to NOHARMM, PO Box 460795, San Francisco, CA 94146).
Steven Svoboda is a 38-year-old attorney who has reorganized his work life to devote the majority of his time to men's work. He is founder and director of Attorneys for the Rights of the Child, an organization devoted to developing legal approaches to stopping circumcision. He cofounded and serves as Secretary/Treasurer of the Northern California Chapter of the Coalition of Free Men, as well as Archivist and Board Member for the national parent organization. He is writing a book as well as regular articles and letters about men's issues, writing and performing solo theater pieces illustrating men's issues, and doing legal and human rights work on behalf of men.
A Key To Male Fertility
Until now, mutations of the LH hormone receptor were the only explanation known for sexual precocity in boys. A team at the Institute of Genetics and Molecular and Cellular Biology (IGBMC, CNRS / Inserm / Université Louis Pasteur de Strasbourg)), in collaboration with researchers at the University of Dallas and the University of Louvain, has just identified a key regulator of male fertility, the SHP protein, bringing to light the major role it plays in controlling the synthesis of testosterone and in differentiation of germ cells in mouse testes. This work, published in the journal Genes & Development, suggests that it is worth exploring the signalling pathways controlled by SHP in men suffering from fertility disorders.
Puberty is the result of endocrine alterations programmed from the moment of sexual differentiation in the embryo and fetus. It is characterized by anatomical alterations: the maturation of primary sexual characteristics (penis, scrotum and testes) and the appearance of secondary sexual characteristics (hair growth, breaking of the voice, growth, etc). Such changes are caused by processes within the brain, and in particular by a neuroendocrine gland, the pituitary gland, which secretes two hormones, FSH and LH. Both these hormones act on the testes, causing the production of sperm as well as the secretion of testosterone. Testosterone in particular is responsible for the development of secondary sexual characteristics in boys. At the current time, mutations of the LH receptor are the only known causes of sexual precocity in boys, which shows the important role that this signaling pathway plays in the control of the endocrine system.
At the Institute of Genetics and Molecular and Cellular Biology, a new player which is involved in the sexual maturation of male mice, the SHP protein, has been identified. The team led by Johan Auwerx decided to study the role of this protein in order to obtain a better understanding of the triggering of testosterone synthesis in the testes.
Two models of mouse were used, those which had SHP protein and those that did not. The result was astonishing. The mice without SHP were able to reproduce about a week earlier than the controls. This is a considerable difference since, as a general rule, male mice are sexually mature at 7 or 8 weeks. In addition, regardless of increased activity in the pituitary gland, mice without SHP produce more testosterone prematurely, leading to premature maturation of primary sexual characteristics. At the same time, the SHP protein controls the timing of the differentiation of the germ cells by inhibiting the metabolism of retinoic acids (see illustration). It should therefore be possible to look for mutations of SHP in order to improve our understanding of certain kinds of sexual precocity whose causes are as yet unexplained. It should also be pointed out that, because of the family that it belongs to, SHP is a potential therapeutic target, thanks to the development of new synthetic ligands. This work therefore opens up new prospects for research aimed at improving the production of sperm in men suffering from fertility disorders.
Further research is vital if we are to understand the overall mechanisms involved in sexual maturation in boys. However, these findings mean that we can now identify a new player involved in the control of male fertility.
Puberty is the result of endocrine alterations programmed from the moment of sexual differentiation in the embryo and fetus. It is characterized by anatomical alterations: the maturation of primary sexual characteristics (penis, scrotum and testes) and the appearance of secondary sexual characteristics (hair growth, breaking of the voice, growth, etc). Such changes are caused by processes within the brain, and in particular by a neuroendocrine gland, the pituitary gland, which secretes two hormones, FSH and LH. Both these hormones act on the testes, causing the production of sperm as well as the secretion of testosterone. Testosterone in particular is responsible for the development of secondary sexual characteristics in boys. At the current time, mutations of the LH receptor are the only known causes of sexual precocity in boys, which shows the important role that this signaling pathway plays in the control of the endocrine system.
At the Institute of Genetics and Molecular and Cellular Biology, a new player which is involved in the sexual maturation of male mice, the SHP protein, has been identified. The team led by Johan Auwerx decided to study the role of this protein in order to obtain a better understanding of the triggering of testosterone synthesis in the testes.
Two models of mouse were used, those which had SHP protein and those that did not. The result was astonishing. The mice without SHP were able to reproduce about a week earlier than the controls. This is a considerable difference since, as a general rule, male mice are sexually mature at 7 or 8 weeks. In addition, regardless of increased activity in the pituitary gland, mice without SHP produce more testosterone prematurely, leading to premature maturation of primary sexual characteristics. At the same time, the SHP protein controls the timing of the differentiation of the germ cells by inhibiting the metabolism of retinoic acids (see illustration). It should therefore be possible to look for mutations of SHP in order to improve our understanding of certain kinds of sexual precocity whose causes are as yet unexplained. It should also be pointed out that, because of the family that it belongs to, SHP is a potential therapeutic target, thanks to the development of new synthetic ligands. This work therefore opens up new prospects for research aimed at improving the production of sperm in men suffering from fertility disorders.
Further research is vital if we are to understand the overall mechanisms involved in sexual maturation in boys. However, these findings mean that we can now identify a new player involved in the control of male fertility.
Saturday, February 24, 2007
Great Skin for Guys
Men have long understood the importance of the ‘dress for success’ image in order to maintain their edge. Guys of all ages are more interested in taking care of themselves and indulging in image enhancing products, gadgets and treatments. However, they are less likely to grasp the concept of maintenance procedures; they prefer to get it over with in one shot. Once they dip a toe into the realm of non-surgical treatments like BOTOX®, Restylane®, and microdermabrasion and like the way they look, they will go back for more of a good thing. Don’t think for a minute that they’re doing it just for us or the scores of women in their lives. They’re doing it for themselves.
Starting a man on a skin care regimen or tweaking his existing one takes careful planning and subtle persuasion. Picking the right products can make the difference between becoming a heroine and causing a nuclear explosion. They may be sheepish about navigating the cosmetics department, but alternative shopping venues like the Internet, mall kiosks, airports, drug stores, and specialty shops offer essential advice on product selections that cater to their needs minus the frilly, fruity, and flowery stuff. They don’t want to be bothered with too many products. Start small, with an edited regimen of basics - cleansing, protection, moisturizing, post shaving, and a weekly anti-clog treatment. Most men don’t have a clue about their skin type or what works for them. They also require remedial assistance to use the right amount, or it can take a while for them to figure it out on their own. Either they slather it all over or use barely enough to get the job done. Recommend a ‘less is more’ approach. Suggest he start with the size of a dime's worth for cleansers and moisturizers, half that for hair gels to play it safe since the tendency is to overdo it. When it comes to sunscreen, if it came in a six pack they might actually use enough to cover all essential body parts.
A man's skin is different. Male skin is thicker, oilier, with larger pores, a richer blood supply, and more of a tendency to sweat, so they are less prone to wrinkling. They also have more hair all over their body. Basically, guys get grimier and need deep cleansing daily.
Deodorant soaps should never be used on the face because they can irritate skin and leave a sticky residue. For the super lazy, multi-tasking products for face, hair and body will save precious steps. Stick with oil-free formulas that won’t add shine. Beware that your favorite desert island product will have a very different effect on his face, and they are not always interchangeable. Eye gels work nicely for men, but rich eye creams that lock in moisture can increase puffiness. Skin that gets shaved on a regular basis may have red bumps, ingrown hairs and leathery patches. Razor burn can be reduced by using a cleanser in the shower, and a softening shave cream with a sharp razor. Changing the blades at least once a week is vital. The problem of shine can be addressed by using a good scrub to turn over dead cells. For blemishes, sneak in a weekly treatment product like DDF Pumice Acne Scrub (www.ddfskin.com). Adding a toner can reduce pore size, control oil slicks, and help avoid nasty ingrown hairs, but anything too harsh will strip away essential oils when the skin is most vulnerable and sensitive. Make sure he doesn’t splash on alcohol or glycolic acid right after shaving to avoid a sting.
Because men tend to be outside more than most women are, they should be encouraged to wear a high SPF on all exposed skin, especially on the face, nose, ears and scalp. Sporty sunscreen in a stick like DDF Matte Finish Photo Age Protection SPF30 is a good choice. Don't forget about the lips – add a lip balm with an SPF. Men have an increasing incidence of skin cancer, since they are less inclined to visit a Dermatologist for a full body check and more likely to scoff at the need for protection.
Starting a man on a skin care regimen or tweaking his existing one takes careful planning and subtle persuasion. Picking the right products can make the difference between becoming a heroine and causing a nuclear explosion. They may be sheepish about navigating the cosmetics department, but alternative shopping venues like the Internet, mall kiosks, airports, drug stores, and specialty shops offer essential advice on product selections that cater to their needs minus the frilly, fruity, and flowery stuff. They don’t want to be bothered with too many products. Start small, with an edited regimen of basics - cleansing, protection, moisturizing, post shaving, and a weekly anti-clog treatment. Most men don’t have a clue about their skin type or what works for them. They also require remedial assistance to use the right amount, or it can take a while for them to figure it out on their own. Either they slather it all over or use barely enough to get the job done. Recommend a ‘less is more’ approach. Suggest he start with the size of a dime's worth for cleansers and moisturizers, half that for hair gels to play it safe since the tendency is to overdo it. When it comes to sunscreen, if it came in a six pack they might actually use enough to cover all essential body parts.
A man's skin is different. Male skin is thicker, oilier, with larger pores, a richer blood supply, and more of a tendency to sweat, so they are less prone to wrinkling. They also have more hair all over their body. Basically, guys get grimier and need deep cleansing daily.
Deodorant soaps should never be used on the face because they can irritate skin and leave a sticky residue. For the super lazy, multi-tasking products for face, hair and body will save precious steps. Stick with oil-free formulas that won’t add shine. Beware that your favorite desert island product will have a very different effect on his face, and they are not always interchangeable. Eye gels work nicely for men, but rich eye creams that lock in moisture can increase puffiness. Skin that gets shaved on a regular basis may have red bumps, ingrown hairs and leathery patches. Razor burn can be reduced by using a cleanser in the shower, and a softening shave cream with a sharp razor. Changing the blades at least once a week is vital. The problem of shine can be addressed by using a good scrub to turn over dead cells. For blemishes, sneak in a weekly treatment product like DDF Pumice Acne Scrub (www.ddfskin.com). Adding a toner can reduce pore size, control oil slicks, and help avoid nasty ingrown hairs, but anything too harsh will strip away essential oils when the skin is most vulnerable and sensitive. Make sure he doesn’t splash on alcohol or glycolic acid right after shaving to avoid a sting.
