Archive for March 31, 2016

Impotence in Teenager

Q. My boyfriend is only 17 and cannot get an erection. I thought only older men had this problem. What could possibly be causing this? I fear that I am not attractive to him, or perhaps he is cheating on me. Am I the cause of the impotence? Is there anything I can do? I try to talk to him about it, but he just gets quiet or frustrated.

A. You must be patient. At 17, there are few medical reasons for erectile dysfunction. In fact, I don’t think I have ever treated or seen a healthy 17-year-old with this problem. However, it is possible to have a problem with the penis if he has ever had injury or surgery to the penis. Also, there can be hormonal reasons for erection problems, such as testicular failure. Still, if a boy goes through puberty with normal pubic hair and body growth, and if he has sexual desires, then there is little to no chance that he has a hormonal imbalance.

It is possible that he might be suffering from psychological issues. As pleasurable as sex can be, for many people the first time (or the first time with a new partner) can be very stressful — stressful enough to cause a person to distance himself or avoid situations that might lead to intimacy, out of fear that he might not be able to perform to another’s expectations. This is called performance anxiety. Another common condition is called fear of failure, in which the person is so scared he won’t get an erection that, in fact, he doesn’t.

I can assure that you almost certainly are quite attractive to him and that he is not cheating on you. I know it is frustrating, but you might try to avoid putting any further pressure on him, and let him know that it is OK to not have sex. Many men perform well when they feel there is no pressure to perform at all. If he has any doubts, then he might want to see a counselor or his doctor.

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Is Viagra OK with Cholesterol Drug?

Q. If a person is on a cholesterol-lowering drug (Zocor 10mg) but otherwise healthy (no high blood pressure, no diabetes, no nitrates), can he safely take Viagra to overcome an erectile dysfunction problem? I heard Viagra has side effects only for people on nitrates.

A. As you correctly pointed out, there is only one contraindication to Viagra, and that is for people on nitrates. The interaction of the drugs can cause heart attacks, and several patients taking nitrates and Viagra together have died. I refer all my patients to the manufacturer’s insert, which lists all the side effects associated with Viagra. For more information, see my earlier article about Viagra.

In my practice I commonly prescribe Viagra to many of my patients with multiple medical problems. At this point people on Zocor are not prevented from taking Viagra, but all patients seeking Viagra need to be seen by a physician to determine the proper dosage and risk profile.

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Injury, Illness & Alcoholism Can Cause Impotence

Q. My 52-year-old husband has been having a lot of problems. First, he wasn’t able to get an erection and was having pain in his lower abdomen. His doctor treated him for prostatitis. It helped relieve the pain, but then he got worse. He went to a urologist and was put on Flomax. He has been able to get erections, but they are painful, especially at the tip.

After taking this medicine for about a month, he began experiencing a curved penis. He went back to the urologist who told him he had Peyronie’s disease and said there was nothing he could do and handed him a brochure.

He used to take meds for hypertension and high blood pressure. He drinks two or three glasses of Scotch every night. He is now taking two vitamin E pills a day. Please send us any information you can.

A. Your husband certainly has more than his share of problems. I hope I can provide some useful information on what are two different but associated problems.

Erectile dysfunction or impotence is defined medically as the inability to achieve or sustain an erection of sufficient rigidity to permit sexual intercourse. Impotence is thought to affect 10 million American men, and it is age-related.

While some cases of impotence are psychological in origin, especially in younger men, most impotence is associated with medical or physical problems.

Because blood flow to the penis is critical to erection, vascular disorders such as atherosclerosis can cause impotence. Damage to nerves to and from the penis can also produce impotence. Such damage may be due to injury, diabetes, stroke and alcoholism.

Drugs are implicated in as much as 25 percent of impotence. Drugs known to have an impact include antihypertensives, antidepressants, sedatives and alcohol. Even pain, such as from prostatitis, can cause impotence.

Flomax (tamsulosin) is given to improve urinary flow and reduce the symptoms of benign prostatic hyperplasia, the increased growth of the prostate. The side effects of tamsulosin include decreased sexual urge.

Your husband’s medical history and the drugs he’s taking, including alcohol, may be implicated in his erectile dysfunction problems. The first step is to work with the urologist to find the cause or causes and deal with them.

