Archive for February 28, 2016

Prozac & Delayed Orgasm

Q. I have been on Prozac for the past 3 months. Recently, I have had trouble when my husband and I have sex. I only reach a certain plateau — not climax or orgasm. I know this is a side effect of the medication, but what can I do about it?

A. You’re right that delayed orgasm is one of the possible side effects of Prozac and some other SSRIs (the class of antidepressants called Selective Serotonin Reuptake Inhibitors). These medications act by inhibiting the central nervous system’s use of the neurotransmitter serotonin, which leaves more of that chemical floating around in the brain.

You might want to talk with the physician who prescribed Prozac for you to see if the dose can be adjusted or if you can be switched to another medication without such side effects. You may also go a different route. Try experimenting with your husband on different or additional sexual activities or positions that might increase your pleasure.

You don’t mention whether you’re in psychotherapy, or if you’ve found Prozac to be helpful in alleviating your depression or any other condition for which the medication was prescribed. If not, your physician could refer you to a psychologist or other therapist who can help you address your depression (and sometimes medical conditions, as well) through psychological and behavioral changes. Such therapy can be an addition to or a replacement for antidepressant medication.

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Peyronie’s Disease Causes Pain, Psychological Trauma

Q. My husband, who is 53, has Peyronie’s disease and we think it was caused by Fosamax. It has gotten much worse and the penis curvature is so severe that intercourse is impossible. My husband’s urologist first gave him some POTABA and told him to take vitamin E. He now feels that surgery is the only option.

My husband would prefer not to have surgery. We have heard that Propoleum injection has been effective. Do you know anything about it? What nonsurgical treatment has been the most effective for your patients?

A. I doubt that taking Fosomax (used to treat and prevent osteoporosis) caused your husband’s Peyronie’s disease, because there is nothing in the medical literature linking this drug to that disease.

Although it is always wise to keep track of changes in health related to starting a new drug, two unrelated events may occur simultaneously.

Peyronie’s disease can be very painful as well as psychologically traumatic. It is a disorder in which an inflammatory fibrosis forms in the covering (tunic) around the spongy erectile tissue of the penis.

This fibrous plaque, similar to scar tissue, is contracted relative to surrounding tissue, causing a curvature of the erect penis that may make sexual intercourse difficult, painful or impossible. If the fibrosis extends into the erectile tissue, it can actually prevent erection.

Often there is also a narrowing of the shaft, causing an hourglass or hinge effect. Shortening of the erect penis length is also seen.

The cause of Peyronie’s disease is unknown, but it’s thought to begin as a local inflammation caused by trauma. Many also believe genetics play a part.

Some investigators see an association between Peyronie’s disease and hypertension and high cholesterol, among other conditions.

No absolutely effective treatment exists for all cases. There are a number of nonsurgical therapies available, but all of them appear only partially successful. For many, the disorder can even go away by itself over a period of weeks or months.

Vitamin E and potassium para-aminobenzoate (POTABA) have long been suggested as treatment for Peyronie’s disease, alone or in combination with other treatment. But these drugs have been effective only in some patients.

Injection of drugs, especially verapamil, a calcium channel blocker, directly into the plaque has been shown to be effective, again, in some cases. Steroid injections or ultrasound may relieve symptoms for some men.

Incidentally, I could not find anything in the medical literature on “propoleum” as a treatment for Peyronie’s disease.

In more severe cases, such as your husband’s, surgery may be recommended. Here again, no one procedure is likely to solve the problem in all men with this condition. A number of factors, such as the severity of the curvature and narrowing and the ability to achieve erection play a part in the selection of surgical method.

Surgical procedures for this condition consist of either incision of the tunic or excision (cutting away) of the fibrous material. Penile prosthetic implants that help straighten the curvature may also be recommended.

I understand your husband’s reluctance to undergo surgery. There are risks with any surgery, and this surgery carries the additional risk of more scar tissue formation and may even cause impotence.

I can only recommend that your husband meet again with his urologist and get further information, such as the expected risks and benefits of all treatment options available to him. With that information, he can balance the potential benefits against the potential risks when deciding what to do.

