Sexual Healing

Farewell Post

Tue, 15 Mar 2011 13:53:01 GMT

This is my last post. My family and I are leaving Froedtert & The Medical College of Wisconsin and the state of Wisconsin. We are moving south and hope to bring sexy back to Texas. They say everything is bigger and better in Texas, we'll see about that.

I thank everyone who has read my posts. I hope people learned a thing or two about their bodies, their relationships, and of course, sex.

Take care everyone.

Margaret Kressin

The following is feedback received for this blog:

Dear Dr. Kressin

I just wanted to say thank you for your wonderful articles/blogs. You truly are a inspiration to many women. I also want to thank you for your advice on relationships. You made me a better person in life and my marriage. I wish you the best in Texas and have no doubt you will be successful. You will be missed by many, but mostly by friends and family. Just remember friends are only a phone call away.

Good Luck
Tracy

Persistent Genital Arousal Disorder — A Real and Devastating Condition

Thu, 23 Jul 2009 11:39:13 GMT

There is a condition known as Persistant Genital Arousal Disorder. It is a condition characterized by spontaneous and unwanted genital arousal characterized as tingling, throbbing or pulsating. It is a serious, distressing, and debilitating condition to the women affected by it. The condition is poorly understood, rare, with limited research and studies in the literature. It can affect any women at any age.

Some causes:

Neurologic — central and peripheral ^2,3,4
Pelvic surgery — such as hysterectomy, placement of a sling for stress incontinence
Pelvic trauma
Arterio-venous malformation (AVM)² — where the artery and vein have an abnormal connection
Medication — abrupt cessation of SSRI’s (such as Paxil, Zoloft etc…)^5,6, trazodone⁷, soy⁸
Malignancy^9,10
Psychological
Idiopathic¹¹ (we just don’t know what caused it)

Part of the problem is that most physicians are not aware that this condition exists resulting in frustration and desperation on the part of the patient. Most patients are told that the sensations they are experiencing are in their head, are thought to be “crazy”, or are thought to be seeking attention or narcotics. To be fair, most physicians just don’t know what to do with these patients. I had one patient visit eleven physicians before she ended up in our emergency department and ended up in my care. At that time she did not know what she had and thought that she may really be going insane. She is now going back to her previous eleven physicians educating them about her condition.

I make sure my residents and medical students that rotate through our service know about this condition, so in case they do encounter a patient in the future they will know what to do or where to send the patient. I am putting this in my blog to let patients and other healthcare providers know about this condition. Also, if there is a woman experiencing this condition, she should know that there is such a condition and that there is help for her.

References

Leiblum SR, Nathan SG. Persistenst sexual arousal syndrome: A newly discovered pattern of female sexuality. J Sex Marital Ther 2001;27:365-80.
Goldstein I, De EJB, Johnson J. Persistent sexual arousal syndrome and clitoral priapism. In: Goldsein I, Meston C, Davis S, Traish A, eds. Women’s sexual function and dysfunction: study, diagnosis and treatment. London: Taylor and Francis; 2006:674-85.
Yero SA McKinney T, Petrides G, et al. Successful use of electroconvulsive therapy in 2 cases of persistent sexual arousal syndrome and bipolar disorder. J Ect 2006;22:274-5.
Reading PJ, Will RG. Unwelcome orgasms. Lancet 1997;350:2:743.
Goldmeier D, Bell C, Richardson D. Withdrawal of selective serotonin reuptake inhibitors (SSRIs) may cause increased atrial natriueretic peptide (ANP) and persistent sexual arousal in women? J Sex Med 2006;3:376.
Elmore J, Quattlebaum J. Female sexual stimulation during antidepressant treatment. Pharmacotherapy 1997;17:612-6.
Medina CA. Clitoal priapism: A rare condition presenting as vulvar pain. Obstet Gynecol 2002;100:1089-91.
Amsterdam A, Abu-Rustum N, Carter J, et al.. Persistent sexual arousal syndrome associated with increased soy intake. J Sex Med 2005;2:338-40.
Krychman M, Amsterdam A, Carter J, et al. Brain cancer and sexual health: A case report. Palliat Support Care 2005;2:315-9.
DiGiorgi S, Schanatz PF, Mandavilli S, et al. Transitional cell carcinoma presenting as clitoral priapism. Gynecol Oncol 2004;93:540-2.
Nappi R, Salenia A, Traish AM et al. Clinical biologic pathophysiologies of women’s sexual dysfunction. J Sex Med 2005;2:4-25

The following is feedback received for this blog:

I read your information on PGAD in which you mention that there is help for this condition. My 27y year old daughter suffers from this condition which began after she was started on birth control medication in Dec. 2008 and experienced a series of side effects following taking this such as dizziness, panic attacks, anxiety, symptoms that she never had before. The dizziness subsided, but anxiety continued. In July 2009 she began to experience involuntary vaginal pulsating sensations and the rest is history. She has been to many different doctors, without improvement. Do you know of a treatment that can help her?? From your experience what medications, treatments have helped other women. Any suggestions would be greatly appreciated.

- Renee K.

I'm sorry to hear your daughter is struggling with this condition, knowing how challenging it can be. While I can't provide medical advice through this blog, there is treatment available. I would be happy to see your daughter to assess her individual situation and offer treatment, or, depending on your location, point you to a practitioner near her. If you wish, she may contact us to make an appointment at 800-272-3666.

- Margarita Kressin, MD

I recently had a nerve sparing radical prostatectomy, which was quite successful. While the nerves "heal" (6 to 24 months), I'm undergoing a protocol to maintain the tissues that allow me to get an erection (viagra + VED).

I've read one artical about including TRT in this sort of therapy. What are your thoughts on this?

- Tim E.

Interesting she claims "there is help for her" but the minute someone asks what that help is she "can't provide medical advice through this blog". Probably because she hasn't got any worth hearing!!!

There is any kind of medical advice on the net for any condition you want.....this person sounds likes she's dangling a carrot in front of us to get us to make an appointment with her. My guess is she knows no more than any of the dozens of doctors we've all been to.

I find references 2, 3, & 7 particularly interesting. Many of us have been in contact with Goldstein....he doesn't know squat!! And electro~convulsive therapy.....I know 3 of us that tried it....2 of us had absolutely no success at all....NONE!!! But I did get something from the ECT's.....loss of memory....parts of my past are gone to me forever.....and for what.....NOTHING!! The other gal has the same residual effect from the ECT's. Thanks to Goldstein's advice, I know my Mother is dead but I have no recall of the event at all.....I don't remember where she lived....I don't remember the cancer....or if I was there for her!!!! I don't remember the surprise 60th birthday party my kids had for me....the fun they say we had scratching off the 60 lottery tickets my son gave me. I was a Registered Nurse....my first love was OB....I couldn't tell you much of anything about delivering a baby!! I hardly remember being a nurse!!

Reference 7 (as well as 2) refer to 'clitoral priapism'. We just had interesting notes about this recently.

And look at reference 1....she refers to Sandra Leiblum.....Jeannie and I have both met Sandra in person; wonderful lady....she described this syndrome....she named it and has tried to help find a treatment but she makes no claim as to a treatment or cure.

While it's good to see that PGAD is being talked about in the medical community, "- Margarita Kressin, MD" has nothing to say that most of us couldn't have said and probably even better.

- Nancy B.

PLEASE READ PROF. DR. M WALDINGERS RESEARCH ON RESTLESS GENITAL SYNDROME, IT HAS GIVEN ME MORE HOPE THAN I'VE HAD IN 6 YEARS XO.

- Meagan Holliday

Hi,i think people who have this condition should try St-Johns wort vitamin.Becose most people with this condition often haven a low serotonin level.ST Johns wort will boost your serotonin level naturally.Its wort a try...

Divorce

Mon, 07 Feb 2011 10:47:26 GMT

My husband and I are now at that time of our life where we are experiencing our friends getting divorced. We have life cycles: college, engagements, weddings, births of first born, births of other children. And now divorces.

Divorce is a strange thing. It’s hard to even wrap our head around it, and we are not even the party involved. We start to reminisce about the times we spent with the couple. We wonder, what happened? What was so terrible that divorce was the only option? I’m sure all married couples walk down the aisle or up the steps to the courthouse or along the sandy beach not thinking that there will be a day that this will end.

Having not done this before, it is hard for me to comprehend how one goes from “to have and to hold, in sickness and in health, till death do us part” to “this is too difficult/not worth salvaging/you’re an evil person/I don’t love you anymore/you are the spawn of Satan.”

All couples have their disagreements and arguments that can be emotionally devastating. But right now, it has never gotten so bad where leaving my husband is an option ... let alone the only option. I hope we never get to that point. Then again, I am 100 percent sure none of our friends ever thought that they would reach that point either.

I am a phone call away from my friend ready for that shoulder when she needs it. My husband has met his friends for a drink when they needed it. We come back to our home thankful it’s still there, thankful our marriage has survived another day.

Priorities

Mon, 17 Jan 2011 10:43:46 GMT

It’s been a while since I have written a blog, and I do apologize. I could come up with a million excuses but the bottom line is it was not a priority in the last few months of 2010. There are two lessons to be gathered from this.

Women sometimes have to be selfish and take care of themselves. Many of my patients come to the clinic saying they love their husband, they would like to have sex, they would like to give him what he wants — BUT ...

a. I’m too busy
b. I’m too tired
c. I have to take care of the kids and by the time I’m done, I barely have time for me
d. I have to work and I have nothing left when I come home
e. He doesn’t help and so I have to do everything
f. I have to go to Pick 'n Save, Target, Boston Store, kids’ (name that sport or lesson)

In some cases, it has gotten so bad that some women don’t even have the time to go to the doctor, dentist, get a haircut. Sex, therefore, goes to the bottom of the list. And I can’t blame them. I get tired just listening to them.

Unfortunately, women are wired to do everything, take care of everyone; often at the cost of their health, their sanity, their relationship, themselves.

Now, I am not advocating these magnificent (because what else could they be) women completely neglect their children or job, but there is only so much time to do everything. So, women, be kind to ourselves and give ourselves the gift of time, to take care of ourselves; sometimes at the expense of certain duties or assignments or obligations. So, I apologize, but the blog was what needed to give.
Women sometimes need to prioritize their husband, their relationship, and sex. I know, I know, refer back to No. 1. I do believe; however, those things that are important to us are the things we choose to devote time and energy. I would argue that our partner, the person we chose to spend the rest of our life with, to build a family with, is an important person to give notice to. It does not have to be a three-hour sex romp (although if you have the time and energy, go for it), but a few minutes to acknowledge them. I have said this in the past: Schedule date night, schedule sex if you have to. We schedule everything else anyway.

Also, it does not have to be sex. It could be an act of kindness. One example is this: My husband and I were going to run our half marathon and he needed nip guards. Nip guards are like pasties for runners so their nipples don’t bleed because of friction from rubbing against their shirts, especially during distance running. (If you have not seen bloody nipples during a marathon, it is not a pretty sight.) Well, we went to three sporting and running stores, and, for some reason, they are impossible to find in Milwaukee. It was too late to order online. So, the next day, I called about five stores (which, by the way, trying to explain nip guards to non-runners generated a lot of giggles on the other end of the phone ... really?) before I found a store that carried them. I then bought the only nip guards, seemingly, in the greater Milwaukee area and gave them to him. It was time I needed to invest for us. It wasn’t really a big “present,” but it was a big deal for him … and for his nipples.

And I do acknowledge him when he does things like shovel, brush the snow off my car, take the dogs out when it’s 8 degrees. It does work both ways. My husband and I are careful not to take each other for granted. Complacency can be the start of indifference and resentment.

So, in conclusion, it is sometimes necessary to be selfish for yourself, for your partner, for your relationship, for sex. And it is not a bad thing.

Sexual Compatibility

Thu, 30 Oct 2008 15:12:09 GMT

Sexual Compatibility. How important is this issue? I raise a potentially controversial topic. How much does one disclose to a potential mate about a potential sexual problem? How important is it to “test the merchandise” so to speak, before buying it?

I am not taking a stance whether or not one must have pre-marital sex or not. But I do see a fair number of patients whose husband/wife was their only partner. And in many religions, abstinence before marriage is practiced. So sometimes the problem doesn’t present itself until after they are married. But it doesn’t happen just to this group.

A friend recently divulged to me that she and her husband are having problems in the sexual arena. What surprised me is that they knew they were not sexually attracted to each other before they got married. They loved each other but there was no sexual spark.

Sex is a critical part of a marriage. But we also know that for most marriages, as the couple gets older and the marriage progress, the amount of sexual activity decreases. So does one give up a potential mate, who would make a devoted partner, a loving parent, a spouse for life, for sexual satisfaction?

What do you think?

The following is feedback received for this blog:

Responding to the last paragraph...

"Till death do us part," not "Till the sex isn't good or runs out." (Right?) Society assumes since you're married, you're taken care of sexually, so you're forgotten about. The truth isn't even close and it can be a tragic dilemma for one spouse: Do you divorce and throw away an otherwise good marriage, with all you've been through together, with financial stability and companionship and security, maybe with kids still at home -just so you can be intimate with someone else in a relationship that's socially acceptable? Maybe loose somebody you'd like to grow old with. Or do you "cheat?" Is that word apply if you're not having sex at home? Shouldn't the one not needing sex be perfectly OK with the other one having a sexual partner on the side, since sex isn't part of the marriage anyway? Or do you just give up on your needs for the rest of your days? I doubt that counseling or therapy or drugs can help here.

