Thursday, October 23, 2008

Understanding Prostate Changes: Evaluating Prostate Health

Digital Rectal Examination (DRE)

The standard technique for evaluating the health of the prostate is by a physical examination called a digital rectal exam (DRE). Typically, a patient is asked to bend forward over a table while the doctor inserts a gloved and lubricated finger (called a digit in the medical community) into the patient's rectum. This allows the physician to feel the back portion of the prostate gland. In addition to gauging the gland's size, the doctor is able to evaluate its firmness and texture. The doctor looks for answers to some key questions: Has its usual rubbery feel changed? Are there any hard areas or lumps, which could signal a cancer? Has a growth spread beyond the prostate?

Prostate-Specific Antigen (PSA)

This is a substance produced by cells of the prostate gland. PSA circulates in the blood and can be deducted and measured with a relatively simple blood test. When the gland enlarges, PSA levels rise. PSA levels can also rise if cancer develops.

Generally, doctors consider readings below four nanograms per milliliter (ng/ml) to be normal, scores between four and 10 to be slightly elevated, scores between 10 and 20 to be moderately elevated and anything above that to be highly elevated. Most men with Benign Prostatic Hyperplasia (BPH) have levels of 10 ng/ml or below.

But many factors can influence PSA levels. Some prostate glands naturally produce more PSA than others. PSA scores also tend to increase with age. Another influence on PSA levels is race: PSA levels tend to be higher in African Americans, and lower among Japanese, than in white Americans.

A variety of conditions can raise PSA levels temporarily. These include prostatitis, prostate biopsy and transurethral prostate surgery.

Transrectal Ultrasound (TRUS)

This procedure uses a small probe that is inserted into the rectum. The probe emits and picks up high frequency sound waves. The sound waves bounce off the prostate, producing a pattern that is converted into a video image. Areas of cancer produce a different pattern than healthy tissue. The value of a TRUS is strongly influenced by the quality of the equipment and the skill of the person operating it.

While ultrasound does not provide enough specific information to make it a good screening toll by itself, doctors find it useful as a follow up to suspicious DRE or PSA. TRUS is also used to guide biopsies in sampling abnormal areas of the prostate, to estimate the volume of the prostate for calculating PSA density and to situate radiotherapy implants.

Self Test for BPH

To help patients and their physicians assess the severity of BPH symptoms, the American Urological Association has developed a seven questions index:

Over the past month how often have you:

1.) Had a sensation of not emptying your bladder completely after urinating?
2.) Had to urinate again less than two hours after urinating?
3.) Found you stopped and started again several times during urination?
4.) Found it difficult to postpone urination?
5.) Had a weak urinary system?
6.) Had to push or strain to begin urination?
7.) Had to get up several times to urinate from the time you went to bed at night until the time you got up in the morning?

How to score:

For the first six questions, give yourself a score of 1 for having problems less than one time in five, a score of 2 for having problems less than half the time, a score of 3 for having problems about half the time, a score of 4 for having problems more than half of the time, and a score of 5 for having problems almost all the time.

For the seventh question, give yourself 1 for each time you got up in the night. (If you had to get up five times or more, use 5 for scoring.)

Symptoms are classified as mild if your score totals 1 to 7, moderate from 8 to 19 and severe from 20 to 35.

Beer in Moderation May be as Heart-healthy as Wine

Drinking moderate amounts of wine, especially red, may lower the risk of heart disease, studies have shown. But researchers have not determined whether it's the alcohol or something else in wine that protects the heart.

So Dr. Martin Bobak of the University College London in England and colleagues compared the drinking habits of 735 healthy men with 206 men who had recently suffered a heart attack, in a population-based case-control study. They were between 25- and 64-years-old, lived in the Czech Republic, and drank on average 148 grams of alcohol per week. Beer was their beverage of choice, as opposed to wine or spirits, almost exclusively.

