Posts Tagged ‘Viagra’

Viagra, Levitra, Cialis or Stendra: Which ED Med Is Right For You?

July 1, 2016

Andrew Siegel MD  7/1/2016

IMG_1457(1)

Cartoon by my patient/artist Ben Blank given to me shortly after  Viagra became available in 1998.  It says it all!

There are lots of options available if you are having erection problems. In my humble opinion, healthy lifestyle measures should always be considered first-line: weight management, healthy eating, exercise (including cardio, strength, core and pelvic floor), sufficient sleep, avoidance of tobacco, excessive alcohol and excessive stress, etc. With respect to ED medications, there are now many choices. Today’s entry will discuss which of the ED meds is best for you.

How the Penis Erects

In an erotic situation, nerves to the penis release nitric oxide that then causes the release of cGMP, resulting in blood flooding into the erectile chambers of the penis, the basis of an erection. As the erection gets fuller, penile veins become compressed, limiting the exit of blood and ultimately the pelvic floor/perineal muscles engage to cause maximal erectile rigidity.

How the Penis Becomes Flaccid

After ejaculation, the enzyme PDE-5 (phosphodiesterase) is released, the chemical mediator of flaccidity. It results in decreased levels of cGMP, resulting in a loss of the erection and a return to flaccid status.

ED Meds

The ED medications include Viagra, Cialis, Levitra and Stendra. They work by inhibiting PDE-5 and are known as PDE-5 inhibitors. Effective for many men with ED, they result in enhanced erectile function, sexual satisfaction and quality of life.

They are taken orally, require some time to get absorbed and necessitate sexual stimulation to work effectively. Although they can result in some increase in penile fullness (tumescence) without sexual stimulation, sexual stimulation is a must in order to induce a fully rigid erection.

Although effective for many men, they will not work for everyone.  If there is significant nerve or vascular compromise to the penis, they will likely be ineffective. It is important to know that the same ED drug at the same dose may work variably depending on the particular time and situation, sometimes more effectively than at other times since there are so many factors that determine erectile rigidity.

Men who are taking nitrates of any kind should never use the ED meds or serious consequences may result, including a dramatic drop in blood pressure (Remember Jack Nicholson in “Something’s Gotta Give”?). All of these ED drugs are metabolized in the liver for breakdown by the body.

Viagra (Sildenefil) This was the first of the group, released in 1998. Dosed at 25, 50 or 100 mg, the half-life (the amount of time it takes for the blood level of the drug to drop by 50%) is about 4 hours. It is taken on demand and kicks in in 15-60 minutes and remains active for 4 or more hours.

Viagra trivia:  Viagra was discovered by chance. Pfizer scientists conducted a clinical trial with an experimental medicine that causes blood vessels to dilate in an effort to treat high blood pressure and chest pain. The medication 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 history.

More Viagra trivia: The name Viagra was born as a fusion of the words “vigor” (physical strength) and “Niagara” (the most powerful waterfall in North America).

Even more Viagra trivia: Viagra is not only used for ED. A 20 mg dose is effective for children with pulmonary hypertension, a condition in which the blood vessels in the lungs have abnormally high blood pressures.

The most common side effects of Viagra are headache, facial flushing, upset stomach, and nasal stuffiness. Less frequent side effects are temporary changes in color vision, sensitivity to light, and blurry vision.

Levitra (Vardenefil) This drug came to market in 2003 and is very similar to Viagra, available in 10 mg and 20 mg doses. The effectiveness and side effect profile is similar to Viagra; however, there are no reports of visual distortions as side effects. It is taken on demand and has an onset of about 25 minutes and has a half-life of about 4 hours and remains active for 4 or more hours.

Levitra trivia: The name Levitra derives from “elevate”; in French “le” indicates masculinity and “vitra” suggests vitality.

More Levitra trivia: Levitra is also formulated in a minty, dissolves-in-your-mouth 10mg formulation called Staxyn.

Cialis (Tadalafil) This was FDA approved in 2003 and is available in 2.5, 5, 10, and 20 mg doses. The effectiveness and side effect profile is similar to Viagra. Uniquely, Cialis has a long duration of action that has earned it the nickname “the weekender” as it can be taken on Friday evening and remain effective for the remainder of the weekend without the need for an additional dose. This affords a considerable advantage in terms of spontaneity. Cialis is either taken on demand (usually 10 or 20 mg, although 5 mg can be effective as well) or on a daily basis (2.5 or 5 mg) and has an onset of 15-45 minutes and remains active for 36 or more hours.

Cialis trivia: Cialis is also approved to treat children with pulmonary hypertension.

In 2012, daily Cialis (2.5 and 5 mg) was FDA approved for the management of urinary symptoms due to benign prostate enlargement.

Cialis, on occasion, can cause backaches and other muscle aches. Cialis is not affected by eating fatty meals, which can slow the absorption of the alternative ED meds.

Stendra (Avanafril) This was FDA approved in 2012. Available in 50, 100 and 200 mg doses, it has the advantage of a rapid onset of action. It is taken on demand and has an onset of about 10 minutes and remains active for 6 or more hours. It seems to have lower rates of hypotension when nitrates are co-administered.

Stendra trivia:  The name Stendra probably is a derivative of the word “extends.”

My Take

I have been in urology practice since 1988 and have plenty of clinical experience managing ED with these meds. In my opinion, Viagra 100 mg is the most potent of the group, but will also incur the most side effects, particularly facial flushing and potentially a nasty headache. Levitra is very similar in most respects to Viagra. Cialis is overall the best of the bunch because of its long duration, the spontaneity factor, the ability to take it with a fatty meal and its dual utility of helping urination as well as sexual function. The downside to Cialis is the occasional muscle aches. Stendra’s rapid onset gives it a small advantage.