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Saw Palmetto, Cardura & Libido

Q. My husband has been taking saw palmetto for many, many years, but it does not seem to have been helpful. What we HAVE noticed, though, is a considerable decrease in his sexual desire. Does saw palmetto adversely affect the libido? Also, after he had problems with urinating frequently during the night, his doctor prescribed Cardura. Since he has taken the Cardura, we have noticed an INCREASE in his sexual desire. Have you had reports on this as a side effect? What can you tell of about long-term use of Cardura?

A. Your husband’s usage of saw palmetto and Cardura demonstrates a typical pattern. Here’s why:

As men get older they commonly experience changes in both their erections and voiding patterns. When a man has slow stream and needs to get up at night to urinate, his doctor often blames the prostate. That’s because the prostate often enlarges with age, placing pressure on the urine flow as it passes through the urethra (the tube that carries urine out of the body). Such pressure causes changes in the bladder, and the man feels a decrease in his stream and more frequent voids. To combat such changes, doctors often prescribe Cardura. This drug is a muscle relaxer for the prostate that causes a decrease in the tension of the prostate and better flow. However, it has no effect on libido.

To stop the increase in growth and size of the prostate, many men use saw palmetto. This is a plant estrogen that might cause decreased libido — such as you have noticed — and less frequent erections. There is no scientific basis for its use, and the clinical studies show that it doesn’t shrink the prostate. It is not FDA-approved, so there are no restrictions on its production, mixing or marketing. That means you should be careful to read the ingredients of your formula; often, over-the-counter prostate supplements include many compounds mixed together.

If your husband has an enlarged prostate, then his doctor can prescribe Proscar (finasteride) which has been scientifically tested and shown to shrink the prostate.

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Risks to Men from Cycling

Q. I am 25 and will be cycling across Canada next year which means 130km (80 miles) a day, for 55 days. I am healthy and will be ready for the level of fitness demanded. However, I’m concerned that I may potentially increase my risk of prostate problems in the future. Are there prostate health risks, or other risks to the male organs, associated with men who cycle long distances?

A. Last year, Dr. Irwin Goldstein reported the results of some research on this very question. Specifically, he looked at long-distance bike riders and found that they were at increased risk of erectile dysfunction. His work revealed that the small seats these riders were using put extra pressure on the nerves and blood vessels to the penis. This pressure was destroying this tissue, and the result was weak erections or none at all.

The suggestions from the study were to use a form of bicycle seat that has a hole in the middle designed to reduce pressure on the base of the penis. Also, wide seats were less likely to cause penile damage.

To date there is no evidence that long-distance riding will hurt the prostate. Good luck with your ride.

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Side Effects of Viagra

Q. What are some of the side effects of Viagra?

A. Let me first explain how Viagra works; this might help you understand the side effects better.

The mechanism of erection is a complex process that we as physicians are only beginning to understand. We know that when a man is aroused, the nerves to the penis cause the smooth muscle in the penis to relax; as a result, the penis fills with blood. When filling is complete, the penis is rigid. It normally remains that way until ejaculation, when a different set of nerves to the penis is activated, and the smooth muscle contracts, resulting in loss of the erection.

So, to achieve and maintain a good erection, you need cooperation between the nerves and the blood supply to the penis. Many medical conditions, such as diabetes, can damage the nerves or blood supply to the penis. The result is lack of erections (erectile dysfunction). Other conditions, such as atherosclerosis (hardening of the arteries), can cause erectile dysfunction when the arteries to the penis become clogged. In addition, many medications for high blood pressure have erectile dysfunction as a side effect. This means that the most important thing to do before taking Viagra is to see a urologist to find out why you need it.

The drug works like this. Viagra (sildenafil) blocks the action of the enzyme phosphodiesterase, which leads to accumulation of a substance called cyclic guanyle monophosphate (Cgmp). Cgmp acts as messenger in the cells to stimulate them. In the smooth muscle of the penis, the result of this cell stimulation is relaxation and filling of blood. Viagra is called a “type 5 phosphodiesterase inhibitor” because it is supposed to be selective for the enzyme in the penis only. Other forms of the enzyme are present throughout the body, and the drug’s function is different in each of these different parts. Unfortunately, some of those effects involve parts such as the eyes, the salivary glands and the blood vessels.

