Archive for October, 2015

Testosterone For Females: Is There A Role?

October 31, 2015

Andrew Siegel MD   10/31/15

Many of my recent entries have been male-oriented. It’s time to give the fairer sex some equal time.

BodybuildingWoman

(Above image entitled: Mujer culturista mostrando la musculación de la espalda y los brazos, author: roonb, created November 2007, no changes to original image, creative commons license 2.0, link to license: creativecommons.org/licenses/by/2.0)

Female sexual dysfunction (FSD) is a common condition that may encompass diminished desire, decreased sexual arousal, difficulty achieving orgasm and pain with sexual intercourse. The most prevalent issue is decreased or lack of sexual desire, now given the formal medical title: Hypoactive Sexual Desire Disorder (HSDD), although I prefer the less formal, non-medical version: “Honey, I’m not in the mood.”

Testosterone (T)—the key male sexual hormone—has a strong role in stimulating sexual drive in both men and women and has long been used to manage diminished female libido and other sexual issues, despite it not being approved by the FDA for this intent. It has been shown to improve libido, arousal, sexual pleasure and overall sexual satisfaction.

Testosterone In Women

Although T is the major male sex hormone, it is also vital in females, similarly to how estrogen is the key female sex hormone, but has important functions in males as well.  In pre-menopausal women, the ovaries and adrenals (those paired glands that sit atop each kidney) each produce about 25% of T, with the other 50% produced by muscle and fat cells. The two biggest factors leading to a decrease in blood T levels are aging and menopause.

Pre-menopausal women produce about 0.25 mg T/day. (Men produce 6-8 mg T/day, about 25 times as much as females). Even after menopause, the ovaries continue to produce T.  Women who have their ovaries removed experience a dramatic decrease in T.

One of the major limitations of measuring T levels in females is the lack of reliable and accurate assays to precisely measure T levels at such low concentrations. Another shortcoming is that there is no concensus on what precisely is the lower level of T in females.

Symptoms of low T in females may include diminished libido, fatigue, lack of energy, decrease in well being, impaired concentration, depression and difficulties with arousal and orgasm. These symptoms of low T are very non-specific and have quite an overlap with the symptoms and changes that accompany normal aging, insufficient or poor quality sleep, overworking and/or an unhealthy lifestyle. Signs of low T in females are decreased muscle mass, increased body fat, thinning hair and bone wasting (osteopenia).

Decreased Female Libido

This is defined as absent or reduced interest in and arousal from sex, erotic thoughts, fantasies, or written, verbal, and visual cues.  There is usually a reduction in initiation of sex and reception to partner’s initiation attempts. When sexual activity does occur, there is often absent or reduced sensation (both genital and non-genital), excitement and pleasure. Although low T is an important cause of decreased sex drive, there are many other competing causes including other sexual issues such as pain with intercourse or inability to orgasm, medical diseases, medications, unhealthy lifestyle, fatigue, pregnancy, breast-feeding, menopause, boredom, stress, many other psycho-emotional factors and relationship issues.

Treatment Options

T has been shown to improve sexual function in both pre-and post-menopausal women. Testosterone replacement therapy (TRT) should only be a consideration after other causes of diminished libido have been eliminated.  It is challenging to predict which women will respond best to T therapy. Another concern is the safety and potential side effects with the long-term use of TRT.

There are currently no FDA-approved TRT products for women in the USA, so any usage is off-label. Products designed for TRT in males are available in a variety of preparations, including skin patches, gels and creams, buccal (gum) preparation, nasal gels, injections and long-acting pellets implanted in fatty tissue. Common side effects of TRT include unwanted hair growth, acne and mood or personality changes.

Addyi (Flibanserin) is a new oral medication for diminished libido.  It is currently being marketed largely to females, but is purportedly effective for both genders. It is the first FDA- approved prescription for diminished sex drive and has been referred to as “pink Viagra.” It is not TRT, but works centrally by affecting serotonin levels. It just became available this month.