Dance Moves

Wed, 22 Sep 2010 12:01:54 GMT

I read a recent article about a study that looked at how women tended to pick mates with dance moves that accentuated the movements of the head, neck and torso. The researchers created avatars to hide what the men actually looked like, and then let them dance. Women tended to pick the men as attractive when their dance moves with the head and torso were exuberant.

Which brings me to a recent festival I went to and observations on the mating rituals of animals and dancing people.

In the animal kingdom, many animals perform “dances” to attract their mates. The male peacock fluffs its tail and struts around in front of the female, the frigate bird puffs up his throat into a giant red balloon then waggles his head from side to side and shakes his wings, the Galapagos turtle bobs his head and bellows to find a mate.

And then we have the humans. I was at a local festival, watching one of the local bands that played music suited and beckoned for dancing to occur. If purely from an observer standpoint, this strange mating ritual can actually be confusing. It is hard to actually distinguish males and females. In the animal world, the males are usually more colorful, more beautiful. Not so in the humans. There is no difference in dress. 95 percent of the humans were wearing jeans. Hair was not necessarily different either. Girls sport shorter cuts, and then there is the occasional mullet from the guys. There was one person, who from the back looked like a female, but then when "she" turned around, it was a definitely a "he," sporting a longer do with locks that some women would be envious. And then there’s the dancing. There is really no distinction in the dance moves of each gender. There was also no distinction as to who approached who to entice them. We were standing and watching for several hours, so we got to see who was clearly trying to make the moves on strangers to get them to dance with them. Women were coming up to men, men to women. And, no, the more enthusiastic dancer did not necessarily attract the opposite sex.

Humans are clearly more complicated. Obviously, dancing is just one of many rituals we perform to show attraction to another person. But sometimes, I think the animals have it clearer and easier. I think some of my girlfriends would agree that it would be nice to know that a guy is interested in you if they flap their arms around or bellow a mating call. Then you know if they don’t do that, there’s no guessing, you move on. You don’t get a dance move, he’s just not that into you.

Pain is Never Normal

Fri, 09 Jul 2010 16:45:37 GMT

Because of what I do, people often open up to me and people ask sex questions. Recently, (let’s call her) Norma complained to me that it hurt to have sex (official medical term is dyspareunia). Nothing hurts any other time, but definitely with sex, there is pain.

How long has it been going on?

10 years.

10 years?! Why did you not get help?

I thought it was just part of getting older. (She is in her late 50s) Besides I didn’t think there was anything we can do for it. So I just dealt with it. But now it’s getting worse that we have had to stop since I was in tears.

Dyspareunia is a common condition and can actually happen at any age. It can be due to a multitude of factors from fibroids, STDs, vulvar issues or vulvodynia, vaginal dryness and atrophy, or muscles of the pelvic floor issues. An examination is necessary to rule out any life-threatening condition.

I told the patient to see her gynecologist to rule out any gynecologic pathology and if there is nothing they could find, and if she still has pain with sex, then I can certainly see her.

She was thankful that there could be a reason and a name to her condition. She was most relieved to find out that it was just “not in her head” and that it wasn’t because of her husband.

The lesson is that pain is never normal. Unfortunately there are cases where it can be the normal if this becomes a chronic pain condition. There are studies that show that if we can get to the patient soon after the pain starts (in this case — pelvic pain seen within a two-year onset) there is a greater chance of curing the patient compared to a patient who was seen after two years. So the second lesson is that the sooner you get your pain taken care of the better the chances that this gets cured.

Going to the Gym

Fri, 02 Jul 2010 14:14:29 GMT

Libido or sex drive in women is a difficult thing to paint plainly. There have been three sexual models that have been proposed to try to explain sexual function in women: the Linear Model, Basson’s circular model and Rosen’s biosociophysical model.

The linear model goes like this: We start with being sexual stimulated (visually or tactile), then get aroused which heightens. Then orgasm comes and then recovery. Few women, we think, respond this way. This fits more males and how they respond sexually.

The Basson model takes a neural women (neither aroused nor stimulated), but then arousal can come via foreplay, massage, etc. … then libido follows. We think more women respond this way than the linear model.

A good analogy to this theory is like going to the gym. Let’s face it, very few of us want to exercise (author included). But we get dressed, put on our shoes, drive to the gym or go outside and begin exercising. Whether we run, use the elliptical or treadmill, or use weights, in the beginning it is somewhat painful. And, at times, we try to talk our way out of it. Then the heart rate goes up. We start to feel good. We start sweating, get into a rhythm, and actually get into it. Sometimes you feel so good, you keep going, longer than what you had planned. Then the run ends, you're sweating, you feel good, the endorphins are going and then you say, "Wow, that was awesome! Why don’t I do this everyday?!" Sex is like this.

I tell my patients and their partners to not expect that the women will start initiating sex. But, sometimes, all it needs is a little foreplay, a little motivation. Help her get her sneakers on and put her on the treadmill. The goal is to enjoy it once the treadmill starts going, and for her to stay on it long enough to feel good.

Putting the Kibosh on Oral Sex

Fri, 30 Apr 2010 09:49:21 GMT

Because of what I do, I am definitely pro-sex. But a caveat I should say is that this be done between consenting adults and be done safely. I went to a recent conference where there was a lecture on oral and throat cancers. In the past, oral and throat cancer’s greatest risk is smoking. However, recently there has been a change in the leading cause of this cancer. This was actually brought up in my colleague Dr. Bruce Campbell's blog, Reflections in a Head Mirror. He writes about the relationship of oral cancer and oral sex.

Some facts about Human Papilloma Virus (HPV):

HPV – most common cause of cervical cancer, now also in vulvar cancer (50 percent of pre-cancerous lesions now seen in 20-39 years of age)
HPV – now seen in 72 percent of oral tumors (D’Souza 2007)
Smokers have a 3x increased risk
Heavy alcohol use a 2.5x increased risk
Greater than 6 oral partners an 8.6x increased risk
HPV 6 and 11 are the strains that cause benign genital warts. HPV 16 and 18 cause 70 percent of cervical cancer
1,700 new cases of HPV-associated head and neck cancers are diagnosed in women and nearly 5,700 are diagnosed in men each year in the United States (Ryerson, 2008)

What caught the attention of the room is the statistic of having more than six oral partners increases your risk more than smoking. We do know that it has been reported that oral sex among teens is often viewed so casually that it needn't even occur within the confines of a relationship. A study published in 1999 in the Journal of the American Medical Association examines the definition of sex based on a 1991 random sample of 599 college students from 29 states. Sixty percent said oral-genital contact did not constitute having sex. And ...

According to a Centers for Disease Control and Prevention survey, 28 percent of males age 15-17 reported giving oral sex to a female and 40 percent reported receiving oral sex from a female.
Among females aged 15-17, 30 percent report giving oral sex to a male, and 38 percent report receiving oral sex from a male.
Some teens reported having oral sex but not vaginal sex (13 percent of males and 11 percent of females aged 15-17).

Erectile Dysfunction Continued

Thu, 01 Apr 2010 14:21:51 GMT

Joe and his wife consider the choices they have. The easiest being the pills, the PDE-5 inhibitors — sildenafil, verdenafil, tadalafil (brand names: Viagra, Levitra, Cialis). Joe gets excited of the prospect of getting an erection. Then he paused and asked: How is my orgasm going to be?

I assured him that it will remain the same.

But how can it be, my erections will be affected, how can my orgasm stay the same?

Like many men out there, Joe doesn’t know that each sexual function actually is independent of itself. What that means is one can have an erection without orgasm (the sensation of sexual peak) or ejaculating (the actual muscle contraction of the pelvic floor of men) or emission (movement of semen outside of the penis). One can orgasm therefore without erection. In post-prostatectomy men (men who have had their prostate removed because of prostate cancer), there is orgasm and ejaculation but erection may not happen and they do not have emission because their seminal vesicle and prostate are gone. Spinal cord patients sometimes can’t have erection on command but they can orgasm but not ejaculate and may or may not have emission.

So I can still have an orgasm even if the penis isn’t very hard?

Absolutely! Let’s say you want to use other things; tongue, fingers, other senses — a practice called sensate focus, you can do this and still ejaculate without getting hard.

This piqued his wife’s interest because she, like Joe, is herself changing sexually and would like to explore more about their sensuality than just focus on the genitals.

I gave them the handout for sensate focus and our sex therapist’s contact. I gave a prescription for one of the PDE-5 inhibitors. They felt that it was good to hear that their intimacy could be preserved and that sex is more than the genitals. But also relieved that if Joe did want to use his penis he still has the option to do this.

Whoop, There it is ...

Wed, 13 Jan 2010 12:00:47 GMT

Kyle and Linda came to the clinic for an appointment. They are a young, attractive couple and the problem they have is actually a relatively common one.

Dr.: How can I help you guys?

Kyle: I can’t please her sexually.

Dr.: Are your erections good.

K.: Yes.

Dr.: Hard, and they last as long as you want?

K.: Well, it goes away after I ejaculate.

Dr.: That’s normal.

Linda then interjects: But he comes too fast. Whoop ... we’re done.

Dr.: Within what time frame?

L.: 30 seconds. I looked it up on the Internet (because women look things up in the Internet) and I think he has premature ejaculation. Is it something I’m doing? Is it me?

Dr.: OK. Kyle, were you able to hold it longer with other partners?

K.: No, not really. Maybe I could go a minute at most.

Dr.: That time period still falls under premature ejaculation. You have what is called lifelong premature ejaculation. It is a fairly common condition occurring between 5 percent and 40 percent of sexually active men (Int J of Psychitr Med 1992). We think that there is actually a higher incidence in adolescents and young adults.

L.: Kyle has been my only partner. What is considered normal?

Dr.: One study that included five countries, using a stopwatch, showed most men ejaculate within 5.5 minutes. This is what we call IELT or intravaginal ejaculation latency time. Most men with PE ejaculate within a minute (0.9 min actually). And, Linda, it is not your fault, there is nothing you are doing that is causing this. The best thing you can do as a partner is be supportive as Kyle works through this.

K.: Is there something we can do?

Dr.: A standard approach is making sure you don’t have any physical and medical issues and also participating in cognitive and behavioral therapy. I will give you a name of a sex therapist and we will check and make sure you don’t have an underlying condition that may be the cause or contributing to this. And recently there have been some medications that we can try to see if we can work on prolonging your IELT. Let’s begin …

Andrew R. McCullough, MD, director of Male Sexual Health, Fertility and Microsurgery at the NYU Medical Center showed that men classified with probable premature ejaculation self-reported:

poor control over ejaculation (50%)
low satisfaction with sexual intercourse (23%)
low satisfaction with sexual relationship (30%)
low interest in actually having sexual intercourse (28%)
difficulty in becoming sexually aroused (34%)
difficulty relaxing during intercourse (31%)

The following is feedback received for this blog:

Too bad not enough couples know anything about getting each other off in all the right ways.

More Than Just ED

Fri, 26 Feb 2010 15:05:12 GMT

After our determination that Joe (worth repeating here that all of my "patient" names and stories are made up) has erectile dysfunction, we then reviewed his medical history (he has mild blood pressure problems and pre-diabetes that is supposed to be diet controlled), surgical history (none), social history (used to smoke a pack per day, but quit 10 years ago). He is not following a diabetic diet and does not exercise. He does not take any medications.

We looked over to his wife and made sure that she is supportive and that she herself does not experience sexual issues. She thinks that their sexual relationship is very important and besides a slight decrease in libido she has no issues. She explains that once she and her husband get going, she does well.

We then focused on lifestyle changes for Joe, what he can do on his part to help his erectile function and prevent further deterioration. We then discussed all his options, from first line therapies (medications, intraurethral systems), second line therapies (injection, vacuum devices, surgeries). We discussed the pros and cons of each therapy, the side effects and possible complications (there is no free ride, no matter what we’d like to think, in medicine), and the benefits of one therapy versus another.

We outlined all of these and made certain recommendations depending on what he would use consistently, and something he and his wife can be comfortable with and incorporate into their sexual activity.

We also offered our sex therapist for sexual counseling (not marital counseling, a point that was important to make) to give them tips and educate them about their sensuality and sexuality. This could also potentially address other issues that we did not address from a medical standpoint. As I always point out — the brain is still the biggest sex organ (as much as Joe would like to think the penis is THE sex organ).

And I reminded them to be careful about what they see and hear in ads. Please do not use any herbal or supplement "medications" advertised on TV. And yes, there are no guarantees. If there were, don't you think legitimate physicians would be using it already?

The biggest lesson Joe and his wife learned was that this was more about erectile dysfunction. It involved sexual health, a couple’s sexual function, and a myriad of therapies that he can choose from.

What's Your Number?

Thu, 10 Dec 2009 15:52:23 GMT

Joe and his wife came to the our clinic, somewhat reluctantly. They have been having some issues in the bedroom.

Do you still get erections? I asked.

Yes!! Joe answered quickly. Then he turned to his wife, Don’t I?

Yeeeeeahhhhhhh? She answered.

Well….

I then asked the questions which let me know better whether he really is getting erections.

Do you get morning erections?

There is an Erection Hardness Scale:

0 — no erections at all
1 — some penile swelling
2 — gets hard, but not enough for penetration
3 — gets hard, and enough for penetration
4 — gets very hard

What number are you?
Does your erection last as long as you and your wife want it to?

He also filled out a SHIM questionnaire — a five item questionnaire that quantifies sexual function.

Here's a definition:
www.prostate-cancer.org/resource/gloss_s.html

And here's a link to the test:
http://www.urologychannel.com/HealthProfiler/healthpro_ed.shtml

A score of 21 or less means that erectile dysfunction (ED) needs to be addressed.

Joe’s score was 19.

Joe has ED.