Because men tend to be outside more than most women are, they should be encouraged to wear a high SPF on all exposed skin, especially on the face, nose, ears and scalp. Sporty sunscreen in a stick like DDF Matte Finish Photo Age Protection SPF30 is a good choice. Don't forget about the lips – add a lip balm with an SPF. Men have an increasing incidence of skin cancer, since they are less inclined to visit a Dermatologist for a full body check and more likely to scoff at the need for protection.
Acupuncture May Improve Sperm Quality
Acupuncture may help some men overcome infertility problems by improving the quality of their sperm, according to a new study.
Researchers found five weeks of acupuncture treatment reduced the number of structural abnormalities in sperm and increased the overall number of normal sperm in a group of men with infertility problems.
They say the results suggest that acupuncture may complement traditional infertility treatments and help men reach their full reproductive potential.
Acupuncture May Ease Male Infertility
An estimated 10% of men are infertile, and the male partner is a factor in up to 50% of infertile couples, write the researchers. In many cases, the cause of male infertility is unknown.
Previous studies of acupuncture and male infertility have suggested that acupuncture can improve sperm production and motility (a measure of sperm movement).
In this study, researchers looked at the effects of acupuncture on the structural health of sperm in men with infertility of unknown cause. The findings appear in the July issue of Fertility and Sterility.
Twenty-eight infertile men received acupuncture treatments twice a week for five weeks, and 12 received no treatment and served as a comparison group.
Researchers analyzed sperm samples at the beginning and end of the study and found significant improvements in sperm quality in the acupuncture group compared with the other group.
Acupuncture treatment was associated with fewer structural defects in the sperm and an increase in the number of normal sperm in ejaculate.
But other sperm abnormalities, such as immature sperm or sperm death, were unaffected by acupuncture.
The researchers write that acupuncture treatment is a simple, noninvasive method that can improve sperm quality.
Researchers found five weeks of acupuncture treatment reduced the number of structural abnormalities in sperm and increased the overall number of normal sperm in a group of men with infertility problems.
They say the results suggest that acupuncture may complement traditional infertility treatments and help men reach their full reproductive potential.
Acupuncture May Ease Male Infertility
An estimated 10% of men are infertile, and the male partner is a factor in up to 50% of infertile couples, write the researchers. In many cases, the cause of male infertility is unknown.
Previous studies of acupuncture and male infertility have suggested that acupuncture can improve sperm production and motility (a measure of sperm movement).
In this study, researchers looked at the effects of acupuncture on the structural health of sperm in men with infertility of unknown cause. The findings appear in the July issue of Fertility and Sterility.
Twenty-eight infertile men received acupuncture treatments twice a week for five weeks, and 12 received no treatment and served as a comparison group.
Researchers analyzed sperm samples at the beginning and end of the study and found significant improvements in sperm quality in the acupuncture group compared with the other group.
Acupuncture treatment was associated with fewer structural defects in the sperm and an increase in the number of normal sperm in ejaculate.
But other sperm abnormalities, such as immature sperm or sperm death, were unaffected by acupuncture.
The researchers write that acupuncture treatment is a simple, noninvasive method that can improve sperm quality.
Should I Be Worried About An Enlarged Prostate?
With sustained improvements in lifestyle, disease prevention, and medical therapies, Americans are living longer. By the year 2020, the number of people now over the age of 60 years is expected to triple. Consequently, diseases and illnesses that are primarily seen in elderly people are becoming more prevalent. One that affects older men is benign prostatic hyperplasia, which is usually referred to by its initials BPH and is commonly known as “enlarged prostate.”
What Happens as My Prostate Enlarges?
What Is the Prostate?
The prostate is a walnut-sized gland found deep in the pelvis in men. It is located just under the bladder and surrounds a tube (urethra) through which urine exits when we urinate. The prostate is rich in nerves and muscle. The function of the prostate is not clearly understood, though it produces 20% of the fluid found in the semen and other substances that are thought to help sperm survive and make penetration easier during sexual intercourse. However, these substances are not essential for fertility. In addition, the prostate is a source of other hormones and enzymes, but these are also not crucial for men to stay healthy. It is common for our prostates to enlarge as we age. Because of where the prostate is located, men may experience problems with urination as it enlarges.
At What Age Is BPH Likely?
It is difficult to know how many men have BPH because we as men often do not have symptoms even though our prostates have enlarged. However, estimates have been made based on examining a representative sample of men in the Untied States:
- Over 30% of men in their 50s- and 46% of men in their 70s have moderate to severe BPH.
- In men who have had their bladder function tested, over half have diminished rates of urinary flow or are unable to fully empty their bladder.
- More than one in three Caucasian men over the age of 50 may have some symptomatic BPH.
- In European men, it has been estimated that 24% aged 50-59 and 40% aged 70-79 have symptoms of BPH.
What Happens as My Prostate Enlarges?
As a prostate enlarges, it goes through three different stages:
- Microscopic (small areas of the prostate are enlarged that can only be detected using a microscope)
- Macroscopic (larger areas are seen under a microscope and felt on rectal examination)
- Symptomatic (causing changes in urinary habits).
As BPH continues to progress, the microscopic areas can increase in size and stimulate certain prostate cells to grow, leading to the development of the next stage: macroscopic BPH. During this stage of enlargement, there is significant growth as well as distortion of your prostate. You may or may not have symptoms, but at this stage your doctor will be able to tell if your prostate is enlarged during a rectal examination.
BPH is considered to be in its final stage when you develop symptoms, most likely difficulty urinating. You may also experience symptoms related to other disorders common in older men, such as those caused by decreased blood supply to the prostate, inflammation or infection of the prostate, and cancer of the prostate.
The progression of BPH is related to age. BPH begins as early as 25-30 years of age in 1 out of 10 men. As we age, the presence of the first stages of BPH (microscopic BPH) increases progressively. And although the size of the prostate increases with age, the rate of growth slows down the older we get. For this reason, only 1 out of 4 men who have microscopic BPH go on to develop symptoms.
What Exactly Are the Symptoms of BPH?
The symptoms of an enlarged prostate -- generally called "prostatism" -- are thought to result from several factors. The prostate surrounds the tube (urethra) that goes from the bladder to the penis, and as the prostate enlarges, it may squeeze this tube. If your urethra becomes partially or completely blocked, you will typically experience one or more of the following symptoms:
- difficulty initiating urination
- decreased force of the urinary stream
- dribbling of urine at the end of the stream
- straining to urinate
- complete inability to urinate, also known as retention. (Urinary retention is often very painful and dangerous because it can result in a backward flow of urine, which can put pressure on the kidneys. Pressure on the kidneys can result in kidney failure, requiring immediate medical treatment.)
- painful urination
- urgency to void
- frequent urination during the day or at night
Individual patients will suffer from different symptoms because of the differences in how the prostate has enlarged and how much pressure it is putting on the urethra. And although these symptoms are typical of BPH, they may be caused by a completely different problem (like infection of the prostate or bladder) that only your doctor can determine.
If you have BPH, the particular symptoms you are experiencing and how they are affecting your quality of life are important in determining the most appropriate therapy for you. Clinicians are faced with the challenge of documenting these symptoms, in order to develop correlations between symptoms and the severity of BPH. A standard symptom questionnaire known as the American Urological Association (AUA) Symptom Index has been developed to assess specific symptoms and determine the severity of the BPH. This survey may be given to you and you will be asked questions about your symptoms within the last month, such as frequency of nighttime urination (nocturia), incomplete emptying, starting and stopping while urinating, hesitancy before urinating, inability to postpone urination, decreased force of stream, and the need for straining. Depending on your score, your BPH would be considered as mild, moderate, or severe. A total score of 0-7 would reflect mild symptoms; 8-19 would reflect moderate symptoms; and 20-35 would reflect severe symptoms.
As mentioned above, it is important for you to know that symptoms commonly associated with an enlarged prostate can also be produced by age-related changes in bladder muscle tone and by other things unrelated to urinary flow obstruction caused by BPH. In fact, many older women have AUA Symptom Scores in the moderate-to-severe range. Nevertheless, the survey is still useful when used as part of your doctor’s overall assessment.
Symptoms of BPH can also vary with time. In a 2-year study, 26% of the men with no urinary symptoms developed some problem with urination within the first year. Of men with moderate symptoms, 34% to 41% worsened, and approximately 36% improved. Almost 50% of men with severe symptoms spontaneously improved on their own to some degree over the first year. However, although symptoms may vary with time, men with moderate to severe symptoms are not as likely to improve that much.
How Dangerous is BPH?
If left untreated, symptomatic BPH may cause serious injury and even death. Bacteria in the urine are found in 9% of men with symptomatic BPH. Decreased kidney function is found in 7% of men at the time of surgical treatment for BPH. If your bladder becomes completely obstructed by an enlarged prostate, you may experience urinary retention or inability to urinate, which may result in kidney failure. In fact, 25% of acute kidney failure patients requiring hospitalization had failure related to urinary obstruction, with 14% of these men having BPH as the cause of obstruction. Another complication of BPH is bladder stones, which occur in 3.4% of men over the age of 60 compared to only 0.4% of men without BPH (similar to women at 0.3%).
Mortality from BPH is most commonly related to kidney failure, infection, and complications of surgery. The mortality rate for BPH is the United States was 3 patients per 1,000,000 in the period between 1985-1989, substantially lower than the 1950s when the mortality rate was 7.5 per 100,000. This improving trend has been noted worldwide with few exceptions and is occurring despite the fact that there are greater numbers of older men alive today.
Wednesday, February 7, 2007
Great Skin for Guys
Men have long understood the importance of the ‘dress for success’ image in order to maintain their edge. Guys of all ages are more interested in taking care of themselves and indulging in image enhancing products, gadgets and treatments. However, they are less likely to grasp the concept of maintenance procedures; they prefer to get it over with in one shot. Once they dip a toe into the realm of non-surgical treatments like BOTOX®, Restylane®, and microdermabrasion and like the way they look, they will go back for more of a good thing. Don’t think for a minute that they’re doing it just for us or the scores of women in their lives. They’re doing it for themselves.