Your husband’s second problem, Peyronie‘s disease, is a medically and psychologically traumatic disorder in which a fibrous plaque forms in the covering around the spongy erectile tissue of the penis. This plaque, similar to scar tissue, causes a curvature of the erect penis that may make sexual intercourse difficult, painful or impossible. Peyronie’s disease can lead to erectile dysfunction.

The cause of Peyronie’s disease is unknown, but it’s thought to be congenital or initiated by genital trauma. Some investigators see an association between Peyronie’s disease and hypertension and high cholesterol, among other conditions.

For milder cases, a number of nonsurgical therapies are available, but all of them appear only partially successful. Vitamin E and potassium para-aminobenzoate have long been suggested as treatment for Peyronie’s disease.

Injection of the calcium channel blocker, verapamil, directly into the plaque has been shown to be effective in some cases. Effective surgical procedures for this condition include incision of the fibrous material and venous patch grafting.

The other good news on Peyronie’s disease is that it often goes away by itself.

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Man’s Sexual Prime

Q. My husband is 42 and continually says that he is in the prime of his life sexually. I doubt that’s true. Can you please clarify this subject for us?

A. You are correct. Most studies have shown that men reach their sexual maturity at age 17. At that time, their sexual drive and stamina are both at their peak. On the other hand, women reach their peak in their mid-30s. Nonetheless, individuals vary. Your husband may actually be in his prime, if that’s what he wants to believe.

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Just a Little Viagra

Q. I am 51, and I have a problem with keeping an erection for more then 10 minutes. I think it is a blood circulation problem, because my feet always feel cold and my balls feel cool to the touch. If only I could stay erect for another 10 minutes I would be satisfied. My doctor gave me a prescription for Viagra. He says I don’t need to use the whole pill, but to cut it in half and see how that works. What would it do if I cut it in quarters? Would that help me out for another 10 minutes? I don’t want to take the whole pill because I’m afraid of side effects.

A. At 51 years old, a 10-minute erection is excellent. In fact, studies have shown that most men ejaculate within 90 seconds of penetration.

I don’t think that you have a circulation problem, since most men with atherosclerosis (clogged arteries) don’t get any erection at all. Furthermore, cold feet and testicles are not signs of a circulation problem. Instead, circulation problems usually first appear as pain in the calves or buttocks when walking.

Nonetheless, Viagra is a common and safe way to increase rigidity and blood flow into the penis. The medication works by relaxing the arteries in the penis to increase the blood flow and in turn strengthen the erection. The standard dosages are 25mg, 50mg and 100mg. Many doctors will prescribe the maximum dose of 100 mg and instruct the patient to break the pill in half. The logic is that all doses are the same price, so by breaking a pill in half you get twice the uses for the same price. In my practice, I only prescribe 100mg, since very few patients respond to the lower dosages.

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New Sexual Enhancers

Q. I have tried Viagra for erectile difficulty, but it gives me headaches. I’ve heard there are some other sexual enhancers available or in testing. What can you tell me about these?

A. One potential competitor for Viagra is a pill called Vasomax. This is a new application of the established drug phentolamine, which used to be injected directly into the penis. It works by blocking blood-vessel constriction, making it easier for the blood vessels to expand. When taken orally, it affects the whole body. Trials showed that 42 percent of men with mild erectile dysfunction develop better erections with this drug. Its effects in men with severe erectile dysfunction are less satisfying. Side effects include headaches, low blood pressure, fast heartbeat and nasal congestion. As of this writing in mid-2000, this agent is working its way through trials required in the FDA approval process.

Another promising agent is Uprima, or oral apomorphine, which should be released soon. The mechanism of action appears to be located in brain centers that enhance the erection and sexual experience. This fast-acting drug might be used in combination with others like Viagra. Known side effects are limited to nausea, which might go away after the first few uses.

Bayer Pharmeceuticals also has a new agent in drug studies; this is a selective phosphodiesterase inhibitor that should have effects similar to Viagra, but hopefully with fewer side effects. However, it is expected to achieve a response only in about 30 percent of the men who use it.

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Marijuana & Erection Problems

Q. My husband is addicted to marijuana. He has had difficulty maintaining a complete erection since I have known him. Could the long-term marijuana use be a factor in his inability to maintain an erection? What should I do? This is a very sensitive issue.

