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Frequently Asked Questions

Prostate problems | Erectile Dysfunction | Enlarged Prostate | Sexually Transmitted Diseases | Testicular Cancer | Viagra

What can I do to prevent myself from developing prostate problems, such as enlargement and prostate cancer?

Your concern is well founded. Approximately a third of all men over 50 suffer from prostate enlargement, and prostate cancer is now the most common malignancy in America. Fortunately, there are important steps you can take to reduce your risk of developing prostate problems.

Perhaps most important, reduce the amount of dietary saturated fat (red meat, and full-fat dairy products) that you eat. It's no coincidence that American men eat more saturated fat and have higher rates of prostate cancer than men from any other nation or that foreign men who move here and adopt our diet soon have a higher incidence of prostate cancer. In fact, research at Sloan Kettering has shown that increased fat in the diet of rats not only increases the risk of prostate cancer, it also affects the rate at which the cancer grows.

Drink at least eight glasses of water per day. A thorough flushing helps keep your prostate, and your entire urinary tract, happy.

Be sure to get adequate zinc in your diet. Good sources include oysters and other seafood, whole grains, nuts and beans. Be careful with zinc supplements, though. More is not necessarily better.

Men who have borderline prostate problems usually find hot baths comforting, and avoiding caffeine, alcohol, and spicy foods is worthwhile. Evidence also continues to accumulate that saw palmetto is helpful to the prostate without causing significant side effects.

Discovering prostate cancer early, when it can be treated successfully, is second best to avoiding it in the first place. Be sure you have an annual digital rectal exam beginning at 40 and a yearly PSA blood test beginning at 50 (earlier if you have a family history of prostate cancer).

Finally, although I know this one will be tough to face, try to ejaculate regularly. Because the prostate provides some of the fluid in semen, ejaculation may help keep it well drained. You can consider that a prescription.

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How can a man relax and let things happen naturally?

It is a widely accepted fact that for a man to have sexual desire, to be able to be aroused to erection and orgasm, he must feel relaxed. Our emotions about a given situation are determined by what we think about that situation. This is called the ABC's of thinking and feeling:

For example, if the situation

As a man moves from pleasure and relaxation to performance and anxiety, the chances of problems increase. In other words, the concerns or fears of being able to perform are sufficient to produce anxiety and result in a lack of ability to attain or maintain an erection.

All men have a psychological reaction to an erection problem even if its cause is primarily physical.

What do women think when a man can't get hard?

When a man has an erectile problem, the couple has a sexual problem.

The women in the relationships frequently have questions, doubts, resentments, insecurities, and a need for information, understanding, and reassurance. Too often the man alone is seen as the patient and his partner is - at best - barely acknowledged, and - at worst- merely tolerated or even discouraged.

It is not enough if the partner's participation is limited only to hearing the patient's interpretations of the doctor's replies. Filtering information and questions through the patient to the woman can lead to misunderstanding and unhappiness. The woman's own concerns and questions must be addressed. Unlike many areas of medicine where only the patient is treated, with erection problems both members of the couple need to be considered.

Sometimes a woman, raised on the myths of men as highly sexual and always ready, sees her partner's erection as an emotional lie detector. A woman may view an erection as proof that a man loves or desires her. Therefore, she believes the absence of an erection means he doesn't care, or doesn't find her attractive.

A potency problem can spiral into a major communication breakdown in a short period of time. A typical scenario goes like this: a man experiences erection difficulties, feeling ashamed, embarrassed, and "less of a man," he withdraws from his partner. With the lack of ability to perform, it's not uncommon for men to have a marked drop in their desire or libido. After all, why put yourself in a position where you may not be able to perform? Over time, he may go so far as to refuse to kiss her, hug her, even to hold hands with her, saying, as did one man, " I didn't want to start anything I couldn't finish." He may start arguments to avoid sexual encounters. Because he doesn't understand that he has a health problem, not a character defect, he may refuse to discuss the issue with anyone including his partner, his doctor, a friend. Meanwhile, the partner is feeling rejected, neglected , and full of self-doubt. She may question her own attractiveness. She may wonder if her husband still cares for her. She may even think he is having an affair. She may withdraw. She is often afraid to bring up the subject that is so obviously painful for her husband. The result: each partner is isolated and miserable. Unfortunately, relationships end over this situation.