The researchers grouped the men according to their average weekly intake of beer: non-drinkers and those who drank less than about 18 grams of alcohol; men who drank between 18 to 144 grams; those who drank 145 to 324 grams; and men who consumed over 325 grams.

The men least likely to have a heart attack drank daily or almost daily, consuming four to nine liters of beer per week, which is 145 to 324 grams of alcohol (or about 15 beers a week at 12 ounces each), the researchers write in a letter in the May 20 British Medical Journal. "This was true even when men with a history of heart disease, stroke, diabetes, or cancer were excluded from the analysis," the researchers report.

As other studies have shown, heavy drinkers didn't benefit from alcohol. Men who drank twice a day had the same risk of having a heart attack as non-drinkers, the researchers report.

"These results support the view that the protective effect of alcohol intake is due to ethanol rather than to specific substances present in different types of beverages," the team concludes. For example, wine contains molecules called flavanoids that are thought to be cardioprotective.

Could people who drink alcohol have something in common that protects them against heart disease, other than their consumption of ethanol? "It is unlikely," Dr. Bobak told HeartInfo/Mediconsult. For one, many studies have ruled out other factors, such as diet. Secondly, "there is good experimental evidence that alcohol influences blood lipids and
blood clotting, both of which influence heart disease," he said. Alcohol may raise levels of HDL ("good") cholesterol.

Bad news for non-drinkers: the chemical characteristics of ethanol can't be added to pills, he said.

Commenting on the study, Dr. Andrew P. Levy, Medical Advisor for HeartInfo, says " It is true that alcohol in moderation appears to protect against heart disease. This may be due to the effect on blood lipids. But alcohol also raises blood pressure significantly, which increases the risk of stroke, heart attack and kidney disease. People should not begin drinking in order to decrease their risk of heart disease."

Frequently Asked Questions Concerning Viagra

This list of frequently asked questions and answers on Viagra has been developed by CDER's Drug Information Branch in response to the numerous telephone calls we have received. If you have other questions concerning Viagra or any other human drug products, please feel free to call Drug Information Branch (301) 827-4573.

1. What is Viagra for?

Viagra is approved for the treatment of men who have difficulty having and maintaining an erection (impotence).

2. When will Viagra be available to pharmacies?

It is our understanding that Viagra will be available to pharmacies in approximately one month. FDA has no control over when products are available in pharmacies after FDA approval for marketing. The decision of availability is completely up to the company marketing the product. For further information contact your pharmacist or Pfizer, Inc. directly.

3. How much will Viagra cost?

The FDA has no input into or legal control over the pricing of any drug product. At the present time, FDA is unaware of the price that Viagra will have when it is available in US pharmacies.

4. Will insurance cover the cost of Viagra?

The FDA has no input into or legal control over whether an insurance company does or does not cover the cost of drugs. Please call you insurance company if you have questions about whether your particular insurance provider will cover the cost of this product for you.

5. How does Viagra work?

An erection is the result of an increase in blood flow into certain internal areas of the penis. Viagra works by enhancing the effects of one of the chemicals the body normally releases into the penis during sexual arousal. This allows an increase of blood flow into the penis.

6. How do I take Viagra?

Viagra is taken orally as a once daily dose, one hour before sexual activity. For more detailed information consult with your health care provider.

7. How will Viagra be supplied?

Viagra will be available as oral tablets in 25mg, 50mg and 100mg strengths.

8. Will Viagra be prescription or OTC?

Viagra will be available by prescription only.

9. Are there any side effects with Viagra?

As with any drug products, there are side effects of the product in some people. The most commonly reported side effects in patients treated with Viagra during the testing of the product were: headache, flushing, stomach ache, and mild and temporary visual changes (color perception changes, light perception changes, and blurred vision).

10. Can Viagra be used with other treatment for impotence?

The safety and effectiveness of Viagra when used with other treatment for impotence has not been studied. The use of such treatments in combination with Viagra is not recommended at present.

