Archive for January, 2014

Enhancing Male Sexual Function: An Update

January 24, 2014

Blog #138  Andrew Siegel MD

“But the wheel of time turns, inexorably. True rigidity becomes a distant memory; the refractory period of sexual indifference after climax increases; the days of coming are going. Sexually speaking, men drop out by the wayside. By 65, half of all men are, to use a sporting metaphor, out of the game; as are virtually all ten years later, without resort to chemical kick-starting.”

—Tom Hickman
God’s Doodle: The Life and Times of the Penis

The term ED (Erectile Dysfunction) is commonly bandied about these days. There are plenty of men who do not have a dysfunction, but simply do not have quite the function they had when they were younger. Their “plumbing” is intact and they function without complaint from their partner, but things are just, well… different from the way they were.

Simply stated, change is to be expected coincident with the aging process. Performance ability with respect to virtually any physical activity will decline with aging and this explains why most professional athletes are in their twenties or early thirties. Everything eventually goes to ground, but hopefully does so slowly.

Young men can achieve a rock-hard erection simply by seeing an attractive woman or thinking some vague sexual thought. As we get older, it is not uncommon for erotic thoughts or sights to be insufficient to provoke an erection, with the need for direct “hydraulic” assistance through touch. Some of the common male sexual changes that occur with aging are the following: diminished sex drive; decreased rigidity and durability of erections; decrease in volume, force, and trajectory of ejaculation; decreased orgasm intensity; and an increase in the time it will take for recovery before being able to get another erection (refractory period).

Altered sexual function can present in various forms, dimensions and magnitudes.  Some men can achieve a very rigid erection readily capable of penetration, but then, much to the bewilderment and dismay of its owner, display a short “attention” span and deflate before business is fully conducted—one might refer to this as penile attention deficit disorder (PADD).  (See Urban Dictionary for full definition—guess who coined this term!)

http://www.urbandictionary.com/define.php?term=penile+attention+deficit+disorder+%28padd%29

Other men are capable of obtaining, at best, a partially inflated erection that cannot penetrate, despite pushing, shoving and manipulating. For some, an erection is but a pleasant memory lodged deep in the recesses of the mind.  So what can a man do?

For starters, good lifestyle habits are first-line measures. Proper eating habits, exercise, adequate quality and quantity of sleep, tobacco avoidance, use of alcohol in moderation, stress avoidance, and a balanced lifestyle are simple means of optimizing sexual potential.  The “golden rule” is relevant to one’s penis: Be nice to your penis (in terms of a healthy lifestyle) and it will be nice to you; treat your penis poorly and it will rebel…and no one wants a rebellious penis!

Pelvic floor muscle exercises are a first-line measure for helping to manage erectile dysfunction. When the pelvic floor muscles contract, they increase blood flow to the genitals, specifically by the actions of the two musclesthe bulbocavernosus and ischiocavernosus—that become engaged at the time of an erection. Contractions of these muscles help prevent the exit of blood from the penis, enhancing rigidity. With each contraction of these muscles, a surge of blood flows into the penis. Additionally, they act as powerful struts to support the roots of the penis, the foundational support that, when robust, will allow a more “skyward” angling erection. It stands to reason that if you can increase the strength, tone and conditioning of these muscles through pelvic muscle floor training, they will function in an enhanced manner—namely more powerful contractions, and more penile rigidity and stamina.

What to do when one employs lifestyle measures and pelvic exercises, but the rebel-down-below still displays some degree of penile attention deficit disorder?  One should stick to the lifestyle measures and the exercises, but consider adding a pill to the regimen.

The Rolling Stones’ song, “Mother’s Little Helper,” referred to Valium in terms of a little yellow pill. In 1998, a little blue pill was manufactured that could be considered “Daddy’s Little Helper”—aka Viagra.  This medication was discovered by chance. In an effort to treat high blood pressure and chest pain, Pfizer scientists conducted a clinical trial with this experimental medication that caused blood vessels to dilate (open).  It did not work particularly well for the intended purposes, but had a side effect in that it dramatically improved erections.  When the study ended, the participants were profoundly disturbed that the drug was no longer available. The rest is simply history

The PDE5 Inhibitor class of medications includes the following: Viagra, Levitra, Cialis, and Stendra.  Stendra is now FDA approved and available as of last week.

