Archive for April 30, 2016

Erection Improvement in Diabetic?

Q. I am 54 and have been diagnosed with type II diabetes for seven years. I have been experiencing erectile dysfunction for the past two years. I initially thought it was due to a circumcision I had performed five years ago, but I now understand that it may be due to the lack of blood sugar control I had during the early stages of my diabetes. I have been in control for the past two years, and lately I have began to experience some slight erections during the mornings and sometimes during the day. Would you please tell me if this means there is hope?

A. I hope you are not keeping your blood sugars under control simply in hopes of regaining erections. Instead, keep your sugars under control to prevent further complications of diabetes, such as heart disease, peripheral vascular disease, neuropathies and strokes. This way, you will live a long healthy life without false expectations. But if you keep your sugars under control hoping you will get better erections and it doesn’t happen, you may be angry and disappointed.

In patients with diabetes, blood flow to the penis diminishes because the small blood vessels in the penis harden and partially clog. When the blood flow is depressed, the penis doesn’t get hard enough for penetration. Also, high blood sugars can damage the nerves to the penis. These changes are not reversible, but the resulting erectile dysfunction is often treatable.

In my practice, once a man with diabetes starts to notice a change in his erectile strength, I treat him with Viagra. This pill increases the blood flow to the penis and helps provide a better, longer-lasting erection. If the patient doesn’t respond to Viagra, then I offer other treatments. One such treatment is the vacuum erection device. This fits around the penis; when activated it sucks blood into the penis, creating an erection. If that doesn’t the patient, we may try prostaglandin injections into the penis. Overall, the patient will have satisfying erections.

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Erection Help After Surgery, Medications

Q. I’m 59, and I’ve had difficulty getting an erection suitable for intercourse since I started taking antihypertensives about 20 years ago. I have also had four back surgeries (three procedures for herniated lumbar discs and a total lumbar fusion) that left me with some permanent nerve damage, causing foot drop and weakness in one leg. I have tried penile suppositories and injections. Although the injections were somewhat helpful, they were not ideal. Might an implant be my best option at this point? Should I see another urologist for an opinion?

A. You have pointed out two possible causes for your erectile dysfunction. However, before you try a penile prosthesis (implant), I think you need to have a better understanding of the problem.

To get an erection suitable for penetration you need three things. The first is good arteries and blood flow into the penis. The second is a good nerve supply to allow the arteries to dilate and turn the blood flow on. Lastly, there needs to be no outflow of blood through the veins during filling, to ensure a rigid erection. So, the problem may not be as simple as medication that decreases the filling of the penis or back surgery that might affect the nerves to the penis.

I think your doctor needs a diagnosis of what exactly is causing the problem — such as arterial insufficiency, neuropathy or a venous leak — before you accept a prosthesis. The reason is that some forms of arterial insufficiency are reversible, and neuropathies should respond to injection therapy like prostaglandin E1 (Caverject). By jumping right to a prosthesis, you miss the opportunity to restore the natural erections. In addition, the average time a prosthesis lasts is 7-10 years. At 59, you would be looking at several operations in your lifetime.

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Erections During Sleep

Q. When a man wakes up in the morning, should he always have an erection? If he does not, should he see a doctor?

A. Nocturnal erections are part of the normal physiologic rhythm for men. There is nothing sexual about nocturnal erections. The erections are the body’s way of refreshing the blood in the penis. Unlike other parts of the body that have a high blood flow all the time, the blood flow to the penis is low during the flaccid (soft) state. When the penis is erect, the blood flow goes up. That means that most of the time, the penis is low on blood flow — which translates into low oxygen and low nutrients. Therefore, at night the body cycles the blood in the penis to bring in oxygen and remove toxic waste. This usually occurs during deep sleep.

The man you are asking about is almost certainly still going through these cycles while he is sleeping. Unless he has difficulty with his erection during sex, there is probably no need to see a doctor. If you are really concerned, you could perform the stamp test. This is done by attaching a postage stamp to the shaft of the penis before he goes to bed. If there is an erection while he is sleeping, than the stamp will be split when he wakes up.