11. What if I am taking other drugs?

Always discuss with your health care practitioner ALL of the medications you are taking (prescription and over-the-counter). In that way, you can receive the best advice for your own situation. At present, Viagra is not recommended for people taking nitroglycerin because the combination may lower blood pressure.

Is impotence your problem? Chances are it can be cured

Although it occurs most often among older men, impotence-the inability to achieve or sustain an erection-is not an inevitable consequence of aging. Instead, the condition often reflects a physical problem. With proper care most cases can be cured or, at least, greatly improved.

Unfortunately, only 10 percent of the 30 million American men affected seek help. What's more, even men who do seek treatment typically wait an average of six to nine months. That's unfortunate because the sooner the problem is diagnosed and treated, the more likely it is that treatment will be successful.

And doctors have found that sexually active men who suddenly have trouble sustaining an erection need to be examined immediately, because the condition may signal that a heart attack or stroke is imminent.

One reason for the reluctance to come forward is embarrassment. Many men are afraid that erectile difficulties are due to psychological problems. In about 80 percent of cases, the causes are mainly in the body, not the mind.

The most common physical cause is damage to blood vessels which impairs blood flow to the penis (usually related to hardening of the arteries, high blood pressure, or diabetes). A reaction to some prescription medications can also cause erectile problems.

Other risk factors include smoking; excessive alcohol or cocaine use; a nerve or hormonal disorder; and nerve damage due to prostate, bladder or colon surgery. Emotional factors such as stress or guilt sometimes come into play, but usually in younger men.

Impotence Relief

The following treatments for impotence are currently available:

  • Caverject. Injected into the penis shortly before intercourse, this produces an erection within 5 to 20 minutes without interfering with sensation or ejaculation. The active ingredient is alprostadil, a synthetic hormone that works by relaxing smooth muscle tissue in the penis to improve blood flow.

  • MUSE (Medicated Urethral System for Erection). This also uses alprostadil. Instead of an injection, the drug is administered with a tiny plunger that drops a pellet of medication into the opening at the tip of the penis. Caution: Alprostadil should not be used by men who have sickle cell anemia; who have had bone marrow tumors, leukemia, prostate or breast cancer; or who have an abnormally formed penis or penile implants. Caverject is not recommended for use more than three times a week; do not use MUSE more than twice in 24 hours. MUSE should not be used with a partner who is pregnant except with a condom.

  • Testosterone replacement therapy. This is used to treat impotence problems related to a deficiency of the male hormone testosterone and is given by intramuscular injection or via adhesive patches that deliver the drug through the skin. The Androderm Testosterone Transdermal System, previously available in a 2.5 mg formulation, is now also available in a 5 mg. version, allowing users to apply a patch only once a day instead of twice.

  • For some men whose impotence stems from impaired circulation, pelvic-muscle exercises called Kegels can help.

  • The Rejoyn support sleeve, sold over-the-counter in pharmacies, fits over the penis and allows men who don't have natural erections to have intercourse.

  • Hand-powered pumps, like the ErecAid system, form a vacuum around the penis. As air is sucked from the tube, blood flows into the penis, creating an erection.

  • Inflatable or noninflatable penile implants.

  • Vascular surgery, to boost the blood supply to the penis, is usually effective only in younger men who can obtain an erection but not sustain one.

  • Reconstructive surgery may be used in the case of Peyronie's disease, where scar tissue forms on the penis. This causes pain and erectile difficulties and bends the penis to one side.

Impotence & Aging

About one in three men over 60 has erectile difficulties due to health problems that are more common among older men. If you're in this group, here's some helpful information from the National Institute on Aging:

Regular sexual activity helps maintain sexual ability, by bringing oxygen-rich blood to the penis. This keeps penile blood vessels and nerves healthy.

Over time, most men (and women) notice a slowing of sexual response. Men may find it takes longer to get an erection, that the erection may not be as firm or as large as in earlier years, or that ejaculation may occur more quickly. Some may find they need more manual stimulation. Using different positions, new techniques, or medical devices can help.

