Sexual Health for Men

WebMD Live Events Transcript

Confused about all of the erectile dysfunction meds being pitched to improve your love life? Just want to know what you can do to be at your healthy, sexual best this Valentine's Day? Urologist Peter Burrows, MD, joined us on Feb. 10 to answer your questions about men's sexual health.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. Burrows. We see so many ads for medications to treat erectile dysfunction (ED). Is ED on the rise or is it simply a matter of new medications coming to market?

BURROWS:
I think it began with Pfizer when they introduced Viagra in 1998. They removed the stigma of erectile dysfunction or impotency. Before this, we never knew the incidence or the true amount of men who suffered from erectile dysfunction. So, with consumer-directed advertising and doctors' comfort levels about discussing erectile dysfunction, we learned how many men truly had this problem. Now there is no longer the stigma with discussing ED and there are three companies with effective medications; it seems that both physicians and patients are interested in learning and treating this condition.

"The choice of which medication to take depends on how the man and his partner typically engage in sexual activity."

MODERATOR:
Can you explain the differences and similarities in the three most common ED meds: Viagra, Levitra and Cialis?

BURROWS:
They all work by inhibiting an enzyme called phosphodiesterase type V (PDE-V). This enzyme is found specifically in erectile tissue.

The three medications differ slightly on their side effect profile, their rate of action and their duration of action:

• Viagra and Levitra are very similar in the rate of uptake, in that the majority of men will have the effect of the medication between 30 and 60 minutes and the medication is metabolized after 8 hours.
• Cialis is slightly slower in uptake, approximately 60 minutes, but has a duration lasting 36 hours.

The choice of which medication to take depends on how the man and his partner typically engage in sexual activity. Some men prefer having a medication that works on demand and is out of their bodies within 8 hours. Some men enjoy the spontaneity allowed by a medication with a long half-life and they do not need to time when the medication is taken relative to sexual activity.

MEMBER QUESTION:
I am a 60-year-old man who occasionally uses Viagra, but there are other times that I don't. Am I creating a dependence on the drug?

BURROWS:
No. The medication works on demand and does not create immunity. That is, you will not need more of the medication as time goes on, even if you take it on daily basis.

MEMBER QUESTION:
When taking any of the prescribed ED drugs over a long period of time, are there any lasting side effects?

BURROWS:
The side effects of all three medications last only as long as the medication is in the bloodstream. There does not appear to be any long-lasting side effects once it has been metabolized.

MODERATOR:
The warning to seek medical attention if erection lasts longer than 4 hours has been the subject of jokes, but it really isn't a laughing matter, is it?

BURROWS:
This condition is known as priapism, and it is no joking matter. However, prolonged erection or priapism from this class of medications is exceedingly rare. To my recollection, there have only been a handful of patients worldwide to have had this condition and the majority of these patients have had other conditions or medications that can promote priapism.

The reason priapism is serious is any erection lasting more than two hours can create permanent scarring of the erectile tissue, making future potency difficult or impossible. And as the drug companies suggest, if an erection should last more than four hours, emergency contact to an urologist or emergency room should be initiated for prompt treatment. When treatment is offered quickly, potency can be restored with minimal loss.

Treatment begins with taking vasoconstrictors, such as pseudoephedrine, found in the over-the- counter medication Sudafed, also application of ice to the penis to help the blood vessels constrict. If these maneuvers are unsuccessful, then a doctor will inject a very small amount of a vasoconstrictor into the penis, such as epinephrine. Rarely, if these maneuvers are ineffective, the physician will withdraw a small amount of blood from the penis to initiate detumescence.

"The reason priapism is serious is any erection lasting more than two hours can create permanent scarring of the erectile tissue, making future potency difficult or impossible."

MODERATOR:
Who is a good candidate for these medications? And who should avoid them?

BURROWS:
The list to avoid is easier than who is a good candidate. Men who should avoid these medications are:

• Men who are on nitrates, such as nitroglycerine, Indur or Nitropaste. The interaction of the PDV family with nitroglycerine can trigger a drop in blood pressure which can be life threatening.
• Men with severe coronary artery disease who cannot tolerate exercise should be counseled by a cardiologist if they can tolerate exercise stress.
• Men with a rare condition called Retinitis Pigmentosa should never take this class of medications.

This leaves the vast majority of men, who may have diabetes, hypertension or surgeries, who would be excellent candidates for this class of medications.

MEMBER QUESTION:
My question regards Uprima, an ED drug available in Europe. Is there any chance it will soon be approved here?

BURROWS:
Uprima, also known as apomorphine, was tested recently in this country and was felt to cause a high incidence of blood pressure drop. It doesn't appear to have a release date any time soon in this country due to this side effect. This medication works very differently than the PDV medications in that it stimulates central receptors, that is, the man's brain, to improve potency.