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Erection Problems with Diabetes

Q. I am 26 and was recently diagnosed with diabetes. I am having a hard time maintaining an erection or reaching orgasm. Can anything be done to correct this problem?

A. Diabetes is not just a sugar problem. Unfortunately, while researchers and doctors can develop effective medicines to control blood sugar, other manifestations of the disease can still occur.

For instance, long after the original diagnosis — typically 10-20 years — some of the body’s autonomic nerves (which control the bladder, bowel and erectile function) may start to fail. This is called diabetic neuropathy. Symptoms could be the inability to urinate, severe constipation and loss of erections. This can happen even in patients with good sugar control, and researchers still aren’t sure why. We do know that neuropathies occur much more quickly in people who do not control their sugar levels, so please keep your blood sugar under control.

Also, diabetes can destroy small arteries in the body; this leads to poor tissue blood supply. This also takes years, and it usually occurs in the feet. The same poor circulation can affect the penis, and you can lose your erection. But again, this usually happens to older men, around age 50.

So, at this point, you are at risk of developing these problems because of your diabetes. But I am not sure the diabetes is responsible for your difficulty in erections now — at least not physically.

However, dealing with your new condition may be having an effect on your mood as a whole, which can in turn affect your sexual response. Someone who is diagnosed with a severe medical condition typically goes through several stages. Usually there is some degree of denial, followed by anger. Eventually the person must learn to accept the problem and go on with life. Once there is acceptance, the person then begins to deal with major lifestyle changes. Your doctor will tell you what to eat and how much to weigh, and every time you go to the doctor there is often more bad news. With this much stress, it is not uncommon for a person, no matter how strong, to get a little depressed.

I am very pleased you are willing to take get help for your erections, because there are several options. First, your urologist can offer support — and Viagra. The Viagra can increase blood flow to the penis and strengthen your erection. Second, look up a diabetic support group — in your community or online — where you can talk to others living with your problem who share common stresses. There you can vent and get reinforcement and encouragement. I believe that a healthy mind leads to a healthy erection.

Don’t forget, also, that there are other causes of erectile difficulty you may wish to explore with your doctor. For more information on erection problems, see my earlier column, Can’t Get Full, Lasting Erection.

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Estrogen-Containing Foods & Male Function

Q. Can eating foods containing phytoestrogens lower a man’s testosterone ratio, thus leading to erection dysfunction?

A. Estrogen supplements can lower testosterone, and in fact some of the early forms of treatment for prostate cancer were estrogen therapies to lower testosterone production. However, I am unaware of any study with phytoestrogens that has been shown to affect testosterone levels.

In urology, the most famous phytoestrogen is an herb called saw palmetto. This substance has been investigated extensively, and it is commonly used for enlarged prostates. Some studies have shown that it can affect prostate growth without affecting sex drive or testosterone production.

If you are concerned about your hormone levels, you could simply ask your doctor to check blood levels of testosterone. If your hormone levels are low, you should see an endocrinologist who specializes in such problems to get it corrected.

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Hair-Loss Drug & Sexual Function

Q. I am considering taking Propecia for male-pattern baldness. Besides the figures the company supplies, can you refer me to any independent information regarding its effect on a man’s erection and urge to have sex?

A. Propecia is the trade name for finasteride. Finasteride was designed for treating enlarged prostates. It works by blocking an enzyme responsible for changing testosterone into dihydrotestosterone (DHT). High levels of DHT can be bad because the substance promotes cell growth in the prostate. If we decrease the production of DHT, the prostate shrinks.

The formulation of finasteride used to treat the prostate comes in 5mg dosages and is called Proscar. At that dose, 5 percent of men will complain of erectile dysfunction or change in sex drive. However, these symptoms are reversible; if the man stops taking the medication, he should return to his normal status.

Propecia, on the other hand, is dispensed as a 2.5mg dose. At that dose it is supposed to have fewer sexual dysfunction side effects. If you develop difficulty with erections while taking Propecia, then I think you should see a urologist for a complete evaluation, as there are other causes of erectile dysfunction.