Excellent reference on this subject: Khera, M. Testosterone Therapy for Female Sexual Dysfunction. Sex Med Rev 2015;3:137-144

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

The Curious Use of Genital and Anal Slang

October 24, 2015

Andrew Siegel MD   10/24/15

* Warning:  This blog contains adult language that you may find offensive. 

asshole_emoticon_by_marynightshade

(Asshole Emoticon, by marynightshade; no changes made Link: http://marynightshade.deviantart.com/art/Asshole-Emoticon-13248436  Licensed under a Creative Commons Attribution—Share Alike 3.0 License)

What an…“asshole”; “dick”; “dickhead”; “bell end” (British variety of dickhead)

He’s such a “jerk-off”; “wanker” (British variety of jerk-off)

She’s a “cunt,” “pussy,” “twat” (British variety of pussy)

The weather “sucks.”

This situation is so “fucked” up.

The aforementioned nouns and verbs are used metaphorically with negative and disparaging intent. What these phrases have in common is that they employ slang terms that refer to either the anatomy of the genitals and anal area, or alternatively, to some element of sexual function.

It is a curiosity that it is the slang terms that are used for derogatory purposes, but the non-slang, proper anatomical terms are never used in this context. Who ever refers to another person as an anus, penis, glans penis, vagina, etc.? Or, he’s such a masturbator? Or, the weather is like oral stimulation of a man’s penis? Or, this situation is like having sexual intercourse?

This genital and anal anatomical region of concern is valuable, often unappreciated human real estate. I am puzzled as to how our slang language evolved to use anatomy and physiology of the nether region in such a pejorative sense. Perhaps it is the fact that our culture has strong underlying puritanical roots. The word pudendum, meaning genitals, derives from the Latin “pudenda,” meaning “shameful parts.” Certainly the fact that these are the most “private” areas of our body and the most “private” of body functions—the only anatomical regions and activities that are considered off limits and politically incorrect to expose or pursue, respectively, in public venues such as beaches—may explain why they are fodder for ridicule.

I think we have it all “ass backwards” (pun intended). Pelvic function—sexual, urinary and bowel—is truly remarkable and never appreciated until dysfunction sets in.

For many men—and women for that matter—the vagina is a dark and mysterious place, but an amazing and versatile structure if you consider that it is a sexual organ that allows entry of the penis, an inflow pathway and receptacle for semen, an outflow pathway for menstruation and a birth canal for the fetus. Vagina magic!

The penis is an equally extraordinary multifunctional organ—no less so than a Swiss army knife—with an impressive ability to multi-task, having an array of functions including urinary, sexual and reproductive. In the words of Eric Gill: “The water tap that could turn into a pillar of fire.” It allows man to urinate with a directed stream and when erect, it enables vaginal penetration and sexual intercourse. Ejaculation deposits semen in the vagina, with the passage of genetic material and ultimately the perpetuation of the species. Penis magic!

Last but not least, the anus is nothing short of brilliant, the “asshole” not only capable of distinguishing gas, liquid and solid, but also is the structure standing between you and diapers. I care for patients with the devastating problem of fecal incontinence and recently evaluated a youthful 50-something year-old woman who recounted to me her circumstance of standing in an elevator with others present when fecal material started dripping out of her bikini bottoms, without her awareness.

So, if you wish to address a contemptible person, call them a “shit” or a “shithead”—so much more appropriate and meaningful slang than calling them an “asshole.” (Thank you Greg Lovallo, MD and Jennifer Bonilla, MA for pointing out the true utility of the S-word as opposed to the other genital and anal slang words.)

Bottom Line: Your “asshole” is your close friend and should never be taken for granted. Likewise, the entire genital/anal region should be admired, respected and held in the highest of esteem and not ridiculed, belittled and vilified. Think about that the next time you call someone an “asshole,” “dick,” or “pussy.” Just sayin’.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

TESTOSTERONE: Truths and Tall Tales—25 Questions Answered

October 17, 2015

Andrew Siegel MD   10/17/15

bodybuilding-311351_1280

(Thank you, Pixabay, for above image)

There has been an “epidemic” of a clincal syndrome based on low testosterone levels.  Is it real or is it a pharmaceutical company “figment” fueled by aggressive direct-to-consumer marketing for expensive and profitable easy-to-apply testosterone products?  Is testosterone replacement therapy the fast track to youth and alpha-male sexuality for the aging male, or is it harmful?  There is no subject rife with more confusion and misinformation than testosterone deficiency and its treatment. Hopefully, the following 25 questions and answers, culled from those commonly asked by my patients at office visits, will help enlighten and inform you and clarify misconceptions and falsehoods.