Part III - My Take on Testosterone Replacement Article

Thu, 08 Oct 2009 10:58:15 GMT

This is Part II to my response on the recent Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html

It is my practice to measure testosterone levels on all my patients presenting with erectile dysfunction. We know that testosterone is needed for all sexual function from libido to erection to orgasm. Here I present evidence on the role of testosterone on erectile function. I will also address the claims that testosterone does not affect mood or energy levels or their bodies.

According to the article:

“... there is so little evidence to back up the claim that supplements … help men 45 and older buck up their sex lives, moods, energy levels or bodies.”

Here are some studies for you to consider.

Testosterone and sex lives:

Erectile dysfunction and testosterone deficiency.
Blute M, Hakimian P, Kashanian J, Shteynshluyger A, Lee M, Shabsigh R
Frontiers of Hormone Research. 37:108-22, 2009

Testosterone replacement alone in hypogonadal men can restore erectile function. A significant proportion of men who fail to respond to a PDE5 inhibitor are testosterone deficient. Testosterone replacement therapy can convert over half of these men into phosphodiesterase type 5 responders. It is now recommended that testosterone levels should be assessed in all patients with erectile dysfunction.

Endothelial effects of drugs designed to treat erectile dysfunction.
Aversa A, Caprio M, Rosano GM, Spera G
Current Pharmaceutical Design. 14(35):3768-78, 2008

… endothelial dysfunction is present in testosterone deficiency syndromes and replacement therapy is able to revert ED and to improve endothelial function.

Testosterone and mood

Effects of Testosterone Replacement in Middle-Aged Men With Dysthymia: A Randomized, Placebo-Controlled Clinical Trial
Seidman, Stuart N. MD; Orr, Guy MD; Raviv, Gil MD; Levi, Rachel BA; Roose, Steven P. MD; Kravitz, Efrat BSc; Amiaz, Revital MD; Weiser, Mark MD
Journal of Clinical Psychopharmacology
Issue: Volume 29(3), June 2009, pp 216-221

Testosterone replacement may be an effective antidepressant strategy for late-onset male dysthymia.

Comparison of long-acting testosterone undecanoate formulation versus testosterone enanthate on sexual function and mood in hypogonadal men.
Jockenhovel F., Minnemann T., Schubert M., Freude S., Hubler D., Schumann C., Christoph A., Ernst M.
European Journal of Endocrinology. 160(5):815-9, 2009 May.

Among the 12 items of subjective mood assessment, agitation, self-confidence, activation, good mood and concentration showed a significant improvement during the treatment and further significant improvement during follow-up with TU treatment. The other items, i.e. sociability, listlessness, dizziness, depression, fatigue, anxiety, and aggressivity, improved too, but not significantly. This tendency was the same during the follow-up with treatment with TU.

Partial androgen deficiency, depression and testosterone treatment in aging men.
Amore M, Scarlatti F, Quarta AL, Tagariello P
Aging-Clinical & Experimental Research. 21(1):1-8, 2009 Feb

Abstract: This study provides a critical review of the literature on depressive symptoms of partial androgen deficiency (PADAM) and their treatment with Testosterone (T). PADAM in aging males is responsible for a variety of behavioral symptoms, such as weakness, decreased libido and erectile dysfunction, lower psychological vitality, depressive mood, anxiety, insomnia, difficulty in concentrating, and memory impairment. The psychological and behavioural aspects of PADAM may overlap with signs and symptoms of major depression. Evidence of the relationship between androgen deficiency and male depression comes from studies that have assessed depression in hypogonadal subjects, the association between low T level and male depressive illness, and the antidepressant action of androgen replacement.

Although data derived from androgen treatment trials and androgen replacement do not support T treatment or replacement as more efficacious than placebo for major depressive disorder (MDD), the clinical impression is that, in some sub-threshold depressive syndromes, T may lead to antidepressant benefits.

Testosterone and bodies:

Low bone density and high percentage of body fat among men who were treated with androgen deprivation therapy for prostate carcinoma.
Chen Z, Maricic M, Nguyen P, Ahmann FR, Bruhn R, Dalkin BL.
Cancer. 2002;95: 2136 –2144

Chen et al (2002) investigated the effect of androgen deprivation (removing testosterone) on total body fat mass after 1–5 years of treatment in 62 men with prostate cancer. There was a significant increase in total body fat mass and reduction in lean body mass.

Effects of Testosterone Administration on Fat Distribution, Insulin Sensitivity, and Atherosclerosis Progression
Shalender Bhasin
Division of Endocrinology, Metabolism, and Molecular Medicine, Charles R. Drew University of Medicine Science, University of California — Los Angeles School of Medicine
Clinical Infectious Diseases 2003;37:S142–S149

In spite of the widespread belief that testosterone supplementation increases the risk of atherosclerotic heart disease, evidence to support this premise is lacking. Although supraphysiological doses of testosterone, such as those used by athletes and recreational body builders, decrease plasma high‐density lipoprotein (HDL) cholesterol concentrations, replacement doses of testosterone have had only a modest or no effect on plasma HDL in placebo‐controlled trials. In epidemiological studies, serum total and free testosterone concentrations have been inversely correlated with intra‐abdominal fat mass, risk of coronary artery disease, and type 2 diabetes mellitus. Testosterone administration to middle‐aged men is associated with decreased visceral fat and glucose concentrations and increased insulin sensitivity. Testosterone infusion increases coronary blood flow. Similarly, testosterone replacement retards atherogenesis in experimental models of atherosclerosis.

Testosterone and growth hormone improve body composition and muscle performance in older men.
Sattler FR., Castaneda-Sceppa C., Binder EF., Schroeder ET., Wang Y., Bhasin S., Kawakubo M., Stewart Y., Yarasheski KE., Ulloor J. Colletti P., Roubenoff R., Azen SP.
Journal of Clinical Endocrinology & Metabolism. 94(6):1991-2001, 2009 Jun.

Supplemental testosterone produced significant gains in total and appendicular lean mass, muscle strength, and aerobic endurance with significant reductions in whole-body and trunk fat.

The management of hypogonadism in aging male patients.
Sharma V, Perros P
Postgraduate Medicine. 121(1):113-21, 2009 Jan

Several studies indicate that testosterone replacement therapy may produce a wide range of benefits for men with hypogonadism, including improvement in libido, bone density, muscle mass, body composition, mood, and cognition.

The Journal Sentinel's claims that "one key problem is that there is a lack of scientific evidence that men over the age of 45 benefit from taking testosterone" is simply untrue. I have presented numerous articles in these posts, all based on scientific and medical research and publications disclaiming their assertion. It is unfortunate that patients are misguided by these articles. Patients should be cautious of what they read in the newspapers and they should always consult their physicians regarding their care and what they read before acting on their own.

The following is feedback received for this blog:

Dr. K - Thanks for writing this rebuttal on that article. Do you know if middle-aged men can do something to increase T without having the actual hormone injections? Something "natural?"

- Don

Despite claims that the benefits of testosterone replacement therapy aren't supported by research, I have all the evidence I need. I use it myself and, believe me, it works.

A daily dose of Testim 1% has significantly improved my sex drive and sexual function. It has given me a sense of mental clarity and accuity that many 50-something men seem to lack. It has dramatically raised my energy level and helped me to add lean muscle mass instead of fat.

It may not be the fountain of youth, but it has improved the quality of my life, and that's good enough for me.

- Kiernan B.

Don,

Yes, there have been studies that show increasing muscle mass can increase testosterone production. So start exercising and pumping iron!

- Dr. Kressin

Part II - My Take on Testosterone Replacement Article

Mon, 05 Oct 2009 12:10:14 GMT

This is Part II to my response on the recent Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html

So the article also claimed that

“concerns that it may increase … cardiovascular disease”

Here I present articles published (364 articles matched), most of them within the last 9 months disputing this point. I didn’t have to go beyond the first page of my medline search to get these:

Endogenous testosterone and the prospective association with carotid atherosclerosis in men: the Tromsø study
Vikan T. Johnsen SH. Schirmer H. Njolstad I. Svartberg J. European Journal of Epidemiology. 24(6):289-95, 2009.

In the cross-sectional study, we found an inverse association between testosterone levels and total carotid plaque area (P < 0.05), after adjusting for age, systolic blood pressure, smoking and use of lipid-lowering drugs.

Androgens and cardiovascular disease.
Liu PY, Death AK, Handelsman DJ
Endocrine Reviews 2003 Jun;24(3):313-40

Observational studies show that blood testosterone concentrations are consistently lower among men with cardiovascular disease, suggesting a possible preventive role for testosterone therapy, which requires critical evaluation by further prospective studies. Short-term interventional studies show that testosterone produces a modest but consistent improvement in cardiac ischemia over placebo, comparable to the effects of existing antianginal drugs.

Reduced testosterone levels in males with lone atrial fibrillation.
Lai J, Zhou D, Xia S, Shang Y, Want L, Zheng L, Zhu J
Clinical Cardiology. 32(1):43-6, 2009 Jan

Mean levels of testosterone were significantly lower in subjects with lone atrial fibrillation when compared with controls (476 ng/dl versus 514 ng/dl, p = 0.005). CONCLUSION: Reduced testosterone levels may be associated with susceptibility to lone atrial fibrillation in men.

The dark side of testosterone deficiency: I. Metabolic syndrome and erectile dysfunction. [Review] [121 refs]
Traish AM. Guay A. Feeley R. Saad F.
Journal of Andrology. 30(1):10-22, 2009 Jan-Feb.

The metabolic syndrome (MetS) is considered the most important public health threat of the 21st century. This syndrome is characterized by a cluster of cardiovascular risk factors including increased central abdominal obesity, elevated triglycerides, reduced high-density lipoprotein, high blood pressure, increased fasting glucose, and hyperinsulinemia.

Central or abdominal obesity, measured as WC, is a classical feature of MetS and is associated with reduced total testosterone levels (Pasquali et al, 1997; Svartberg et al, 2004a,b, 2007; Osuna et al, 2006).

Other studies have confirmed the significant inverse correlation between total T and obesity (Pasquali et al, 1991; Laaksonen et al, 2003; Kalyani and Dobs, 2007). Therefore, men with visceral obesity are in a vicious cycle as T deficiency leads to reduced lipolysis, reduced metabolic rate, visceral fat deposition, and insulin resistance.

The dark side of testosterone deficiency: II. Type 2 diabetes and insulin resistance. [Review] [99 refs]
Traish AM. Saad F. Guay A.
Journal of Andrology. 30(1):23-32, 2009 Jan-Feb.

Low testosterone precedes elevated fasting insulin, glucose, and hemoglobin A1c (HbA1C) values and may even predict the onset of diabetes. Treatment of prostate cancer patients with surgical or medical castration exacerbates insulin resistance (IR) and glycemic control, strengthening the link between testosterone deficiency and onset of type 2 diabetes (T2D) and IR. Androgen therapy of hypogonadal men improves insulin sensitivity, fasting glucose, and HbA1c levels. We suggest that androgen deficiency is associated with IR, T2D, MetS, and with increased deposition of visceral fat, which serves as an endocrine organ, producing inflammatory cytokines and thus promoting endothelial dysfunction and vascular disease.

The dark side of testosterone deficiency: III. Cardiovascular disease. [Review] [99 refs]
Traish AM. Saad F. Feeley RJ. Guay A.
Journal of Andrology. 30(1):23-32, 2009 Jan-Feb.

Androgen deficiency is associated with increased levels of total cholesterol, low-density lipoprotein, increased production of proinflammatory factors, and increased thickness of the arterial wall and contributes to endothelial dysfunction. Testosterone supplementation restores arterial vasoreactivity; reduces proinflammatory cytokines, total cholesterol, and triglyceride levels; and improves endothelial function but also might reduce high-density lipoprotein levels.

And finally a few others in summary:

Diaz-Arnjonilla, et al Intl J of Impot Res 2009 —
- Low T in obese men
- Lot T in men with metab syn and DM
- BMI inv propor to serum total T
Schandt et al Current Opinion in Urology 2009 — Link of androgen deprivation therapy in prostate cancer to development of metabolic syndrome
Corona et al J of Sex Med 2008 — Low levels of androgens in men with erectile dysfunction and obesity
Dandona P et al Postgrad Medicine 2009—
- Hypogonadotropic hypogonad seen in DM2 is assoc with obesity but not duration of DM2
- 1/3 of DM2 have low T

My Take on Testosterone Replacement Article

Mon, 28 Sep 2009 08:57:09 GMT

Two patients of mine recently asked me about the Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html

One of them actually stopped it because he became very concerned about T after reading the article. One of them asked me if he should stop it.

So, I was asked to write about this as I do prescribe testosterone, and I want to help ease the potential fears created by this article. Because of the detail of the article and the rebuttal of many points, I thought I would break it into three parts so the important points are not missed. The other two posts will come in the next few days.

I will quote the article and then cite articles that counter the point:

“... concerns that it may increase the risk of prostate cancer…”

"The relationship between total and free serum testosterone and the risk of prostate cancer and tumour aggressiveness."

Morote J. Ramirez C. Gomez E. Planas J. Raventos CX. de Torres IM. Catalan R.
BJU International. 104(4):486-9, 2009 Aug.

CONCLUSION: Prostate cancer risk and tumour aggressiveness are not related to serum levels of total and free testosterone, but hypogonadal patients do not have a greater risk of prostate cancer and tumour aggressiveness.
"Pretreatment serum testosterone and androgen deprivation: effect on disease recurrence and overall survival in prostate cancer patients treated with brachytherapy."