Most men can start having sex again 12 to 16 weeks after a heart attack. But many men lose potency because they fear that sex will cause another attack. The risk of this happening is very low. Follow a doctor's advice.

Q & A: Impotence, Causes, Treatment

Impotence is a consistent inability to sustain an erection sufficient for sexual intercourse. Medical professionals often use the term "erectile dysfunction" to describe this disorder and to differentiate it from other problems that interfere with sexual intercourse, such as lack of sexual desire and problems with ejaculation and orgasm. This fact sheet focuses on impotence defined as erectile dysfunction.

Impotence can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining impotence and estimating its incidence difficult. Experts believe impotence affects between 10 and 15 million American men. In 1985, the National Ambulatory Medical Care Survey counted 525,000 doctor-office visits for erectile dysfunction.

Impotence usually has a physical cause, such as disease, injury, or drug side-effects. Any disorder that impairs blood flow in the penis has the potential to cause impotence. Incidence rises with age: about 5 percent of men at the age of 40 and between 15 and 25 percent of men at the age of 65 experience impotence. Yet, it is not an inevitable part of aging.

Impotence is treatable in all age groups, and awareness of this fact has been growing. More men have been seeking help and returning to near-normal sexual activity because of improved, successful treatments for impotence. Urologists, who specialize in problems of the urinary tract, have traditionally treated impotence--especially complications of impotence.

How Does an Erection Occur?

The penis contains two chambers, called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa.

What Causes Impotence?

Since an erection requires a sequence of events, impotence can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area of the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of impotence. Diseases--including diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and vascular disease--account for about 70 percent of cases of impotence. Between 35 and 50 percent of men with diabetes experience impotence.

Surgery (for example, prostate surgery) can injure nerves and arteries near the penis, causing impotence. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to impotence by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

Also, many common medicines produce impotence as a side effect. These include high blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug).

Experts believe that psychological factors cause 10 to 20 percent of cases of impotence. These factors include stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure. Such factors are broadly associated with more than 80 percent of cases of impotence, usually as secondary reactions to underlying physical causes.

Other possible causes of impotence are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as insufficient testosterone.

Erection begins with sensory and mental stimulation. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the open spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps to trap the blood in the corpora cavernosa, thereby sustaining erection. Erection is reversed when muscles in the penis contract, stopping the inflow of blood and opening outflow channels.

How Is Impotence Diagnosed?

Patient History

Medical and sexual histories help define the degree and nature of impotence. A medical history can disclose diseases that lead to impotence. A simple recounting of sexual activity might distinguish between problems with erection, ejaculation, orgasm, or sexual desire.

A history of using certain prescription drugs or illegal drugs can suggest a chemical cause. Drug effects account for 25 percent of cases of impotence. Cutting back on or substituting certain medications often can alleviate the problem.

Physical Examination

A physical examination can give clues for systemic problems. For example, if the penis does not respond as expected to certain touching, a problem in the nervous system may be a cause. Abnormal secondary sex characteristics, such as hair pattern, can point to hormonal problems, which would mean the endocrine system is involved. A circulatory problem might be indicated by, for example, an aneurysm in the abdomen. And unusual characteristics of the penis itself could suggest the root of the impotence--for example, bending of the penis during erection could be the result of Peyronie's disease.

Laboratory Tests

Several laboratory tests can help diagnose impotence. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. For cases of low sexual desire, measurement of testosterone in the blood can yield information about problems with the endocrine system.

Other Tests

Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of impotence. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then the cause of impotence is likely to be physical rather than psychological. Tests of nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be applied for best results.

Psychosocial Examination

A psychosocial examination, using an interview and questionnaire, reveals psychological factors. The man's sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse.

How Is Impotence Treated?

Most physicians suggest that treatments for impotence proceed along a path moving from least invasive to most invasive. This means cutting back on any harmful drugs is considered first. Psychotherapy and behavior modifications are considered next, followed by vacuum devices, oral drugs, locally injected drugs, and surgically implanted devices (and, in rare cases, surgery involving veins or arteries).