Viagra (Sildenefil). Viagra was born as a fusion of the words “vigor” (physical strength) and “Niagara” (the most powerful waterfall in North America). Viagra is available in three doses: 25 mg, 50 mg, and 100 mg.  It is taken on demand and once swallowed, it will produce an erection in most men within 30-60 minutes if they are sexually stimulated, and will remain active for up to 8 hours.

Levitra (Vardenefil).  This is an oral medication similar to Viagra, available in 5 mg, 10 mg, and 20 mg doses.

Cialis (Tadalafil).  This is an oral medication similar to Viagra, available in 2.5 mg, 5 mg, 10 mg, and 20 mg doses. The fact that it lasts for 36 hours or so has earned it the nickname “the weekender,” as it can be taken on Friday evening and remains effective for the remainder of the weekend without the need for an additional dose.  This affords a considerable advantage in terms of spontaneity.  In 2012, daily lower doses of Cialis were FDA approved for the management of urinary symptoms due to benign prostate enlargement.

Who Knew?  Cialis—a pill that helps erections and urination…now that’s a winning combo for the aging male.  Talk about killing two birds with one stone!

Stendra (Avanafril).  This supposedly has the advantage of a very rapid onset of action.  It is available in 50 mg, 100 mg, and 200 mg doses.

These medications are not for everybody and are not effective in everyone. However, for many, they are highly beneficial in treating ED and in improving erectile function that may have diminished a bit over the years.  Many men use a low dosage (typically one-quarter of the full dosage) of these medications “recreationally,” meaning that they can function perfectly well without the medication, but with it their function is enhanced significantly.

BOTTOM LINE: If you are experiencing ED or just some changes in function, there are several courses of action to improve the condition: first-line treatments include a healthy lifestyle as well as pelvic floor muscles exercises to increase erectile strength, endurance, stamina and rigidity. Should these measures fail to restore erections to the degree desired, there are oral medications that can prove beneficial.  And if pills don’t help enough, us urologists have many other tricks up our sleeves, but that is a topic for another day.

TAKE HOME MESSAGE:  Even if you are young and functioning superbly, pursue a healthy lifestyle and do pelvic floor exercises to maintain that functional status!

Andrew Siegel, M.D.

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Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in March 2014. www.MalePelvicFitness.com

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:www.promiscuouseating.com

Author of Finding Your Own Fountain of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity  (free electronic download) www.findyourfountainofyouth.com 

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The Magic of Chia

January 17, 2014

Blog # 137

My first exposure to chia was the silly but iconic television commercial for the chia pet that touted pottery figures that sprouted green fur: http://www.youtube.com/watch?v=tzY7qQFij_M

Little did I know that chia was so much more than just a fluffy friend! Botanically speaking, chia is a flowering plant that is in the mint family (Salvia hispanica). In recent years, chia has made it to prime time and been seemingly transformed from curious plant to power food, now thought of as a little seed that packs a wallop of a nutritional punch. These tiny, oval, brown seeds have become very popular among the foodie and health enthusiast crowds.

Although chia seems to be the trendy seed-du jour super-food, its use actually dates back to the Aztec civilization, where it was broadly cultivated and used as a tribute to the gods. Currently, Australia is the leading chia producer in the world, followed by Mexico, Bolivia, Argentina, Ecuador, Nicaragua and Guatemala.

Chia seeds are a concentrated nutritional source, being high in fiber, protein, magnesium, calcium, phosphorus, anti-oxidants and omega-3 fatty acids. They are a terrific alternative to fish oil and seafood for those seeking omega-3 fatty acid supplements.

Chia can be eaten as a snack or, alternatively, used as an ingredient to add to recipes. The seeds are ideally suited to add to yogurt because of their “crunch factor” and are useful in smoothies to add texture and nutritional energy. The seeds can be dissolved in water to make an energy gel, which also can be used as an egg substitute for baked goods.  Additionally, the seeds can be pulverized and used as a flour substitute.

Bottom line: Chia has come a long way from the days of the chia pets.  Consider adding it to your diet to reap its nutritional benefits.

Reference: Discover the Chia, Harry Dowden, Bergen Health and Life

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health   Please visit page and “like”: www.facebook.com/promisceating

You Tube page: www.youtube.com/incontinencedoc

Author of Finding Your Own Fountain of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity  (free electronic download) www.findyourfountainofyouth.com 

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in 2014.

www.MalePelvicFitness.com

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Botox: Not Just for a Pretty Face

January 11, 2014

Blog #136

Image

Botox is derived from a poison produced by the Clostridium bacterium, the microorganism responsible for botulism in humans and animals.  Botulism—caused by eating foods contaminated with the Clostridium bacterium—is a rare but serious illness that can result in paralysis and is considered a potentially fatal medical emergency. The highly toxic and lethal botulinum toxin was initially identified by Kerner in rancid sausages and was refined and purified by van Ermengen in the Netherlands.

