Male's Concerns of Enhancement Options

Media such as various forms of pornography generally depict men with large genitalia, not for accuracy or realism but for fantasy and showmanship. Spam emails convey messages about not being good enough or big enough, thus playing on male insecurities to make billions of dollars annually on male enhancement products.

It is important for health professionals, partners, parents, and caregivers, and educators to be sensitive to a male's concern for penis size, whether founded or unfounded. Concerns can lead to a man’s lower self-esteem, self-worth, depression, and even radical reactions, such as spending money and resources on unproven male enhancement products or even surgery.

Ironically, with men knowing that so many men are concerned for their penis size, it should become more obvious that only a few males exceed well beyond the average. Health professionals are advised to have frank age appropriate discussions with males when they are younger, and educators should not be averse to covering this topic in sexuality or even psychology and sociology classes.

Educators can help dispel common myths and teach media literacy strategies and skills to help redefine the norm of penis sizes.

Options and Treatments

The medical industry has responded to male's concerns by offering many options and treatments ranging from the mild to the extreme (Korenman, 2004). Many companies offer ED products that claim to reverse ED or enhance male sexual pleasure.

Unfortunately, many of the latter are little more than "snake oil." The term enhancement is vague. Men may perceive these claims to mean a bigger (longer or thicker) penis, while claims may refer to increased blood flow to the organ and thus more frequent and/ or stronger erections.

Some of the older methods of enhancing manhood include herbal remedies and physical devices such as pumps. Herbal claims include products such as yohimbe, epimedium leaf extract (horny goat weed),cuscuta seed extract, gingko biloba extract, tribulis terrestrius, saffron, taj, and safflower root (Gutmann, 2009).

Many commercial products include these herbal products in their proprietary blends to enhance male function. Major health issues concerning these products are threefold:

1. they are largely unregulated by agencies such as the Food and Drug Administration (FDA) and therefore lack appropriate data as to their relative efficacy and safety;
2. men often are misled by the product claims and may misuse or overuse the product, and;
3. men may delay treatment or medical follow-up by trying these products.

Other non-health issues concerning these products include efficacy, financial issues, and whether they are well documented or even physiologically possible. It is not possible to "grow a larger penis," as several products claim to do, but these herbals may optimize erectile function by enhancing blood flow or encouraging systemic testosterone levels, which also has been shown to produce better, more frequent erections.

Herbals have not been scientifically proven or supported to cause the penis to grow longer or thicker, but, instead they may help with what a man already has. Nonherbal products include gadgets and devices such as pneumatic pumping devices (penis pumps), stretching (traction) apparatuses, and combinations of the two.

Most of these devices provide little to no empirical evidence that their products do what they claim. Pneumatic penis pumps generally incorporate a suction canister connected to a pump hose that can be manually or electronically activated. Pumping causes the air to be evacuated outside of the canister, thus creating a vacuum seal around the head and shaft of the penis.

This technique encourages blood flow to the penis, but does not increase size. While blood flow appears to increase the relative size of the penis, the results are temporary once the device is removed and blood flow returns to a pre-pumped state. Used over time, these devices may encourage blood to flow more freely, especially if there are blockages, scar tissue, or plaques built up in the blood vessels of the penis (Kazem, llosseini, Alizadeh, 2005).

It should be made clear however, that there is no empirical evidence that pumping devices make the penis longer or thicker permanently. Stretching or traction devices have recently become popular. Devices are attached to the closest part of the base of the penis as the stable end, and the far end encompasses the tip of the penis. A predetermined amount of traction force is then applied to the penis and is left on for a specified amount of time per day.

The theory behind these types of products is that the erectile tissues and suspensory ligaments that stabilize the penis will yield over time and become more plastic in terms of mobility. While there may be theoretical concepts and anecdotal support for these types of enhancement devices, evidence-based empirical data are not available (Kazem et al, 2005).

Combination devices attempt to merge these two concepts. Efficacy appears to be the same. Ultimately, there is little to no strong evidence that these devices work and are little more than a novelty or fetish for some people. Alternatively, some men and their partners may enjoy the excitement and novelty of using penis enhancement products. If these are used as part of healthy sexual experience and there are no known health risks, enhancement devices can be quite enjoyable.

A trained medical professional such as a primary care physician or a specialist such as a urologist can advise if a man is concerned about his penile health or related issues.

Reference

James E. Leone - Concepts in Male Health: Perspectives Across The Lifespan

Boosting anabolic hormone (testosteron) with Tribulus Terrestris

Although each of the anabolic hormones (testosterone, growth hormone, insulin, lGF-l) is required to stimulate maximum levels of skeletal muscle hypertrophy, testosterone may be the most anabolic. It is important to recognize that not all of the testosterone in the blood is bioavailable; rather, most of it is bound to proteins such as sex hormone binding globulin (SHBG) or other carrier proteins. Testosterone that is not bound is referred to as “free” or “bioavailable” testosterone; and it is able to bind to the androgen receptor and exert its anabolic signaling.