A number of women whose partners have potency difficulties feel inadequate. It's not uncommon for a woman to blame herself. A woman may be fairly open about her self-blame or she may keep her feelings quite hidden. A woman may also feel hurt and angry because her partner has withdrawn from her physically and emotionally. The relief felt by an insecure partner who understands she is not to blame can be enormous and can enable her to more fully participate and support her partner's diagnosis and treatment.

What causes an erection?

During an erection blood fills two chambers in the penis and is trapped there. The erection begins when the arteries open up as the smooth muscles of the vessel walls relax.

The veins which drain the blood then close down and prevent blood from leaking out. A man must have an adequate blood pressure to carry blood into the penis, and can have no leaks in the veins of his penis that will allow the blood to escape.

The nerves are the control mechanism which coordinate the increase in pressure in the penis as well as the closing down of the veins. A man needs sufficient levels of testosterone in order to have the desire, feel aroused, and to get an erection.

Any physical or emotional factor that affects a man's arteries, veins, nerves, or hormones can impact his erections. A man must allow himself to relax in order for the blood vessels of the penis to also relax so that he can get and maintain an erection.

A discussion of the problem followed by a physical examination is the first step toward diagnosing the cause of the problem.

How does stress relate to impotence?

Stress is defined as any mental or physical demand that is placed on a person. Stress comes from "good" things as well as events labeled as "bad." Adrenaline is an erection buster. Adrenaline is fine when we're cheering for our favorite team or in the middle of a heated argument... certainly not when we'd want to get an erection.

A person's reaction to stressful events is physiological. Stress can cause a man's heart rate to increase, and it can elevate blood pressure, increase muscle tension, and speed breathing. This phenomenon is called the "fight or flight" response.

What some people don't know is that stress can pile on and cause a cumulative effect. Constant arousal due to stress, can affect sleep, energy level, and concentration, as well as sexual desire and functioning.

Most patients and their partners are not surprised that stress can cause an ulcer or a rise in blood pressure. They are often surprised, however, that these factors can have an effect on erections. A man's normal response to stress, such as being afraid or angry, is for the nervous system to move blood away from "nonessential" activities and into muscles so that he can either fight or get away from the situation.

Ironically, fear of not being able to achieve an erection can actually cause an impotence problem. That's because if a man thinks that he is not going to get a erection, his body may respond to this belief by shunting blood away from his penis, thus making his erection go away.

Are there any medical conditions that may affect sexual intimacy?

There are a number of medical conditions that are associated with impotence. Probably the most common is the use of certain medications that have side effects that can affect a man's potency. Examples are drugs used to treat high blood pressure, sedatives, tranquilizers, and pain pills. Fortunately, the side effect of impotence is reversible when the dosage is altered, or a different medication is prescribed by the physician.

Medical illnesses that are often associated with impotence are diabetes, heart conditions and kidney and liver diseases. There are various surgical procedures that are often associated with impotence. The most common are cancer surgery of the colon, rectum, bladder, and prostate gland.

Most problems of intimacy in the elderly can successfully be treated. If a woman is suffering from the problem of estrogen deficiency, then she should consult with her gynecologist who might prescribe some form of estrogen replacement therapy. If a man suffers from impotence, he should contact a urologist who has sophisticated diagnostic techniques to identify the cause of the problem and recommend appropriate treatment.

I know there's an injectable medication that produces erections, but I can't face the needle. Is there an alternative?