Starting a man on a skin care regimen or tweaking his existing one takes careful planning and subtle persuasion. Picking the right products can make the difference between becoming a heroine and causing a nuclear explosion. They may be sheepish about navigating the cosmetics department, but alternative shopping venues like the Internet, mall kiosks, airports, drug stores, and specialty shops offer essential advice on product selections that cater to their needs minus the frilly, fruity, and flowery stuff. They don’t want to be bothered with too many products. Start small, with an edited regimen of basics - cleansing, protection, moisturizing, post shaving, and a weekly anti-clog treatment. Most men don’t have a clue about their skin type or what works for them. They also require remedial assistance to use the right amount, or it can take a while for them to figure it out on their own. Either they slather it all over or use barely enough to get the job done. Recommend a ‘less is more’ approach. Suggest he start with the size of a dime's worth for cleansers and moisturizers, half that for hair gels to play it safe since the tendency is to overdo it. When it comes to sunscreen, if it came in a six pack they might actually use enough to cover all essential body parts.
A man's skin is different. Male skin is thicker, oilier, with larger pores, a richer blood supply, and more of a tendency to sweat, so they are less prone to wrinkling. They also have more hair all over their body. Basically, guys get grimier and need deep cleansing daily.
Deodorant soaps should never be used on the face because they can irritate skin and leave a sticky residue. For the super lazy, multi-tasking products for face, hair and body will save precious steps. Stick with oil-free formulas that won’t add shine. Beware that your favorite desert island product will have a very different effect on his face, and they are not always interchangeable. Eye gels work nicely for men, but rich eye creams that lock in moisture can increase puffiness. Skin that gets shaved on a regular basis may have red bumps, ingrown hairs and leathery patches. Razor burn can be reduced by using a cleanser in the shower, and a softening shave cream with a sharp razor. Changing the blades at least once a week is vital. The problem of shine can be addressed by using a good scrub to turn over dead cells. For blemishes, sneak in a weekly treatment product like DDF Pumice Acne Scrub (www.ddfskin.com). Adding a toner can reduce pore size, control oil slicks, and help avoid nasty ingrown hairs, but anything too harsh will strip away essential oils when the skin is most vulnerable and sensitive. Make sure he doesn’t splash on alcohol or glycolic acid right after shaving to avoid a sting.
Because men tend to be outside more than most women are, they should be encouraged to wear a high SPF on all exposed skin, especially on the face, nose, ears and scalp. Sporty sunscreen in a stick like DDF Matte Finish Photo Age Protection SPF30 is a good choice. Don't forget about the lips – add a lip balm with an SPF. Men have an increasing incidence of skin cancer, since they are less inclined to visit a Dermatologist for a full body check and more likely to scoff at the need for protection.
Source: HealthNewsDigest.com
Starting a man on a skin care regimen or tweaking his existing one takes careful planning and subtle persuasion. Picking the right products can make the difference between becoming a heroine and causing a nuclear explosion. They may be sheepish about navigating the cosmetics department, but alternative shopping venues like the Internet, mall kiosks, airports, drug stores, and specialty shops offer essential advice on product selections that cater to their needs minus the frilly, fruity, and flowery stuff. They don’t want to be bothered with too many products. Start small, with an edited regimen of basics - cleansing, protection, moisturizing, post shaving, and a weekly anti-clog treatment. Most men don’t have a clue about their skin type or what works for them. They also require remedial assistance to use the right amount, or it can take a while for them to figure it out on their own. Either they slather it all over or use barely enough to get the job done. Recommend a ‘less is more’ approach. Suggest he start with the size of a dime's worth for cleansers and moisturizers, half that for hair gels to play it safe since the tendency is to overdo it. When it comes to sunscreen, if it came in a six pack they might actually use enough to cover all essential body parts.
A man's skin is different. Male skin is thicker, oilier, with larger pores, a richer blood supply, and more of a tendency to sweat, so they are less prone to wrinkling. They also have more hair all over their body. Basically, guys get grimier and need deep cleansing daily.
Deodorant soaps should never be used on the face because they can irritate skin and leave a sticky residue. For the super lazy, multi-tasking products for face, hair and body will save precious steps. Stick with oil-free formulas that won’t add shine. Beware that your favorite desert island product will have a very different effect on his face, and they are not always interchangeable. Eye gels work nicely for men, but rich eye creams that lock in moisture can increase puffiness. Skin that gets shaved on a regular basis may have red bumps, ingrown hairs and leathery patches. Razor burn can be reduced by using a cleanser in the shower, and a softening shave cream with a sharp razor. Changing the blades at least once a week is vital. The problem of shine can be addressed by using a good scrub to turn over dead cells. For blemishes, sneak in a weekly treatment product like DDF Pumice Acne Scrub (www.ddfskin.com). Adding a toner can reduce pore size, control oil slicks, and help avoid nasty ingrown hairs, but anything too harsh will strip away essential oils when the skin is most vulnerable and sensitive. Make sure he doesn’t splash on alcohol or glycolic acid right after shaving to avoid a sting.
Because men tend to be outside more than most women are, they should be encouraged to wear a high SPF on all exposed skin, especially on the face, nose, ears and scalp. Sporty sunscreen in a stick like DDF Matte Finish Photo Age Protection SPF30 is a good choice. Don't forget about the lips – add a lip balm with an SPF. Men have an increasing incidence of skin cancer, since they are less inclined to visit a Dermatologist for a full body check and more likely to scoff at the need for protection.
Source: HealthNewsDigest.com
Monday, February 5, 2007
Penis Size Q & A
How big should my penis be?
The size of your penis is simply determined by factors, called genetic traits, which you inherited from your parents. There is nothing you can do to increase or decrease the size of your penis-it will develop into its adult size as you change from a boy to a man through the process called puberty. Most boys start the changes of puberty between 10 and 14 years of age, though a few will start earlier or later than these ages. First, the testicles (balls) begin to enlarge and then hair starts to grow around the them. The penis then starts to enlarge, first in length and then later in thickness. Though there is much normal variation, the final penis size is reached four to six years after the testicles first started to enlarge.
This process of normal penis growth can be disturbing to many males. Since the testicles enlarge first (and later followed by growth of the penis), many young male teens do not notice the testicles growing and worry that they are not changing and that their penis is too small. If you are overweight, fat tissue can hide the penis somewhat and give an impression that the penis is smaller than it really is. Some males in your class may have started their changes of puberty well ahead of you and they may seem like they have an adult-size penis-that can be very upsetting! It is difficult to know how large a penis will be in its erect state, simply by looking at it when not erect (or when flaccid).
It is also true that adult penis size varies considerably from person to person. Just as with any body part, different people will have different penis sizes. We live in a society that pushes a myth that the male with a larger penis has a better sex life than one with a smaller penis. This is constantly noted in sexual jokes, in comments heard on TV, or in the movies and in many other places. Well, the truth is that normal penises vary tremendously in size, and sex is just as good for each of these males. You will need to wait a year or two after your overall height has stopped changing to see what final size your penis will be. If at any time during your growing, you are worried that your penis is abnormal, just go to your doctor and ask him or her directly about this. In almost every case, you will be told that it is fine.
The skin on my scrotum (balls) is getting darker. Is that normal?
Yes, it is normal for skin over the scrotum to get darker as you change from a boy to an adult. The result of puberty is an increase in chemicals called hormones. Darkening of the skin over the scrotum or balls is actually one of the first steps of puberty. It is noted to occur at the same time that skin over the balls changes from a smooth appearance to a more rough appearance (called stippling). Also at this time, the testicles or balls themselves will begin to enlarge. These changes are all the first visible signs that puberty has begun. The darkening of the scrotal skin is perfectly normal and will be followed over the next few years by even more dramatic changes: adult pubic hair, growth of the penis, hair in the armpits, larger and stronger muscles, facial hair, growth to an adult size, among others. These changes are all determined by factors called genetic traits-these traits come from your parents and determine how fast these changes will occur and what the final results will look like. So if you see this normal darkening of your scrotal skin, you will know that many changes are about to happen over the next few years-changes that start out looking small, but result in taking you from being a boy to being a man!
When do boys start growing hair around the penis?
The growth of pubic hair over the penis and testicles is a normal part of puberty-the time when boys physically change into men. Most boys begin this time of puberty between 10 and 14 years of age and notice many changes in their bodies that occur over several years. Growth of the testicles is a first visible sign of puberty, followed by growth of the penis. Though much variation is noted, pubic hair usually begins to develop several months after the testicles, or balls, begin to grow. In some boys, the hair may even start growing before any changes in the balls are noted. At first, this hair is limited in amount, is straight (or slightly curled), and soft; it is found at the base or beginning of the penis. Over the next several months or few years, it becomes much darker and curly; it also spreads over the balls and inner parts of the thighs. The final amount of hair is usually reached as other parts of puberty are completed-such as final size of the penis and testicles, final height, and facial hair. However, there is much normal variation in the amount and distribution of this hair. The timing and amount of this hair growth is determined by genetic traits inherited from your mom and dad.
Most of the other guys in the locker room have circumcised penises. I am uncircumcised. Is that normal?
All males are born with a fold of skin over the tip of the penis. Doctors call this fold of skin a prepuce, or foreskin, and the surgical removal of this skin is called circumcision. It has been practiced in many cultures for many centuries, often because of religious reasons. There are some doctors who feel that males should be circumcised for medical reasons and note that circumcision will reduce the chances of male infants getting an infection in their bladders. Some doctors feel that circumcised males will have fewer infections when sexually active and will have less cancer of the penis as adults. But-not all doctors agree with these theories and the medical debate continues regarding the medical need for circumcision. However, doctors do agree that being either circumcised or uncircumcised is normal. When you were born, your parents or guardians chose not to have you circumcised. You are part of a large number of men in the world who are not circumcised-and you are all normal. So, do not worry about this difference! It is perfectly OK!
Why does the doctor have to touch my testicles during the medical exam?