Many men are capable of functioning satisfactorily without any of these medications, but find that taking a “recreational dose” of Cialis 5 mg enhances erectile capability and takes 20 years or more off the functional age of the penis. It is particularly useful for those with performance anxiety.

$$$$$

These drugs have gradually increased in price to the point where they are ridiculously expensive, unaffordable for many. None of the ED meds are yet generic. They typically retail for $40 or more per pill.

Tip of the Day: Viagra 20 mg (for pulmonary hypertension in children) is now generic and significantly less expensive than the branded variety and can be used for ED (taking up to 5 pills) at significant savings.

Bottom Line: The arrival of this class of medication in 1998 revolutionized the management of erectile dysfunction. Each of the available ED medications in this class is effective in improving erectile dysfunction issues for most men. There are subtle differences among the four that provide potential advantages and disadvantages. Trial and error will determine what works best for your needs.

Wishing you the best of health and a wonderful Independence Day weekend,

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 THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com

Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  In the works is the female PelvicRx pelvic floor muscle training DVD. 

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

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Viagra, Levitra, Cialis, Stendra: Which One Is Right For You?

July 1, 2016

Andrew Siegel MD   7/1/16

IMG_1457(1)

                     Cartoon by my patient/artist Ben Blank given to me shortly after  Viagra became available in 1998.  It says it all!

There are lots of options available if you are having erection problems. In my humble opinion, healthy lifestyle measures should always be considered first-line: weight management, healthy eating, exercise (including cardio, strength, core and pelvic floor), sufficient sleep, avoidance of tobacco, excessive alcohol and excessive stress, etc. With respect to ED medications, there are now many choices. Today’s entry will discuss which of the ED meds is best for you.

How the Penis Erects

In an erotic situation, nerves to the penis release nitric oxide that then causes the release of cGMP, resulting in blood flooding into the erectile chambers of the penis, the basis of an erection. As the erection gets fuller, penile veins become compressed, limiting the exit of blood and ultimately the pelvic floor/perineal muscles engage to cause maximal erectile rigidity.

How the Penis Becomes Flaccid

After ejaculation, the enzyme PDE-5 (phosphodiesterase) is released, the chemical mediator of flaccidity. It results in decreased levels of cGMP, resulting in a loss of the erection and a return to flaccid status.

ED Meds

The ED medications include Viagra, Cialis, Levitra and Stendra. They work by inhibiting PDE-5 and are known as PDE-5 inhibitors. Effective for many men with ED, they result in enhanced erectile function, sexual satisfaction and quality of life.

They are taken orally, require some time to get absorbed and necessitate sexual stimulation to work effectively. Although they can result in some increase in penile fullness (tumescence) without sexual stimulation, sexual stimulation is a must in order to induce a fully rigid erection.

Although effective for many men, they will not work for everyone.  If there is significant nerve or vascular compromise to the penis, they will likely be ineffective. It is important to know that the same ED drug at the same dose may work variably depending on the particular time and situation, sometimes more effectively than at other times since there are so many factors that determine erectile rigidity.

Men who are taking nitrates of any kind should never use the ED meds or serious consequences may result, including a dramatic drop in blood pressure (Remember Jack Nicholson in “Something’s Gotta Give”?). All of these ED drugs are metabolized in the liver for breakdown by the body.

Viagra (Sildenefil) This was the first of the group, released in 1998. Dosed at 25, 50 or 100 mg, the half-life (the amount of time it takes for the blood level of the drug to drop by 50%) is about 4 hours. It is taken on demand and kicks in in 15-60 minutes and remains active for 4 or more hours.

Viagra trivia:  Viagra was discovered by chance. Pfizer scientists conducted a clinical trial with an experimental medicine that causes blood vessels to dilate in an effort to treat high blood pressure and chest pain. The medication 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 history.

More Viagra trivia: The name Viagra was born as a fusion of the words “vigor” (physical strength) and “Niagara” (the most powerful waterfall in North America).

Even more Viagra trivia: Viagra is not only used for ED. A 20 mg dose is effective for children with pulmonary hypertension, a condition in which the blood vessels in the lungs have abnormally high blood pressures.

The most common side effects of Viagra are headache, facial flushing, upset stomach, and nasal stuffiness. Less frequent side effects are temporary changes in color vision, sensitivity to light, and blurry vision.

Levitra (Vardenefil) This drug came to market in 2003 and is very similar to Viagra, available in 10 mg and 20 mg doses. The effectiveness and side effect profile is similar to Viagra; however, there are no reports of visual distortions as side effects. It is taken on demand and has an onset of about 25 minutes and has a half-life of about 4 hours and remains active for 4 or more hours.

Levitra trivia: The name Levitra derives from “elevate”; in French “le” indicates masculinity and “vitra” suggests vitality.

More Levitra trivia: Levitra is also formulated in a minty, dissolves-in-your-mouth 10mg formulation called Staxyn.

Cialis (Tadalafil) This was FDA approved in 2003 and is available in 2.5, 5, 10, and 20 mg doses. The effectiveness and side effect profile is similar to Viagra. Uniquely, Cialis has a long duration of action that has earned it the nickname “the weekender” as it can be taken on Friday evening and remain effective for the remainder of the weekend without the need for an additional dose. This affords a considerable advantage in terms of spontaneity. Cialis is either taken on demand (usually 10 or 20 mg, although 5 mg can be effective as well) or on a daily basis (2.5 or 5 mg) and has an onset of 15-45 minutes and remains active for 36 or more hours.