Abbreviations:

T: Testosterone (the key male sex hormone)        TD: Testosterone Deficiency

TRT: Testosterone Replacement Therapy       E: Estrogen (the key female sex hormone)

  1.  I don’t recall hearing much about testosterone years ago–Why has it suddenly become such a hot and trendy topic?

Big Pharma with their deep pockets and oversized advertising budgets started the “T” ball rolling. In 2008, AbbVie—manufacturer of Androgel—began an “Is it low T?” television campaign. Since that time, T has become a household word and T sales are up over 500% in a very competitive several billion-dollar market.

     2.  What exactly is T?

Testosterone is an “anabolic” hormone, a chemical messenger that promotes growth via protein synthesis, which drives the building of muscle and bone mass as well as strength; testosterone is equally an “androgenic” hormone, causing masculinization. T is made from cholesterol with most produced in the testes, with a small amount made in the adrenal glands (organs that sit above kidneys). Healthy men produce 6-8 mg testosterone daily, in a rhythmic pattern with a peak in the early morning and a lag in the later afternoon. If you find that you are most amorous in the early morning, now you have a good biochemical explanation.

   3.   When does T kick in and what does it do?

T surges around age 12-14 or so and drives puberty, causing the following: penis enlargement; development of an interest in sex; increased erections; pubic, underarm, facial, chest and leg hair; decrease in body fat and increase in muscle and bone mass, growth and strength; deepened voice and prominence of the Adam’s apple; sperm production; and bone and cartilage changes including growth of jaw, brow, chin, nose and ears and the transition from “cute” baby face to “angular” adult face.

   4.   Is T important after puberty?                                                                                                                                                                                                                                                                                                                                                        Throughout adulthood, T helps maintain libido, masculinity, sexuality, and youthful vigor and vitality. Additionally, T contributes to mood, red blood cell count, energy, and general “mojo.”

   5.   What is TD and why does it occur?

TD is a clinical and biochemical syndrome characterized by relevant symptoms and signs in conjunction with a deficiency of T or T action. Symptomatic TD occurs in 2-6% of men.  There is approximately a 1% decline in T level each year after age 30. Most commonly it is an impaired testicular production of T. It can also happen because of a pituitary issue in which there is not enough production of luteinizing hormone (LH), the hormone that drives the testes to manufacture T.  Furthermore, it can happen under circumstances of normal T levels when there are elevated levels of the hormone that strongly binds T (SHBG), reducing the amounts of T available for action. It is important to distinguish TD on the basis of testes impairment vs. pituitary impairment, as the management is different.                                                                                                          

   6.   Is T going to help my erections, which are not quite what they used to be?  

Maybe.  Although T is important for sexual function and for maintaining the health and vitality of the penis, one does not need high or even normal levels of T to obtain an erection.  A good example is a pre-pubertal boy who gets erections all the time, but has no interest in sex.  The more compelling role of T is in driving libido.                                                                                                                                                                                                                                                                                                           7.   T seems like such a vital hormone for men…is it for me?                                                                                                                                                                                                                                                                                                               ONLY under the circumstances of a testicular or pituitary problem causing the characteristic symptoms of TD coupled with a blood test that proves that low T levels is it worth pursuing a trial of TRT. It is only beneficial continuing the TRT if it is providing meaningful symptom improvement in the face of a normalized T level.

   8.   How does T get to the body tissues where it works?

Since T is a hormone–a chemical messenger that is made in one locale but works elsewhere–it needs to be transported to get to those cells where it acts.  T circulates in the blood stream–60% is inactive as it is tightly bound to SHBG (sex hormone binding globulin), 38% is weakly bound to albumin, and 2% is free. The albumin-bound and free T are the biologically “active” forms of T.

   9.   How does T work?

Much of T is converted to dihydrotestosterone (DHT), a more potent form, which couples with a special receptor enabling it to move into the nucleus of cells and bind to DNA, where it provides the blueprint for protein synthesis. Some T does so without being converted to DHT and some T is converted to E, the main female hormone.