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Impotence From Blood Leak

Q. I am 32 and can’t sustain a rigid erection for a long period of time. I’ve been to one doctor, two urologists, an impotence center and a psychologist and the only answer I have is a prescription of Viagra. The impotence center did thorough testing and determined I had a blood leak. An electrode rigid meter verified I did not have normal erections during sleep. I obtained two semi-erections, about 50 percent of normal. With Viagra I feel like I did when I was younger. However, I don’t want to depend on drugs the rest of my life. The alternatives seem to be a pump, MUSE or Caverject injections, which I find unacceptable. What do they do for blood leaks? Is there surgery to correct this?

A. I understand completely — I would not want lifelong medication either. I would like to give your urologists some credit because they at least did a complete workup and determined the cause of your problem.

A venous leak means that blood does not stay stored in the penis. An erection only stays hard as long as the penis stays full. Think of a car tire — when there is a small leak, it slowly loses pressure and goes flat. But you can fix the problem either by patching the leak or putting in air faster than it leaks out. Your doctor is doing the same thing to your penis.

MUSE (alprostadile) suppositories or Caverject (alprostadile) injections are both prostaglandin E1 derivatives that dilate the arteries and thus increase blood flow to the penis, overcoming the leak. These help you get an erection; unfortunately, it is not your own, nor is it as good.

The other option is to fix the leak with surgery. This to can be accomplished by a urologist who specializes in microsurgery of the penis. Such specialists can perform studies that will localize the exact leak point, and they may be able to perform surgery to tie off the leak. There are many in the United States; you should ask your doctor for a referral to one of them.

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Hepatitis, Cirrhosis & Erection Problems

Q. My fiance is 49 and has liver cirrhosis and is positive for the hepatitis C virus. His erection is short-lived and very weak, and it is not easy for me to get orgasm with him. He was a heavy alcoholic, but he stopped drinking completely six months ago. Do you think there is a possibility of improvement in his case? What medication or advice can you suggest? I am shy about telling him my problem with this, as he thinks he is perfect.

A. From what you are describing, your fiance has a very serious problem. First, hepatitis C is permanent, incurable and contagious. If you are not already infected, then please realize that unprotected sex puts you at risk for getting this dangerous virus. Hepatitis C causes end-stage liver failure requiring a transplant in up to 50 percent of the people it infects.

Secondly, cirrhosis damages the liver. Unfortunately, liver failure changes a person’s hormone metabolism. The liver controls the conversion of testosterone (the male hormone) to estrogen (the female hormone). A man with liver failure experiences excess estrogen and less sexual drive. Also, his body fills with toxins that affect cell metabolism throughout the body, not just in the liver. Unless and until his liver problem is corrected, there is no medication that will help his sexual function.

For cases such as this, some men use a vacuum erection device. The man puts this on the penis when he wants a erection. The device draws blood into the penis, allowing it to become hard. Once it is hard, a constriction band is released at the base of the penis that squeezes it tight to keep the blood in it. This not only provides erection, it can also help for some playful foreplay.

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Improving Man’s Sex Drive

Q. Would you recommend Viagra for increasing the libido in a man who can get an erection but has trouble with sex drive?

A. Viagra works by increasing the blood flow to the penis and in effect producing a stronger erection. Unfortunately, it requires the user to supply the desire. for sexual relations (libido). Viagra alone will not increase libido.

In general, men with a decreased sex drive have either a physiologic issue or a hormonal imbalance. When I see a man with this complaint I spend time trying to identify stressful social issues like problems with work or money. Also, I make sure the patient is not using alcohol or drugs (marijuana, cocaine), which can depress the sex drive. If there are signs of mood depression and stress, these can often be relieved with the help of a psychiatrist.

In addition, men need a hormone called testosterone to fuel the sex drive. Therefore, I always check testosterone level with a blood test when I see a patient with this complaint. Normal levels are between 270ng/ml and 1,200ng/ml. If the level is low, this hormone can be replaced by injection or transdermal patches; your physician can help.

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