Although many men are quite pleased with injections, you're not alone in your dislike of needles. In the long run, self-injection is well accepted by only about half of my patients. A number of devices have been developed to hide the needle—including a pen-like apparatus about the size of a cucumber that extends the needle with a push of a button—but the needle-prick sensation is still there. Fortunately, a couple of new approaches to inducing erections have arrived recently or soon will.

Another form of delivery of the medication used for injections (Prostaglandin) is available through a small little rice-sized pellet that is inserted into the opening of the penis (MUSE). With this approach, the dose is slipped into the urethra using small plunger-like device. There it is absorbed through the urethra and into the penis.

While all my experience is not as successful as injections, the erection can last up to an hour and side effects are minimal, generally at the most a mild burning sensation for 10 or 15 minutes after insertion.

Three oral drugs are available (Viagra, Cialis, Levitra). These drugs work by prolonging the relaxation event of an erection. While all three drugs have a similar mechanism of action, there are some differences.

Viagra, the first drug out, must be taken on an empty stomach and its effects last for approximately four to six hours. Viagra and Levitra must be taken on an empty stomach, and the effects last for four to six hours. Cialis can be taken at any time and its effect can last for 24-36 hours. Side effects with the medication include light headedness, facial flushing, nasal congestion, and indigestion. Additionally, with Cialis, there is an incidence of back pain. Cialis is also available in a low dose tablet that is taken daily. This allows sexual intercourse at any time that the moment is right.

A little farther out on the horizon, an oral medication absorbed under the tongue is now undergoing early trials to determine an effective dose with minimal side effects. It may be a number of years before it becomes widely available, but you should ask your doctor to keep you up to date on progress.

You might also consider trying a vacuum device, which produces an erection through suction developed by a pump. Most men can achieve an erection using one, although many also tire of bothering with the apparatus every time they want to have sex. It works, but it's not for the singles set.

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Am I at risk for an enlarged prostate?

Prostatic enlargement is very common, and 50% of men over the age of 50 will experience enlargement in their lifetime. If you are experiencing some or all of these symptoms, it is important to consult a urologist. There are a number of tests that can be performed to evaluate the enlarged prostate as well as the effect on the kidney and bladder.

These tests can usually be performed in the office or outpatient setting. It is important to stress that all men over the age of 40 should have a rectal examination once a year to screen for prostate cancer.

The blood test called PSA is recommended for all men over the age of 50 with at least a life expectancy of 10 years, and all men over the age of 40 who are at high risk, including African-American men and those who have a family history of prostate cancer. The PSA can be elevated with enlargement, infection, or cancer.

Quiz

Here are some good questions to ask yourself, or if you are a woman checking this out for your partner, quiz him with these questions. Rate each question with the following points: Not at all=0, Less than 1 time in 5=1, Less than half the time=2, about half the time=3, more than half the time=4, almost always=5.

• Over the past month, how often have you had a sensation of not emptying out your bladder completely after you finished urinating?
• Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
• Over the past month, how often have you found you stopped and started again several times when you urinated?
• Over the past month, how often have you found it difficult to postpone urination?
• Over the past month, how often have you had a weak urinary stream?
• Over the past month, how often have you had to push or strain to begin urination?
• Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

If the score is under 8, prostate disease is mild and no real treatment is needed; a score of 8 to 17 indicates moderate disease and treatment can be done; a score over 18 is severe disease and treatment is most frequently surgery.

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There's a lot of hype about how risky it is to have unprotected sex. What are the real odds of catching a disease?

The real answer to your question is that it depends on which disease is being transmitted and who it's being transmitted to. The odds are as high as 50 percent in some cases. For example, if a woman has unprotected sex with a man who has gonorrhea, she has a 50 percent risk of becoming infected. In the opposite case, the risk is 30 percent. In fact, in nearly all cases, women are more likely to become infected by carrying males than men are to be infected by carrying females. The risk for younger women and, perhaps, for women who use birth control pills, may be even higher. To worsen the situation, some diseases, such as chlamydia, may not produce symptoms in a man, even though he can pass the disease to his partner.