Taira AV. Merrick GS. Galbreath RW. Butler WM. Wallner KE. Allen ZA. Lief JH. Adamovich E.
International Journal of Radiation Oncology, Biology, Physics. 74(4):1143-9, 2009 Jul 15.

CONCLUSION: Low pretreatment testosterone levels alone did not affect disease recurrence or overall survival. Patients with baseline low testosterone who also were treated with androgen deprivation therapy had a trend toward decreased overall survival.
"Testosterone therapy in hypogonadal men and potential prostate cancer risk: a systematic review."

Shabsigh R, Crawford ED, Nehra A, Slawin KM
International Journal of Impotence Research. 21(1):9-23, 2009 Jan-Feb.

CONCLUSION: Of studies that met inclusion criteria, none demonstrated that testosterone therapy for hypogonadism increased prostate cancer risk or increased Gleason grade of cancer detected in treated vs. untreated men. Testosterone therapy did not have a consistent effect on prostate-specific antigen levels.
"Testosterone Therapy in Men With Prostate Cancer: Scientific and Ethical Considerations"

Abraham Morgentaler
Journal of Urology 181 (3):972-79, 2009 Mar.

CONCLUSION: Although no controlled studies have been performed to date to document the safety of testosterone therapy in men with prostate cancer, the limited available evidence suggests that such treatment may not pose an undue risk of prostate cancer recurrence or progression.

Also there have been active research studies in supplementing men with low testosterone who had prostate cancer. If we really thought that T caused prostate cancer, we would never even consider this. These original research studies by some of the leading urologists in the country and the world were presented in the 2008 meeting of the Sexual Medicine Society of North America:

"Testosterone therapy in men with untreated porstate cancer on active surveillance"

Morgentaler A, Bennet R, Mohamed O, Chan R, Khera M, LIpshults L

CONCLUSION: Testosterone therapy in 13 hypogonadal men with untreated prostate cancer for a mean of 12 months was not associated with an increase in PSA or substantial rate of grade progression on repaeat prostate needle biopsy. These pilot results suggest that testosterone therapy may be cautiously considered in men with low-risk untreated prostate cancer.
"Testosterone replacement therapy following radical prostatectomy"

Khera M, Grober E, Najari B, Mohmed O, Colen J, Lamb, D, Lipshultz L

CONCLUSION: Testosterone replacement therapy (TRT) is effective in improving testosterone levels in hypogonadal men following radical prostatectomy (RP). In this cohort of hypoogonadal men on TRT after RP there was a significant rise in testosterone values with no significant rise in PSA following TRT.
"Analysis of the PSA response after initiating testosterone supplementation (TS) in patients who have previously received management for their localized prostate cancer"

Davila H, Arison C, Hall M, Salup R, Lockhart J, Carrion R

CONCLUSION: TS by T injection or transdermal gel is effective in improving T level in men following RP and external beam radiation therapy. No significant differences were noted between these groups with regard to PSA levels after TS. This pilot study confirmed consistent efficacy and safety concerning the use of TS after prostate cancer therapy, regardless they type of cancer treatment.

These are just articles within the last year. The urologic community has shifted its thinking on the relationship of testosterone and prostate cancer. The newspaper article did not show or quote any scientific studies. I hope that these studies in our medical and scientific literature can allay some of the questions and fears with testosterone replacement and prostate cancer risk.

Inflammation Equals Bad Sex

Wed, 09 Sep 2009 15:05:29 GMT

A recent article came out regarding inflammation causing female sexual dysfunction. The article -— The Metabolic Syndrome: a Cause of Sexual Dysfunction in Women by K Esposito et al., published in the International Journal of Impotence Research looked at the relationship of the metabolic syndrome and levels of C-reactive protein to female sexual dysfunction.

Metabolic syndrome is a condition defined as having at least three of the following:

Obesity: In this study, they used abdominal fat as defined by a waist circumference of >102 cm in men (about 40 inches) and >88 cm (about 35 inches) in women
Low HDL levels (the good cholesterol): (<40 mg/dl in men or <50 mg/dl in women)
High triglycerides: Elevated triglycerides >150 mg/dl
Elevated blood pressure: >130/85mmHg
Abnormal glucose sensitivity: fasting glucose of >110 mg/dl

C-reactive protein (CRP) is a protein produced during systemic inflammation in the body. It has been used to determine risk of atherosclerosis and cardiovascular disease.

This study used the Female Sexual Function Index score to measure sexual function in their study group composed of pre-menopausal women (age range 20-48 years) and controls (a group of similarly aged women without metabolic syndrome). FSFI domains include desire, arousal, lubrication, orgasm, overall satisfaction and pain.

Total score is 36
Good level = >30
Intermediate 23-29
Poor <23

They then compared FSFI, CRP and metabolic syndrome. They found that women with the metabolic syndrome showed statistically decreased score in arousal, lubrication, orgasm and satisfaction.

FSFI scores	Metabolic Syndrome	Control
Good	56%	70%
Intermediate	37%	19%
Poor	9%	2%

They also found that women with metabolic syndrome had lower FSFI and higher CRP levels — 2.2 vs 0.8 mg/L.

So the bottom line is that having the metabolic syndrome can increase inflammation and can lead to bad sex. The key is to keep inflammation down. So take care to keep blood pressure down, keep the bad cholesterol down and good cholesterol up, minding your sugar levels, and keeping the weight down. Not only this is good for the heart and but also for your sex life.

I Eat, Therefore I Run.

Wed, 24 Jun 2009 09:48:17 GMT

I eat, therefore I run. This is the mantra written on my RoadID tag on my running shoe. What does this have to do with sex?

I have been listening to several podcasts during my runs on health, weight loss, nutrition. There are common themes as anyone would guess: eat right, get enough sleep, get regular health checks, watch your stress, and exercise. The one thing that people have a hard time doing, I think, is the last one. Each of these is linked one way or another and each contribute to the benefit or demise of each one. For example, when we are stressed we eat badly (or emotionally — chocolate anyone?) and sleep fitfully. When we don’t sleep well, we don’t have the energy sometimes to work out. When we don’t work out, we gain weight and then stress out about that. Then we don’t like to see our doctor because we have gained weight since our last visit, and our blood pressure is up because of the stress. You get the picture.

However, I have been known to be a cockeyed optimist and so the converse of the above is true. When we eat healthy, we feel better. When we have less stress, we sleep better. I am a big believer of moving. I think the word exercise sometimes makes people stress out. But I think it is my duty as a healthcare provider to ask what they are doing to move. It doesn’t come easy for anyone. But it has to be done as part of a healthy lifestyle. Cutting down on calories and eating healthy is great, don’t get me wrong, but we all have cravings and we can only avoid bacon and chocolate only so much (my particular downfall). But moving allows us to have an occasional craving (or two), lets us sleep well, keeps our weight down, and is a great stress reliever. Moving makes us feel good, endorphins are released, and if the side effect is a little weight loss, most of us will tolerate this. It is indisputable that all of the above makes us feel good and makes us feel better about ourselves, our bodies, ergo more sexy. This phenomenon has been reported in studies and by my patients’ own personal experience, regardless of whether weight loss actually occurred.

So maybe the next shoe tag should read: I run therefore I have sex.

The following is feedback received for this blog:

great blog-

nice to see that these things are interlinked. cannot wait to read more of your writings/blog

- kim t.

Yoga

Thu, 29 Jan 2009 13:43:49 GMT

I am by no means a yoga master. At best I am still a novice. I have taken several classes, and I think it has helped me in my flexibility and prevented injuries I may have incurred while running.

My husband on the other hand, is not only a skeptic but also finds that yoga is beneath him. Further, it is not a manly thing to do. After his third injury right before his third marathon (yes, an injury right before every race), and after I told him that in one of the yoga classes I took half the people were men and a few of them were also training for marathons, he finally conceded to take a class. Of course, I had to be with him, he didn’t want to be alone, and he made me promise not to laugh at him.

I’m happy to report we are in our second set of classes. He just ran the Rock 'N 'Roll Arizona Marathon (I ran the half) and besides a dead toe nail in his right foot, he survived and even beat his personal record by five minutes.

This leads me to the article below. I showed this to my husband to show him that we are doing something not only for our running but for, ahem, our other marital activities.

Keep on yoga’ing!!

Here's the article:
Yogis Have Better Sex, Study Finds at msnb.com
By Sally Law
Special to LiveScience

The following is feedback received for this blog:

Dr Kressin, I am concerned with your blind recomendation of yoga. You did not once mention any religous implications that are obviously associated with this practice. Yoga means 'to yoke" or "to unite" with the Hidu god through exercise and meditation. Are you a Hindu? This recomendation implies that you are spreading the religion. Does the Medical College approve of this? I am sure that you find benefit from the physical part of yoga, but you cannot not separate the religious part of the practice. Try looking up yoga on http://en.wikipedia.org/wiki/Yoga

I disagree with the other commenter. You can enjoy and participate in Yoga without attaching the religious aspect to it. There is peace in finding yourself and your center while doing Yoga without thinking religion. Also, I'm not sure what the commenter meant by "does the Medical College know about this"? Even if she mentioned religion, MCW is a PRIVATE institution--not the same as a STATE RUN school such as UW-Madison.

I agree that, while the word "yoga" technically relates to Hinduism, the practice of yoga and its immense physical benefits can be separated from Hindu religious practice.

My yoga instructor, Bryant Macharenas with Santosh Yoga in Wauwatosa, is a practicing Christian who was mentored by a Catholic priest in India. My religious principles have never been compromised while attending Bryant's classes and, physically, I've never felt better.

-

He Is Still Into You

Tue, 26 May 2009 13:25:03 GMT

This conversation really happened and although it appears I am eaves dropping, I really am not. I just can’t reveal how I got this conversation and the people’s identities have been changed.

There were four ladies lunching, who we will call Charlotte, Carrie, Samantha, and Miranda. Charlotte was complaining how her husband Harry was always asking for sex. She just had a baby and she’s exhausted and she still feels heavy with post-baby weight, and she was annoyed that he was bugging her to have sex.

Carrie the ever supportive friend tried to console Charlotte. “Of course you’re exhausted, sweetie. And you look fantastic. You don’t even look like you have post-baby weight.”

Miranda then piped in, “At least he is lusting after you and not another woman. What’s wrong with your husband's wanting to have sex with his wife.”

Samantha joined in, “Oh, Honey, it’s great he’s still after you. You just need a little waxing to feel sexy and in the mood.”

I’m not saying women shouldn’t say “no” to a little romance from time to time, but isn’t it great that the husband is still into his wife?

Prostate Check

Tue, 19 May 2009 09:27:34 GMT

With two studies released about a month ago regarding prostate cancer screenings and their utility, I am still making an announcement that our department is again giving free prostate checks on Thursday, May 28, at Miller Park.

There is too much to explain regarding the analysis of those two studies on this blog. I will say this: Despite the studies, the American Urological Association subsequently came out in support of the screenings for "asymptomatic men 40 years of age or older who have a life expectancy of at least 10 years." And I am hoping that men who have a history of prostate cancer or African-American men will come and get a free prostate and PSA check. These are still life-saving and relatively benign tests.

It's a Psych Thing

Mon, 06 Apr 2009 09:02:30 GMT

A patient told me once that she would like to continue to be sexually active because she had a psychological need to be connected with her husband. I was pleasantly surprised because of her candidness, her honesty, and frankly, I had never had anyone express this particular reason to me before. My patient is over the age of fifty and has been married over twenty five years.

I have certainly heard other reasons:

My husband is still quite virile and I want to keep up.
I would like to still be physical with my husband.
My husband misses it.
I miss it.
It makes me feel good.
My husband might divorce me if I don’t do something. (My favorite ... I’m being facetious.)
I love my husband and I want to continue this.
We have a good marriage except this part.
I want to continue to please my husband.
My husband wants me to enjoy this too.

I think what impressed me was her articulation of sex beyond the physical. Her comment has clearly stuck with me.

I always counsel my patients that the brain is the biggest sex organ and sometimes we have to fix things from the top down. It’s more than just the vagina or penis or things working or not. It’s even more than just a feeling. It’s a psych thing.

The following is feedback received for this blog:

Great post. New to your blog, but you got great writing style. You had some very interesting points that I liked. Looking forward to more of your thoughts. - Singing Bowl Crystal

A Bone is Broken

Thu, 19 Feb 2009 16:51:20 GMT

This article was in the recent AUA Daily Scope (and apparently, Grey’s Anatomy)

Urologists explain penile fractures after injury is featured on TV show. ABC News (1/23, Friedman) reported that, after being featured on an episode of the television show "Grey's Anatomy," many are asking if penile fractures are real. "The answer, unfortunately, is a definite yes."

Explaining penile fractures, Dr. Darius Paduch, a urologist at New York Presbyterian-Weill Cornell Medical Center, who "treats around four fractured penises a year, said that penile fractures are usually accompanied by a 'popping sound' and then an immediate loss of erection for the man."

Dr. Ira Sharlip, spokesman for the American Urological Association, elaborates "that in addition to the popping sound that occurs at the time of injury, the penis will also be swollen and quite painful."

Dr. Paduch warns, however, that "sex isn't the only way a man can break his penis." In fact "any time the penis is hit while erect, damage can occur."

Still, Dr. Sharlip, "who also practices urology at the University of California San Francisco," emphasized, "It's important to remember this is a minor injury because it's repairable and that men can go completely back to normal after surgery."

My message to guys out there is that if this happens, it is an emergency and they need to go to the hospital or make an appointment to see a urologist ASAP. They should not wait to see if the penis will repair itself. The fracture needs to be repaired surgically. This is often successful to restore function without any consequences. The key is that it needs surgical intervention ... sooner rather than later.