The main reason to touch your testicles (balls) during a medical exam is to check for any abnormality with them. It is important to be sure both balls are of approximate size, and that there is no unusual lump or bump on them. Cancer of the testicle can occur in teen males and it is discovered by the doctor (or even you) touching your testicles. If this cancer is found early, most can have the testicle removed and do well. Finding the cancer early is the key to the best outcome. Your doctor should advise you to check your balls on a regular basis-once a month or so. It is often easy to do this while taking a shower. You will quickly learn how your testicles feel and will be able to discover a new lump or bump on them. If you do feel a lump, see your physician immediately to have it checked out. If you notice pain in or around the testicles, have it checked out also. For example, a lump in the scrotum may not be a tumor of the testicle, but a collection of veins called a varicocele. Sometimes surgery is recommended to remove it. At any rate, expect that a physical examination will include an examination of your testicles. The doctor needs to examine them by touching to be sure they and you are healthy! In fact, if your doctor does not do this during an examination, ask him or her why this very important part of your body is being ignored!
The size of your penis is simply determined by factors, called genetic traits, which you inherited from your parents. There is nothing you can do to increase or decrease the size of your penis-it will develop into its adult size as you change from a boy to a man through the process called puberty. Most boys start the changes of puberty between 10 and 14 years of age, though a few will start earlier or later than these ages. First, the testicles (balls) begin to enlarge and then hair starts to grow around the them. The penis then starts to enlarge, first in length and then later in thickness. Though there is much normal variation, the final penis size is reached four to six years after the testicles first started to enlarge.
This process of normal penis growth can be disturbing to many males. Since the testicles enlarge first (and later followed by growth of the penis), many young male teens do not notice the testicles growing and worry that they are not changing and that their penis is too small. If you are overweight, fat tissue can hide the penis somewhat and give an impression that the penis is smaller than it really is. Some males in your class may have started their changes of puberty well ahead of you and they may seem like they have an adult-size penis-that can be very upsetting! It is difficult to know how large a penis will be in its erect state, simply by looking at it when not erect (or when flaccid).
It is also true that adult penis size varies considerably from person to person. Just as with any body part, different people will have different penis sizes. We live in a society that pushes a myth that the male with a larger penis has a better sex life than one with a smaller penis. This is constantly noted in sexual jokes, in comments heard on TV, or in the movies and in many other places. Well, the truth is that normal penises vary tremendously in size, and sex is just as good for each of these males. You will need to wait a year or two after your overall height has stopped changing to see what final size your penis will be. If at any time during your growing, you are worried that your penis is abnormal, just go to your doctor and ask him or her directly about this. In almost every case, you will be told that it is fine.
The skin on my scrotum (balls) is getting darker. Is that normal?
Yes, it is normal for skin over the scrotum to get darker as you change from a boy to an adult. The result of puberty is an increase in chemicals called hormones. Darkening of the skin over the scrotum or balls is actually one of the first steps of puberty. It is noted to occur at the same time that skin over the balls changes from a smooth appearance to a more rough appearance (called stippling). Also at this time, the testicles or balls themselves will begin to enlarge. These changes are all the first visible signs that puberty has begun. The darkening of the scrotal skin is perfectly normal and will be followed over the next few years by even more dramatic changes: adult pubic hair, growth of the penis, hair in the armpits, larger and stronger muscles, facial hair, growth to an adult size, among others. These changes are all determined by factors called genetic traits-these traits come from your parents and determine how fast these changes will occur and what the final results will look like. So if you see this normal darkening of your scrotal skin, you will know that many changes are about to happen over the next few years-changes that start out looking small, but result in taking you from being a boy to being a man!
When do boys start growing hair around the penis?
The growth of pubic hair over the penis and testicles is a normal part of puberty-the time when boys physically change into men. Most boys begin this time of puberty between 10 and 14 years of age and notice many changes in their bodies that occur over several years. Growth of the testicles is a first visible sign of puberty, followed by growth of the penis. Though much variation is noted, pubic hair usually begins to develop several months after the testicles, or balls, begin to grow. In some boys, the hair may even start growing before any changes in the balls are noted. At first, this hair is limited in amount, is straight (or slightly curled), and soft; it is found at the base or beginning of the penis. Over the next several months or few years, it becomes much darker and curly; it also spreads over the balls and inner parts of the thighs. The final amount of hair is usually reached as other parts of puberty are completed-such as final size of the penis and testicles, final height, and facial hair. However, there is much normal variation in the amount and distribution of this hair. The timing and amount of this hair growth is determined by genetic traits inherited from your mom and dad.
Most of the other guys in the locker room have circumcised penises. I am uncircumcised. Is that normal?
All males are born with a fold of skin over the tip of the penis. Doctors call this fold of skin a prepuce, or foreskin, and the surgical removal of this skin is called circumcision. It has been practiced in many cultures for many centuries, often because of religious reasons. There are some doctors who feel that males should be circumcised for medical reasons and note that circumcision will reduce the chances of male infants getting an infection in their bladders. Some doctors feel that circumcised males will have fewer infections when sexually active and will have less cancer of the penis as adults. But-not all doctors agree with these theories and the medical debate continues regarding the medical need for circumcision. However, doctors do agree that being either circumcised or uncircumcised is normal. When you were born, your parents or guardians chose not to have you circumcised. You are part of a large number of men in the world who are not circumcised-and you are all normal. So, do not worry about this difference! It is perfectly OK!
Why does the doctor have to touch my testicles during the medical exam?
The main reason to touch your testicles (balls) during a medical exam is to check for any abnormality with them. It is important to be sure both balls are of approximate size, and that there is no unusual lump or bump on them. Cancer of the testicle can occur in teen males and it is discovered by the doctor (or even you) touching your testicles. If this cancer is found early, most can have the testicle removed and do well. Finding the cancer early is the key to the best outcome. Your doctor should advise you to check your balls on a regular basis-once a month or so. It is often easy to do this while taking a shower. You will quickly learn how your testicles feel and will be able to discover a new lump or bump on them. If you do feel a lump, see your physician immediately to have it checked out. If you notice pain in or around the testicles, have it checked out also. For example, a lump in the scrotum may not be a tumor of the testicle, but a collection of veins called a varicocele. Sometimes surgery is recommended to remove it. At any rate, expect that a physical examination will include an examination of your testicles. The doctor needs to examine them by touching to be sure they and you are healthy! In fact, if your doctor does not do this during an examination, ask him or her why this very important part of your body is being ignored!
Saturday, February 3, 2007
Understanding Erectile Dysfunction
What is Erectile Dysfunction?
Erectile dysfunction means the same thing as impotence. Both erectile dysfunction and impotence mean the inability to have or keep an erection that is good enough for sexual intercourse. If you have erectile dysfunction, it does not mean that you have an inability to have orgasm or a decreased libido (sex drive) or have premature ejaculation; although if you have these other conditions, they can affect the extent of your erectile dysfunction.
What Is an Erection?
How your body actually produces an erection and then maintains it is a complicated process that depends on
- blood flow
- steroid (androgen) production
- nervous system (neurological) stimulation
- chemical signals from the brain (neurotransmitters)
- enzymes
The increase in blood into the penis also compresses the blood vessels (veins) that allow blood to circulate back out of the penis. So once blood flows in, it is trapped and cannot flow out. This allows the erection to be maintained during sexual activity.
What Are the Causes of Erectile Dysfunction?
The causes of erectile dysfunction or impotence can be divided into two broad groups: organic and non-organic.
Organic
Organic causes are related to physical problems, problems involving your body. Examples include:
- neurological deficits caused by diabetes, spinal cord injuries, or brain (cerebral) injuries
- physical injury (trauma)
- poor blood circulation caused by atherosclerotic disease often related to smoking
- inadequate blood vessel compression, which does not allow the erection to be maintained
- drug-induced changes that decrease erectile ability (listed in Table 1)
| Antidepressants | amitriptyline, doxepin, phenelzine |
| Benzodiazepines | diazepam, midazolam |
| Anti-androgens | medications for prostate cancer like flutamide (Eulexin) and leuprolide |
| Antihypertensives | atenolol, propranolol, nifedipine, enalapril, thiazide, clonidine |
| Other | digoxin, cimetidine |
Non-Organic
Non-organic causes are related to psychological factors. The non-organic causes of erectile dysfunction are less well understood. Personal issues, such as marital problems, performance anxiety, or lack of desire, can and do affect erectile ability. (This is also called psychogenic impotence.)
Evaluation of Erectile Dysfunction
My evaluation of erectile dysfunction can be extensive but initially involves a careful history and physical examination. I often order blood tests to look at hormone levels and other elements in your blood. Some examples of the many possible tests that I might use include a test to measure the largeness and frequency of your night time erections (also called nocturnal penile tumescence), Doppler ultrasound to examine blood flow, and different forms of penile pressure measurements.
What Are the Treatment Options?
Unfortunately, despite the recent press involving Viagra, there is no cure-all for impotence. Depending on your medical and surgical history, there are different treatment options that are best suited for your situation and should be discussed with your urologist. Some options may work for some individuals but may prove unsatisfactory for others. Every treatment option has its advantages and disadvantages, and each one should be considered carefully before choosing any of them.
Oral Medication
Viagra is the best known, but others will soon be available. The side effects of Viagra include headache, nausea, and vision changes. You should not use Viagra if you have heart or high blood pressure problems before discussing carefully this with your physician.
Intraurethral Medication
This is a small pellet that is placed into the penis at the tip and the medication is then absorbed. It is the same medication that is often used for injection therapy. This method avoids many of the side effects of injections but is often not as effective.
Intracavernous Medication
This is often called penile injection therapy. Using a small needle or an auto-injection device, medication is injected at the base of the penile shaft that causes increased blood flow and an erection. Possible side effects include pain, toughening of the penis (penile fibrosis), and prolonged, unwanted erections (priapism) of several hours or more that must be treated medically or sometimes surgically. The chance of this is small but real. The first injection is given at the clinic after carefully teaching you how the injection should be administered.
Vacuum Constriction Devices
These devices fit over the penis and have a pump that pulls blood into the penis. The blood pulled into the penis is trapped by a ring-like device that is placed at the base of the penis. Possible problems include bruising, difficulty in ejaculation, and decreased sensation.