   10.   What about the female hormone estrogen…is it important for men?

Yes…More than 80% of E in males is derived from T. When levels of T are low, a decline in E levels will occur. E deficiency is important in terms of osteopenia (bone thinning) in men. As commonly happens with abdominal obesity, E levels become too high as abdominal fat is an active endocrine organ that converts T to E, causing low T, high E, breast development, the appearance of a smaller penis and general emasculation.

   11.   Why have T levels been dropping over the years?

Unhealthy lifestyle and the use of alcohol, steroids (for asthma, arthritis, connective tissue disorders and inflammatory bowel diseases) and opiate pain medications (methadone, tramadol, etc.) are risk factors. Obesity has played a huge (pardon the pun) role. Diabetes and metabolic syndrome have contributed to the low T epidemic as well. Physical and psychological stress affect pituitary hormone synthesis, which can give rise to low T levels. Sleep apnea can contribute to TD. Environmental factors such as phthalates, commonly used in plastic products, as well as many other environmental exposures, are associated with low T levels.

   12.   How important of a factor is obesity in causing TD?

Obesity is the single most common cause of TD in the developed world. More than half of men with TD are overweight or obese.  The good news is that it is potentially reversible with weight loss.

   13.  What is the issue with diagnosing low T based upon the established ADAM (androgen deficiency in the aging male) screening test?

The ADAM screening questions are very general and involve decreased libido, diminished erections, lack of energy, decrease in strength/endurance, loss of height, decreased joy, the presence of sadness or grumpiness, deterioration in sports performance, falling asleep after dinner and deterioration in work performance.  These symptoms have an enormous overlap with changes that accompany normal aging, insufficient or poor quality sleep, overworking and/or an unhealthy lifestyle.

Take, for example, a professional athlete of your choice who is at peak performance in his early 20’s. Fast-forward 30 years…how many of the aforementioned questions do you think will be answered positively?… Is it low T?…Possibly, but certainly not probably.

   14.   What are the symptoms that indicate the possibility of TD?

5 domains may be affected by TD: physical, sexual, cognitive, affect and sleep. Physical changes are reduced muscle mass and strength, increased body fat and abnormal lipid profiles, frailty, breast development, loss of body hair and central obesity. Sexual changes include decreased desire, diminished erection quality and weakened ejaculation and orgasm. Cognitive changes that may occur are impaired concentration, diminished verbal memory and altered visual-spatial awareness. Changes in affect can be a reduced sense of general wellbeing, decreased energy and motivation, anxiety, depression and irritability. Sleep issues include fatigue, tendency to sleep during the day and difficulties falling and staying asleep.

   15.   How does one diagnose TD with lab testing?

The diagnosis of TD is made via a blood test for total T and free T as well as for the pituitary hormones, LH and prolactin. In cases of obese or elderly men, SHBG can be useful. It is important to know that T levels can vary depending on the particular lab and can fluctuate on a day-to-day basis as well as depending on what time of day it is drawn, as T has circadian biorhythms.  T can be temporarily suppressed by illness, nutritional deficiency and certain medications. Fasting T levels are generally higher than T levels after a meal. The bottom line is that T should be checked on at least two occasions.

   16.   What is the first-line approach to treating TD?

Lifestyle improvement measures including weight reduction, exercising regularly, management of sleep apnea and stopping the use of opioids.

   17.   When should TRT be used?

When TD fails to respond to first-line approaches in a man with characteristic symptoms and laboratory documentation of TD.

   18.   What is the goal of TRT?

To restore T levels to the mid-normal range of levels observed for healthy men and alleviate the signs and symptoms of TD without causing significant side effects or safety issues.

   19.   What are some of the testicular side effects of TRT?

Because TRT is an external source of T, it suppresses testes function, resulting in diminished sperm count, decreased fertility and the possibility of testes atrophy (shrinkage) with long-term use. Men who wish to retain fertility should not be put on TRT, but should consider the use of an oral medication that stimulates the testes to produce natural testosterone without suppressing sperm count.

   20.    What are some of the other side effects of TRT?

Acne, oily skin, breast development, worsening of sleep apnea, hair loss, fluid retention, elevated blood count and aggression.

   21.   How is TRT administered?

There are many different preparations: buccal (applied to the gums); transdermal (patches and gels); nasal gel; injections; and pellet implants. Each has advantages and disadvantages.