Experts often treat psychologically based impotence using techniques that decrease anxiety associated with intercourse. The patient's partner can help apply the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when physical impotence is being treated.

Drug Therapy

Drugs for treating impotence can be taken orally or injected directly into the penis. Oral testosterone can reduce impotence in some men with low levels of natural testosterone. Patients also have claimed effectiveness of other oral drugs, including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone--but no scientific studies have proved the effectiveness of these drugs in relieving impotence. Some observed improvements following their use may be examples of the placebo effect, that is, a change that results simply from the patient's believing that an improvement will occur.

Many men gain potency by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and prostaglandin E1 widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, sometimes can enhance erection when rubbed on the surface of the penis.

Research on drugs for treating impotence is expanding rapidly. Patients should ask their doctors about the latest advances.

Vacuum Devices

Mechanical vacuum devices cause erection by creating a partial vacuum around the penis, which draws blood into the penis, engorging it and expanding it. The devices have three components: a plastic cylinder, in which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis, to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body (see figure 2).

One variation of the vacuum device involves a semirigid rubber sheath that is placed on the penis and remains there after attaining erection and during intercourse.


Surgery usually has one of three goals:

1. to implant a device that can cause the penis to become erect;

2. to reconstruct arteries to increase flow of blood to the penis;

3. to block off veins that allow blood to leak from the penile tissues.

Implanted devices, known as prostheses, can restore erection in many men with impotence. Possible problems with implants include mechanical breakdown and infection. Mechanical problems have diminished in recent years because of technological advances.

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa, the twin chambers running the length of the penis. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid (see figure 3). Tubes connect the cylinders to a fluid reservoir and pump, which also are surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis somewhat. They also leave the penis in a more natural state when not inflated.

Surgery to repair arteries can reduce impotence caused by obstructions that block the flow of blood to the penis. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the crotch area or fracture of the pelvis. The procedure is less successful in older men with widespread blockage.

Surgery to veins that allow blood to leave the penis usually involves an opposite procedure--intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes rigidity of the penis during erection. However, experts have raised questions about this procedure's long-term effectiveness.

Points to Remember

  • Impotence is a consistent inability to sustain an erection sufficient for sexual intercourse.
  • Impotence affects 10 to 15 million American men.
  • Impotence usually has a physical cause.
  • Impotence is treatable in all age groups.
  • Treatments include psychotherapy, drug therapy, vacuum devices, and surgery.

What Causes Erectile Dysfunction?

Until recently, many people believed erectile dysfunction was purely psychological. Men were often told, "It's all in your head." But experts now agree that about 80 percent of men with erectile dysfunction have an underlying physical reason for the condition. In other words, a health problem or lifestyle practice makes it difficult to have an erection, no matter what a person's emotions are like. For the other 20 percent of men, emotions or 'psychological' reasons are thought to be the main cause of ED. This doesn't make the erectile dysfunction any less real, and psychological causes can still be treated. In some cases, both psychological and physical reasons can cause the condition.

Physical causes: Erectile dysfunction that slowly becomes more noticeable over time usually has a physical cause.

Physical causes can include:

  • blockage in the arteries going to the penis
  • a disease that affects tissue in the penis
  • injury or surgery in the pelvic area (between the hipbones)
  • a chronic disease, such as kidney or liver failure
  • health conditions that affect the nervous system
  • diabetes
  • unusual changes in hormones
  • side effects of some medications
  • alcoholism and/or drug abuse
  • heavy smoking

Psychological Causes: Men who notice a sudden change in their ability to have an erection often have a psychological reason for their condition. For example, just as thinking about sex may cause an erection, negative thoughts can stop one from happening. In fact, when erectile dysfunction is caused by psychological reasons only, a man may still have an erection during his sleep or when he wakes up in the morning.