Cialis trivia: Cialis is also approved to treat children with pulmonary hypertension.

In 2012, daily Cialis (2.5 and 5 mg) was FDA approved for the management of urinary symptoms due to benign prostate enlargement.

Cialis, on occasion, can cause backaches and other muscle aches. Cialis is not affected by eating fatty meals, which can slow the absorption of the alternative ED meds.

Stendra (Avanafril) This was FDA approved in 2012. Available in 50, 100 and 200 mg doses, it has the advantage of a rapid onset of action. It is taken on demand and has an onset of about 10 minutes and remains active for 6 or more hours. It seems to have lower rates of hypotension when nitrates are co-administered.

Stendra trivia:  The name Stendra probably is a derivative of the word “extends.”

My Take

I have been in urology practice since 1988 and have plenty of clinical experience managing ED with these meds. In my opinion, Viagra 100 mg is the most potent of the group, but will also incur the most side effects, particularly facial flushing and potentially a nasty headache. Levitra is very similar in most respects to Viagra. Cialis is overall the best of the bunch because of its long duration, the spontaneity factor, the ability to take it with a fatty meal and its dual utility of helping urination as well as sexual function. The downside to Cialis is the occasional muscle aches. Stendra’s rapid onset gives it a small advantage.

Many men are capable of functioning satisfactorily without any of these medications, but find that taking a “recreational dose” of Cialis 5 mg enhances erectile capability and takes 20 years or more off the functional age of the penis. It is particularly useful for those with performance anxiety.

$$$$$

These drugs have gradually increased in price to the point where they are ridiculously expensive, unaffordable for many. None of the ED meds are yet generic. They typically retail for $40 or more per pill.

Tip of the Day: Viagra 20 mg (for pulmonary hypertension in children) is now generic and significantly less expensive than the branded variety and can be used for ED (taking up to 5 pills) at significant savings.

Bottom Line: The arrival of this class of medication in 1998 revolutionized the management of erectile dysfunction. Each of the available ED medications in this class is effective in improving erectile dysfunction issues for most men. There are subtle differences among the four that provide potential advantages and disadvantages. Trial and error will determine what works best for your needs.

Wishing you the best of health and a wonderful Independence Day weekend,

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 THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com

Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  In the works is the female PelvicRx pelvic floor muscle training DVD. 

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

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.

Man’s Motivation for Medical Ministration: His Penis

October 18, 2014

Andrew Siegel MD

 

shutterstock_side view manjpeg

 

You—as a man—are a master of denial, who, through a combination of nature and nurture, often play the stoic, tough guy, independent, cool as a cucumber, stubborn, non-demonstrative, too-proud-to-ask-directions act. You typically serve the role of provider, protector, hunter, and warrior as opposed to your nurturing and more emotional female gender mate. Furthermore, you are literally “tainted” by testosterone levels that can biochemically impair your ability to think rationally. Truth is that deep inside, most men are actually weak-kneed milquetoasts who are put to shame by women when it comes to true bravado. Regarding seeking help in the form of medical care, men are much more reluctant to do so than women, particularly preventive health care, and medical care is often not sought until after a problem develops, establishes itself and worsens.

Men’s Health: Facts

  • Men live 6 years less than women on average
  • 36% of men seek medical care only when they become really ill
  • 30% of men defer seeking medical help as long as they can
  • 90 million men have a usual place of medical care, as opposed to 106 million women
  • 30 million men reported no office visits with a physician in the past year, as opposed to 16 million women
  • Men have higher rates of inactivity, poor nutrition, and excessive alcohol consumption than women
  • More than 50% of premature death in men in the USA are result of chronic, but preventable medical conditions

One of the challenges of being a physician is to persuade men to pursue preventive health services. Over the years, however, getting the male patient into the office has actually become much easier, thanks to the emerging field of sexual medicine, the availability of Viagra and other ED drugs, and Big Pharma’s extensive direct-to-consumer advertising.

Viagra was the initial drug in its class that addressed a previously unmet medical need with the collateral effect of being the “carrot” that enticed men to see their doctor. The direct-to-consumer advertising effort has resulted in a change in name of the pejorative term “impotence” into the more euphemistic term “erectile dysfunction,” de-stigmatizing sexual dysfunction, resulting in patients more readily making appointments. Big Pharma has also made the word “testosterone,” previously the domain of endocrinologists and urologists, into a commonly used household word, and numerous patients now appear in the office requesting to know what their “T” is.

Men may be stoic when it comes to their general health but when it comes to their genital health it is a different story. To many, their penis is literally their GPS, and when its function goes south, they become immediately motivated to find medical help! Never mind that they are having chest pain that gets dismissed as indigestion—an episode or two of failure to launch an erection is all it takes for an “emergency” appointment! There is some real truth to the concept that men think with their penises.

What most men do not realize is that they actually have a “canary in their trousers,” analogous to the “canary in the coal mine” carried by mine workers into the mines, the death of which would indicate the presence of dangerous gases. Since the penile arteries are generally rather small (diameter of 1 to 2 millimeters) and the coronary (heart) arteries larger (4 millimeters), it stands to reason that if vascular disease is affecting the tiny penile arteries, it may soon affect the larger coronary arteries as well—if not now, then at some time in the future. In other words, the fatty plaque that compromises blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a genital “stress test.” 

In fact, the presence of ED is as much of a predictor of cardiovascular disease as is a strong family history of cardiac problems, tobacco smoking, or elevated cholesterol. The British cardiologist Graham Jackson expanded the initials ED to mean: Endothelial Dysfunction (endothelial cells being the type of cells that line the insides of arteries); Early Detection (of cardiovascular disease); and Early Death (if missed).