MEMBER QUESTION:
Are there alternatives to these drugs which are just as or almost as effective?

BURROWS:
The most important change a man can do to improve loss of sexual function is to quit smoking and to increase exercise. In addition, management of other medical problems, such as hypertension, diabetes, elevated cholesterol, can all improve a man's potency without requiring more medication. Supplements do not appear to help or hurt.

"Libido and erectile dysfunction are often confused. Some men have no trouble obtaining erection but have no desire to engage in sexual activity."

MEMBER QUESTION:
What is the best remedy for premature ejaculation?

BURROWS:
Premature ejaculation is currently where ED was ten years ago, and that is, it is not talked about commonly, but there are an enormous amount of men who suffer from this. There are no FDA-approved medications to treat this, but several physicians are trying medications off label in combination with Viagra, Levitra or Cialis with good results. Some of the drug companies are working on combination medicines that will hopefully have FDA approval shortly.

MEMBER QUESTION:
Are there any medications or treatments to increase libido?

BURROWS:
Libido and erectile dysfunction are often confused. Some men have no trouble obtaining erection but have no desire to engage in sexual activity. These men should have their blood levels tested for testosterone and if this is found to be low, have the option of receiving testosterone replacement therapy. The most common reasons for a man's testosterone to decrease are medications and age greater than 60. Supplements such as DEHA do not appear to improve libido significantly.

MEMBER QUESTION:
I have been married for 4 years and had a baby about 5 months ago. Since then, and while I was pregnant, my husband refuses to have intercourse or anything sexual for that matter. It's been 10 months and he will not talk about it. What he does say is that having the baby "messed with him", and he thinks it will get better. I have tried talking to him a million times in non-accusatory ways. Everything else in our relationship is great and he adores our baby. I don't know what else to do. I've tried everything. I wish I knew what he was thinking.

BURROWS:
Your husband may benefit from an underlying evaluation of his general health. The doctor would examine him, question him and draw hormone levels. Most likely these will return normal and the two of you would benefit from couples counseling. Possibly, however, seeing a physician rather than counselor would be a good step to initiate this process.

MEMBER QUESTION:
Hi Dr. Burrows, thanks for answering our questions. I have read so much research on saw palmetto saying it's a weak inhibitor, and it does not reduce the prostate by much compared to Proscar. I'm 24 years old; will it do any harm to me? Is it also good for hair loss? My doctors say it will not do any harm but it won't do any good, considering my age. Is that true?

BURROWS:
Saw palmetto was initially thought to act similarly to medications such as Proscar. However, after extensive testing it does not appear to inhibit the same enzyme that Proscar works on. Saw palmetto does seem to have a beneficial effect for men with DPH symptoms, and also may be beneficial in preventing prostate cancer. As for hair loss, there have been no studies or even anecdotal reports showing saw palmetto having any influence.

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MEMBER QUESTION:
I recently heard of an experimental drug developed as a tanning agent that also caused erections and weight loss. Do you have any information? (And, can we all buy stock in the company?)

BURROWS:
I think you're referring to a melanocyte-stimulating hormone (MSH) product that is in development by a company called Palotin. Preliminary data appears that it will increase the libido of both men and women. I am uncertain of its effect on diet and weight loss. This medication looks promising and is in phase two of trials, possibly one to two years away from being released.

"The most important change a man can do to improve loss of sexual function is to quit smoking and to increase exercise."

MEMBER QUESTION:
I play college hockey and I was wondering if taking shots to the groin frequently will affect me later on in life. I am 21 right now.

BURROWS:
If you have ever noticed significant bruising or swelling after one of these injuries, then a scrotal ultrasound should be done to see if there has been a rupture to a testicle. Injuries which cause testicular rupture can result in scarring which will decrease both sperm production and testosterone production.

MEMBER QUESTION:
My husband's testicles have grown very large. He refuses to go to the doctor. What should I do?

BURROWS:
Send him to the doctor emergently for an ultrasound. He likely, however, has a hydroseal, which is water around the testicle, but he should be evaluated for testicular cancer.

MEMBER QUESTION:
Why does cranberry juice help urination so much? What's special about it?

BURROWS:
Cranberry juice does not appear to have any beneficial effect on urinary tract infections or prostatitis. It is a good way to increase your fluid intake, but also has a lot of sugar, so be careful of calories.

MEMBER QUESTION:
I'm thinking about taking an antidepressant for premature ejaculation. I'm looking into the PC exercises, but I need something right now for my relationship. I'm 24 years old.

BURROWS:
Currently many physicians are using off label SSRI family of antidepressants treated in conjunction with Viagra, Levitra or Cialis, to be taken two to four hours prior to sexual activity. Common SSRIs include Zoloft. Lexapro, Paxil. They are not taken daily, such as for depression, but as a low dose along with the potency medication.