Psychological causes of erectile dysfunction include:

  • stress or anxiety at work or at home
  • worry or fears about ability to "perform"
  • unresolved sexual orientation
  • problems in the marriage or relationship
  • depression

Whether erectile dysfunction is caused by physical factors, psychological factors, or both, the effect it has on a man and his partner can become a significant source of emotional and physical distress for both people.

Does Impotence and Depression Go Hand-in-Hand?

As if impotence isn't depressing enough for many men, new research suggests that men with symptoms of depression are almost twice as likely to experience impotence as men who aren't depressed.

In the first study to scientifically examine the relationship between depression and impotence, researchers from the New England Research Institutes in Boston, Massachusetts, looked at data gathered from 1,265 men, ages 40 to 70, who had completed interviews for the Massachusetts Male Aging Study about their health and lifestyles, including questions about erectile dysfunction and depression.

Even after the scientists accounted for factors that are often associated with impotence, such as age and health status, men who had symptoms of clinical depression were almost twice as likely to report moderate to complete erectile dysfunction.

The researchers point out that they can't tell from this study whether impotence is contributing to depression or vice versa, because data was collected at one point in time. If impotence causes depression, then doctors should screen their male patients with erectile dysfunction for depression as well. On the other hand, if depression causes impotence, then they should screen their patients with depression for erectile dysfunction. Either way, it's important to be aware of the link between the two.

Meanwhile, researchers at the New England Research Institutes are carrying out new studies to sort out the "cause and effect" relationship between depression and impotence.

In a related study, doctors from the Max Planck Institute of Psychiatry in Munich, Germany, report that severe depression in men changes the way the body produces sex hormones. The researchers analyzed blood samples from 15 men with major depression and 22 men who were not depressed.

Over a 24-hour period, the depressed men's blood had significantly less testosterone and more cortisol than those who weren't depressed. Testosterone is one of the primary male sex hormones, and cortisol is the body's main stress hormone.

The researchers believe that depression causes a disruption of the body's ability to produce the various hormones in the correct balance. This disruption, they say, may be partly responsible for impaired sexual function, as well as putting the men at greater risk for heart attacks and osteoporosis.

Your Antidepressant May Be Causing Your Sexual Problems

Depression is often accompanied by sexual dysfunction, such as decreased interest and impotence, but the cure for depression may cause even more problems in this area. What's more, most patients who are having sexual difficulties while taking antidepressants don't mention it to their doctors.

All of the most popular antidepressants can cause sexual difficulties in both men and women, particularly a group of drugs called selective serotonin uptake inhibitors (SSRIs). This includes fluvoxamine (Luvox), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). Studies show that these drugs can cause delayed orgasm or ejaculation or inability to reach orgasm or ejaculate at all. They also may inhibit sexual or erection. One study estimates that more than 80 percent of patients taking these drugs suffer some form of sexual difficulty.

Scientists must be careful when studying this problem. First, they must separate problems caused by depression from those caused by antidepressant medication. Also, they need to ask patients about sexual side-effects, since many folks won't mention them on their own. Finally, they need to make sure that sexual difficulties aren't being caused by factors other than depression and antidepressants.

Researchers at the Robert Wood Johnson Medical School in New Jersey evaluated recent studies of sexual dysfunction among people taking SSRIs. Overall, it appears that more than half of patients taking these drugs experience sexual difficulty. The most common complaint is delay of orgasm or ejaculation, followed by inability to reach orgasm or ejaculate at all (anorgasmia). Most studies report that sexual difficulties get worse with higher doses of antidepressants.

So what can be done for patients suffering from these effects? One choice is to add another drug that will overcome them. A number of drugs have been reported to help, but no clinical studies have been done to affirm the effectiveness of these drugs.

Some clinical studies report success with changing to antidepressants that are not SSRIs. These include amineptine (used in France, Spain, and Italy), bupriopion (Wellbutrin), mirtazapine (Remeron), and nefazodone (Serzone). These drugs, however, may not be as effective as SSRIs in controlling depression, especially if the patient also has a concurrent obsessive-compulsive or anxiety disorder.