Bottom Line: Because many men have an “obsession”—if not a “fascination,” with their penises—a dysfunction in this department is often the motivating factor that drives them to seek medical help, which often uncovers other medical issues. The pharmaceutical companies have developed excellent medications to treat ED and are credited with the name “ED” and for de-stigmatizing sexual issues are also responsible for getting the stoic gender into the physician’s office. So man’s peno-centric focus and Big Pharma are actually beneficial for men’s health.

 

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: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com

What You Don’t Know About Penile Erections, But Should

June 21, 2014

Blog #158

Although there are many who don’t care to know the details of how things function as long as they are functioning well, there are others who are curious about what’s “under the hood.” This blog, largely excerpted from my new book: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, is for those who are interested in what is actually happening down there one encounters a sexually stimulating situation.

A penis is a mechanical device and, as with any machine, it is important to understand how it works before it can be used and its operation mastered. In order to begin to understand how a penis works, the names and functions of its parts must first be learned.

The control center for erections is housed within the cerebral cortex (brain), of immense importance to our sexuality and what can be considered to be the “governor” of erections and sexuality. The brain can initiate erections in the absence of tactile (touch) stimulation and in direct response to sights, sounds or smells that are perceived as erotic. It might be a quick glance at someone who is smoldering hot, a sexy and sultry voice, or the alluring scent of perfume. The stimuli need not be external, as even a thought can initiate an erection.

There are several “centers” in our brain that integrate sexual functioning and erections. Studies have demonstrated that electrical stimulation of these brain centers can induce erections, and disease processes that involve these areas can cause ED. There are also several spinal cord erection centers and illnesses that involve these spinal areas can also cause ED.

The cerebral cortex is the site where the sensations of sexual arousal are experienced and processed. The brain then sends nerve signals to the erectile nerves, the cavernosal nerves, which are also stimulated by direct sensory contact, including foreplay or the act of sexual intercourse itself.

Bottom Line: The brain is the master control unit of sexuality.

There are three types of erections: psychogenic, reflex, and nocturnal. Psychogenic erections are on the basis of sights, sounds or smells. Nerve impulses travel from the brain to the spinal cord centers to the penis to produce an erection. Reflex erections occur in response to direct tactile stimulation of the penis. Nerve impulses travel from the penis to the spinal cord centers. Nocturnal erections have a unique mechanism controlled in thebrainstem and occur during REM (rapid eye movement) sleep. Most healthy men have 3-6 nocturnal erections while sleeping, each lasting about 10-15 minutes.

Bottom Line: Erections can originate from the following: erotic thoughts; stimulation of our senses of vision, hearing and/or smell; and direct touch. Nocturnal erections have a unique brainstem origin.

Who Knew? When the urinary bladder is full, it stimulates the same sacral nerves that are involved with penile sensation and erection. Because the bladder and the penis share a common nerve supply, when the bladder is distended, an erection may occur, often referred to in slang terms as a “piss hard-on.”

Who Knew? Some men ejaculate spontaneously during sleep while in REM sleep. These “wet dreams” or more formally, “nocturnal emissions,” demonstrate the central role that the brain plays with respect to both erections and ejaculation.

The erectile apparatus of the penis consists of three spongy erectile cylinders that run the length of the entire penis, both internally and externally: the solitary corpus spongiosumthat contains the urethra and forms the glans penis, and the paired erectile cylinders called the corpora cavernosathat are anchored internally to the pelvic bones and extend to the glans. These erectile cylinders communicate with each other and are enclosed in a fibrous sheath, the tunica albuginea. Erectile rigidity is on the basis of blood flowing into and being trapped in the penis.

Bottom Line: The penis obtains its bone-like rigidity (hence the term boner) by virtue of blood filling and inflating the spongy tissue within the three cylinders of the penis (corpora), similar to air inflating the tire of a car

Who Knew? It only takes 2 ounces or so of blood to inflate the average flaccid penis into a fully erect one.

Who Knew? The penis of many mammals has an “os penis,” a bone coursing through the penis to facilitate sexual intercourse by maintaining penile rigidity at all times.

Who Knew? When dogs copulate, the canine penis is not erect at the time of penetration. By virtue of the os penis, the penis can enter the vagina. After penetration, swelling of the erectile tissue at the penile base occurs. With vaginal contraction, the canine penis locks inside the female. The locking functions to decrease leakage of semen after ejaculation.

Who Knew? Pigs have a rather oddly shaped penis that twists into a corkscrew during erection, a shape that bears an uncanny resemblance to the coiled tail of the pig. Thrusting creates a motion that can best be described as semi-rotary. Not surprising, the female pig has a corkscrew-shaped cervix.

The penis can be thought of as an extension of the principal artery of our body, the aorta. In fact, one can think of the penis as a “dangling” aorta. The aorta gives rise to the common iliac artery, which gives rise to the internal iliac artery, which gives rise to the internal pudendal artery, which gives rise to the penile artery that divides into the dorsal artery (to the glans), the bulbourethral artery (to the corpus spongiosum) and the cavernous artery (which supplies the helicine arteries to the erectile tissues).

Bottom Line: The penis is essentially an extension of our blood vessels.

The corpora contain sinusoids(small sinuses that consist of spongy, vascular tissue) that have a very rich blood supply. In a sexually stimulating situation, the sinusoids of the corpora become engorged with blood, resulting in an erection.

Who Knew? Under the microscope, the tissues of the corpora appear virtually identical to the tissue of our nasal sinuses.