Penile Prosthesis Surgery
There are different types of prostheses. All involve surgery, and each type has its own advantages and disadvantages. Semi-rigid devices are not as life-like but are associated with less injuries and complications. The various inflatable prostheses available, however, are much more life-like and tend to be more satisfying for both partners. Over a period of time, there is a possibility of infection and mechanical problems that would require another operative procedure. A penile prosthesis should be the last resort, and other treatment attempts should be made before pursuing surgery.
Thursday, February 1, 2007
Is There a Link Between Viagra and Blindness?
July 11, 2005—The Food and Drug Administration (FDA) has ordered the makers of Viagra, Cialis and Levitra to add new warnings about rare cases of sudden vision loss. A recent study also noted these vision problems, known as non-arteritic anterior ischemic optic neuropathy (NAION), in seven men who had taken Viagra.
The agency is advising patients to stop taking these medicines or call a doctor or right away if they experience sudden or decreased vision loss in one or both eyes. In a statement, the agency said that a small number of men lost their sight some time after taking Viagra, Cialis or Levitra. "It is not possible to determine whether these oral medicines for erectile dysfunction were the cause of the loss of eyesight or whether the problem is related to other factors such as high blood pressure or diabetes or to a combination of these problems," the FDA said.
Well over 20 million men have taken these anti-impotence drugs, meaning that whatever risk there is of developing vision loss—if there is a risk at all—would seem extremely small. Still, just how serious of a condition is NAION, and what can be done in men who develop it?
What is NAION?
NAION is one of the most common causes of sudden vision loss in older Americans.
The condition leads to swelling around the optic disc, a connection point where the optic nerves reach the back of the eye. Ultimately, this swelling compresses the optic nerves and causes a rapid drop in vision. About 6,000 people develop NAION each year, according to the National Eye Institute.
How does NAION develop?
The symptoms are painless and often appear without notice. In a study led by researchers at the University of Iowa, about three quarters of NAION patients first discovered their vision was blurry and impaired after waking up in the morning. The condition starts in one eye and can cause complete blindness if both eyes are eventually affected.
Is there a risk from Viagra and other anti-impotence drugs?
No one can say for sure. Pfizer, the manufacturer of Viagra, defends the safety of its drug. "A review of 103 Viagra clinical trials involving 13,000 patients found no reports of non-arteritic anterior ischemic optic neuropathy," the company stated. "There is no evidence showing that NAION occurred more frequently in men taking Viagra than men of similar age and health who did not take Viagra."
Andrew Schachat, MD, an ophthalmologist with the Wilmer Eye Institute at Johns Hopkins University, who has no financial ties to Pfizer, is equally skeptical. "With the millions of patients who use Viagra, it is not surprising to find cases of NAION and in fact, one would expect to find some," he said.
The FDA continues to investigate whether there is a connection. Schachat said he doubts Viagra or other anti-impotence drugs cause NAION, "but a careful study would be needed."
So far, the warnings about side effects—such as NAION and erections that last more than four hours—are the same for each of the three popular anti-impotence drugs.
Why is the concern about Viagra and NAION surfacing now?
The chance that Viagra might lead to NAION was first brought up by Howard Pomeranz, MD, an eye expert at the University of Minnesota. In 2000, he reported the case of a man who developed NAION soon after he took Viagra. There have been several other reports since then.
In a study published in the Journal of Neuro-Ophthalmology this past March, Pomeranz noted seven new cases, bringing the total to 14 men who developed NAION possibly because of Viagra. On May 26, the FDA first confirmed to CBS News that they were investigating similar reports in nearly 50 men.
Does NAION lead to permanent vision loss?
Not always. Until a few years ago, it was estimated that only a small minority of patients were likely to regain their vision. But new studies have shown that a surprisingly high number of NAION patients spontaneously recover on their own.
Following some 100 or so men and women who were involved in a major trial sponsored by the National Eye Institute, researchers found that about 40 percent of NAION patients had some improvement in eye sight after three months. Indeed, they fared better than a similar number of patients who underwent an experimental procedure to prevent further vision loss.
"It's much better than we expected," said Kay Dickersin, PhD, a professor of Community Health at Brown University who has helped with the study, known as the Ischemic Optic Neuropathy Decompression Trial.
Is the vision loss substantial?
NAION can be disabling, especially if it affects both eyes. In the National Eye Institute study, whatever gains the patients had were partly lost after two years. But even with declining eyesight, most had better vision than when they were first afflicted with NAION. "These improvements are a noticeable difference," Dickersin said.
Is there any treatment for NAION?
There is no effective treatment as of yet, although researchers are examining different therapies in clinical trials.
Who is at risk for NAION?
Those who have bad eyesight already appear to have the highest chance for developing NAION. While people who have diabetes, hypertension or high cholesterol seem to be a greater risk for NAION as well, there is some debate on how much. "None of these systematic disorders are firmly associated with NAION, and diabetes could only account for only a minority of the cases," stated Simmons Lessell, MD, of the Massachusetts Eye and Ear Infirmary in an editorial for the Archives of Ophthalmology.
Is there a strong reason to suspect that Viagra raises the risk of blindness?
The seven men in Pomeranz's recent study all developed NAION soon after they took Viagra. After taking two blue Viagra pills the day before, one 50-year old man said he felt "a flashbulb go off in my eyes." The onset of vision loss within hours of taking Viagra "supports an association between use of this agent and NAION," Pomeranz wrote.
However, NAION appears suddenly in some 6,000 people a year for a variety of unknown reasons. "We don't really know what the natural history of NAION is," said Dickersin. Pomeranz is also cautious about Viagra causing NAION: "A definite casual relationship cannot be established at this time," he noted.
The Bottom Line
Recent guidelines from the American Urological Association recommended either Viagra, Cialis or Levitra as the first option for treating erectile dysfunction, which have not changed in light of the recent bad publicity about their potential link to NAION.
In general, as many as 80 percent of men will benefit from these drugs, said Drogo Montague, MD, of the Cleveland Clinic in announcing the new guidelines. Men can try injections, external pumps or a penile implants if Viagra or similar drugs fail to work. "For those men who are not helped by these agents, one or more of the remaining treatment options are almost always successful," said Montague.
The agency is advising patients to stop taking these medicines or call a doctor or right away if they experience sudden or decreased vision loss in one or both eyes. In a statement, the agency said that a small number of men lost their sight some time after taking Viagra, Cialis or Levitra. "It is not possible to determine whether these oral medicines for erectile dysfunction were the cause of the loss of eyesight or whether the problem is related to other factors such as high blood pressure or diabetes or to a combination of these problems," the FDA said.
Well over 20 million men have taken these anti-impotence drugs, meaning that whatever risk there is of developing vision loss—if there is a risk at all—would seem extremely small. Still, just how serious of a condition is NAION, and what can be done in men who develop it?
What is NAION?
NAION is one of the most common causes of sudden vision loss in older Americans.
The condition leads to swelling around the optic disc, a connection point where the optic nerves reach the back of the eye. Ultimately, this swelling compresses the optic nerves and causes a rapid drop in vision. About 6,000 people develop NAION each year, according to the National Eye Institute.
How does NAION develop?
The symptoms are painless and often appear without notice. In a study led by researchers at the University of Iowa, about three quarters of NAION patients first discovered their vision was blurry and impaired after waking up in the morning. The condition starts in one eye and can cause complete blindness if both eyes are eventually affected.
Is there a risk from Viagra and other anti-impotence drugs?
No one can say for sure. Pfizer, the manufacturer of Viagra, defends the safety of its drug. "A review of 103 Viagra clinical trials involving 13,000 patients found no reports of non-arteritic anterior ischemic optic neuropathy," the company stated. "There is no evidence showing that NAION occurred more frequently in men taking Viagra than men of similar age and health who did not take Viagra."
Andrew Schachat, MD, an ophthalmologist with the Wilmer Eye Institute at Johns Hopkins University, who has no financial ties to Pfizer, is equally skeptical. "With the millions of patients who use Viagra, it is not surprising to find cases of NAION and in fact, one would expect to find some," he said.
The FDA continues to investigate whether there is a connection. Schachat said he doubts Viagra or other anti-impotence drugs cause NAION, "but a careful study would be needed."
So far, the warnings about side effects—such as NAION and erections that last more than four hours—are the same for each of the three popular anti-impotence drugs.
Why is the concern about Viagra and NAION surfacing now?
The chance that Viagra might lead to NAION was first brought up by Howard Pomeranz, MD, an eye expert at the University of Minnesota. In 2000, he reported the case of a man who developed NAION soon after he took Viagra. There have been several other reports since then.
In a study published in the Journal of Neuro-Ophthalmology this past March, Pomeranz noted seven new cases, bringing the total to 14 men who developed NAION possibly because of Viagra. On May 26, the FDA first confirmed to CBS News that they were investigating similar reports in nearly 50 men.
Does NAION lead to permanent vision loss?
Not always. Until a few years ago, it was estimated that only a small minority of patients were likely to regain their vision. But new studies have shown that a surprisingly high number of NAION patients spontaneously recover on their own.
Following some 100 or so men and women who were involved in a major trial sponsored by the National Eye Institute, researchers found that about 40 percent of NAION patients had some improvement in eye sight after three months. Indeed, they fared better than a similar number of patients who underwent an experimental procedure to prevent further vision loss.
"It's much better than we expected," said Kay Dickersin, PhD, a professor of Community Health at Brown University who has helped with the study, known as the Ischemic Optic Neuropathy Decompression Trial.
Is the vision loss substantial?
NAION can be disabling, especially if it affects both eyes. In the National Eye Institute study, whatever gains the patients had were partly lost after two years. But even with declining eyesight, most had better vision than when they were first afflicted with NAION. "These improvements are a noticeable difference," Dickersin said.
Is there any treatment for NAION?
There is no effective treatment as of yet, although researchers are examining different therapies in clinical trials.
Who is at risk for NAION?
Those who have bad eyesight already appear to have the highest chance for developing NAION. While people who have diabetes, hypertension or high cholesterol seem to be a greater risk for NAION as well, there is some debate on how much. "None of these systematic disorders are firmly associated with NAION, and diabetes could only account for only a minority of the cases," stated Simmons Lessell, MD, of the Massachusetts Eye and Ear Infirmary in an editorial for the Archives of Ophthalmology.
Is there a strong reason to suspect that Viagra raises the risk of blindness?