   22.   What about treating TD without TRT?

Since TRT impairs sperm development and fertility and may result in testes atrophy, an alternative to TRT–clomiphene citrate–works by stimulating the testes to produce natural T. It is approved by the FDA for both male and female fertility, but not for TD, so must be prescribed “off-label” for TD.

    23.   Do men with TD on TRT need follow up?

Yes, regular follow up is imperative to ensure that the TRT is effective, adverse effects are minimal, and T blood levels are in-range. Periodic digital rectal exams are important to check the prostate for enlargement and irregularities, and, in addition to T levels, other blood tests are important including a blood count to check for increased hematocrit (thicker, richer blood) and PSA (Prostate Specific Antigen).  With the commonly used gel products, absorption rates vary considerably from person to person depending on skin thickness, body hair, preparation, application site, degree of sweating, etc., so dose adjustments need to be made depending on T levels that are periodically checked.

   24.   What about TRT in men with cardiac disease or prostate cancer?

To quote a review article from the Journal of Sexual Medicine (Dean et al: The ISSM’s Process of Care for the Assessment an Management of TD in Adult Men, 2015;12:1660-1686) “TRT use has been complicated by controversies regarding prostate cancer and cardiovascular risks. Although the absence of large-scale, long-term controlled studies with TRT limits the ability to make definitive conclusions regarding these risks, the weight of evidence fails to support either concern.”

    25.   How about T supplements or boosters that can be bought online?

A. The Internet is overrun with male “sexual enhancement” products. They capitalize on male insecurity, which has created a huge market, with hordes of men willing to pay top dollar for products that have misleading claims and are often mislabeled, contaminated and falsely advertised. Unfortunately, such supplements are exempt from the stringent regulatory oversight applied to prescription drugs, which requires reviews of a product’s safety and effectiveness before it goes to market. Do not waste your money!

Bottom Line: TD is very real entity, but not as common as Big Pharma makes it out to be. The symptoms can be devastating and when accompanied by lab testing confirming the suspected clinical diagnosis, TRT can be magical.  I had one patient who eloquently described his “world of black and white turning into a world of color” after his T level was normalized. For many others with the syndrome, the beneficial effects of TRT are far more subtle.  If your T level is normal, it is highly unlikely that your symptoms are on the basis of low T and TRT should not be a consideration.  

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

An Erection Is A Symphony, With An Orchestra And Conductor

October 10, 2015

Andrew Siegel MD    October 10, 2015

Gaga_Symphony_Orchestra

(Gaga Symphony Orchestra live at Palazzo Zuckermann, Padua, Italy; photo taken by Carlo Alberto Cazzuffi, September 2012; Permission to copy and distribute under the terms of the GNU Free Documentation License)

Achieving a rigid erection is a “symphony” that results from the interplay of four “orchestral sections,” nerves, blood vessels, erectile smooth muscle, and erectile skeletal muscle (pelvic floor muscles). The orchestral sections are led by the “conductor,” the brain (the main sex organ). Although each individual “musician” within the orchestral sections has a unique role, all work together in harmony to create a beautiful “symphony.” If any musician or orchestral section is off key, the disharmony can cause the “symphony” to be flawed resulting in a sub-par performance.

Sections of the Orchestra

Nerves: You can think of the nerves as the string instruments—the violin, viola, cello and double bass—vibrating in sync. This is arguably one of the most important sections, providing more than half of the musicians.

The penis has a rich supply of nerves that connect with the spinal cord and brain. Without these nerves and connections, the penis would be numb, cut off from the rest of the body and incapable of being stimulated with either touch or erotic stimulation.

Here is how things work when nerves are functioning well:

  • When the penis is stimulated by touch, nerves relay this information to spinal cord centers, which then relay the message to the penile arteries to increase blood flow, resulting in the penis becoming engorged.
  • Touch to the penis is also conveyed directly to the brain, enhancing this reflex spinal cord response.
  • Erotic stimulation (visual cues, sounds, smells, touch, thoughts, memories, etc.) further stimulates the penis from excitatory nerve pathways that descend from the brain.
  • With touch stimulation of the head of the penis, a reflex contraction of the pelvic floor muscles causes even more blood to be pushed into the penis, leading to a rigid erection.

Blood vessels: You can think of the blood vessels as the percussion instruments—the piano, xylophone, cymbals, drums, etc.—pulsing rhythmically. Kettledrums or timpani bring a level of excitement to the music. 

