Impotence (Erectile Dysfunction)

“My brain? It’s my second favorite organ,” says Woody Allen in Sleeper.

For many men, like Woody, a properly functioning phallus is fundamental to their self esteem, says Dr. Alain Gregoire, Consultant Psychiatrist and Senior Lecturer at University of Southampton.

The proper functioning of this organ depends on many factors – internal and external -and now chemical with the advent of Viagra (sildenafil).

Sexual function and satisfaction have many components: desire, erectile function, orgasmic function, ejaculation, and fertility. About 20 percent of men have problems relating to one of these functions.

Erectile dysfunction (impotence) is the most common complaint and the most distressing of all complaints related to sexual function and satisfaction. It can destroy a man’s ego and threaten happy relationship.

Erectile dysfunction (ED) affects 52 percent of men aged 40 to 70 years and is estimated to affect as many as 2 to 3 million couples in Canada. Many men suffer in silence and less than 10 percent of men seek medical treatment.

Now, Viagra (sildenafil) has brought the whole problem “out of the closet.”

Normal erectile function is initiated by body’s five senses: touch, sight, smell, taste, hearing and by imagination. This results in increased blood flow to the penis followed by erection.

Many medical and psychological conditions can impair erectile function. Some of them are: high blood pressure, diabetes, kidney failure, and diseases of the nervous system. Any chronic illness can have a negative effect. Several medications can do the same.

Viagra is now available in most Medicine Hat pharmacies. Before Viagra, there were limited treatment options: penile injections, suppositories, vacuum constriction devices and surgical implants. Now, there is a pill which can work within an hour.

Public’s expectations are raised to a new height!

Does it help all men with erectile dysfunction? No.

Viagra increases the blood flow to the penis. It does not increase sexual desire. It only works with stimulation. It is not an aphrodisiac. It only helps 60 to 70 percent of men with erectile dysfunction.

It has side effects too. It should not be taken by men who use nitrates (nitroglycerin for angina). If nitrate is combined with Viagra then there may be a sudden drop in blood pressure. It can also cause headaches, facial flushing, indigestion, nasal congestion, and visual problems – a bluish discoloration and difficulty differentiating blue from green.

All side effects disappear within 3 to 4 hours.

Viagra comes in 25, 50, and 100mg strengths. One pill to be taken an hour before sexual activity. Daily dosage not to exceed 100mg. Your doctor will advise you the appropriate dose for your problem.

The “little blue pill” has already helped millions of men. In U.S., 85 percent of the prescriptions were written for men between the ages of 50 and 70. The sales of Viagra are estimated to top $400 million this year in North America.

In the next few years, we will see if Viagra will stand the test of time. In the meantime, it is considered an effective and safe oral therapy for impotence.

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“Dr. B, its my indigestion. It is getting worse. Could it be an ulcer?” asks Susan as I enter the examination room.

Well Susan, what do you mean by indigestion?

“Dr. B, its my stomach!”

O.K. Susan, indigestion means different things to different people. Doctors describe indigestion as dyspepsia. Both terms are pretty vague. Medical text books describe this as a chronic (usually over 3 months), recurrent, often meal-related upper abdominal discomfort, pain or fullness.

Dyspepsia occurs in about 10 percent of the population. Most people carry on with off- the-counter medications. One-third of the people, who do seek help, will have no ulcer on investigations. This is called non-ulcer dyspepsia.

“Dr. B, what is an ulcer?” An ulcer is a break in the lining of an organ. The body responds to this with tissue reaction which may heal the ulcer or produce local tissue destruction with a crater formation.

There are 3 conditions to think about when a patient presents with indigestion: 1) ulcer of the stomach or duodenum (first part of small intestine), 2) cancer of the stomach and 3) non-ulcer dyspepsia.

Symptoms from gall bladder and pancreatic disease may mimic above conditions but they are more acute in nature with intervals where everything may be fine.

Clinically, I do not think Susan has cancer of the stomach as she is 38, has a good appetite and has not lost weight. Abdominal examination does not reveal any lumps.

Complicated ulcers can present with bleeding, weight loss, or vomiting and may mimic symptoms of cancer. Patients who are on non-steroidal anti-inflammatory drugs are prone to ulcers. In Susan’s case, there was no such history.

“Dr. B, what next? I have already tried off-the-counter medications. Is there a way to find the cause and treat it?”

Sure, Susan, let’s investigate with an ultrasound and gastroscopy. Ultrasound will check the gall bladder, liver and pancreas. Gastroscopy will examine the lining of the esophagus, stomach and duodenum.

Most of the ulcers in the stomach and duodenum are caused by Helicobacter pylori organisms (bugs). Biopsies taken during gastroscopy will identify whether these bugs are present. Gastroscopy will check for ulcer and cancer as well.

“Dr. B, you lost me! Gastroscopy? Helicobacter pylori………bugs? Scary stuff!

Susan, gastroscopy is not a difficult procedure. A flexible instrument with light and camera at the tip is swallowed under mild sedation. The magnified lining of the esophagus, stomach and duodenum are seen on a TV screen.

It allows us to do biopsies, remove polyps, dilate narrow areas, can often control bleeding and allows us to take photographs and video of the procedure.

Helicobacter pylori (H. pylori) is a bacteria found beneath the mucus layer of the stomach. In Canada, 10 to 20 percent of the population is infected with this organism. In developing countries, most people are infected before the age of 10 years.

It is estimated that 1 in 5 individuals with H. pylori will develop gastric or duodenal ulcer. A very small percentage may develop cancer of the stomach.