The seven men in Pomeranz's recent study all developed NAION soon after they took Viagra. After taking two blue Viagra pills the day before, one 50-year old man said he felt "a flashbulb go off in my eyes." The onset of vision loss within hours of taking Viagra "supports an association between use of this agent and NAION," Pomeranz wrote.
However, NAION appears suddenly in some 6,000 people a year for a variety of unknown reasons. "We don't really know what the natural history of NAION is," said Dickersin. Pomeranz is also cautious about Viagra causing NAION: "A definite casual relationship cannot be established at this time," he noted.
The Bottom Line
Recent guidelines from the American Urological Association recommended either Viagra, Cialis or Levitra as the first option for treating erectile dysfunction, which have not changed in light of the recent bad publicity about their potential link to NAION.
In general, as many as 80 percent of men will benefit from these drugs, said Drogo Montague, MD, of the Cleveland Clinic in announcing the new guidelines. Men can try injections, external pumps or a penile implants if Viagra or similar drugs fail to work. "For those men who are not helped by these agents, one or more of the remaining treatment options are almost always successful," said Montague.
Milk's health benefits outweigh its prostate risks
Should my husband cut back on milk to prevent prostate cancer?
The answer is no. Although a recent study seemed to link high calcium intake with prostate cancer, even the study's authors say it's too soon to stop aiming for the Daily Value of 1,000 mg (1,200 if you're over 50).
"More studies showing a prostate cancer link need to turn up before you should even consider changing calcium intake," says June Chan, ScD, of the University of California, San Francisco (Amer. Jour. of Clinical Nutrition, Oct 2001). Besides guarding bones (men get osteoporosis too), calcium appears to prevent high blood pressure and colon cancer.
The answer is no. Although a recent study seemed to link high calcium intake with prostate cancer, even the study's authors say it's too soon to stop aiming for the Daily Value of 1,000 mg (1,200 if you're over 50).
"More studies showing a prostate cancer link need to turn up before you should even consider changing calcium intake," says June Chan, ScD, of the University of California, San Francisco (Amer. Jour. of Clinical Nutrition, Oct 2001). Besides guarding bones (men get osteoporosis too), calcium appears to prevent high blood pressure and colon cancer.
Herbal Help for Prostate Health
Scientific research can be a slow process. It starts with simple observation, followed by the collection of scientific data. A few years ago, an Austrian herbalist named Maria Treben wrote a bestselling book that was translated into English as Health Through God's Pharmacy (Ennsthaler, 1998). In it, she recommended a tea prepared from the small-flowered willow herb (Epilobium parviflorum) as an effective treatment for benign prostatic hyperplasia (BPH), or prostate enlargement. The herb became very popular in Europe, but there was no evidence to support its value.
Scientists have isolated compounds known as oenotheins from the Epilobium species and, in test-tube experiments, have shown them to inhibit the enzymes aromatase and 5-alpha-reductase, both of which are involved in prostate enlargement. Clinical studies have not yet been carried out, but the signs are hopeful that the traditional use of this herb will be validated. Willow herb is not yet widely available in the US.
Scientists have isolated compounds known as oenotheins from the Epilobium species and, in test-tube experiments, have shown them to inhibit the enzymes aromatase and 5-alpha-reductase, both of which are involved in prostate enlargement. Clinical studies have not yet been carried out, but the signs are hopeful that the traditional use of this herb will be validated. Willow herb is not yet widely available in the US.
Wednesday, January 31, 2007
Premature ejaculation: Management in primary care
The most common dysfunctions of the ejaculatory process seen in primary care are ejaculation prior to the time desired by the patient and/or his partner (premature or rapid ejaculation), painful ejaculation (dysorgasmia), absence of ejaculation (anejaculation), blood with ejaculation (hematospermia), and retrograde ejaculation (usually postsurgical or associated with alpha-blocker treatment for benign prostatic hypertrophy). Of these, premature ejaculation (pEJ) is by far the most prevalent, affecting as many as 39% of men in the general community.1
Nonetheless, men are often reluctant to acknowledge the presence of pEJ, no pharmacotherapeutic agent has yet been FDA-approved for its treatment, and the education of primary care clinicians about ejaculatory dysfunctions has often been scanty. Because pEJ may cause distress for the patient and/or his partner, and clinical trials have demonstrated the efficacy of a variety of remedies, clinicians may wish to familiarize themselves with the appropriate diagnosis and management skills necessary for successfully addressing this problem.
DEFINITION Defining pEJ has been difficult for investigators because of a lack of adequate population-based data to establish normative boundaries for either the duration of intravaginal intercourse or number of thrusts until ejaculation. Similarly, quantifying what constitutes appropriate maintenance of erection prior to ejaculation from the vantage point of partner satisfaction has been elusive.
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) has defined pEJ as "persistent or recurrent ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it."2 While this definition probably accurately describes most men who suffer from pEJ, it lacks finite boundaries that might make case definition simpler for clinicians.
Furthermore, all definitions of pEJ should contain some notion of "bother," since if the patient or his partner is not bothered by the duration of intercourse, no treatment is required regardless of the brevity of the experience. For the discussion that follows, we consider any of the 3 following operational descriptors, as a complement to the DSM-IV definition, adequate for the functional delineation of pEJ:
A consistent experience of unwanted inability to delay ejaculation beyond 2 to 3 minutes of intromission
A consistent experience of ejaculation prior to 7 minutes of intromission that is problematic for the patient or partner satisfaction
A 50% or greater decrease in the amount of time to ejaculation compared with a previously established long-term pattern of sexual experience, which might also be labeled secondary pEJ.
The vast majority of patients with pEJ will be described by one or more of these criteria. Because pEJ may affect heterosexual or same-sex encounters, no terminology involving vaginal intromission is used, although readers should be aware that a good deal of the literature about pEJ uses intravaginal latency as a metric.
The rationale behind the first descriptor is the fact that, despite the lack of adequate normative population data, an average duration of intercourse of 4 to 7 minutes has been reported, leading to the consideration that duration substantially less than this, if unwanted, should clearly qualify as pEJ. Similar issues confirm the utility of the second descriptor, so that when intercourse lasts less than 7 minutes, if the patient finds this duration insufficient, consideration may be given to offering treatment. Lastly, pEJ may become problematic when a patient reports a departure from his usual experience of ejaculatory timing. For instance, patients with prostatitis may report changes in ejaculatory latency, with a trend toward earlier ejaculation, difficulty maintaining an erection, or both. Although typically a transient phenomenon, opioid withdrawal has also been associated with pEJ.3
YES, BUT WHY BOTHER? According the one survey, pEJ is epidemiologically the most common sexual dysfunction reported by American men, with an overall prevalence of 29%.4 Yet, although pEJ has not been a common presenting complaint in primary care, men and/or their partners may be quite distressed by it. Perceptions of the problem on the part of both patients and clinicians tend to preclude disease identification and treatment. Patients often do not complain about pEJ because they are embarrassed by the condition, there is minimal public awareness that pEJ is a legitimate health issue, and there is also a lack of insight that safe, effective treatments are available. Clinicians may not be familiar with an appropriate mode of inquiry, may have had scant guidance on pharmacotherapeutic management, and, despite the burden of distress that the disorder may cause to patients, may perceive pEJ as a low-priority disorder.
There is reason to be optimistic about pEJ management. Men who were dissatisfied with prior treatments may find newly discovered interventions more attractive. The widespread public awareness of the role of phosphodiesterase-5 (PDE-5) inhibitors in erectile dysfunction (ED) may facilitate disclosure of other sexual dysfunctions to the clinician. ED has increasingly moved into the bailiwick of primary care clinicians, so the opportunity for discussion of various sexual dysfunctions has also increased. Finally, with pharmacotherapy and/or counseling, most patients will find a satisfactory degree of pEJ improvement or resolution.
The epidemiologic patterns of pEJ are surprising to some clinicians. The disorder is most common between ages 20 to 40 years (average age, 33.1), and cases are fairly evenly distributed between primary (lifelong) and secondary disease (occurring after an established period of normal ejaculatory function). In men older than age 40 years, primary pEJ becomes the dominant category.5
DIAGNOSIS Primary care clinicians tend to prioritize the line of inquiry during a patient visit by disease-state hierarchy, so that cardiovascular disease, hypertension, and diabetes often obtain first notice and follow-up. Quality of life issues such as pEJ may be significantly problematic for patients or their partners and deserve our attention if they are a priority for the patient. Because clinical inquiry into sexual function has been relatively uncommon in the recent past, it is usually incumbent on the clinician to initiate the dialogue.
The diagnosis of pEJ occurs via the history; appropriate laboratory tests and physical examination rule out secondary causes. Clinicians need to be explicit in their inquiry if meaningful information is to be obtained. A variety of appropriate questions may help initiate discussion of sexual matters. Here is an example of the universal-to-specific shepherding technique: "Mr Anderson, many men who take SSRIs notice changes in their ejaculation. Has this been a problem for you?"
Some clinicians, however, consider inquiry about sexual function to be one of the vital signs of lifestyle, hence this approach: "Mr Anderson, I would like to ask you some personal questions at this point, and of course we can leave out any questions that make you uncomfortable or that you do not wish to answer. Are you having any difficulties with sexual function? Specifically, do you experience any problems with the duration of intercourse or orgasm?"
The key issues that need to be elucidated regarding ejaculatory function include time to ejaculation, whether time to ejaculation is within the patient's control, and whether the ejaculatory experience causes the patient (or his partner) distress.5 The following questions are appropriate, revolve around these issues, and also target possible causes:
Typically, how long does sexual activity last before orgasm?
Is this a change from your prior experience?
Is the duration of intercourse you are experiencing a problem for you or your partner(s)?
If duration of intercourse is problematic, what strategies have you tried to remedy the situation?
Have there been any emotional or psychological stressors that occurred around the time you first noticed the changes in your sexual function?
Are there any medications, herbs, vitamins, or other substances that you started taking around the time you noticed changes in your ejaculatory function?
ETIOLOGY When pEJ is associated with a medication, a noteworthy psychological stress, or physical trauma, little further investigation for culpable sources is necessary. Unfortunately, the cause is commonly unknown and, in many cases, may be a combination of biologic and psychological factors.