Inflation of the penis is all about blood inflow and trapping. When there are issues with blood flow or blood trapping, it becomes very difficult to obtain and/or maintain an erection.

Here is how things work when the blood vessels are functioning well:

  • With touch or erotic stimulation, nerves (as discussed above) cause the muscle within the walls of the penile arteries to relax, which increases penile blood flow.
  • Muscle relaxation within the small arteries of the sinuses of the penile erectile chambers increases blood flow, resulting in penile engorgement.

Erectile smooth muscle: You can think of the erectile smooth muscle as the woodwind instruments—the piccolos, flutes, oboes, clarinets and bassoons—ranging from the highest tones in the orchestra to the lowest, analogous to the great range of smooth muscle contractility within the erectile chambers.

The erectile smooth muscle within the sinuses of the erectile chambers governs the inflation/deflation status of the penis. When the smooth muscle is contracted (squeezed), the penis cannot inflate with blood, but when the muscle relaxes, blood gushes into the sinuses and inflates the penis. Issues with the erectile smooth muscle make it difficult to obtain or maintain an erection.

As we age, smooth muscle in all arteries of the body stiffens, causing high blood pressure; paralleling this, there is an age-related stiffness of the erectile smooth muscle, which causes erectile dysfunction.

Here is how things work when the erectile smooth muscle is functioning well:

  • With touch or erotic stimulation, the smooth muscle within the sinuses of the erectile chambers relaxes, under control of the nerves, which allows blood to flow into and fill the sinuses.
  • As the sinuses approach complete filling, veins that drain them are pinched, trapping blood within the sinuses.
  • This smooth muscle relaxation results in penile blood pressure becoming equal with the overall systolic blood pressure (normally 120 millimeters) and an engorged penis, plump but not rigid.

Erectile skeletal muscles (pelvic floor muscles): You can think of the erectile skeletal muscles as the brass instruments—the trumpets, French horns, trombones, and tubas, made of brass and capable of the loudest sounds in the orchestra. These instruments are particularly important in the loudest, most exciting portions of the music, corresponding to the role of the pelvic floor muscles as one approaches climax, maintaining rigidity and driving ejaculation.

The pelvic floor muscles are the rigidity muscles, necessary for transforming the plump penis to a rock-hard penis. These “rigidity” muscles surround the deep roots of the penis. When these muscles are not functioning optimally, one loses the potential for full rigidity.

Half of the penis is hidden and internal and is known as the penile roots. Like the roots of a tree responsible for  foundational support, the roots of the penis stabilize and support the erect penis so that it stays rigid and skyward-angling with excellent “posture.” When erect, it is these muscles that are responsible for the ability to lift one’s penis up and down as the muscles are contracted and relaxed. These rigidity muscles compress the roots of the penis, causing backflow of pressurized blood into the penis; additionally they are responsible for ejaculation—compressing the urethra (urinary channel that runs through the penis) rhythmically at the time of climax to cause the expulsion of semen.

An erection–defined in mechanical (hydraulic) terms– is when the penile blood inflow is maximized while outflow is minimized, resulting in an inflated and rigid penis. The pressure in the penis at the time of an erection is sky-high (greater than 200 millimeters), the only organ in the male body where high blood pressure is both acceptable and necessary for healthy function. If the systemic blood pressure were this high, it would be considered a “hypertensive crisis.” This explains why blood pressure pills are the most common medications associated with erectile dysfunction.

Unlike humans, many mammals have a bone called the os penis to permit penile rigidity. In the absence of this handy set up, nature has cleverly engineered a better alternative…after all, who wants an erection 24-7-365? A convenient and readily available fluid—blood—is used as a liquid medium and pressurized tremendously to achieve an erection. Brilliant!

Here is how things work when the pelvic floor muscles are functioning well:

  • With touch stimulation of the head of the penis, there is a reflex contraction of the pelvic floor muscles; every time the head of the penis is stimulated, the pelvic floor muscles contract.
  • The pelvic floor muscles surround the roots of the penis and as they compress and squeeze the roots with each contraction, blood within the roots is forced back into the external penis, thereby pushing more blood into the penis and causing more clamping of venous outflow—a tourniquet-like effect—that results in penile high blood pressure and full-fledged rigidity—a brass-hard penis.