The statistics look like this:

Risk of Infection (%) from One Unprotected Encounter

How do I prevent sexually transmitted diseases?

1. Limit your number of sexual partners.
2. Avoid sex with people you don't know well or people who have multiple partners.
3. Always use condom and spermacide, regardless of the need for contraception.
4. Avoid sex with people who are being treated for a sexual disease.
5. Avoid sexual contact with anyone who has visible lesions on the genitalia.
6. If you are infected with an STD, refrain from sexual activity until treatment has completed.

Is there anything new in treatments for that frustrating sexually transmitted disease, herpes?

Unfortunately, herpes' main calling card—that it's controllable, not treatable—hasn't changed. Once you get it, the painful bumps and flu-like symptoms may recur four to eight times per year for years. (Bear in mind that herpes can be transmitted even when a person has no symptoms.) For most people, the frequency and severity of outbreaks decline over the years, but especially in the early years, medication may be helpful.

Acyclovir (brand name Zovirax) has been around for several years. For people with frequent and severe recurrences, it can be taken regularly, which may reduce the likelihood of a recurrence. More often, it is taken at the onset of symptoms, which reduces their severity.

The disadvantage of acyclovir is that it may need to be taken 5 times per day for 5 to 10 days to reduce symptoms and 1 to 4 times per day to suppress recurrences. The price tag can amount to about $5 per day.

Two newer medications on the market include famciclovir (Famvir) and valacyclovir (Valtrex). Both are effective in combating the symptoms of recurrence. Additionally, recent studies have come out showing that one can reduce the outbreak and even transmission without an outbreak by daily dosing in a prophylactic, or preventative, fashion.

At least four other antiviral therapies are in clinical trials now. You can find out more about them on the Internet at Center Watch - Clinical Trials Listing Service. For the foreseeable future, though, the best herpes therapy is to avoid it in the first place.

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How can I prevent testicular cancer?

All men should perform monthly self-testicular examinations just as women do monthly self-breast examinations. The optimal time to perform the examination is while taking a warm shower. Both hands should be used to examine each testicle with the thumbs in front and the first two fingers behind the testicle. The testicle should be rolled between the fingers and thumb, feeling for any lumps or bumps.

The testicle normally feels like a hard-boiled egg without the shell. If lumps or bumps are discovered, a physician, preferably a urologist, should be consulted at once. The best chance of prevention is early detection and treatment.

I have persistent discomfort in my testes during the day, particularly after sitting. Should I be concerned about cancer?

You're wise to be concerned about testicular cancer; it's all too common in young men and returns as a risk after your 40s. I suggest that you see a doctor to rule out that possibility, but as long as you've been doing monthly self-exams, and no lumps or hard spots have developed, that probably isn't your problem.

A variety of difficulties can lead to pain in one or both testes. When you're examined by your doctor for cancer, he can also check for hernia, which can cause the symptoms you describe.

If you feel pain mainly when you ejaculate, one of two problems is likely. Infection is a possibility, either in the testes or the epididymis (the mass of tubes that extend from the back of the testes). Mumps, of course, can infect the testes and occasionally leads to infertility. And sexually transmitted diseases such as chlamydia can infect the epididymis.

Still, infections just aren't that common, even though many men who complain of testicular pain are offered a simple course of antibiotics as treatment. If the pain is in both testes, and antibiotics don't seem to be helping, resist trying another course of a different antibiotic. When both hurt, it's rarely infection or a hernia.

More likely, a general discomfort such as you describe is caused by muscle spasms. Most men don't appreciate how many muscles there are in the vicinity of the testes. The tip-off of a muscular problem is if the pain or symptoms disappear with a hot bath. Besides the regular baths, medication to relax the muscles will probably be helpful, and wearing a jock strap will offer support. Knowing that you don't have cancer will also do a world of good for your ability to relax.

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