Supporting the role of serotonin in ejaculatory function is the consistent impact of delayed ejaculation in men who receive selective serotonin reuptake inhibitors (SSRIs) for depression. Much of the other data ascribing pEJ to various neurologic or hormonal factors is based on rat studies, without convincing confirmation in humans. Data from the 1970s by Masters and Johnson reported simple counseling techniques for pEJ had success rates as high as 97%, a statistic which would lend credence to the dominantly psychogenic components of the etiology. Recently, these early data have been criticized because of lack of placebo controls, small data sets, and insufficient replication. Hypogonadism has rarely been associated with pEJ, but correction of hypogonadism with anastrozole did not improve pEJ.6
TREATMENT The goal of treatment for pEJ is to delay ejaculation sufficiently to relieve the distress experienced by the patient or his partner. Available methods include behavioral therapy, counseling, sexual stimulation techniques, pharmacotherapy (topical and systemic), and mechanical therapies such as vacuum pumps and penile constriction rings.
Counseling Since pEJ is very often solely psychogenic, counseling is an appropriate tool that is usually provided by sex therapists. Clinicians may also be able to provide simple instructions about distraction techniques, Kegel exercises, and stop-start vaginal intromission methods that will allow the patient to develop a sense of ejaculatory control. The usefulness of such interventions is largely unknown, but anecdotal reports suggest some efficacy.
Physical maneuvers include the squeeze technique and penile constriction devices. For the squeeze technique, the patient and his partner are instructed that when the patient feels a sensation of ejaculatory imminence, he should withdraw his penis and his partner should provide a firm squeeze (2-3 seconds) at the base of the glans penis. Often, this withdrawal from vaginal stimulation, cessation of thrusting, and contrasexual stimulus will produce a sufficient deescalation of ejaculatory imminence to allow the couple to resume intercourse a few seconds later.
Men who use a vacuum constriction device will be familiar with the incorporation of a constricting band (constriction ring) to maintain penile turgidity during intercourse. Even after ejaculation, the presence of a constriction band at the base of the penis will maintain turgidity sufficient for vaginal penetration and continued vaginal thrusting in most patients. Once the patient has a constriction device on the base of his penis and knows that the erection will be maintained even after ejaculation, ejaculatory anxiety is reduced, and the subsequent reduction in sympathetic tone may be useful in extending vaginal latency. A popular adjustable constriction ring has the brand name Actis. Penile constriction rings are very inexpensive and may be used many times before they need to be replaced.
Patients may consider wearing one or more condoms to reduce penile glans sensitivity. Topical agents that reduce glans sensitivity are also effective, but the practicality of these agents is limited by the need to wash them off after intercourse and to use barrier methods to prevent topical application on the partner.
Pharmacotherapy In the authors' experience, most patients who present with pEJ want pharmacotherapy. Most of the experience with neurohumoral modulation has been obtained with various SSRIs or with tricyclic antidepressants (TCAs), particularly clomipramine. Consonant with the literature that pEJ may be accompanied by a reduction in serotoninergic neurotransmission,7 the most common medications used for pEJ are SSRIs.
Widespread use of SSRIs for depression soon led to the observation that SSRIs could cause ejaculatory delay, or even anejaculation, in men without prior ejaculatory dysfunction. It was a logical next step to study these agents in men with pEJ.8 Adding credence to the serotonin-modulation theory of ejaculatory dysfunction, withdrawal of citalopram has been associated with pEJ.9 A variety of SSRIs have been studied for pEJ, most of them producing favorable effects for prolonging ejaculatory latency. Even though the data on clomipramine, a TCA indicated for obsessive-compulsive disorder, appear to be equally favorable, the adverse-effect profile of TCAs may limit their use.
Three primary methods of drug administration have proved to be efficacious: medication on demand (within hours of anticipated intercourse), maintenance medication (such as a daily regimen), or sequential medication (a course of daily medication for 4-6 weeks, followed by medication on demand). All the SSRIs studied so far have had some favorable effects, but comparison studies indicate that paroxetine may be the most effective.10 With maintenance therapy, patients can generally anticipate a 3- to 10-fold increase in ejaculatory latency time. Consequently, men who have not been able to delay ejaculation beyond 30 seconds to 1 minute might be able to enjoy prolongation of intercourse for 1.5 to 7 minutes. Note that, for all the agents studied to date, pEJ is an off-label indication.
Because paroxetine has been demonstrated to have the most pronounced effect on ejaculatory latency, it may be considered as a drug of choice, with therapy initiated at 20 mg/d. Failure to respond within 4 weeks of daily medication (titrated to 40 mg/d of paroxetine—or 100 mg/d of sertraline, 40 mg/d of fluoxetine, or 50 mg/d of clomipramine) should prompt consideration of another method of treatment.11 Although higher dosages of SSRIs and TCAs may produce greater prolongation of ejaculatory latency, side effects may also increase incrementally. Since some patients will prefer one SSRI over another, or the metabolic effects of some SSRIs may be problematic (for example, paroxetine and fluoxetine are very potent cytochrome P-450IID6 inhibitors), clinicians may consider sertraline, which lacks significant cytochrome P-450 interactions and is associated with less sedation than paroxetine.
Rather than adhering to a daily regimen, patients may wish to try on-demand medication. Although scant data support this use, clomipramine, 25 to 50 mg administered within 4 to 6 hours of intercourse, has shown some efficacy for pEJ, with a duration of up to 15 hours.11 Initial data suggest that sildenafil may be an effective treatment for pEJ in some men. One comparison trial of patients with lifelong pEJ that evaluated SSRIs, clomipramine, sildenafil, and the squeeze technique found sildenafil to be the most efficacious, but because this study had no placebo control and showed other methodologic limitations, the results must be considered preliminary.1,12
The effectiveness of combination pharmacotherapy is supported by limited, but promising, data. A prospective study of 80 patients compared combination therapy with a regimen of paroxetine (10 mg/d for 21 d, followed by 20 mg/d on demand) with or without sildenafil. Combination therapy was more effective: Monotherapy increased mean ejaculatory latency time from 0.33 minutes (baseline) to 4.2 minutes at 6 months, whereas combination therapy improved ejaculatory latency from 0.35 minutes (baseline) to 5.3 minutes at 6 months and was associated with greater intercourse satisfaction.13
Because some men will continue to use SSRIs for pEJ treatment on a long-term basis, it is appropriate to address medication safety with them. Like all pharmacotherapeutic agents, SSRIs may have problematic adverse effects. There is now also clearer recognition that there may be a population of individuals for whom SSRIs may transiently accentuate the risk of suicide or suicidal ideation. Hence, prior to initiating a program of sustained SSRI treatment, the clinician should be aware of the patient's status for depression and suicidal ideation, and inform him of this risk.
Topical treatment Topical anesthetics can improve ejaculatory latency time by reducing penile sensitivity, but excessive topical anesthesia can prevent erection due to lack of sensory input. In addition, unless a barrier method is used in conjunction with topical agents, application to the sexual partner may concomitantly reduce the partner's cutaneous sensitivity.
Examples of topical agents found to improve intravaginal ejaculatory latency time in randomized placebo-controlled trials include lidocaine 2%, and lidocaine 2.5%/prilocaine cream 2.5%.Data suggest that such agents may be applied 10 to 30 minutes before intercourse.
Nonetheless, men are often reluctant to acknowledge the presence of pEJ, no pharmacotherapeutic agent has yet been FDA-approved for its treatment, and the education of primary care clinicians about ejaculatory dysfunctions has often been scanty. Because pEJ may cause distress for the patient and/or his partner, and clinical trials have demonstrated the efficacy of a variety of remedies, clinicians may wish to familiarize themselves with the appropriate diagnosis and management skills necessary for successfully addressing this problem.
DEFINITION Defining pEJ has been difficult for investigators because of a lack of adequate population-based data to establish normative boundaries for either the duration of intravaginal intercourse or number of thrusts until ejaculation. Similarly, quantifying what constitutes appropriate maintenance of erection prior to ejaculation from the vantage point of partner satisfaction has been elusive.
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) has defined pEJ as "persistent or recurrent ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it."2 While this definition probably accurately describes most men who suffer from pEJ, it lacks finite boundaries that might make case definition simpler for clinicians.
Furthermore, all definitions of pEJ should contain some notion of "bother," since if the patient or his partner is not bothered by the duration of intercourse, no treatment is required regardless of the brevity of the experience. For the discussion that follows, we consider any of the 3 following operational descriptors, as a complement to the DSM-IV definition, adequate for the functional delineation of pEJ:
A consistent experience of unwanted inability to delay ejaculation beyond 2 to 3 minutes of intromission
A consistent experience of ejaculation prior to 7 minutes of intromission that is problematic for the patient or partner satisfaction
A 50% or greater decrease in the amount of time to ejaculation compared with a previously established long-term pattern of sexual experience, which might also be labeled secondary pEJ.
The vast majority of patients with pEJ will be described by one or more of these criteria. Because pEJ may affect heterosexual or same-sex encounters, no terminology involving vaginal intromission is used, although readers should be aware that a good deal of the literature about pEJ uses intravaginal latency as a metric.
The rationale behind the first descriptor is the fact that, despite the lack of adequate normative population data, an average duration of intercourse of 4 to 7 minutes has been reported, leading to the consideration that duration substantially less than this, if unwanted, should clearly qualify as pEJ. Similar issues confirm the utility of the second descriptor, so that when intercourse lasts less than 7 minutes, if the patient finds this duration insufficient, consideration may be given to offering treatment. Lastly, pEJ may become problematic when a patient reports a departure from his usual experience of ejaculatory timing. For instance, patients with prostatitis may report changes in ejaculatory latency, with a trend toward earlier ejaculation, difficulty maintaining an erection, or both. Although typically a transient phenomenon, opioid withdrawal has also been associated with pEJ.3
YES, BUT WHY BOTHER? According the one survey, pEJ is epidemiologically the most common sexual dysfunction reported by American men, with an overall prevalence of 29%.4 Yet, although pEJ has not been a common presenting complaint in primary care, men and/or their partners may be quite distressed by it. Perceptions of the problem on the part of both patients and clinicians tend to preclude disease identification and treatment. Patients often do not complain about pEJ because they are embarrassed by the condition, there is minimal public awareness that pEJ is a legitimate health issue, and there is also a lack of insight that safe, effective treatments are available. Clinicians may not be familiar with an appropriate mode of inquiry, may have had scant guidance on pharmacotherapeutic management, and, despite the burden of distress that the disorder may cause to patients, may perceive pEJ as a low-priority disorder.