Brain: You can think of the brain as the conductor of the orchestra—the maestro—who has the vital role of unifying and coordinating the individual performers, setting the tempo, executing meter, “listening” critically and shaping the sound of the ensemble accordingly. The conductor is the key player and if he is having an off day and does not bring his “A” game, there will be disharmony in the orchestra and the symphony will be flat and unimpressive.

Psychological and emotional status has a significant impact on erectile function. Mood, stress levels, interpersonal and relationship issues, etc.—acting via the mind-body connection and mediated via the release of neurochemicals—can influence erectile function for better or worse. Stress, for example, induces the adrenal glands to release a surge of adrenaline. Adrenaline constricts blood vessels, which has a negative effect on erections, the basis for the common occurrence of adrenaline-fueled performance anxiety.

The Fix

Now that we have looked at the sections of the orchestra and have deconstructed the erectile process, let us use this schema as a means of treating the specific part of the process that may have gone awry.

Nerves: Since intact and functioning nerves are fundamental to the erectile process, stimulation of the nerves can be an effective means of resurrecting erectile function. Penile vibratory stimulation induces the reflex between the penis and the spinal cord that results in gradual filling of the penis with arterial blood. It contributes to erectile rigidity via inducing reflex contractions of the pelvic floor muscles when the vibrations are applied to the head of the penis. By enhancing this reflex and triggering nerve activity in the brain, spinal cord and peripheral nerves, vibratory stimulation is capable of inducing an erection and ejaculation.

Blood Vessels: Clogged arteries caused by fatty plaques, often a consequence of an unhealthy lifestyle, can compromise the blood supply to the penis. Lifestyle “remake” consists of common-sense measures to improve all aspects of health in general and blood vessel health in particular. This means getting down to “fighting” weight, adopting a heart-healthy (and penis-healthy) diet, exercising regularly, drinking alcohol moderately, avoiding tobacco, minimizing stress, getting enough sleep, etc. The oral ED medicationsViagra, Levitra, Cialis and Stendra—can be helpful when there is compromised blood flow to the penis. They work by inhibiting the chemical that causes erections to dissipate.

Erectile Smooth Muscle: Age-related dysfunction of erectile smooth muscle is a difficult issue to manage. However, lifestyle measures can be helpful as well as adopting a “use it or lose it” attitude towards sexual function—exercising the penis via regular sexual activity will actually help the health of the smooth muscle of the penile arteries and sinuses.

Erectile Skeletal Muscle: Pelvic floor muscle training will improve the strength, tone and endurance of the pelvic floor muscles and will optimize the rigidity function.

Brain: Finding a solution for the psychological and emotional issues that adversely affect sexual function would merit winning the Nobel Prize! Lifestyle measures are vital for optimal brain function. Getting sufficient sleep is particularly important. Stress management is essential as stress is one of the main erection killers. Finding balance in life is key. When in a sexual situation, being “in the moment” as opposed to “spectatoring”—observing your performance as if you are a third party—is fundamental for optimal functioning.

Bottom Line: An erection is a highly complex symphony, orchestrated by the main sex organ—the brain—and executed at the level of the penis via the individual performances of the orchestral members who comprise the orchestral sections—the nerves, blood vessels, erectile smooth muscle and the pelvic floor muscles. All orchestral members play a vital role in the creation of a magical synergy, resulting in a spirited, powerful, passionate performance that climaxes in a tension-releasing symphonic finale.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

Is There A Better Way To Manage Erectile Dysfunction Than “Doping”?

October 3, 2015

Andrew Siegel, MD    10/3/15

IMG_1457(1)

(My patient Ben Blank, a talented artist and cartoonist, gave me the cartoon shown above in 1998 when Viagra first became available.  It is hanging in one of my exam rooms)

Erectile dysfunction is usually caused by a combination of many factors, including lifestyle, medical issues, medications, impaired blood flow, nerve damage, pelvic muscle weakness, stress and psychological conditions.

Managing any medical problem should employ a sensible strategy trying the simplest, safest, and least expensive alternatives first. If unsuccessful, more aggressive, complicated and invasive options can be entertained.