A. To start with, your husband needs professional help. Addiction to marijuana is no different from addiction to alcohol or other mind-altering drugs. These drugs all affect a person’s ability to adapt in most social settings, resulting in difficulties in intimacy, friendships and all aspects of daily activities. I understand it is a sensitive issue, but it needs to be addressed. There are many social services available in most large U.S. cities, and many large companies offer their employees access to trained professionals who specialize in addictive behavior. Perhaps there is a family counseling network in your neighborhood that you and your husband can attend together, where you can discuss this freely.

Medically, human studies have shown that marijuana usage can lower the level of testosterone in the blood. This decrease in testosterone will cause a decrease in libido and erectile function. I would expect that when your husband stops marijuana usage, his erections will eventually return; however it may take many months.

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Penile Implants

Q. What can you tell me about penile implants? Is that the same thing as the pump? How natural does it feel? Is it filled with fluid or made out of something rigid?

A. Penile implants are quite diverse. In general, there are three categories.

First are what we call rigid implants. These are solid rods of plastic or silicone that go in the penis. In this situation, the penis is erect all the time.

The second category are the malleable implants. These are flexible silicone rods with reinforced centers that allow the person to flex the penis up and down. The penis doesn’t stick straight out, and it allows you to tuck it in your pants. Nonetheless, it is still quite rigid regardless of how you bend it.

The third and most common type of implants are the inflatable devices. Their advantage is that the penis can be inflated for sex and deflated for normal daily activities. The two leading manufacturers are Mentor, which makes the Alfa-one device, and AMS, which makes the AMS 700. Both devices are very popular and very reliable.

The devices come in three pieces: a pump that fits comfortably into the scrotum, a reservoir that holds saline (salt water), and two cylinders that fit into the penis, one on each side. To use them, you simply pump the penis up by squeezing the pump mechanism in the scrotum. To deflate the penis, you press the release valve and squeeze the penis, and it will relax. When the penis is inflated, it looks natural, and it feels natural to both parties concerned. If you want to be picky, there are two differences you will notice: The head of the penis will not be engorged and swollen as in the natural erect state, and the man will feel as if he has three testicles because the pump in the scrotum feels like a testicle. Overall, the men in whom I have put these devices — and their partners — have been very satisfied.

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Overcoming Impotence

Q. I’m a 38-year-old man. I have undergone 15 surgeries since 1991, and I was doing fine until recently. I had a knee replacement and two discs removed, and I’ve been taking various medications. My problem is that I have the sex drive, but I’m lacking in the staying power. The most I can last is only two minutes, a far cry from my better days. My girlfriend of five years left me over this. I’m wondering what if anything can help me feel “manly” again. I’ve tried vitamins, DHEA, etc. to no avail.

A. Because you have had back surgery and are taking medications, I would recommend you return to your doctor for evaluation of the cause of your impotence. Inability to get or maintain an erection can be due to a number of causes. Many medications — including blood pressure medications, sedatives, tranquilizers and stimulants — can cause impotence. Your doctor will know if any medication you are taking has this side effect and may be able to change your medication to something different.

Another possible cause of impotence is damage to the spinal nerves. Since you have a history of back surgery, this is a possibility. A neurological examination by your doctor will be able to determine if there is any problem with the nervous system. Occasionally, endocrine disorders such as diabetes, low thyroid and low pituitary hormones cause impotence. Blood tests can rule out these disorders. Alcohol consumption and cigarette smoking can also cause impotence. So, if you smoke, stop. If you drink alcohol, stop or limit your intake to one drink a day.

The most common cause of impotence is decreased blood flow in the penis due to atherosclerosis or blockage of the arteries. A healthy diet with lots of fresh fruits and vegetables, whole grains and lean meats and fish along with a good vitamin-mineral supplement will help lower cholesterol levels and prevent atherosclerosis. Regular exercise is also important. The new drug Viagra is useful to increase penile blood flow. It works immediately, but it carries a risk of heart attack, especially in men who have atherosclerosis. Ginkgo is an herb that has been shown to be effective in increasing blood flow to the penis; unlike Viagra, it takes six to eight weeks to have an effect, but it will also be beneficial if you have blockage in the arteries of the heart.

Finally, you might also want to see a counselor. The issues with your girlfriend over this may also be having an effect on your erections. While psychological problems are rarely the primary cause of impotence, just having difficulty with erections may add a psychological component to the problem.

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