Interesting Articles

Thu, 22 Jan 2009 11:03:55 GMT

Just some more interesting articles recently posted in our AUA Daily Scope. It’s good to know female sexual medicine is getting more coverage each time and physicians and researchers are paying more attention to the sexual needs of women (and not just men).

Young, female breast cancer survivors may often suffer from sexual, intimate relationship issues, research indicates.
UPI (11/12) reports, "Young, female breast cancer survivors often suffer from sexual and intimate relationship issues and use sexual enhancement products," according to research published in the journal Cancer Nursing. Researchers found that "a significant number of women reported vaginal dryness, genital pain, premature menopause, fatigue, and fertility problems. In addition, survivors experienced significant problems related to sexual arousal, desire, and orgasm."

Ultra-low-dose estradiol vaginal tablet may reduce symptoms of vaginal atrophy after 12 weeks of treatment, trial indicates.
Medscape (11/14, Barclay) reported, "An ultra-low-dose estradiol (E2) vaginal tablet reduces symptoms of vaginal atrophy after 12 weeks of treatment, according to the results of a multicenter, double-blind study reported in the November issue of Obstetrics & Gynecology." For the trial, "... 309 postmenopausal women were randomly assigned to receive 10-µg 17β-E2 or placebo vaginal tablets for 52 weeks." Researchers found that "there was significant improvement from baseline to week 12 in vaginal Maturation Index for 10 µg of 17β-E2 vs. placebo.

Studies examine sexual problems in women.
In the Boston Globe (11/10) White Coat Notes blog, Stephan Smith wrote that two studies of "women's sexual problems — whether they care about them and, if they do, how to address them ... get to the heart of what qualifies as a medical disorder and what risks might be involved in taking drugs to treat them." In a study in Obstetrics and Gynecology, "more than 31,000 women [were asked] if they had [sexual difficulties] and whether these problems caused them unhappiness. About 43 percent ... had one or more problems, but" only 12 percent were troubled by them. The study's lead researcher said that "something ... in 40 percent of otherwise healthy women" should not be called a disorder. In a New England Journal of Medicine study, "about 800 postmenopausal women [wore] patches that delivered ... high or low levels of testosterone or no hormone at all." Researchers found that high-dose patch wearers "experienced a 'modest but meaningful' improvement in their sex lives." The study's lead author said, "Clearly it's only for that group of women for whom any potential risk would be justified."

Study indicates testosterone patch may improve libido in older women.
UPI (11/6) reported, "Australian researchers suggest a testosterone patch may significantly improve flagging libidos in older women, though there are side effects," according to a study published this week in the New England Journal of Medicine. The study included "800 postmenopausal women who weren't on estrogen therapy [and] who reported low sexual desire."

While "either dose of testosterone significantly increased the women's sex drive," Rob Stein noted in the Washington Post (11/6) Checkup blog, women who received "higher doses reported a big increase in the frequency of 'satisfying sexual episodes' each month -- from about two a month before the treatment to more than four." These women also "reported more orgasms and pleasure."

The Right Person

Fri, 02 Jan 2009 09:06:11 GMT

Continuing along the lines of meeting someone, how do we know we met Mr. or Ms. Right?

Granted, what makes two people fall in love is beyond reason sometimes. I always say, “For every crooked pot, there is a crooked lid.”

Is the difficulty of meeting Mr. or Ms. Right a symptom of something bigger? Is it people are so cautious because of the high rate of divorce in this country? Have our expectations of what makes a good mate become unattainable that before we know it, there is no one left? But then, aren’t we told we should never settle?

Has Hollywood or the media distorted our image of Mr. or Ms. Right so much that unless you look like you work out 10 hours a day, went to the Right colorist, drove the Right car or carried the Right purse, you don’t qualify? Are we looking for our parents in our search for our mate — which may or may not be a good thing, depending? Have our checklists gotten so long, that Jesus wouldn’t have qualified?

Interestingly, eHarmony only allows you 10 each of "must haves" and "can’t stands" so you really have to think of what is truly important to you.

I certainly don’t have the answer. But if the divorce rate is at 50 percent in this country, then we are doing something that’s not Right.

Technological Advances Prompt Moral Issues

Mon, 15 Dec 2008 08:35:08 GMT

There was an interesting and thought-provoking news briefing in the American Urological Association Daily Scope about a California sperm bank's extending a discount program for military men.

In the Seattle Post Intelligencer (11/19) Now Hear This: Seattle's Military Blog, Mike Barber wrote that "one of the nation's largest sperm banks, California Cryobank, is extending a discounted program it offered years ago for military men to ensure they can father children in the event of injury or death. The offer this month was extended for another year but potentially indefinitely ... (the offer included) an option for post-mortem sperm retrieval of sperm within 48 hours after death, (although) company officials acknowledge that can be difficult to carry out in a war zone." Barber added that "California Cryobank and others say they also can harvest and store eggs or embryos, although that process is more costly, invasive and not always as reliable as sperm storage."

This issue raises some ethical, moral and financial questions. Are the sperm frozen considered an asset? In which case, does the wife/parents/girlfriend/fiancee inherit them when the person has passed? Obviously if there is a will and there are clear-cut instructions, it would not be an issue, but what if there weren't any will and instructions?

As is commonly the case, most Americans are unprepared for death. According to one legal Web site, 57 percent of Americans do not have a will. Who then owns said sperm? Who decides who gets it? What happens to the offspring produced from the sperm? From a financial standpoint, does the progeny inherit like "normal children."

There was a similar situation we encountered as a department several years ago when a man was on life support. The details escape me at this point. I do remember that there was contention between the parents and the woman involved (I don't remember if it was a wife or a girlfriend/fiancee). The parents did not want to harvest the sperm, the woman did.

In the end, and currently, the stance is to have an actual legally written will as to what to do: to harvest or not, who gets the sperm? Unfortunately, the legal, moral, ethical issues typically fall way behind technological advances. We are presented with issues that provoke discussion, legal upheaval, and self-examination.

SWF Looking for ...

Wed, 19 Nov 2008 10:49:21 GMT

Single or divorced male, kind to animals, not in prison, good teeth, preferably have a job. More or less.

I was helping my friend go through her eHarmony application. I was amazed at how detailed the questions got: what best friends think of you, the last book you read, "must haves" and "can’t stands" in seeking a mate. Don’t get me wrong. I obviously care that my friend meets a decent guy, so I am glad they get pretty detailed. But I stop to think, this is what it takes nowadays?!

My friends are intelligent, not physically grotesque, have never been arrested let alone been in prison, have all their teeth, are college educated, have good jobs, kind to animals, chew with their mouths closed, and they don’t spit when talking. Really, what does it take?

Within the last two years, I know of three friends who met their husbands through some sort of online dating. I know of four people right now actively going through some dating service. I see ads on TV, hear them on the radio, even read them on the airline magazine I flip through when flying — Just Lunch, Great Expectations, match.com, eHarmony, just to name a few. There are also speed-dating services in order to increase your chances of meeting that special someone. It is playing on odds and statistics that maybe, just maybe, there is that one-in-30-or-so two-minute encounters that you will connect with.

I myself became Dr.-Mrs Kressin as a result of a set-up, so I empathize with my friends having a difficult time meeting other people (good decent people with no criminal record and have all their teeth. I know I’m obsessing about the teeth thing, but my friend just mentioned this, and now I can’t seem to stop looking at people’s teeth).

When you think about it, however, classifieds have been around for a long time. Our online and speed dates are just more sophisticated forms of looking for that special someone. So maybe it isn’t that it has become more difficult to meet someone. Maybe it’s just that we’ve just developed a fancier way to say:

SWF looking for S/DM, NS for LTR.

Female Viagra

Tue, 30 Sep 2008 09:17:47 GMT

Several people have approached me about an article that came out at the end of July regarding female Viagra. Here is a link referring to the study and the article.

http://www.healthcentral.com/depression/news-257087-31.html

We know that SSRI’s (selective serotonin reuptake inhibitors — a major class of anti-depressants) use is a risk factor for developing sexual dysfunction. The study found that sildenafil (generic name of Viagra) helps with orgasmic function and lack of arousal. Because of the sexual dysfunction caused by SSRI’s, some patients discontinue their use. The study shows that sildenafil improves these sexual side effects. The study was well-done with good patient choices (inclusion and exclusion criteria) and was very thorough in evaluating patients.

There have been past studies showing how sildenafil improves arousal disorder in women without desire (libido) disorder*. It has been shown to help women with spinal cord injuries as well**. Sildenafil is not for low libido or sexual desire issues.

Unfortunately, any of the PDE-5 inhibitors (sildenafil-Viagra, tadalafil-Cialis, and vardenafil-Levitra) are not paid for by insurance for women. And the average cost is about $15 a pill, so this may be prohibitive.

Female sexual function is complex and typically affected by multiple factors. It is promising that more and more research is being done in regards to female sexual function. With each study, we are collecting data, knowledge, awareness, and treatment modalities to help our patients.

*Kaplan et al, 1999; Berman et al, 2003
**Ferrara 2007

The following is feedback received for this blog:

Hello, Somewhat related to this post, I am an internist and have heard that Bremelanotide is a promising medication specifically for problems with arousal. Can you comment on this? Thank you very much.

- Jason

Thats so wonderful those articles, you get to learn so much! Thank you!

- Jeena
www.drugdelivery.ca

What a Difference 30 Minutes Make

Mon, 20 Oct 2008 14:40:24 GMT

Remember Jack and Jill? Our couple presents to our clinic wanting us to fix them. I applaud them that at least they came in together. They are at least aware that they both needed help.

Our sex therapist started with them first. All the anger, resentment, frustration came out. They would argue in front of me and our sex therapist. Blame and insult start flying.

At this point, our sex therapist and I agree that sex should be the last thing they should be working on right now. They need to like each other first.

Their first assignment was to spend 30 minutes a day together alone. They are to talk, not argue. They can talk about the weather, how their day is going, the grocery list; it does not matter. They just cannot argue. It was deplorable how much time they spent arguing compared to time they spent talking to each other with civility. It was also shocking how little time they truly spent with each other.

Mind you, at this juncture in their life, they are both retired. Jack spent more time on his lawnmower and Jill spent more time with her hairdresser than they did with each other.

This is what they did for the next three months, nothing else. Sometimes we have to start from scratch. Relationships, and sex for that matter, are living entities. They need to be tended to and taken care of. They need to change as life situations change. When neglected, disaster happens … sometimes they start to die. And really, one cannot expect a dying thing to just spring up to life and start jigging.

We have a ways to go for Jack and Jill. It took them 30 years to get their relationship to this point, so an overnight success or a magic pill is just not going to happen. With time and care, we hope to get them to liking each other … and having sex eventually.

Responding to Another Blog

Fri, 10 Oct 2008 14:35:35 GMT

Dr. Bruce Campbell had some interesting feedback in his blog, Reflections in a Head Mirror. A reader writes, "As a female I have always worried about passing on a yeast infection to the performing partner, although that never happend to me, it happened so a few people I knew when their husbands came down with a bad case of thrush. ... I would usually get a bladder infection, something I am prone too, after receiving oral sex. After avoiding oral sex, my incidence of bladder infection is way, way down. I really think there is a link, and women seem to have bladder infections a lot."

There was actually some exchange of e-mails from professionals on an Internet community board for ISSWSH (the International Society for the Study of Women's Sexual Health, to which I belong) about a patient who was getting frequent urinary tract infections.

She had the million dollar work-up to rule out stones, reflux, incomplete bladder emptying. Turns out, the patient had a partner who had a tongue piercing. When they cultured the tongue accessory, it came back as the same bacteria that the patient had been growing. So lesson to all of us out there ... yes, oral sex may be the reason a person is having frequent infections. I certianly ask about sexual practices now with my patients who present with frequent urinary or vaginal infections (there are penile piercings, use of vibrators and other paraphernalia as well that needs to be discussed).

As for Dr. Campbell and his response to his reader, I appreciate his candor and honesty. In his defense, physicians (acutally, most people, not just the medical profession) are embarrassed to talk about sex and sexual practices because of the following reasons:

It is still considered taboo in our culture
Frankly, we are not taught how to in medical school
Because MDs don't want to open the patient's pandora's box (affairs, unknown STD's, fetishes ...)
The disease the patient has in front of the treating physician is the focus at that moment
Most MDs are not comfortable/trained/feel competent talking frankly about sex
If there is a problem, most MDs don't have the training to know what to do (especially when it comes to female sexual medicine)
Sexuality and fertility are typically the last thing other physicians think about when they are trying to just save their patient's life

When I talk to other physicians, I tell them to typically just pass them on to our clinic (or to the Reproductive Medicine Center in cases of fertility questions) or at least give the patient our number as a future resource.

This is what we do in our clinic every day. And as much as I don't expect to talk to my patients about their diabetes, high blood pressure or other things, I don't expect other physicians to talk to their patients openly about their sexual habits. There is a difference between asking if they have diabetes or if they are sexually active (what we call screening questions) versus getting into their daily blood sugar levels or inquiring if they masturbate and perform oral sex on a regular basis.

It is improtant for patients and physicians to know that at least at Froedtert & The Medical College of Wisconsin, we have this resource. As an academic medical center, we have that resource and not many centers in Wisconsin or in the United States have a comprehensive program where we treat not just men, but also women.

About Implants

Wed, 03 Sep 2008 11:04:05 GMT

This is a general response to a question posted by one of our readers.

There are many options for erectile dysfunction. Most urologists typically follow an algorithm, starting with pills — the PDE-5 inhibitors (better known as Viagra, Levitra, Cialis), then with either the injection therapy or vacuum device, and then a penile implant when the other therapies no longer work or the patient chooses to have the implant done.