Vascular smooth muscle exists both in the penile arterial walls as well as the sinusoids. In the flaccid state, this smooth muscle is contracted, allowing only a minimal amount of arterial inflow, sufficient to meet the basic needs and nutritional demands of the penis. During this flaccid state, the sinusoids are closed while the venules (small veins that conduct blood out of the penis) remain open. In terms of oxygenation, the flaccid penis is filled with venous blood, while the erect penis is filled with arterial blood.

Bottom Line: The erectile tissue of the penis consists of sinuses, which under the circumstances of stimulation, become “congested” with blood.

Who Knew? The penis behaves as a vein when flaccid and an artery when erect.

Who Knew? Viagra, Levitra, Cialis and Stendra cause nasal stuffiness as a side effect since they act on the facial sinuses as much as they do on the sinuses of the corpora, causing congestion in both.

Who Knew? One of the treatments for priapism—an unwanted, persistent, painful erection—is an injection of neo-synephrine directly into the corpora. This is the very same medication that we squirt into our noses to relieve nasal congestion, aka nose drops.

Under the circumstance of erotic or tactile stimulation, the cavernosal nerverelays a chemical message to the cavernosal arteries to dilate (increase in diameter and pour in blood) and a message to the smooth muscle of the corpora to relax, allowing blood to fill the corpora. The cavernosal nerves release the neurotransmitter nitric oxide, the main chemical mediator of erections. The nitric oxide increases the release of another chemical known as cGMP (cyclic guanosine monophosphate)within the smooth muscle of the corpora. This causes relaxation of the smooth muscle of the small arteries and dilates the sinusoids within the erectile bodies. The sinusoids become “congested” with blood, causing engorgement and tumescence with an increase in penile length and girth. The small veins directly under the tunica albuginea (located between the tunica albuginea and the sinusoids) become compressed, reducing venous outflow. As the penis gets increasingly engorged, the tunica gets stretched to capacity, which occludes the small veins within the tunica itself, helping to maintain the erection.

Bottom Line: In an erotic situation, nerves to the penis release a chemical that increases blood flow to the penis, flooding blood into the sinusoids, filling the corpora and resulting in an erection. As the erection gets fuller, penile veins are compressed, limiting the exit of blood and enhancing the erection. The penis lengthens, thickens, and rises, resulting in quite the “proud soldier.

At this point, the blood pressure within the corpora cavernosa is about the same as arterial blood pressure, over 100 millimeters of mercury. Ultimately, with the contraction of the bulbocavernosus (BC) and ischiocavernosus (IC) muscles, the pressure inside the corpora cavernosa rises to way above systolic blood pressure (the numerator in our blood pressure reading), creating a rock-hard erection. The corpora cavernosa become rigid while the corpus spongiosum and glans become full and spongy plump. The blood pressure in the corpus spongisum and glans is only a fraction of that in the corpora cavernosum as a result of the tunical covering of the former being much thinner than that of the latter.

Bottom Line: PFM contractions, by further trapping blood in the penis, cause rock-hard erectile rigidity.

Who Knew? At the time of a fully rigid erection, the penile blood pressure is off the charts high. If our systemic blood pressure were this high, it would be considered an emergency situation—a hypertensive crisis—with the potential for a heart attack, stroke or rupturing of an aneurysm (weakness of the wall of an artery). Who knew that penile hypertension is what allows us to have bone-hard rigidity? The next time you have a rigid erection, tell your partner that you have penile hypertension and that you need “intervention.” See where that gets you!

The pudendal nerveprovides the nerve supply (sensation and contraction) to the ischiocavernosus (IC)and bulbocavernosus (BC) muscles. Contraction of the IC and BC muscles enhances penile rigidity and engorgement of the glans. The IC muscle contraction is primarily involved in generating a rock-hard erection while the BC muscle contraction maximizes engorgement of the corpus spongiosum and glans and is the motor of ejaculation, an event that occurs when the BC contracts rhythmically at the time of climax.

Bottom Line: The IC muscle generates a rock-hard erection while the BC muscle engorges the corpus spongiosum and glans and contracts rhythmically at the time of ejaculation.

The corpus spongiosum and glans essentially behave as an arterio-venous shunt (a connection between an artery and a vein) during an erection, until the point that the BC muscle compresses venous return sufficiently to cause full engorgement of the glans and corpus spongiosum. When fully engorged, the corpus spongiosum functions to “pressurize” the urethra, which will facilitate forceful ejaculation.

In summary, for an erection to occur, three events need to take place. There must be an increase in arterial blood flow to the corpora. Relaxation of vascular and corporal smooth muscle has to occur. Finally, venous outflow has to decrease in order to trap blood within the corpora. The seemingly simple process of getting an erection is actually an incredibly complex event requiring integrated functioning of the brain, nerves, blood vessels, and hormones. The thrust of the matter is that it is really nothing short of a stunning orchestration.

Bottom Line: For an erection to occur, penile blood flow has to increase, the smooth muscle in the walls of the penile blood vessels and sinuses must relax, and venous outflow needs to decrease, thus trapping blood in the penis.

After ejaculation, the enzyme PDE (phosphodiesterase)is released. This chemical can be considered the main chemical controller of flaccidity—this degrades cGMP, resulting in a return to the flaccid state by a reversal of the aforementioned chemical mechanisms. Viagra, Cialis, Levitra, and Stendra work by inhibiting PDE.

Bottom Line: After ejaculation, the penis becomes flaccid from a reversal of the chemical mechanisms that created the erection.

 

Andrew Siegel, MD www.AndrewSiegelMD.com

The aforementioned is largely excerpted from my new book: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook) and coming soon in paperback. www.MalePelvicFitness.com

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Man Kegels (Pelvic Floor Muscle Exercises for Men)-Part 2

March 15, 2014

Andrew Siegel MD, Blog# 145

photo

The photo above was taken by a pharmaceutical rep friend who discovered this phallic carving among the Roman ruins in Fez, Morocco.