There is reason to be optimistic about pEJ management. Men who were dissatisfied with prior treatments may find newly discovered interventions more attractive. The widespread public awareness of the role of phosphodiesterase-5 (PDE-5) inhibitors in erectile dysfunction (ED) may facilitate disclosure of other sexual dysfunctions to the clinician. ED has increasingly moved into the bailiwick of primary care clinicians, so the opportunity for discussion of various sexual dysfunctions has also increased. Finally, with pharmacotherapy and/or counseling, most patients will find a satisfactory degree of pEJ improvement or resolution.
The epidemiologic patterns of pEJ are surprising to some clinicians. The disorder is most common between ages 20 to 40 years (average age, 33.1), and cases are fairly evenly distributed between primary (lifelong) and secondary disease (occurring after an established period of normal ejaculatory function). In men older than age 40 years, primary pEJ becomes the dominant category.5
DIAGNOSIS Primary care clinicians tend to prioritize the line of inquiry during a patient visit by disease-state hierarchy, so that cardiovascular disease, hypertension, and diabetes often obtain first notice and follow-up. Quality of life issues such as pEJ may be significantly problematic for patients or their partners and deserve our attention if they are a priority for the patient. Because clinical inquiry into sexual function has been relatively uncommon in the recent past, it is usually incumbent on the clinician to initiate the dialogue.
The diagnosis of pEJ occurs via the history; appropriate laboratory tests and physical examination rule out secondary causes. Clinicians need to be explicit in their inquiry if meaningful information is to be obtained. A variety of appropriate questions may help initiate discussion of sexual matters. Here is an example of the universal-to-specific shepherding technique: "Mr Anderson, many men who take SSRIs notice changes in their ejaculation. Has this been a problem for you?"
Some clinicians, however, consider inquiry about sexual function to be one of the vital signs of lifestyle, hence this approach: "Mr Anderson, I would like to ask you some personal questions at this point, and of course we can leave out any questions that make you uncomfortable or that you do not wish to answer. Are you having any difficulties with sexual function? Specifically, do you experience any problems with the duration of intercourse or orgasm?"
The key issues that need to be elucidated regarding ejaculatory function include time to ejaculation, whether time to ejaculation is within the patient's control, and whether the ejaculatory experience causes the patient (or his partner) distress.5 The following questions are appropriate, revolve around these issues, and also target possible causes:
Typically, how long does sexual activity last before orgasm?
Is this a change from your prior experience?
Is the duration of intercourse you are experiencing a problem for you or your partner(s)?
If duration of intercourse is problematic, what strategies have you tried to remedy the situation?
Have there been any emotional or psychological stressors that occurred around the time you first noticed the changes in your sexual function?
Are there any medications, herbs, vitamins, or other substances that you started taking around the time you noticed changes in your ejaculatory function?
ETIOLOGY When pEJ is associated with a medication, a noteworthy psychological stress, or physical trauma, little further investigation for culpable sources is necessary. Unfortunately, the cause is commonly unknown and, in many cases, may be a combination of biologic and psychological factors.
Supporting the role of serotonin in ejaculatory function is the consistent impact of delayed ejaculation in men who receive selective serotonin reuptake inhibitors (SSRIs) for depression. Much of the other data ascribing pEJ to various neurologic or hormonal factors is based on rat studies, without convincing confirmation in humans. Data from the 1970s by Masters and Johnson reported simple counseling techniques for pEJ had success rates as high as 97%, a statistic which would lend credence to the dominantly psychogenic components of the etiology. Recently, these early data have been criticized because of lack of placebo controls, small data sets, and insufficient replication. Hypogonadism has rarely been associated with pEJ, but correction of hypogonadism with anastrozole did not improve pEJ.6
TREATMENT The goal of treatment for pEJ is to delay ejaculation sufficiently to relieve the distress experienced by the patient or his partner. Available methods include behavioral therapy, counseling, sexual stimulation techniques, pharmacotherapy (topical and systemic), and mechanical therapies such as vacuum pumps and penile constriction rings.
Counseling Since pEJ is very often solely psychogenic, counseling is an appropriate tool that is usually provided by sex therapists. Clinicians may also be able to provide simple instructions about distraction techniques, Kegel exercises, and stop-start vaginal intromission methods that will allow the patient to develop a sense of ejaculatory control. The usefulness of such interventions is largely unknown, but anecdotal reports suggest some efficacy.
Physical maneuvers include the squeeze technique and penile constriction devices. For the squeeze technique, the patient and his partner are instructed that when the patient feels a sensation of ejaculatory imminence, he should withdraw his penis and his partner should provide a firm squeeze (2-3 seconds) at the base of the glans penis. Often, this withdrawal from vaginal stimulation, cessation of thrusting, and contrasexual stimulus will produce a sufficient deescalation of ejaculatory imminence to allow the couple to resume intercourse a few seconds later.
Men who use a vacuum constriction device will be familiar with the incorporation of a constricting band (constriction ring) to maintain penile turgidity during intercourse. Even after ejaculation, the presence of a constriction band at the base of the penis will maintain turgidity sufficient for vaginal penetration and continued vaginal thrusting in most patients. Once the patient has a constriction device on the base of his penis and knows that the erection will be maintained even after ejaculation, ejaculatory anxiety is reduced, and the subsequent reduction in sympathetic tone may be useful in extending vaginal latency. A popular adjustable constriction ring has the brand name Actis. Penile constriction rings are very inexpensive and may be used many times before they need to be replaced.
Patients may consider wearing one or more condoms to reduce penile glans sensitivity. Topical agents that reduce glans sensitivity are also effective, but the practicality of these agents is limited by the need to wash them off after intercourse and to use barrier methods to prevent topical application on the partner.
Pharmacotherapy In the authors' experience, most patients who present with pEJ want pharmacotherapy. Most of the experience with neurohumoral modulation has been obtained with various SSRIs or with tricyclic antidepressants (TCAs), particularly clomipramine. Consonant with the literature that pEJ may be accompanied by a reduction in serotoninergic neurotransmission,7 the most common medications used for pEJ are SSRIs.
Widespread use of SSRIs for depression soon led to the observation that SSRIs could cause ejaculatory delay, or even anejaculation, in men without prior ejaculatory dysfunction. It was a logical next step to study these agents in men with pEJ.8 Adding credence to the serotonin-modulation theory of ejaculatory dysfunction, withdrawal of citalopram has been associated with pEJ.9 A variety of SSRIs have been studied for pEJ, most of them producing favorable effects for prolonging ejaculatory latency. Even though the data on clomipramine, a TCA indicated for obsessive-compulsive disorder, appear to be equally favorable, the adverse-effect profile of TCAs may limit their use.
Three primary methods of drug administration have proved to be efficacious: medication on demand (within hours of anticipated intercourse), maintenance medication (such as a daily regimen), or sequential medication (a course of daily medication for 4-6 weeks, followed by medication on demand). All the SSRIs studied so far have had some favorable effects, but comparison studies indicate that paroxetine may be the most effective.10 With maintenance therapy, patients can generally anticipate a 3- to 10-fold increase in ejaculatory latency time. Consequently, men who have not been able to delay ejaculation beyond 30 seconds to 1 minute might be able to enjoy prolongation of intercourse for 1.5 to 7 minutes. Note that, for all the agents studied to date, pEJ is an off-label indication.
Because paroxetine has been demonstrated to have the most pronounced effect on ejaculatory latency, it may be considered as a drug of choice, with therapy initiated at 20 mg/d. Failure to respond within 4 weeks of daily medication (titrated to 40 mg/d of paroxetine—or 100 mg/d of sertraline, 40 mg/d of fluoxetine, or 50 mg/d of clomipramine) should prompt consideration of another method of treatment.11 Although higher dosages of SSRIs and TCAs may produce greater prolongation of ejaculatory latency, side effects may also increase incrementally. Since some patients will prefer one SSRI over another, or the metabolic effects of some SSRIs may be problematic (for example, paroxetine and fluoxetine are very potent cytochrome P-450IID6 inhibitors), clinicians may consider sertraline, which lacks significant cytochrome P-450 interactions and is associated with less sedation than paroxetine.
Rather than adhering to a daily regimen, patients may wish to try on-demand medication. Although scant data support this use, clomipramine, 25 to 50 mg administered within 4 to 6 hours of intercourse, has shown some efficacy for pEJ, with a duration of up to 15 hours.11 Initial data suggest that sildenafil may be an effective treatment for pEJ in some men. One comparison trial of patients with lifelong pEJ that evaluated SSRIs, clomipramine, sildenafil, and the squeeze technique found sildenafil to be the most efficacious, but because this study had no placebo control and showed other methodologic limitations, the results must be considered preliminary.1,12
The effectiveness of combination pharmacotherapy is supported by limited, but promising, data. A prospective study of 80 patients compared combination therapy with a regimen of paroxetine (10 mg/d for 21 d, followed by 20 mg/d on demand) with or without sildenafil. Combination therapy was more effective: Monotherapy increased mean ejaculatory latency time from 0.33 minutes (baseline) to 4.2 minutes at 6 months, whereas combination therapy improved ejaculatory latency from 0.35 minutes (baseline) to 5.3 minutes at 6 months and was associated with greater intercourse satisfaction.13
Because some men will continue to use SSRIs for pEJ treatment on a long-term basis, it is appropriate to address medication safety with them. Like all pharmacotherapeutic agents, SSRIs may have problematic adverse effects. There is now also clearer recognition that there may be a population of individuals for whom SSRIs may transiently accentuate the risk of suicide or suicidal ideation. Hence, prior to initiating a program of sustained SSRI treatment, the clinician should be aware of the patient's status for depression and suicidal ideation, and inform him of this risk.
Topical treatment Topical anesthetics can improve ejaculatory latency time by reducing penile sensitivity, but excessive topical anesthesia can prevent erection due to lack of sensory input. In addition, unless a barrier method is used in conjunction with topical agents, application to the sexual partner may concomitantly reduce the partner's cutaneous sensitivity.
Examples of topical agents found to improve intravaginal ejaculatory latency time in randomized placebo-controlled trials include lidocaine 2%, and lidocaine 2.5%/prilocaine cream 2.5%.Data suggest that such agents may be applied 10 to 30 minutes before intercourse.
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