Once the implant is in, the other options will no longer work. (Although sometimes the pills are used for engorgement of the head of the penis, but that will definitely not work on the shaft.)

The implant, like any other mechanical device, will break at some point. The longevity of most implants is upwards of 15-20 years because of better technology and materials. The implants are typically replaceable when they break.

Finally, just a reminder that we cannot dispense medical advice in our blogs, and our goal is to dispense information. Always consult with your physician for specific problems.

The Holidays

Fri, 04 Jan 2008 13:19:59 GMT

The holidays have come and gone. I should hope that we have spent some time with our significant others and nourished the relationships with the people we care about.

Intimacy can mean so many things. And with the craziness of the holidays, there may be more yelling and bickering than kissing and hugging. But intimacy can be as simple as holding hands, a “thanks” for the efforts made to make the holidays special, giving your partner the last piece of pie.

A new year has started, and it's time to turn a new leaf for many people. Resolutions are made. Among the common ones (I, too, am guilty) are to lose weight, eat healthier, exercise more, be more productive at work. Please include:

smile at your partner more
kiss just because
argue less
talk more
praise your partner more in front of him/her and to other people

They are free, have no calories, can actually burn calories, and the results are priceless.

The following is feedback received for this blog:

Love the upbeat encouragment to be found on this blog. Thanks a bunch!!

- VICKI RADDANT

Me and My Blog

Wed, 19 Sep 2007 15:32:23 GMT

My name is Margarita Kressin and I am a practicing urologist at Froedtert & the Medical College of Wisconsin. My areas of expertise are male and female sexual dysfunction and male infertility. I also see women with incontinence and other urinary issues since these affect women’s sexuality immensely. My work involves helping men and women regain, reclaim, and rejuvenate their sexual lives. I also work with spinal cord injured men so that they have the ability to have children.

When asked why sexuality and fertility? I (and some of my colleagues in my department) often feel they are mostly overlooked when dealing with other medical issues. Not to downplay the medical issues such as cancer, heart disease, spinal cord injury, etc …; and I do think that when the patient first hears these words that perhaps fertility and sexuality are the furthest things in their minds. But I also think this is when physicians need to step up and let patients know their options. Many patients will survive these medical conditions, and sexuality and fertility may become an issue in their future.

Sex especially is not something most physicians are comfortable discussing with their patients. I often say to both physicians and patients, this should NOT be a two minute conversation. Physicians as it is do not get adequate sexual education. So how else can they educate and discuss this with their patient?

And so here I am. My colleagues and I hope to educate patients, their partners and physicians about these issues. Please let me know if there are topics that you wish I would cover by clicking on the Feedback link below. If you wish to remain anonymous, please leave your name blank (it is optional) and it will not be printed as part of the feedback.

The following is feedback received for this blog:

Could you please talk about Premature Ejaculation in men and some of the ways in which it is addressed. Thanks

In the second year of our three and 1/2 years of marriage, we discovered my sperm count was low and also the reduced motility. We had a few of my wife's eggs and sample of my sperm studied and none of the eggs were impregnated.

I am 39, almost 40, and my wife is 36 and has always dreamed of mothering our own children. What does acupuncture accomplish, Omega-3, which foods are helpful, we exercise reasonable, ride our bikes ... Is there still time after Jun08 to slow down, meditate, and are we still young enough to continue with this expensive approach to conceiving a healthy child? Thank you!

I had a penile implant done 16 years ago prior to the new medications. The implant lasted 13 years and now no longer works. Pills dont really work for me now. Are there any options?

Hiding the Underwear

Wed, 27 Aug 2008 13:27:08 GMT

A funny conversation happened today in the clinic. It started out as my colleague and I discussed how when we see female patients we need more time so we are not able to see as many women as men.

We often have to step out to let the female patient undress, bring in a nurse to assist, set her up for a pelvic, and step out again to let her dress. We typically ask men to just lower their pants and underwear.

And then the observation: women have to fold their underwear neatly and tuck it in her pants or skirt. Physicians are not allowed to see this ritual. But almost all women know this curious behavior. My colleague states, “It doesn’t matter that I’m about to see everything, I’m not allowed to see her underwear.”

Men on the other hand, don’t seem to care. Even when we step out and let them wear a gown, the underwear just lies there. No folding, no tucking. They don’t care who sees it.

Why is that? What are we hiding? Are we embarrassed? I have no answer, but just observing another interesting difference between men and women.

Don't Walk Like a Bear

Mon, 18 Aug 2008 16:21:19 GMT

Kirk, a 20-year-old college student walked into my office. I was the fourth urologist he had seen. He has symptoms that are similar to having a urinary tract infection — frequency, urgency, some burning, and pain “right were you sit” at the end of his shift as a security guard. He also had some pain with intercourse, but only with certain positions.

The previous three urologists had worked him up as a urinary tract infection, as appropriate — checked his urine, cultured it, looked inside his bladder, and got a CT scan to check for kidney stones. All were negative. He was given antibiotics, but that didn’t really help.

So he was sent to me. After going through all of his symptoms and history (again … the patient, as you can imagine, is quite frustrated at this point), I diagnosed him with pelvic floor dysfunction.

Since then, he has been working with our pelvic physical therapist and some of the things we found:

He doesn’t use his abdominal muscles.
He overworks his pelvic floor.
He walks like a bear (confirmed by his friends as it turns out) which means he doesn’t use his pelvic, hip, abdominal, and back muscles correctly every time he walks. Just imagine how often one walks.

Unfortunately, Kirk is not unusual. Many men carry the diagnosis of pelvic floor dysfunction but don’t know it. For one thing, if you put “pelvic pain” as a diagnosis, it only refers to women (in our big book of codes). As if men don’t have a pelvis.

Women are very aware of their pelvis — between the pelvic exams, pregnancy, knowing and performing Kegel exercises, and incontinence and prolapse issues — oh, let me tell you, women know they have a pelvis. They may not necessarily be treating it correctly either, but at least they know they have one.

So, this is a call to all men. I work with our own pelvic physical therapist at Froedtert & The Medical College of Wisconsin, and several others around town and the state and here is a call to men to be their own advocates for pelvic floor health:

Know you have pelvic floor muscles and a pelvis
Pelvic floor muscles are important for continence (to prevent urinary leakage) and sexual function
Pelvic floor muscles may be involved in prostatitis, lower urinary tract symptoms, and groin pain.
Know what Kegels are; do them correctly; don’t overdo it.

* Thanks to Debbie and Sherese from The Continence and Pelvic Wellness Clinic for sharing their article with me.

I've Lost My Libido

Wed, 10 Oct 2007 09:23:46 GMT

I’ve lost my libido, have you found it?

One of my friends (let’s call her Barb), came to me one day, distressed, crying, that sort of crying where the mascara is running, shoulders are going up and down, and you're gasping for air. I could barely make out what she was saying ...

”Chris ... (gasp) divorce ... guggghh ... no sex ... sob … (gasp) his needs ... snort ... one year.”

Chris was her husband, and I think he wanted a divorce, that much I could figure. I’ve stopped guessing what friends are trying to tell me. They know what I do, and lately, all bets are off when it comes to what they confide in me.

After a cocktail, a box of tissues, lots of hugging, she finally uttered a complete sentence … well several.

“Chris wants a divorce. We haven’t had sex in a year and he finally broke. He said he has needs. What am I going to do?”

Barb was 45, a mother of three, two dogs, a cat. She was a nurse and up until now, had what I thought was a loving, close, and still sexual relationship with her husband that I wished to have at her age.

“What happened to afternoon delight on Sundays that you told me,” I asked.

“All lies. I couldn’t tell anyone we weren’t having sex. I can’t tell anyone I don’t even feel anything sexual towards my husband. I love him though. Isn’t that strange?”

Actually, not really.

“Help me,” she pleaded. “Why do I feel this way? I used to want to have sex, you know. Now, not so much. What can I do?”

Barb’s story continues in subsequent blogs, though the name may change …

The following is feedback received for this blog:

I sympathize with both people in this sex-starved relationship, but I identify more closely with poor Chris -- because for nearly three years now, I've been walking in his shoes. Sadly, I know all too well what it feels like to have physical and emotional needs that go unmet and unfulfilled.

Back in 2005 my wife lost her ovaries due to illness, and along with them she lost her once robust interest in sexual intinacy.

Since then, sex has been infrequent at best -- on average, just once a month or so. Moreover, once passionate lovemaking has given way to mechanical, and largely emotionless sex grudgingly offered up to placate me.

I find it extremely difficult to feel good about sex when my wife dispassionately instructs me to "Hop on and just get it over with." Under these conditions, it's hard for me to respond, let alone maintain an erection.

The fact that a robust sex life is a normal, health and wholly necessary component of a successful marriage seems entirely lost on her. She deals with the situation by rationalizing that my sex drive is abnormally high, rather than confronthing the fact that hers is abnormally low.

Because of my wife's breast cancer history, she can't have estrogen replacements, and testosterone therapy has been largely ineffective in restoring her flagging libido. Surely there must be some treatment that will restore the loving, passionate partner I married some 13 years ago.

- Kiernan

If you don't use it....

Thu, 24 Jul 2008 11:37:56 GMT

When I counsel patients and couples or give talks, I always say that we have a saying in urology: If you don't use it, you lose it.

I am specifically talking about erectile dysfunction. There is just no other way to get that kind of blood flow to the penis except having an erection. I also ask patients about morning erections, given that they are a good indication of erectile function.

That being said, I am attaching an article from US News and World Report. This was a Finnish study by Dr. Juha Koskimki, from Tampere University Hospital's Department of Urology:

http://health.usnews.com/articles/health/healthday/2008/07/03/lots-of-sex-may-prevent-erectile-dysfunction.html

To borrow from Nike: Just Use It.

The following is feedback received for this blog:

I can say from personal experience that this is absolutely true. Erection quality suffers as a result of disuse.

Many men are conscientious about conditioning other parts of their body, so, why not their penises?

- Kiernan

What a Difference 30 Minutes Makes

Thu, 31 Jul 2008 13:28:13 GMT

Here’s the story:

Jack meets Jill. They fall in love. They get married; start a family. She stays at home to take care of the kids and the home. He goes to work and tries to provide for the family. They prosper. They continue with their roles. At some point, they start to lose touch. She buries herself in making the home, raising responsible children, participating in her own activities (PTA, book club, gardening …). He consumes himself with his work. He spends more and more time at the office. He spends more time with his co-workers and his secretary than he does his wife. He comes home exhausted, with nothing else to give.

The kids grow up. They leave the home. One day, our couple realizes they are home alone … together for the first time in 20 years. They look at each other. They have no idea who this person is. Worse, they have some resentment towards each other.

They come to the clinic wanting to revamp their sex life.

How does our medical team approach our couple? Stay tuned.

Making Time

Mon, 07 Jul 2008 16:37:39 GMT

It can be very easy to take your partner (spouse, significant other, fiancée, boy/girlfriend) for granted, especially if you have been together for a long time (what that time frame is can be very different for everybody). One way this can happen is the time we spend with said partner becomes shorter as other people, events, life, take place.

The reason I am discussing this is that some patients wonder why their sex life is starting to diminish. When asked about their history, they often have kids, work (sometimes more than one job), and are involved in countless activities — whether it be their kids' activities (soccer moms) or their own (book clubs, PTA, etc...).

I too am guilty of this phenomenon. I find myself spending Sunday morning with my friends for coffee since my husband is typically working on the house. However, we make sure we have date night once a week. We have the luxury of not having children. I have patients who have to work two jobs to support themselves or have three children under the age of five.

It takes a lot of effort to spend time with your partner, however, it doesn’t have to be fancy or expensive or particularly long either. Take five minutes before going to bed to talk to your spouse. Dinner time (or any mealtime, as long as you guys are together) even with your kids can be a time to share your day. Instead of the next hair cut or golf game, pencil in your spouse.

You need that connection to keep a relationship, you need that connection for sex. You need time to make that connection.

The following is feedback received for this blog:

Well put.

- John

Vaginas are Like Snowflakes

Tue, 27 May 2008 13:17:16 GMT

There is a trend in California with women getting labioplasties to make their vaginas “prettier”. The International Society for the Study of Women’s Sexual Health (ISSWSH) does not condone this practice. These surgeries are cash-pay typically, like any other cosmetic surgery. The women bring in pictures from Playboy, for example, and have the surgeon copy the vagina in the picture.

There are only two real reasons labioplasties should be performed, in my mind: women who have to self-catheterize, and when it starts to interfere with sexual penetration. Sometimes the lips do get caught if it is quite copious when the catheter is inserted, or with the insertion of the penis, the labia get caught resulting in prohibitive or painful sexual intercourse.

The vagina should be wrinkly and bumpy with folds and nooks and crannies. No two are exactly alike. And remember, you need to look to know your own wrinkles and bumps and folds and nooks and crannies.

Sex Ed Begins at Home

Fri, 09 May 2008 11:13:14 GMT

I don’t really know exactly how I knew what I knew about sex when I was growing up. I had one of those classes in 5th grade on sex ed. The boys went to one side of the school; the girls were gathered on the other side in several classrooms. We talked about having your period, the difference between girls and boys, but they actually did not really talk about sex or sexual response.

My mother pretty much delegated what I needed to know regarding my sexuality and sex in general to the schools. I think the parents of today are doing a better job, I hope.

I do encourage my female patients to have a conversation with their daughters regarding their bodies. I hope they do tell their daughters to look at their genitals. That it is a body part and like any body part needs to be looked at and maintained. I hope they tell them that sex is a wonderful thing. It is not in and of itself sinful, ugly, a bargaining chip. Sex should not be painful, coercive, manipulative, or forceful.