It is shocking that the most poisonous substance known to humanity—Botulinum toxinwhen used in minute quantities in a derivative known as Botox, becomes a magically effective and powerful potion to treat a variety of conditions. Talk about making lemonade from lemons!

Most people are aware of the use of Botox to prevent or improve the cosmetic appearance of facial wrinkles. When injected into the frown lines it paralyzes the facial muscles involved and makes creases, furrows and grooves disappear. Facial Botox injections are among the most common cosmetic procedures performed in the United State and have fostered a billion dollar industry. It is important to know that getting beyond cosmetics, Botox can be beneficial for a variety of medical conditions that have in common some form of localized muscle over-activity.

Technically speaking, Botox is a neuromuscular blocking agent that weakens, if not paralyzes muscles. It has numerous potential uses involving the following: overactive bladder (condition causing urinary urgency, frequency and incontinence); urinary incontinence due to neurological conditions including spinal cord injury and multiple sclerosis; chronic migraine headache; upper limb spasticity; cervical dystonia (involuntary contraction of the neck muscles causing abnormal movements and an awkward posture of the head and neck); axillary hyperhidrosis (excessive underarm sweating); blepharospasm (eyelid spasm with uncontrollable blinking); strabismus (cross-eye or wall-eye); and of course, the cosmetic usage to improve the look of frown lines and wrinkles. For all of the aforementioned conditions, the effect of Botox is temporary and needs to be repeated on an indefinite basis in order to maintain the therapeutic effect.

Overactive bladder and incontinence due to neurological conditions: Botox can be useful in those who have not responded to conservative methods including behavioral methods, pelvic floor exercises and medications. Such persistent and disabling urgency, frequency and urgency incontinence can be effectively managed by injecting Botox into the urinary bladder. It works by paralyzing or weakening the bladder muscle. It is done via cystoscopy (a visual inspection of the bladder with a lighted narrow telescope) and requires injecting the Botox into about 20 sites within the bladder muscle.

Chronic migraine headache: Botox is useful for preventing migraines in adults affected more than 15 days per month with headaches lasting for more than 4 hours daily. It is accomplished by injecting the Botox into different areas of the head and neck including muscles of the following areas: forehead; temples; back of head; and the neck and upper back.

Upper limb spasticity: Botox is helpful to decrease the severity of the excessive muscle tone in the elbow, wrist and finger flexors and works by paralyzing these spastic muscles. It is injected directly into the flexor muscles as well as the biceps.

Cervical dystonia: Botox can be effective to reduce the severity of the abnormal head position and neck pain. It works by paralyzing the dystonic muscles and is injected into the sternocleidomastoid muscle.

Axillary hyperhidrosis: Botox is useful in those with severe underarm sweating that has not been managed successfully with topical agents. The Botox functions to paralyze the sweat glands and is injected in numerous sites to cover the area of hyperhidrosis.

Blepharospasm and strabismus: Botox is indicated when these conditions are associated with dystonia as well as benign essential blepharospasm and facial nerve disorders. It works by paralyzing the eyelid and eye muscles and is injected into the eyelid muscles and extraocular muscles, respectively.

Bottom line: Botox, a toxin produced by Clostridium that causes paralysis, can be beneficial when injected into virtually any muscle in the body that is in a state of hyper-contraction and spasticity and has found utility for a variety of medical conditions.

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

Please visit page and “like”: www.facebook.com/promisceating          You Tube page: www.youtube.com/incontinencedoc

Author of Finding Your Own Fountain of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity  (free electronic download)

 www.findyourfountainofyouth.com 

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in 2014.

www.MalePelvicFitness.com

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.

Must My Prostate Cancer Be Treated?

January 4, 2014

Blog # 135

“To do nothing, that’s something.”

Samuel Shem, The House of God

Prostate cancer needs to be accorded respect as there are 240,000 new cases diagnosed annually and it accounts for 30,000 deaths per year, being the second leading cause of cancer death in men, only behind lung cancer.

Unlike many other malignancies, prostate cancer is often not a lethal disease and may never need to be treated. Shocking, right…a cancer that does not necessarily need to be cut out or managed in any way! Patients with slow-growing, early stage cancer as well as older men with other health issues may be put on surveillance, aka watchful waiting, as opposed to traditional treatment with surgery or radiation.