The following is largely excerpted from my forthcoming book, Male Pelvic Fitness: Optimizing Sexual and Urinary Health, available in April 2014:

With respect to sexuality, medical publications—and more specifically the urological literature—rarely, if ever make mention of targeted exercise as a means of optimizing function or helping to treat a dysfunction. The preeminent urology textbook, Campbell’s Urology, a 4000 page, 4-volume tome, devotes precisely one paragraph to the use of pelvic floor muscle exercises in the management of male sexual dysfunction and makes no mention of its use in maximizing sexual function.

Despite numerous studies and research demonstrating the effectiveness of targeted pelvic exercises, they have been given short shrift. Part of the reason for this is simply that there has never been an easy-to-follow exercise program or well-designed means of facilitating pelvic floor muscle training in men. Instead, there is an emphasis on oral medications, urethral suppositories, penile injections, vacuum devices and penile implants. In the United States we have a pharmacology-centric medical culture—“a pill for every ill”—with aggressive prescription writing by physicians and a patient population that expects a quick fix.

It is shameful that traditionally there has been such little emphasis on lifestyle improvement—healthy diet, weight management, exercising, and avoidance of tobacco, excessive alcohol and stress—as a means of preventing and improving sexual dysfunction.

In addition to general lifestyle measures, specific exercises targeted at the pelvic floor can confer great benefits to pelvic health and fitness, an important element of overall health and fitness. The pelvic floor muscles (PFM) are critical to healthy  sexual function and achieving fitness in this domain is advantageous on many levels: to enhance sexual health; to maintain sexual health; to help prevent the occurrence of sexual dysfunction in the future; and to aid in the management of sexual dysfunction. PFM exercises should be considered first-line treatment of sexual dysfunction and a safe and natural self-improvement approach ideally suited to the male population, including the baby boomers, generation X, and generation Y.  PFM fitness can serve as an effective means to help keep the boomers “booming.”

I do not mean to downplay and disparage the role of medications and other options in managing sexual dysfunction. The availability of that magic blue pill in April 1998—Viagra—was a seminal moment in the world of male sexual dysfunction that enabled for the first time a simple and effective means of treating erectile dysfunction (ED).  On the polar opposite end of the treatment spectrum—but of no less importance—was the development and refinement of the penile implant, used in severe cases of ED unresponsive to less invasive options.

But why should we not initially try to capitalize on simpler, safer, and more natural solutions and consider, for example, using a targeted exercise program or medications in conjunction with a targeted exercise program?  Sexual function is all about blood flow to the penis and pelvis.  And what better way to enhance blood flow than to exercise?  We engage in exercise programs for virtually every other muscle group in the body.  Working out our PFM can result in a strong, robust and toned pelvic floor, capable of supporting and sustaining sexual function to the maximum.

Physical therapy is a well-accepted discipline that is commonly used for disabilities and rehabilitation after injury or surgery.  The goal of a physical therapy regimen is to promote mobility, functional restoration and quality of life. A targeted PFM exercise regimen can be considered the equivalent of genital and pelvic physical therapy with the goal of increasing the bulk, strength, power and function of the PFM.

The PFM can be thought of as a vital partner to our sexual organs, whose collaboration is an absolute necessity for optimal sexual functioning, little different than the relationship between the diaphragm muscle and the lungs. The role of the PFM in sexual function has been vastly undervalued and understated. The hard truth is that a well-conditioned pelvic floor that can be vigorously contracted and relaxed at will is often capable of improving sexual prowess and functioning as much as fitness training can enhance athletic performance and endurance.

Such targeted exercises confer advantages that go way beyond the sexual domain. These often-neglected muscles are vital to our genital-urinary health and wellness and serve an essential role in urinary function, bowel function and prostate health.  Additionally, they are important contributors to lumbar stability, spinal alignment and the prevention of back pain. Specifically, PFM exercises can be beneficial with respect to the following spectrum of issues: erectile dysfunction; orgasmic dysfunction; premature ejaculation; urinary incontinence; overactive bladder; post-void dribbling; pelvic pain due to levator muscle spasm; bowel urgency and incontinence; and in mitigating damage incurred from saddle sports including cycling, motorcycling and horseback riding.

The PFM, comprised of muscles that form a muscular shelf that spans the gap between our pelvic bones, form the base of our “core” muscles.  Our core muscles are the “barrel” of muscles in our midsection.  The top of our core is our diaphragm, the sides are our abdominal, flank, and back muscles, and the bottom of the barrel are our PFM.

The core muscles, including the PFM, are not the glitzy muscles of the body—not those muscles that are for show. Our core muscles are often ignored and do not get much respect, as opposed to the external glamour muscles of our body, including the pectorals, biceps, triceps, quadriceps, latissimus, etc.  In general, muscles that have such “mirror appeal” are not those that will help in terms of sexual and urinary function. Our core muscles are the hidden gems that work diligently behind the scenes—the muscles of major function and not so much form—muscles that have a role that goes way beyond movement, which is the cardinal task of a skeletal muscle.  On a functional basis, we would be much better off having a “chiseled” core as opposed to having “ripped” external muscles, as there is no benefit to having all “show” and no “go.”

The pelvic floor seems to be the lowest caste of the core muscles—the musculus non grata, if you will kindly accept my term. The PFM, however, do deserve serious respect because, although concealed from view, they are responsible for some very powerful and beneficial functions, particularly so when intensified by training.  Although the PFM are not muscles of glamour, they are our muscles of “amour.”