Sex is a beautiful thing when shared by consenting adults. It’s about giving (and receiving). It is fun and exciting and considerate. It should bring people together and not tear them apart.

Talking about sex does not mean nor does it give our young people permission per se to try it. It is simply information and knowledge. And it is better that they get this information from the parents than misinformation from peers.

And Then There's the Cat

Thu, 24 Apr 2008 16:47:14 GMT

(A follow up to the dog analogy and what not to do)

I also have a cat. And as much as I love this cat, it is quite a bizarre kind of relationship. First, I don’t think the cat has really accepted me. He was my husband’s cat, and I felt like I was, and still am, a visitor in his world.

My dogs are rescue dogs adopted when they were both around one-year-old; so it’s not like I raised them from birth. And yet, they attached to me instantly. My older dog met my husband when she was 10, and she is definitely daddy’s girl. So, I think it’s the cat …well ... just being a cat.

The cat meows when he is hungry and stalks me until I feed him. Otherwise, I actually don’t see the cat much. When I come home, I have to call for the cat to see where he is. Sometimes he comes, more often he doesn’t. He shows up and meows during dinner time, though.

He only has 4 teeth so we feed him wet food. But he won’t eat the food if it’s been sitting around and dries up a little. So he typically meows every 2-3 hours since we give him a little food at a time. He's very demanding. When he’s done, he disappears again. No acknowledgment; I feel so used.

He always tries to escape by trying to go outside every chance he gets. He is completely declawed so he would be defenseless. And so we try to protect him, but he clearly does not seem to know that. We are his warden and he must escape.

Worse, we are his servants and must serve him at his beck and call.

He is not a snuggler in general, which I hear is typical for most cats. However, he comes to our bed to “snuggle” around 3:00 am by putting all of his 10 pounds of weight on the one little paw that is pressing on my bladder. (Every time, every single time. I don’t know how he knows to target my relatively full bladder, but he does. And I think he does it on purpose.)

So, don’t be this cat to your partner. Don’t be demanding. Don’t just disappear and then show up at dinner time. Don’t try to escape as if you don’t want to spend time with your loved one. Come and greet them when they come home with enthusiasm. Your partner is neither your warden nor your slave. Know when to shut up, know when to acknowledge a good deed, and know when to give a snuggle at the right time.

Good Boy

Mon, 14 Apr 2008 10:12:52 GMT

Goo’ boy, oh what a goo’ boy!

I read somewhere:

Greet people like you would your dogs.

Can you just imagine what kind of a world this would be if we did greet each other this way? Dog owners and dog lovers right now are smiling. Think about it. Unadulterated, uninhibited, unconditional love.

I made a vow that I would greet my husband this way once a week.

Hi Honey Love! How you doin’?! Come here, come here! Who does momma love?!

(Mind you, these are phrases I totally use to greet my two dogs — with a voice easily an octave higher than my speaking voice.) The first time I did this, my husband looked at me like I was crazy. (A look I am quite used to, by the way.) Since he is accustomed to me doing some bizarre experiment or behavior from time to time at home, he responded:

And how is my little girl … did my girl have a good day?! Who’s your daddy?!

We just started cracking up. I explained what I was doing. I got the “you are so certifiable” look again. But I didn’t care. I could feel the tension drop from both our shoulders. He shook his head, but I knew this technique worked in bringing us closer.

I still do it, and every time, without fail, he starts smiling; we laugh; the day is better.

They say people who own pets live longer, happier lives. Dogs in particular have a way of wearing their hearts on, well, their wagging tail. Theirs is a love that is given without preconceived notions, without judgment, unqualified, unreserved, absolute, enthusiastic, a whole body response. The next time your partner comes home, greet them the way you would your dog. Welcome them the way your dog would. Shake your booty; jump up and down; heck, go ahead and lick them. Give your partner that love that dogs have perfected.

The following is feedback received for this blog:

Margaret,

I love your blog! You write about your topics with such sensitivity and humor - definitely makes me want to read them all! I've added this site as one of my favorites - I will smile every week when I read them! See you soon!

- Jody Breckenridge

The Metric System

Tue, 01 Apr 2008 13:28:29 GMT

You’ve all heard of the metric system and it’s conversion to the English system and vice-versa.

1 in = 2.54 cm
32ºF = 0ºC
1 oz = 29.6 ml

Well, apparently there is another one:
35 lb = 1 in

What does this mean? How does weight convert to distance?

This is the conversion of the amount of weight gained and apparent loss of penile length.* And conversely, amount of weight lost and penile length gained.

I’ve heard Dr. Oz even mention this during an episode of Oprah. I’m not even sure where this conversion exactly came from. I actually tried to look for the original study or paper that came up with this. The crux of the message is with weight gain, penile length decreases. Obviously, there are limitations. One can only lose so much weight (losing 210 lbs, does not gain you 5 inches of penis), and this really only applies to heavier men.

The reason this is brought up is twofold:

Men seem to want to know how to increase their penile length.
And not to prejudice against heavy men, but to point out another potential downside of gaining weight.

The penis is at a fix point. So when one gains weight, the area around the penis grows engulfing the penis. So as men get heavier, their penis appears to get smaller.

One more thing to add to the scourge of obesity — a smaller penis.

3:00 p.m. - Sex

Fri, 21 Mar 2008 10:54:39 GMT

I just glanced at my calendar for this week and am amazed at how I’ve somehow scheduled meetings, dinner, appointments, a talk, pet nail clipping, and an oil change in one week; besides the fact that I work between 50 to 60 hours per week.

I marvel at my friends and colleagues who have kids. Their calendars are splattered with lessons, games, and doctors' appointments on top of their own agendas. (And people wonder why my husband and I don’t have kids yet; but that will be a future blog entry.)

Our lives, in general, seem to be filled with so much stuff. With better technology, we are able to do things more efficiently. This gives us permission to, in turn, cram more things into our busy lives more and more each year. And so we have to schedule things or else they won’t get done: grocery shopping, trips to Target, doing laundry, coffee, and, oh yes, sex. I tell my patients to schedule sexual activity and/or intimacy. We all have to if we want to keep the relationship going.

Some may argue that this way loses spontaneity. There is no romance, no surprises. Actually, there can be spontaneity and romance and the element of surprise — a bit like organized chaos. For example, the time and date may be scheduled, but what you as a couple do may completely be a surprise. I suggest taking turns planning the intimate activity. Sexual intercourse need not be the planned event. Watching a movie, sensual couple’s massage, necking (yes, making out, macking, fooling around, what else do people call it nowadays?). This is also why date night is very important to couples, to maintain intimacy.

Also, given the choice, would one rather have scheduled sex (or macking or massaging) than not have it at all? The next time you right down the next meeting on your iPhone or Palm, think about when you last had an intimate moment with your partner. If you can’t remember or it’s been too long, then put it in your schedule.

Just Look

Fri, 29 Feb 2008 16:10:13 GMT

OK, people. I have said this a million times in my clinic and am appalled at some of the responses, so I am telling the world (or at least the people who read this blog). PLEASE LOOK AT YOUR GENITALS.

If you have to think when the last time was that you looked, it’s been too long. Once a month is all I ask. Like when you do your breast exam or inspect your testicles — which you should be doing once a month. (I can see some people cringing since they don’t do these either.)

It seems so logical, so easy. For the guys, bend your neck. Whoop … there he is. Pull back the skin if he is not circumcised. Inspect. Is there anything new, anything that does not look right? Smegma? No? All done. If there is something funky, call your doctor.

To the females in the house: grab a mirror. No one is that flexible. Look. Anything new? Red? Discharge? If you have a question, ask a physician if this is normal.

Now we do this LIFELONG. This practice will detect abnormalities earlier, prevent unneeded surgeries (like dorsal slits or circumcisions for guys who can no longer pull the skin back), notice changes, and identify lesions, tumors, etc …

This is not gross. It is good practice; hygiene even. It is just a body part. A body part that sadly gets neglected. So please look and make sure it’s OK. It literally is good for you and your health. Just look.

Just Be Nice

Tue, 19 Feb 2008 08:28:51 GMT

My nurse came out to me after she finished explaining instructions for a test to a patient.

Joan says thank you and then she says, "It’s so nice to be in a place where people listen and are nice."

I look at my nurse incredulously.

Reasons why Dr. Kressin would have an incredulous look after such a comment:

As if to say, how else should we treat a patient?
What else should the patient expect from a doctor, or another person for that matter?
Where are these patients coming from since this is not the first time someone said so?
How exactly are these patients treated in the outside world?

We are not patting ourselves in the back. I don’t think we treat one patient differently from the next. Granted, we do treat patients that have complicated, long-standing, and embarrassing issues. And there are days when I pray, "Please grant me the serenity to ..." But it’s just patient care. When did that change?

A fellow physician came up to me one day. I apparently had treated his wife.

You were the first person to let her talk without interrupting. She has been blown off before thinking that this is all in her head. Thank you.

In my field where we talk about private body functions, sensitive topics, and catch patients at their most vulnerable, there is little room for rudeness and arrogance. We, as physicians, should remember a basic rule in life. Just be nice.

If You Don’t Play the Piano …

Fri, 08 Feb 2008 11:19:35 GMT

I do think that there is a range of sexuality. Much like anything else out there, I think sexuality has a huge gray area and not so black and white. I have met women who are what we like to call “high T” women or high testosterone women. Samantha from Sex and the City comes to mind as an archetypal representation. Then there are those that think sex is good, but consider themselves not very sexual in general.

Why do I bring this up? It seems that there is a belief that perhaps our clinic can change one’s tendencies. As my chairman says to his pre-prostatectomy patients (these are men about to undergo prostate surgery for prostate cancer, and generally they have questions regarding sexual function after the procedure): if you don’t play the piano before the surgery, you ain’t gonna play it afterwards.

Now there are women who are by nature sexual and who for whatever reason — whether it is their partner, health reasons, psychosocial changes — change their habits. We also find that these are the women who are devastated when their sexuality is diminished because of the aforementioned factors.

Then there are those who in their nature will never be very sexual. There is nothing wrong with that but it is an unfair expectation to think that we can change that. Another way to put it is this: You know how there is always one person in your department or office who is always funny and witty and whatever comes out of his/her mouth is always catchy and hilarious and people gravitate toward him/her? They grab attention, because they have that inherent quality. I would like to be that person. I will never be that person because it’s not in my nature. As hard as I try (and there are days when I am darn funny), I will never be that kind of person. One of my partners is like that, so is one of our chief residents. It’s part of their personalities, and they don’t even have to try. I can take lessons on how to tell a joke or story-telling, but I will never reach that kind of natural repartee.

I don’t mean to imply that if women are not happy with their sex life they should just accept it. I emphasize the importance of getting checked especially if this is a change they have recently noticed. I just want to put forth a realistic view of sexuality and of what the medical community can do. There is definitely better living through chemistry. But I have yet to find a pill that will make me play the piano.

George and Harriet

Mon, 21 Jan 2008 12:53:29 GMT

Recap: George and Harriet are a happily married couple. They have not had sex in 5 years and George one day brings home the little blue pill. He expected sex to just happen. Harriet is apprehensive and scared. They try to have sex and it was miserable. Now there is tension and they haven’t brought it up again. That was six months ago.

At George’s follow-up appointment, he explains the situation.

I explain to George that sex at 60 is very different from what it was in their younger years. It may seem obvious, but many men think that they can pick up where they left off when it comes to sexual activity. And some couples may have not have had sex for many years because of different reasons. To assume that sex will be as it was in their 20s or even in their 40s is an unfair and unrealistic expectation.

I explain to George how women are different from men when it comes to sex. Again, it sounds intuitive, but understanding the differences can bring to light an already complicated and confusing process.

I asked George to bring Harriet to his next appointment. More importantly, I schedule an appointment with the sex therapist alone and then together as a couple. Sex therapy is good for everyone. It is not necessarily marriage counseling (although obviously, topics regarding the marriage are touched on), but more on sex therapy. Sexual communication is also explained and techniques are taught. Sexual communication is distinct and different from other communication, and it is a skill that most people need to learn. It is also a skill that is easily ignored. Marriage counseling also does not necessarily touch on sex. So there is benefit in seeing a sex therapist.

Next I see Harriet alone and discuss with her her needs and issues. Then we all come together and come up with a sexual plan. There is no pill to make this all better. It requires communication and work from the couple, and it may take weeks to months to get them to their goal. But it is doable.

After the appointment, George and Harriet are getting on the same page. They are not there, yet. They require continued work with the sex therapist and follow-up visits with me to teach them techniques, and progress is made slowly.

At the end, it is their goal as a couple and a revival of their sexual relationship that is accomplished.

Benetton Commercial

Wed, 16 Jan 2008 08:30:23 GMT

My friends and I gather at Alterra at the Lake on a cold Sunday morning. We try to get together at least once a month, to catch up —what everyone has been up to since the last coffee klatch, who had a bad date, who is on the road to date number two, who lost weight, who gained weight, what’s going on at work, who hates their job, what is going on with our significant others and our pets.

We are arguably the most animated table in the coffee shop, hands are flying, the laughter is infectious, three conversations going on at once, coffee cups with varying degrees of consumption decorate the table. The energy is palpable.

We are quite a sight I’m sure; a veritable Benetton commercial. We have a red-head, two blonds, several brunettes, a straight Catholic guy, a gay Jewish guy, a married Asian girl (that’s me), two Lutherans (Missouri and Wisconsin synods both represented), an Episcopalian by marriage, a born-again Christian.