Susan’s ultrasound is normal. Gastroscopy reveals a duodenal ulcer with presence of H. pylori infection. Susan is treated for seven days with “triple therapy” – two antibiotics and an acid reducing agent.

Response rate to this therapy is over 90 percent for healing the ulcer and eradicating the bugs. The risk of recurrent infection is 1 to 3 percent over 5 years, usually from the immediate environment.

Susan feels great and is happy that we are able to identify the cause and treat it. A classic example of modern technology at work!

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Hormone Replacement Therapy (HRT)

Are you worried about menopause? Is estrogen a frightening word for you? Do you have an opinion on hormone-replacement therapy (HRT)?

Well, here is some information you may have been looking for!

Ovary secretes four types of hormones: estrogens, progestogens, androgens, and relaxin. Estrogen has the most diverse physiological effect on the body. It is mainly involved in the development and maintenance of the female sex organs. Its most general effect is to promote tissue growth.

Women, who survive to middle life, experience diminished ovarian function and reduction in hormonal levels resulting in menopause (menstrual pause!). Median age of menopause is 50 years. After menopause, the level of estrogen in blood can fall to 90 percent from their lifetime high.

With menopause come the dreaded symptoms of hot flashes, painful coitus, mild depression and osteoporosis. Osteoporosis affects about 25 percent of the elderly women and is a very serious consequence of menopause. Osteoporosis has been discussed in this column before.

Recently, NEWSWEEK reported that by the year 2000, there will be about 50 million women in America over 50. Many of them will suffer from menopausal symptoms.

Can we treat menopause? Yes, with estrogen (HRT).

For the last 41 years, the most widely prescribed HRT is Premarin – derived from the urine of pregnant mares – containing estrogens. HRT has benefited millions of women control hot flashes and other symptoms of menopause.

Are there any other benefits?

Yes. Women who are on HRT show 20 percent reduction in death rates from all causes including coronary artery disease and some cancers. Risk of having breast cancer is reduced among short term users of estrogen but is worse for women on estrogen for more than 10 years.

Estrogen has a significant positive effect on osteoporosis, delays Alzheimer’s disease, and reduces by half the chance of dying from colon cancer.

But remember the protective effect is there as long as the woman is on HRT and upto 5 years after it has been discontinued.

If HRT is so wonderful then why doctors ask: “To prescribe or not to prescribe”; and post-menopausal women ask: “To take or not to take”?

The answer is simple – the fear of acquiring breast and uterine cancer. As one of the functions of estrogen is to promote tissue growth.

But the good news is that addition of another hormone (progestin) to estrogen can substantially reduce the risk of uterine cancer.

New drugs like SERMs (selective estrogen receptor modulators) are being developed. They selectively work on bones, heart and brain but not on the breast or uterine tissues. Thus eliminating the risk of cancer in these areas.

In some cases the benefits of HRT therapy far outweigh the risks. A lot depends on your personal and family history of heart disease and breast cancer and the severity of post-menopausal symptom like hot flashes and risk of osteoporosis.

NEWSWEEK says: …….until the perfect SERM comes along, women must weigh the pros and cons of estrogen. This reminds me of what my wife always says: A woman’s work is never done….there is always something to worry about!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Physicians and Second Opinions

I like Susan. She is a good patient. She comes to the office well prepared. She can describe her symptoms well. She has a list of questions to which she expects answers. It saves me time. I wish all patients can be like Susan.

Her husband Dave is different. He likes his doctor to take responsibility for his care He likes his doctor to do all the worrying. His doctor is very obliging. Dave thinks all doctors should be like his doctor.

My brother is my accountant. I do not think he rates me very highly as a client. He is my big brother and I trust him. I let him do all the thinking for me to keep my finances healthy! He says, “My little brother, I wish you would be like my other clients who do their home work and come prepared with the right information and questions!”

This shows that patients, doctors, clients and other professionals come in all varieties.
To receive optimum service, we have to strike a right balance between expectancy and reality. The flow of good will has to be both ways.

“Doc, how can we get the most out of a visit to doctor’s office? Most doctors are overbooked, they are running late, in the middle of a physical the pager sets off, then the phone rings because another doctor is on the line, then it could be emergency department or labor quarters! Do you guys ever stop?”

Two common complaints we hear about doctors are: 1. They do not spend enough time with patients and hence do not listen to their complaints 2. They do not refer patients for a second opinion soon enough if they are unsure of diagnoses.

Recently, on CHAT 6&3 News series called MEDICAL MOMENT, I have been using a new slogan: “Help your doctor keep you healthy!” Is that possible? Let us examine this further.

The time factor. A doctor’s office is overbooked not because he loves to kill himself or that he hates his family; but he tries to accommodate as many patients as possible including last minute urgent appointments. So, he ends up seeing more patients than he had planned for. Then some patients take longer to be examined than others.

By the end of the day, the poor receptionist is expected to have done the job just right – keep everybody happy. I wonder how often she succeeds!

Getting a second opinion. A family physician, as primary care giver, is expected to know everything from brain tumors to ingrown toenails. Of course, this is not possible.

Depending on his experience and comfort level, he will get a second opinion if he is unsure of the diagnoses or if you are not happy with his findings or conclusions. He has to be careful that specialists or Alberta Health do not accuse him of crying wolf too often.

So, how can you help your doctor keep you healthy? Make sure he knows why you are there. Do your homework to save time. Ask him questions if you are not satisfied with his findings or conclusions.

For continuity of care, walk-in clinics and emergency departments are not good. Stick to one family doctor if you like him and trust him. Establish a good open honest dialogue. Try it! See how it works.

So, next time you step out of your doctor’s office, see if you can say: My doctor is the most wonderful human being on this earth!

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!