If you're taking antidepressants and have any kind of sexual difficulties, talk to your health-care provider. These problems may be caused by your medication, and if so, there are ways to improve your situation and quality-of-life significantly.

Short on Sex Drive? Low Testosterone Probably Isn't the Problem

Physicians evaluating erectile dysfunction typically order blood tests to measure testosterone levels. Supposedly, a low level of this male hormone indicates a low sex drive. But recent research suggests that testosterone level is not a good predictor of sex drive.

Researchers at Bassett Healthcare in Cooperstown, New York, examined the records of 108 men (average age 59) who had gone to an erectile dysfunction clinic. The men completed a questionnaire, called the "Sexual Function Inventory," and had a blood test that measured total testosterone and "free" testosterone (which is not bound to other substances) levels.

Half of the men had low sex drive, 35 percent had medium sex drive, and 14 percent had high sex drive. There were no group differences, however, in the men's testosterone levels. Total testosterone was almost identical in each of the three groups. Of the 49 men with testosterone levels below normal, 29 had low sex drive, 15 medium, and five had a high sex drive.

The researchers noted that among men with erectile dysfunction, only about 6.6 percent have low testosterone levels. Although scientists do not know what role testosterone plays in either sex drive or erectile dysfunction, U.S. Medicare guidelines recommend measurement of testosterone in men with erectile dysfunction if they report a loss of sex drive. And, it is common practice for doctors to routinely order these tests when evaluating men with erectile dysfunction.

The average cost of measuring total testosterone in the blood is $52 and $58 for measuring free testosterone. The researchers estimate that if testosterone tests are ordered for every man who seeks medical treatment for erectile dysfunction, the total cost would be about $419 million.

Since testosterone doesn't seem to predict sex drive and the researchers also found that total and free testosterone levels are closely related, there doesn't seem to be any reason to routinely order even one of these tests, not to mention both.

The researchers suggest that more research is needed to determine what role testosterone may play in sex drive and erectile dysfunction, but until more is known, it is a waste of money to order these tests. This study was published in the September 1999 issue of "The Journal of Urology."

Korean Red Ginseng Shows Promise in Treating Erectile Dysfunction

We hear all sorts of claims about the ability of various herbs to help men achieve and sustain erections, but not too many of these preparations have been clinically studied to determine their effectiveness. A recent study reports that Korean red ginseng, which has been used in Asian countries as a "men's tonic" and aphrodisiac for hundreds of years, seems to have a positive effect on erection in animals and may be helpful in humans too.

Researchers at Yonsei College of Medicine in Seoul, Korea, studied the effects of Korean red ginseng on rats and rabbits in the laboratory. They fed the animals 50 mg/kg of body weight daily for three months. Then they measured the animals' response when the nerve that goes to the to corpus cavernosum was stimulated. The corpus cavernosum is the spongy tissue in the penis that becomes engorged with blood during an erection.

None of the animals showed any side-effects from taking ginseng. Their blood pressure and body weight remained similar to that of control animals.

Compared to rats that had received placebo, those who took the ginseng had a significantly greater response to stimulation, with larger increases in pressure within the corpus cavernosum.

In addition to studying live animals, the researchers also compared the penile tissue of ginseng-treated rabbits and control rabbits in vitro. Compared to the tissues of control animals, tissues of rabbits that had been treated with ginseng were more responsive to the effects of acetylcholine, a brain chemical that stimulates the nerves in a process essential to erection.

"Ginseng has long been used in maintaining physical vitality throughout the Far East, including Korea and China, as a tonic and restorative," the researchers noted, adding that it's also been reported to have helpful effects in people with diabetes, atherosclerosis, high blood pressure, and cancer.

In this study, reported in the October issue of "The Journal of Urology," Korean red ginseng enhanced the erectile response in normal animals. Now that they've shown this, the authors plan to study the effects of the herb in animal models of erectile dysfunction, especially that caused by diseases such as diabetes.