MEMBER QUESTION:
I have been having problems when I get aroused with maintaining an erection. I have also noticed a lot of semen leakage when I have this problem. If there is no leakage, then I can have an erection without any problems. What might be going on?

BURROWS:
This sounds like premature ejaculation and loss of erection with a climax, hence the semen leakage. You should discuss this with your physician to determine if you are a good candidate for medical therapies.

"Many men have a difficult time reaching sexual climax with vaginal intercourse when they are accustomed to masturbation or manual stimulation."

MEMBER QUESTION:
My boyfriend can't feel sex. We've been told it's due to rough masturbation. We didn't have sex and he didn't masturbate for a long time, but it didn't work. Can rough masturbation cause no sensitivity during sex?

BURROWS:
Many men have a difficult time reaching sexual climax with vaginal intercourse when they are accustomed to masturbation or manual stimulation. It appears to be less of a problem of lack of sensitivity, but these men need more stimulation at a greater frequency than through vaginal intercourse. It may be worthwhile to have a testosterone check as occasionally, when testosterone is low, there is less penile sensitivity.

MEMBER QUESTION:
My husband had a trauma injury to his urethra. It was torn in half. The urologist reattached and after months of surgery he is normal, except for a sexual problem with erection. Is it normal for problems to occur in this way? He is also a heavy alcohol user. Is this the problem? I read in articles that use of alcohol produces sexual problems.

BURROWS:
Urethral disruption or trauma, such as your husband's, can injure the nerves which create erection. Upward of 50 percent of men with urethral reconstruction after trauma will have lost potency. Medications such as Viagra, Levitra or Cialis may help. Other options such as vacuum erection device (VED) and injection therapy are also available. Certainly the alcohol intake is a factor, but I suspect the majority of the impotency is from the injury and the subsequent repair.

MEMBER QUESTION:
I am currently taking samples of Levitra and Cialis and they have helped with erection, but I am having problems with achieving an orgasm. There seems to be less sensitivity in the penis. I do have Type 2 Diabetes. Is there anything I can do?

BURROWS:
Lack of sensitivity may be a sign of low testosterone. This should be checked through a blood test. Diabetes can slowly injure the nerves that contribute to penile sensitivity. This problem however, is irreparable and I would suggest having the testosterone checked and replaced if it is indeed low. Give it more time.

MEMBER QUESTION:
Recently I had a birthmark removed from my groin area. It was a simple cut and stitch. Before removal, I would have erections easily, but afterwards, I haven't been able to. It has been about two weeks. I am young, I don't smoke, I have a healthy diet and I am not overweight. Could you please help?

BURROWS:
Give it more time.

"Regular ejaculation daily, weekly, or monthly, depending on the man's sexual habits, is helpful for prostate health and preserving sexual function."

MEMBER QUESTION:
Will ejaculation (intercourse or masturbation) daily be good or bad or really doesn't make any difference for prostate health? I assume regular ejaculation, whatever that is, is good for my prostate.

BURROWS:
Regular ejaculation daily, weekly, or monthly, depending on the man's sexual habits, is helpful for prostate health and preserving sexual function. There does not appear to be an upper limit or lower limit.

MEMBER QUESTION:
I masturbate a lot and now I have white bumps on both sides of the head of my penis. What can I do for this?

BURROWS:
These are likely pearly papules, a harmless benign condition, but you should see your doctor for confirmation that you do not need any treatment.

MEMBER QUESTION:
I have experience with Viagra. Is there any reason to switch?

BURROWS:
There's no reason to switch other than curiosity's sake. Viagra is very effective and safe.

MODERATOR:
We are almost out of time, Dr. Burrows. Before we wrap things up for today, do you have any final words for us?

BURROWS:
Male sexual medicine, treatment of potency, and management of men's hormones have very recently been getting attention. This is a new field but an old problem. A lot of new medications that can treat libido, premature ejaculation and erectile dysfunction are on the horizon. A man or couple should never be afraid or embarrassed to bring these topics up with their physician because very likely in your community there is someone specialized in this new area of medicine.

Supplements seem to be advertised everywhere you look. There does not appear to be a single supplement at this point that has greater than placebo effect. Spend your money wisely.

Erectile dysfunction may also be a symptom of underlying medical conditions, such as coronary artery disease, hypertension, diabetes or heart disease. These should all be addressed and discussed in the evaluation of erectile dysfunction.

"A lot of new medications that can treat libido, premature ejaculation and erectile dysfunction are on the horizon."

MODERATOR:
Our thanks to Peter Burrows, MD, for joining us today. And thanks to you, members, for your great questions. I'm sorry we couldn't get to all of them.

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