Who Knew? Having “ripped” external glamour muscles might help get your romance going, but having a chiseled core and conditioned PFM will help keep it going…and going…and going!

The female pelvic floor muscles, exercises for which were popularized by gynecologist Dr. Arnold Kegel, have long been recognized as an important structural and functional component of the female pelvis. But who has ever heard of the male pelvic floor?  The male pelvic floor has been largely unrecognized and relegated as having far less significance than the female pelvic floor.  Yet from a functional standpoint, these muscles are of vital importance, certainly as critical to male genital-urinary health as they are to female genital-urinary health.

The PFM, as with other muscles in the body, are subject to the forces of adaptation.  Unused as they are intended, they can suffer from “disuse atrophy.” Used appropriately as designed by nature, they can remain in a healthy structural and functional state. When targeted exercise is applied to them, particularly against the forces of resistance, their structure and function, as that of any other skeletal muscle, can be enhanced.

The key responsibility of most of our skeletal muscles is for joint movement and locomotion. The core muscles in general, and the PFM in particular, are exceptions to this rule.  Although the core muscles do play a role with respect to movement, of equal importance is their contribution to support, stability, and posture. Consider that the pelvic floor muscles, particularly the superficial PFM, have an essential function in the support, stability and “posture” of the penis.  They should be considered the hidden “jewels” of the pelvis.

Who Knew? If you want your penis to have “outstanding” posture and stability, you want to make sure that your PFM are kept fit and well-conditioned.

The PFM have three main functions that can be summarized by three S’s: support, sphincter, and sex. Support refers to their important role in securing our pelvic organs—the urinary, genital and intestinal tracts—in proper anatomical position. Sphincter function allows us to interrupt our urinary stream and pucker the anus and contributes in a major way to urinary and bowel control.  These vital responsibilities are generally taken for granted until something goes awry. With regard to sexual function, the PFM are active during erection and ejaculation.  They cause a surge of penile blood flow that helps maintain a rigid penile erection throughout sexual activity and at the time of orgasm, contract rhythmically, enabling ejaculation by propelling semen through the urethra.

The PFM can become atrophied, flabby and poorly functional with aging, weight gain, a sedentary lifestyle, saddle sports and other forms of injury and trauma, chronic straining, and surgery.  Sexual inactivity can lead to their loss of tone, texture, and function.  However, PFM integrity and optimum functioning can be maintained into our golden years with attention to a healthy lifestyle, an active sex life, and PFM training, particularly when such exercises are performed against progressive resistance.  The goal of such a regimen is the attainment of broader, thicker and firmer PFM and maintenance and/or restoration of function.

The PFM may physically be the bottom of the barrel of our core, but functionally they are furthermost from the bottom of the barrel.  For those who are already functioning well, an intensive PFM training program—as with any good fitness regimen—can impart better performance, increased strength (rigidity), improved endurance (ejaculatory control), and decreased recovery time (the amount of time it takes to achieve another erection).  Keeping the PFM supple and healthy can help prevent the typical decline in function that accompanies the aging process. On so many domains, diligently practiced PFM exercises will allow one to reap tangible rewards, as they are the very essence of functional fitness—training one’s body to handle real-life situations and overcome life’s daily obstacles.

Andrew Siegel, M.D.

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

www.MalePelvicFitness.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 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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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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Testosterone: Not Just For Men; Estrogen: Not Just For Women

October 5, 2013

Andrew Siegel MD Blog # 122

What’s going on with the unrelenting direct–to-consumer television advertising for medications?  On television and radio we are bombarded with ads for drugs for the “ABC” diseases—ED (erectile dysfunction), OAB (overactive bladder), low T (testosterone).  What’s all this hubbub about T (testosterone) anyway?  Why is T suddenly so special, so hot and trendy, the hormone de jour, the “new” Viagra?  Is this for real or mere media hype?

Medicine is truly in its “infancy” with respect to its understanding of the male and female sex hormones, testosterone (T) and estrogen (E), respectively. Not too long ago it was dogma that T was solely the male hormone and that E was solely the female hormone.  As is often the case in science, “dogma” turns to “dog crap” with time, research, and progressive understanding.

Dr. Joel Finkelstein, in the September 13, 2013 New England Journal of Medicine, disrupted the endocrine status quo and provided the scientific basis for the major importance of both T and E for male health and wellness (and there is little doubt that both E and T are also equally crucial for female health and wellness). His study clearly demonstrated that muscle size and strength are controlled by T; fat accumulation is primarily regulated by E; and sexual function is determined by both T and E.

Some basics about T:

In the life of the male embryo, T is first produced during the mid-first trimester, and this hormonal surge causes the male external genitalia (penis and scrotum) and internal genitalia (prostate, seminal vesicles, etc.) to develop. In the absence of T, the fetus becomes a female, making the female gender the “default” sex. Dihydrotestosterone (DHT) is the activated form of T required by the fetus to initiate the development of male physical characteristics. In the absence of DHT, male genitalia do not develop.  DHT is far more potent than T and is the hormone that also gives rise—much later in life—to male pattern baldness and the condition of benign prostate enlargement.

T is produced mostly in the testes, although the adrenal glands also manufacture a small amount. T has a critical role in male development and physical characteristics. It promotes tissue growth via protein synthesis, having “anabolic” effects including building of muscle mass, bone mass and strength, and “androgenic” (masculinizing) effects at the time of puberty.  With the T surge at puberty many changes occur: penis enlargement; development of an interest in sex; increased frequency of erections; pubic, axillary, 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; occurrence of fertility; and bone and cartilage changes including growth of jaw, brow, chin, nose and ears and transition from “cute” baby face to “angular” adult face.  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.