What You Don't Know About Impotency Can Ruin Your Love Life

Impotency—inability to achieve or sustain an erection—occurs most often in older men, but it isn't an inevitable consequence of aging. While psychological factors can cause impotence, at least 80 percent of all cases of sexual dysfunction are due to an underlying physiological problem that can be treated.

As men age, production of the male hormone testosterone declines, and the force and amount of semen ejaculated decreases, notes Gerald Brock, M.D., associate professor of Urology at McGill University in Montreal, Canada. "The good news is we seldom want to have children as we age, and the orgasms are still great! So in most cases it's only an academic finding without any significant consequences."

Studies have shown that testosterone is not essential for erection, but it definitely plays a role in sex drive, and erections are more frequent and rigid when a man has an adequate level of the hormone. Not only does testosterone affect libido, research has shown that it increases production of nitrous oxide in the erectile tissue of the penis (corpora cavernosa), which is important in regulating erectile function. That may be why it takes some older men longer to achieve an erection, or their erection may not be as firm or large as in the past.

Men who are impotent due to a low level of testosterone can be treated with hormone replacement therapy. However, impotence in older men is frequently the result of a medical condition or medication that interferes with erectile function. An erection requires a sequence of events, which involve nerve impulses in the brain, spinal column and penis, as well as response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa. Any disruption of this sequence of events can trigger impotence.

Therefore, the most common cause of impotence (70 percent) is disease that causes damage to arteries, smooth muscle and fibrous tissues, including diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and vascular disease. Prostate, colon or bladder surgery--any surgery in the pelvic area--can cause impotence if nerves and arteries near the penis are injured. Smoking may also affect sexual performance, because it affects blood flow in veins and arteries. Medications that can affect erectile function includes high blood pressure drugs like lisinopril and atenolol, antihistamines, tranquilizers, appetite suppressants, and cimetidine (ulcer treatment). Additionally, antidepressant medications, especially serotonin uptake inhibitors (Luvox, Prozac, Paxil, Zoloft) may inhibit erection and delay or prevent ejaculation.

While one in three men over age 60 suffer from some form of sexual difficulty, only about 10 percent actually seek treatment. Possibly, many men suffer in silence because they're unaware of causes and treatments for impotency. In a survey, conducted by the Impotence World Association, less than five percent of respondents knew that erectile dysfunction is usually physiological, and less than 15 percent were aware of new impotency medications, such as Viagra.

Viagra® (sildenafil) and Uprima (apomorphine) are oral medications that improve a man's erection ability. However, men who become impotent following surgery may not respond to these drugs. "Viagra will only help those men who have preservation of some of the nerve fibers after the surgery. The good news is that if Viagra doesn't work, injection therapy with Caverject or other vasoactivator meds probably will help." Caverject and MUSE (Medicated Urethral System for Erection), another vasoactivator, involve self-administered injection of medication into the penis opening. However, men who don't respond to oral medications or injections may be helped with a penal implant or vacuum pump, which Dr. Brock notes is common in men with diabetes or very poor circulation. The pump, which is available without a prescription, forms a vacuum around the penis. As air is sucked out of the tube, blood flows into the penis, creating an erection.

Some studies indicate that Viagra presents a risk for men with cardiovascular diseases. However, Dr. Brock notes that the risk of heart attack depends on an individual's own risk factors, such as cholesterol level, age, and smoking among others. "People with diabetes, heart disease, and hypertension (high blood pressure) do develop heart attacks in the real world. When you have 1.5 million men, many of them with these problems, taking any medication, some will die from cardiac causes." Dr. Brock suggests that the risk for heart attack may not be higher with Viagra, but higher for the group of men likely to need Viagra. He stresses, however, that men who take nitroglycerine should not use Viagra, because it stops the body's ability to break down the chemicals in nitroglycerine.

While there is no known prevention for erection dysfunction, Dr. Brock suggests that exercise and eating a low-fat diet--the same strategies used to reduce the risk for heart disease--may be helpful, since erection is dependent on a healthy vascular system.