For example, when a patient presents with arthritis, he or she is not offered a total knee replacement from the get-go (at least I hope not!). In accordance with the aforementioned strategy, managing knee arthritis should start with rest and anti-inflammatory medications and proceed, if necessary, down the pathway of exercise/physical therapy, arthroscopy, endoscopic knee surgery, and ultimately if all else fails, under the proper circumstances, to prosthetic joint replacement.

A Sensible and Practical Approach To Erectile Dysfunction

A similar approach should be applied to managing erectile dysfunction. Unfortunately, however, many patients and physicians alike seek the “quick fix” and ignore many treatments that can help prevent or reverse the condition.

I like to adhere to the following principles to manage sexual dysfunction:

  1. Provide education (verbal and in writing) so informed decisions can be made.
  2. Try simple and conservative solutions before complex and aggressive ones.
  3. If it isn’t broken, don’t fix it: “First do no harm.”
  4. Healthy lifestyle is crucial: “Genes load the gun, but lifestyle pulls the trigger.” Lifestyle improvement measures are of paramount importance.

“Doping” is common among athletes, who use illicit drugs to enhance their athletic performance. In my urology practice, many of my patients “dope”—with legal drugs—in an effort to improve their sexual performance. Is there not a better and more natural way than starting with performance-enhancing drugs from the get-go?

Don’t get me wrong, the oral meds for ED (Viagra, Levitra, Cialis and Stendra) are “revolutionary” additions to the limited resources we once had to treat ED. Although far from perfect—expensive, contraindicated with certain cardiac conditions and for those on nitrate medications, associated with some annoying side effects, and not effective in everyone—nonetheless, for many men they are highly effective in creating a “penetrable” erection.

These drugs are commonly used as the first-line approach to ED. As useful as they are, I contend that “doping” should not be first-line treatment, but should be reserved for situations in which the simple and natural first-line interventions fail to work.

Since erections are nerve/blood vessel/erectile smooth muscle/pelvic skeletal muscle events, optimizing erection capability involves doing what you can to have healthy nerves, blood vessels and muscles. How does one keep their tissues and organs healthy? The first-line approach is commonsense—getting in the best physical (and emotional) shape possible. This might mean a lifestyle makeover to get down to “fighting” weight, adopting a heart-healthy (and penis-healthy diet), exercising regularly, drinking alcohol moderately, avoiding tobacco, minimizing stress, getting enough sleep, etc.—measures that will improve all aspects of health in general and blood vessel health in particular.

Focused pelvic floor muscle exercises improve the strength and endurance of the male “rigidity” muscles that surround the deep roots of the penis.

Since intact and functioning nerves are fundamental to the erectile process, activation of the nerves via penile vibratory stimulation can be an effective means of resurrecting erectile function.

The vacuum suction device—a.k.a., the penis pump—is a means of drawing blood into the penis to obtain an erection and enable penetration.

Second-line treatments are the well-established oral medications for ED. Although Viagra, Levitra, Cialis and Stendra all have the same mechanism of action, there are nuanced differences in potency, time to onset, duration of action, side effects, etc., so it may take some trial and error to find out which works best for you. Cialis uniquely is approved for both ED and prostate issues, so can be an excellent choice if you have both sexual and urinary issues.

Third-line alternatives include urethral suppositories and penile injection therapy. Suppositories are absorbable pellets that are placed in the urethra that act to increase penile blood flow. Injections do the same, but are injected directly into the penile erectile chambers.

Fourth-line treatment is the prosthetic penile implant. One variety is a semi-rigid non-inflatable device and another is a hydraulic inflatable device. They are implanted surgically within the erectile chambers and can be deployed on demand to enable sexual intercourse. For the right man, under the right circumstances, the penile implant is a life changer—as magical as a total knee replacement can be—converting a penile “cripple” into a functional male. However, it is vital to understand that the implant is a fourth-line approach, and less invasive options should be exhausted before its consideration.

Bottom Line: Sadly, our medical culture and patient population often prefer the quick fix of medications or surgery rather than the slow fix of lifestyle measures. A sensible approach to most medical issues—including ED—should be the following:

  • Get educated about all treatment options.
  • Explore the simplest, safest, and least expensive alternatives first.
  • Before considering medications to improve performance, think about committing to a healthy lifestyle and getting into optimal physical shape, including exercising the rigidity muscles of the penis and using vibratory nerve stimulation.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.