Thanks to the advertising of Big Pharma, patients now come to the office requesting—if not demanding—to know what their T levels are. Prescriptions for T have increased exponentially over the last five years, creating a $2 billion industry with numerous pharmaceutical companies competing for a piece of the lucrative T pie, as the cost of the product is minimal and the markup is prodigious.  Little did Butenandt and Hanisch—who earned the Nobel Prize in chemistry for their synthesis of testosterone from cholesterol way back in 1939—know of what their discovery would lead to 70 years later!

Who Knew? Humans manufacture T using cholesterol as a precursor, so don’t be under the delusion that all cholesterol is bad. However, don’t get carried away consuming cholesterol-laden foods reasoning that the Big Mac with cheese will raise your T.

T can bind to specialized receptors that are present in many cells in the body and exert numerous anabolic and androgenic effects; alternatively, T can be converted to 5-DHT  (the active form of T) or can be converted to estradiol—a form of E—by the chemical process of aromatization. More than 80% of E in men is derived from T as a source. When levels of T are low, there is a decline in E levels. E deficiency is important in terms of osteopenia (bone thinning) in both men and women.

Dr. Finkelstein’s study was really a more sophisticated and quantitative take on the original study by organic chemist Professor Fred Koch at the University of Chicago in 1927, this time using humans instead of animals, and quantitating the effect of the T replacement as opposed to a qualitative assessment. Professor Koch used capons—roosters castrated surgically (having their testes removed) at a young age.  He then injected them with a substance obtained from bull testicles—readily available from the Chicago stockyards—which essentially was T.   After injecting the capons with this extraction, the capons crowed like roosters, a feat that capons are incapable of.  When the study was repeated in castrated pigs and rats, the substance was found to re-masculinize them as well.  Unlike Professor Koch, who used surgically castrated animals, Dr. Finkelstein used humans who were temporarily “castrated” via a reversible medication.

In Dr. Finkelstein’s study, as reported in the NEJM, there were 2 groupings of 5 populations of men. Both groupings had their T production blocked chemically. One population was given no replacement T, another 1.25 grams T daily, another 2.5 grams T daily, another 5 grams T daily, and the last group 10 grams T daily. The average serum T and E levels of each population were the following: no testosterone replacement: 44/3.6; 1.25 grams: 191/7.9; 2.5 grams: 337/11.9; 5 grams: 470/18.2; 10 grams 805/33. The second grouping of 5 populations had their E blocked as well.  Testing was done to see the effects of T and E levels on lean mass, muscle size and strength, fat mass, and sexual function.

By looking at the aforementioned numbers, one can see a direct relationship between T dose and serum level of both T and E.  The higher the T dose, the greater is the serum T and E.  The study concluded that lean mass, muscle size and strength were T dose-dependent, meaning the higher the T, the more the lean mass, muscle size and strength.  Additionally, fat mass was seen to be E dose-dependent and sexual function was both T and E responsive.

Dr. Finkelstein concluded that E deficiency in men is a manifestation of severe T deficiency and is remediable by T replacement. Fat accumulation seems to occur with a mild T deficiency (T measurements in the 300-350 range); muscle mass and muscle strength are preserved until a more marked T deficiency (T <200) occurs.   E was shown to have a fundamentally important role in the regulation of body fat and sexual function and evidence from previous studies demonstrated a crucial role for E in bone metabolism. Therefore, low T is not just about low T, but is also about E deficiency, which is responsible for some of the key consequences of T deficiency. Measuring levels of E are helpful in assessing sexual dysfunction, bone loss, and fat accumulation in men with low T.

The amount of T made is regulated by the hypothalamus-pituitary-testicular axis, which acts like a thermostat to regulate the levels of T.  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. T levels can be low based upon testicular problems or hypothalamus/pituitary problems, although the problem most commonly is due to the aging testicle’s inability to manufacture sufficient levels of T.  T levels gradually decline—approximately a 1% decline each year after age 30—sometimes giving rise to symptoms.  These symptoms may include the following: fatigue; irritability; decreased cognitive abilities; depression; decreased libido; ED; ejaculatory dysfunction; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; and abnormal lipid profile. A simple way to think about the effect of low T is that it accelerates the aging process.

T is commonly prescribed for T deficiency when it becomes symptomatic. There are many means of testosterone replacement therapy (TRT).  Oral replacement is not used because of erratic absorption and liver toxicity. Injections are not the first-line means of TRT because of wide fluctuations in testosterone levels and injection site reactions. There are a number of testosterone gel formulations that are commonly used. There are also skin patches, pellets that are injected into the fatty tissue of the buttocks, and a formulation that is placed in the inner cheek or gum. Currently in the works is a long-acting injection.

Men on replacement T need to be followed carefully to ensure that the TRT is effective, adverse effects are minimal, and 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 obtained including a blood count and PSA (Prostate Specific Antigen).  Potential complications of TRT include acne and oily skin, increased hematocrit (thicker, richer blood), worsening of sleep apnea, hair loss, and suppression of fertility.

Bottom Line: T and E levels are of vital importance to men (as well as women), greatly impacting physical development, sexuality, mood, energy levels, etc. So while T advertisements may be annoying and confusing, it is wise nonetheless to assess and monitor T levels, particularly if one is experiencing any of the myriad of symptoms associated with low T.

Reference: “Gonadal Steroids and Body Composition, Strength, and Sexual Function in Men by Joel Finkelstein, M.D., et al:  ”The New England Journal of Medicine (September 12, 2013)

Andrew Siegel, M.D.

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;  book is in press and will be available in e-book and paperback formats in November 2013.

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