Republicans and Democrats break bread together. Four of us are married, four singles, several of us have children (one human, seven canines, three felines, and there may be a hawk thrown in there somewhere), one actively dating, one pining, one in a new relationship, and one recently broken up.

There are two doctors, a nurse, several computer-somethings or other, several in sales and marketing, an ex-real estate mogul, and a straight opera singer from New Jersey.

The conversations flow continuously, and we hit one person at a time covering the recent event in our lives.

At any given point during this soiree, the one constant that is always a topic of conversation is sex. It may be a casual, short, to-the-point question: Did you get any? It can be deep and borderline philosophical: When does the line between friendship and love blur, and does it necessarily involve a sexual relationship?

It also never ceases to amaze me that it doesn’t matter whether we are single, married, gay, straight, in or out of a relationship, there is always a sexual question, a titillating controversy or intrigue, a carnal pearl to share.

And so to my coffee klatch friends, this is my ode to you.

What I have learned about sex, I learned from my friends:
I am blessed to have them.
They come in different shapes and sizes.
Religion and politics can mix.
You need to keep the connection constant.
You sometimes have to schedule them.
It takes work to make them happen.
You make them a priority.
Sometimes you need to be encouraged and sometimes you do the encouraging.
Sometimes chemicals are involved (coffee, chocolate, alcohol, Viagra …)
Sometimes they get sassy, sometimes they are sweet and gentle.
Sometimes you are the active participant, sometimes more passive.
Although it can happen, it is rarely a dull moment.
When life gets busy and you don’t make it to a meeting one time, you try and try to make it to the next.
You need to be flexible, both in the true and literal sense of the word.
There may be tears or laughter involved.
There may be some apologizing.
There may be some screaming.
There may be praises and clapping and pivoting.
And, finally, even though you don’t feel like it and you have a million things to do after, the benefits achieved from participating are priceless.

I Feel I Have to Inform You ...

Tue, 04 Dec 2007 13:58:39 GMT

I recently caused an uproar in my clinic. I was seeing a young woman, I will call Irene, who was having urinary issues and part of her complaints was external vulvar burning. We go through the usual evaluation: history, physical, meds, habits.

I then asked if she douches, which women should NEVER do. The vagina is a self-cleaning oven. One does not need to flush stuff in it to get it clean.

No, but I do use soap to wash down there?

Oh, no, no, no.

The vagina’s pH is acidic (about 4) and most soap is basic (anything above 7). At best they are neutral (7).

You must have a base, or caustic solution to make soap. The two most common caustic solutions in use for soap making today are sodium hydroxide (lye) [NaOH] and potassium hydroxide [KOH], both bases.

Here are some sample pH values:

Soap	pH
Camay	9.5
Dial	9.5
Dove	7.0
Irish Spring	9.5
Ivory	9.5
Lever 2000	9.0
Palmolive	10.0
Zest	10.0

Irene, as well as the nurse and nursing student following me in my clinic, were surprised with this fact. They were all using soap in that area; as do the majority of our nurses and patients, I am coming to find out. In essence, they are going against the natural way the vagina keeps itself healthy by counteracting the vagina’s pH and neutralizing it.

I normally do not endorse any products, but since I told you what NOT to use, I should at least give alternatives. Plus, when I showed this article to some of my co-workers, they all wanted to know what was safe to use.

Summer’s Eve for sensitive skin and Sweet Spot Brand (Small Stones, a Froedtert & the Medical College of Wisconsin health resource center, carries this one). We actually tested these products with pH paper in the clinic and the pH’s came out to 4, which match the vagina.

So ladies, please, please, please do not use soap to clean the vaginal area. Tell your mother, sister and friends not to use soap. Water is good enough. If you must, for whatever reason (habit, fear of odor, just want to), use soap, there are pH-balanced (to the vagina, not just pH-balanced, as in, neutral) products out there.

Also, if there is truly a smell that is quite offensive, I would consult your doctor as this may be a medical issue.

The following is feedback received for this blog:

The article about soap was really surprizing! I will forward it to my girl friends. Thank you.
- Kathleen T.

I never heard of this before. I wonder if this would help some VV patients. I'm going to add you to my site. Thanks!
-- Lauren Kunis
www.vulvodyniasupport.com

Re: 'I fell I have to inform you'. Who ever knew?! Dr. Kressin's information re: the PH of soap is fasinating and clearly makes sense. Gardeners know that the soil PH needs to meet specific flower requirements to provide vibrant, gourgeous, long lasting flowers. Ladies, we are so much like flowers. Dr. Kressin's PH insite, I'm sure, will help my husabnd and me. thank you Dr. Kressin!
- E. Lauren

A Different Measure of Heart Health

Fri, 21 Dec 2007 10:45:15 GMT

A penis is not just a penis.

One of the things that was covered quite comprehensively at the Sexual Medicine Society of North America meeting I recently went to was the topic of how erectile dysfunction (ED or when a man can’t get an erection) can be a marker for cardiac disease. Let me explain:

There is a huge association between ED and coronary heart disease (CHD). We know that CHD is a marker for ED and consequently, ED is a predictor for future CHD especially in younger (40s) patients. One study that took into account the age of the patient when he develops ED showed that if you are young (40s) and have ED, you have double the risk of having CHD versus if you are older (70s) when you develop ED.

We know that there are common risk factors between ED and heart disease such as:

Age >40
High blood pressure
High cholesterol
Diabetes
Depression
Obesity
Sedentary lifestyle (couch potato)
Smoking

So, the message is if you have any of the above, you have a greater chance of developing ED. And if you have ED, you need to make some lifestyle changes or at least get checked to prevent heart disease. On the plus side, if you are healthy, and prevent the development of the above conditions, your risk of developing ED and CHD is lowered. So yes, it’s a bit simplified, but the penis is a measure of cardiac health.

FSD — In a Man's World

Thu, 13 Dec 2007 13:53:05 GMT

I came from a meeting this past weekend in Chicago of the Sexual Medicine Society of North America (SMSNA). It was a very good meeting, and I learned a lot of new things that I can incorporate in my practice.

What was interesting, and one of the speakers did make an observation of it, was that Female Sexual Medicine was not well-represented. Case in point, the meeting started on Thursday at 1:00 pm and went until Sunday at 12:30 pm. Essentially four days of sessions — mostly on male sexual medicine. The lecture on female sexual dysfunction (FSD) went from 9:00 to 9:30 one day as a debate. The debate was whether FSD was relevant to the ED (erectile dysfunction) specialist? There is nothing wrong with this question. The problem is that even the FSD session is linked to a male question. Even the topic of Circumcision for the Prevention of HIV was given a whole hour.

There were also six poster sessions, and one was at least delegated to FSD. Don’t get me wrong, I love treating my guys as much as my women. And they do have issues themselves (some of which will be covered in the next few blogs. Don’t worry I haven’t forgotten about Harriet and George.) that should not be ignored. But it just shows that women, female sexual health specifically, has a loooong way to go.

One may say, "But you have ISSWSH, the International Society for the Study of Sexual Health." And thank goodness for that. My point was that this is the SMSNA, not the Male SMSNA. Or maybe the meeting should be changed to that name.

Again, I was glad I went and learned a lot. I just couldn’t help noticing the disparity in the representation of female sexual health. And, unfortunately, I don’t foresee it changing anytime soon.

Harriet's Story

Wed, 28 Nov 2007 10:42:00 GMT

This is Harriet’s story.

"I am a 58-year-old woman, with a great husband, four kids, seven grandchildren. I love being retired with my husband: we golf, we dance, we cook. Life is wonderful.

"Then he comes home with the little blue pill. What the devil?! I thought we had an understanding. We haven’t had sex for the last five years. We used to have a fulfilling sex life, and I did enjoy it. But after menopause, I just lost interest. He stopped asking after a while. Our life, I thought, was fulfilling enough.

"And then he messes it up by bringing home this pill. I don’t even know if this will work. I don’t know if I’ll work. I’m scared, I’m confused. I think he actually wants us to have sex tonight."

The story continues …

Honey, Look What I've Got

Mon, 12 Nov 2007 11:48:48 GMT

This is a very common scene in my office. A man, about 65, comes to the office — let’s call him George — and during our conversation he is asked about sexual function. He says that his erections are no longer the way they used to be, and they don’t last as long anymore. When asked when the last time they had had sexual intercourse: "Oh, maybe 6 months ago. The Mrs. is not that interested."

I asked if he would like to try some PDE-5 inhibitors (Viagra, Levitra, Cialis). So he is given some samples, a prescription, and he goes home.

I see him six months later, and I asked how the sexual activity is going on at home. He says he tried the pill once, and he hasn’t filled the prescription.

Did it not work? Was it too expensive? Were there terrible side effects?

Let’s wait for his wife’s (Harriet) view on the subject.

Love Comes Quickly

Thu, 01 Nov 2007 11:05:25 GMT

Fred came into my office quite distressed. He was in a new relationship and things were progressing well. He and his partner have decided to take their relationship to the next level. Just as things were getting hot and heavy, a scene reminiscent of a particular moment in American Pie happened — without the video camera and the whole student body watching.

It’s never happened to me before. I didn’t do anything different or crazy. We tried again later and it happened again.

Premature ejaculation. It is a common condition which can be caused by both psychological and biological factors. Treatment is therefore achieved best with medication and psychological and behavioral intervention.

In this particular case, the condition resolved by itself after the patient settled into the relationship and his anxiety abated. It certainly helped that he had a partner that was open, patient, and non-judgmental. In the process, they learned all about sexual communication ... that’s a story for another time.

Magic Potion

Tue, 16 Oct 2007 13:38:37 GMT

I recently saw my patient, let’s call her Emma. Emma has been on my “magic potion” to try to restore her libido and restore sexual function.

Like some of my critics, she was skeptical at first. After all, it had been close to 15 years since she felt the “urges,” she calls it. Sex has become a duty and a job and could these meds really help her?

I asked her how things are going. She smiled, rather sheepishly. “I think … I felt horny.” (Rockstar!) But then she started crying.

Were there bad side effects? Did you have trouble with the drugs? Was it too expensive that you can’t afford it? Was your husband not happy? Oooh ... I struck a nerve.

“He thinks I’m cheating because I tried to initiate sex. He’s so angry. He thinks I’m addicted to sex.”

Like most magic potions, there could be good and bad consequences that happen. We usually deal with physiologic side effects with most medication. I always say that women have a mind/body approach to sex, so with the treatments, relationship and emotional side effects may happen.

I referred Emma (and her husband) to our psychologist for counseling and they are on their way to healing. Sometimes, all it takes is the Princess and Prince Charming for a fairy tale to happen. But sometimes, we need seven dwarfs, a fairy godmother, or a talking donkey to have a happy ending.

Housekeeping Duties

Tue, 02 Oct 2007 10:32:25 GMT

One of the duties I have working in academics is teaching the community and my fellow physicians about what I do: sexuality and fertility.

This is something I love to do. Luckily for me, these topics trigger interest in most of my audience, and I can usually capture and keep their attention for the hour that I have them. Falling asleep and yawning is not accepted!

I often ask if there are questions at the end of the talk, and understandably, most don’t ask questions, but people do come up to me at the end, individually.

Sex and fertility (or lack thereof ...actually), after all, are sensitive subjects. We also don’t want to reveal our insecurities, difficulties or perhaps unusual practices out in public.

That being said, I have been asked by our computer gods to tell you that the e-mails and feedbacks are not encrypted or blacked out; therefore, names are printed when I get them. Unless you want to be identified, we suggested not leaving your name.

Also, I will try to answer questions posed (which I have enjoyed receiving and reading), understanding that I cannot do this all the time. I will use the feedback whenever possible as subject matter for future blog entries, but the answers will remain rather general so as not to reveal people’s identities.

Nothing in this blog is intended to be specific medical advice for any condition. Please see your own doctor for specific questions.

I thank you for your interest and your questions.

How Much is Your Orgasm Worth?

Mon, 24 Sep 2007 16:02:14 GMT

When I was doing my fellowship in Los Angeles, a patient came in (let’s call her Anna) who has never had an orgasm in her life. She certainly was quite distressed about it the older she got, and the more she and her girlfriends talked about it. She felt she was missing something. She was married with two kids, a loving and supportive husband, and quite successful professionally.

Anna had some abuse issues in the past and made some relationship mistakes. She had her meeting with our psychologist who found out other psycho-social issues that could be contributing to her problems. She was told to continue counseling with the psychologist.

She then saw my mentor and me. She exercised, ate healthily, and was a picture of health. She underwent nerve testing as well as blood flow testing, and we found her sensation was somewhat deficient.

She then saw our physical therapist to deal with her pelvic muscle to see if this was contributing. They were normal.

We then sat down and gave her the news. Some psychological issues needed to be worked on and, unfortunately, there was nothing to attribute to her decreased sensation. There wasn’t a magic pill we could give her to make the orgasms happen.

After explaining to her that up to 25 percent of patients do not orgasm*, one, she was surprised; and two, she was willing to do anything to not be in that 25 percent.

She was surprised since everywhere she looked — TV, magazines, movies — everyone seems to be having orgasms … and in concert with the guy! If everyone is doing it, why can’t she?

Our clinic in Los Angeles was a self-pay clinic**. Her bill was $2,600. How much are you willing to pay to find your orgasm?

* Paik A & Laumann EO (Chapter 2.1) Prevalence of women’s sexual problems in the USA. Goldstein I, Meston CM, Davis SR & Traish AM Eds. Women’s Sexual Function and Dysfunction. Abingdon: Taylor and Francis, 2006;23-33.

** Many clinics in California are turning into cash pay because of the HMO environment.