The problem is that not all prostate cancers are slow-growing and early stage, and the challenge is how to predict the future behavior of the cancer so as to treat it appropriately—offering cure to those with aggressive cancer, but sparing the side effects of treatment in those who have non-aggressive cancer. The goal of active surveillance is to allow men with low risk prostate cancer to avoid radical treatment with its associated morbidity and/or delay definitive treatment until signs of progression occur. This involves two things—vigilant monitoring and a compliant patient who is compulsive about follow-up.

The ratio of 7:1 of the lifetime likelihood of diagnosis of prostate cancer (about 1 in 6 men) to death from prostate cancer (about 1 in 40 men) points out that many men with prostate cancer have an indolent (i.e., slow growing) cancer. Because of this fact, an alternative strategy to aggressive management of all men with prostate cancer is active surveillance, a structured means of careful follow-up with rigorous monitoring and immediate intervention should signs of progression develop. Being a candidate for this approach is based upon the results of the PSA blood test, findings on the digital rectal exam, and the details of the biopsy, which usually involves obtaining one dozen samples of prostate tissue.

General eligibility criteria for active surveillance include all of the following (Note that these are basic guidelines and need to be modified in accordance with patient age and general health— certainly if one has a life expectancy < 10 years, he would be a good candidate for active surveillance, regardless of the following):

  • PSA (Prostate Specific Antigen) less or equal to 10 (PSA is the blood test that when elevated or accelerated indicates the possibility of a problem with the prostate and is often followed by a prostate ultrasound/biopsy)
  • Gleason score 6 or less (possible score 2-10, more about this below)
  • Stage T1c-T2a

 (T1c = picked up by PSA with normal prostate on rectal exam; T2a = picked up by abnormal prostate on rectal exam, involving only one side of the prostate)
  • Less then 3 of 12 biopsy cores involved with cancer
  • Less then 50% of any one core involved with cancer

Prostate cancer grade is often the most reliable indicator of the potential for growth and spread. The Gleason score provides one of the best guides to the prognosis and treatment of prostate cancer and is based on a pathologist’s microscopic examination of prostate tissue. To determine a Gleason score, a pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells. The numbers range from 1 (the cells look nearly normal) to 5 (the cells have the most cancerous appearance). The sum of the two grades is the Gleason score. The lowest possible score is 2, which rarely occurs; the highest is 10. The Gleason score can predict the aggressiveness and behavior of the cancer. High scores tend to suggest a worse prognosis than lower scores because the more deranged and mutated cells usually grow faster than the more normal-appearing ones.

Prostate cancers can be “triaged” into one of three groupings based upon Gleason score. Scores of 2-4 are considered low grade; 5-7, intermediate grade; 8-10, high grade.

The active surveillance monitoring schedule is typically:

  • PSA and DRE every 3-6 months for several years, then annually
  • Prostate biopsies: one year after initial diagnosis, then periodically until age 80 or so (once again, a judgment call)

As long as the cancer remains low-risk, the surveillance protocol may be continued, sparing the patient the potential side effects of surgery or radiation.

Another meaningful way of predicting the behavior of prostate cancer is by using the PSA Doubling Time (PSADT)—defined as the amount of time it takes for the PSA to double. A short PSA doubling time is indicative of an aggressive, rapidly growing tumor, whereas a long PSA doubling time is indicative of an indolent, slow growing tumor. A PSADT of less than 3 years is clearly associated with the potential for progression of prostate cancer.

A change in plan from active surveillance to more active intervention needs to be instituted if any of the following occurs:

  • PSA doubling time is noted to be less then 3 years
  • Biopsy reveals grade progression to Gleason 7 or higher
  • Biopsy reveals increased prostate cancer volume

Approximately half of men on active surveillance remain free of progression at ten years, and definitive treatment is most often effective in those with progression. The absence of cancer on repeated prostate biopsy (because the cancer is of such low volume) identifies men who are unlikely to have progressive prostate cancer.

Bottom Line: Active surveillance is an effective means of minimizing over-treatment of indolent prostate cancer and avoiding the side effects of immediate treatment. Its disadvantages are the need for frequent and repeated testing and biopsy, the anxiety of living with untreated prostate cancer, and the possibility that delayed treatment may not be curative, although that is not usually the case.

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

Please visit page and “like.”

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in  2014.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.