The most important contraindication to taking Viagra is the use of nitroglycerin medication. Some people take this type of medication for their hearts or blood pressure. The combination of Viagra with nitros is serious, as both drugs can relax the blood vessels, so the combination can cause the blood pressure to drop too low. Other unwanted effects include:

  • headache
  • flushing
  • upset stomach
  • stuffy nose
  • urinary tract infection
  • visual changes, such as mild and temporary changes in blue/green color vision or increased sensitivity to light
  • diarrhea

These are only the more common side effects. Other effects have been reported. For a more complete list, see your doctor.

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Sexual Activity & Weight Training

Q. How does sex affect weight training and muscle growth? I have heard of boxers who would not have sex with their wives for six months because they were weight training for a fight. Does it have anything to do with a man’s testosterone level?

A. The mythology of athletic depletion and sexual activity goes back to the Middle Ages, when crusading knights were warned to not fall prey to the love interests of damsels, lest their powers be wasted and heathens not be conquered. Today, that same fear is echoed by high school PE teachers, athletic trainers and professional coaches. “No nookie the night before the big game, fellas” — or else you’ll be a noodle on the playing field.

There is no scientific evidence to support these claims, although you will find plenty of anecdotal stories — lots of guys with scary tales about their athletic performance suffering due to sex. Most men have sufficient testosterone and androgen production in general to have a normal sex life and to support weight training, aerobic and anaerobic performance. Besides, the muscle growth resulting from weight training depends on many factors, such as nutrition, rest, training specifics, overload, progression and so on — not just on circulating testosterone levels.

As for the boxers who didn’t have sex with their wives for six months, I would bet it’s more likely due to taking anabolic steroids, which can lead to impotence and shrinkage of the gonads.

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Smoking & Sexual Performance

Q. Could smoking (20 cigarettes per day) affect erection and ejaculation during intercourse?

A. Smoking has many effects on the body. One of them is certainly decreased erectile function. The loss in erections is due both to decrease in blood flow to the penis and to loss in elasticity of the penis.

As you know, for a man to have an erection, the small muscles in the penis must relax so that the arteries to the penis can allow blood to enter it. Once the penis is full of blood, it is hard and erect. Unfortunately, smoking can lead to clogging of those arteries in the penis. The decrease in blood flow means less blood in the penis, which equals a weaker erection.

In addition, the smooth muscle relaxation in the penis depends on nitric oxide metabolism. Smoking interferes with the body’s production of nitric oxide, and therefore interferes with muscle relaxation in the penis. This translates into less filling of the penis, and again a weaker erection.

In my practice, I insist patients stop smoking before I treat them with any medicines to improve erections.

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Testosterone Replacement for Low Libido

Q. I lost a testicle about 10 years ago, and my remaining testicle is smaller than usual. I had a low sex drive before the procedure, and it is even lower now. Would testosterone therapy help my sex drive?

A. Normally, losing one testicle should not affect a man’s ability to have sex or reproduce. The remaining testicle functions well enough to keep body testosterone levels normal.

However, since you feel your remaining testicle is smaller, that may be a sign it is not functioning properly, for reasons unrelated to the loss of the other testicle. If it is making less testosterone, that may cause decreased libido. Still, without examining you, I cannot be sure your problem is low testosterone. There are many causes of low sex drive, and low testosterone is just one of them.

Your doctor can make the diagnosis of low testosterone based on three separate blood tests, each a week apart. Normal testosterone levels range from 270-1,200mg/dL of blood. If your levels fall below the 270 mark, then testosterone replacement should improve your sex drive.

Unfortunately, testosterone replacement is not easy. You see, testosterone can only be given two ways: by injection every three weeks, or through transdermal patches that are replaced daily. Most men use the transdermal patches. They come in 2-10mg doses; 5mg daily is usually sufficient. Two companies make such patches. The Androderm patch is applied to the scrotum. However, it falls off easily, and when that happens, most of the dose is wasted. The Testoderm patch is best applied to the shoulder area, but it too can sometimes fall off. Also, it may be quite visible to other people around and perhaps embarrassing to some. Nonetheless, the patch systems do work to restore sex drive.

One warning: Some people who think they have low testosterone try to treat themselves with illegal drugs or other substances. This is typically not effective, particularly if the actual cause of the problem has not been determined — and it may be dangerous. To be sure, please see your doctor, get your testosterone tested, and get the proper treatment.

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