This is an important distinction because as one attempts to increase testosterone levels
(via testosterone-enhancing supplements) in the body, it is only the bioavailable testosterone that exerts anabolic actions. Another important consideration is the avoidance of increasing SHBG to a greater extent than total testosterone increases, which would result in an environment in which there is less bioavailable testosterone present. Therefore, when investigating sports supplements designed to increase testosterone, each of these factors must be considered.

Currently, there are a few sports supplements that claim to increase testosterone levels: ZMA, Tribulus terrestris, and aromatase inhibitors.

Tribulus terrestris
Tribulus terrestris is often marketed as a testosterone-boosting sports supplement. There are relatively few, if any, scientific studies to substantiate these claims. In fact, one clinical investigation demonstrated that Tribulus terraslris exerts no effect on increasing testosterone levels (94). In this study, healthy men were instructed to supplement with T ribulus terrestris for a 4-week period after which serum levels of testosterone and luteinizing hormone were measured at l, 3, IO, 17, and 24 days after supplementation. Tribulus terrestris supplementation did not increase the levels of either testosterone or luteinizing hormone. Given the unsubstantiated claims of Tribulus terresrris relative to increasing testosterone levels, supplemental Tribulus is not recommended.

Reference

Nutritional Supplements in Sports and Exercise - Douglas Kalman, Mike Greenwood, Jose Antonio

When Should Open Prostatectomy Be Performed?

Transurethral resection of the prostate (TUR) is the method of choice in the management of benign prostatic hyperplasia (BPH). This is true for adenomas with an estimated weight of up to 60g. However, is TUR also the best procedure for adenomas larger than 60g?

Many urologists perform transvesical or retropubic open prostatectomy for prostatic adenomas weighing more than 50-60g. If the right moment is chosen for open prostatectomy in such a case, this operation is superior to TUR. The cumulative percentage of patients undergoing a second prostatectomy is substantially higher after transurethral than after open prostatectomy (12% versus 4.5%).

Investigations on this subject were conducted by Roos of al. in 1989, and the data are based on more than 50000 patients in Denmark, the United Kingdom, and Canada. A distinct difference was seen in long-term mortality, with an elevated rate for TUR patients compared to Nose receiving open prostatectomy. The follow-up periods were 3 months, 1, 5, and 8 years after the operation.

Only at the first postoperative examination after 90 days was the mortality rate for TUR patients in Denmark between aged 75-84 years slightly lower than that for open prostatectomy. In all the other age groups in all three countries the open operation was more favorable regarding long-term mortality and probability for a second prostatectomy after 1, 3, and 8 years.

Which patients should be considered for open prostatectomy? First, patients aged up to 65 years with an prostatic adenoma weighing more than 50-60g, would benefit by the lower risk of second prostatectomy. Further advantages are due to the large amount of tissue removed in short operating time, more radical tissue removal, and low rate of postoperative contracture of the bladder neck, ranging from 0.9% to 1.1%.

Disadvantages of open prostatectomy include: higher perioperative mortality, ranging from 2% to 3.1% compared to TUR (0.016-2%), higher risk of postoperative bleeding, the possibility of wound infection, and the risk of urinary infection by long-term indwelling urethral catheter.

We would like to call attention to two problems, those of urinary infection and postoperative blood loss. The incidence of postoperative urinary infection can be reduced by modifications in the open prostatectomy. From 1967 to 1976, 350 patients with prostatic adenomas were managed by the catheterless method of suprapubic transvesical prostatectomy. The aim of this technique was the avoidance of the bacterial urinary infection due to the indwelling catheter and of the bladder neck stricture.

Reference
Benign Prostatic Hyperplasia - Conservative and Operative Management - G. Hubmer, T. Colombo, and M. Rauchenwaldt

Goal and Indications for Evaluation of the Infertile Male

Male infertility can be attributed to a variety of conditions; however, most of the time an exact cause is not found, but if found, not all can be trnated and/or corrected. An abnormal semen picture may be the only finding; in these cases, the cause of infertility is termed idiopathic.

The aim of male infertility evaluation is to identify and treat potentially correctable causes. The identification of genetic disorder during male infertility workup would help in counseling the couple about the potential risks involved to the offspring and also help guide the couple to alternate treatment strategies. Potential serious conditions like testicular cancer and pituitary tumors may also present with infertility and/or sexual dysfunction as the only primary symptom during an assessment (Honig et al. 1994).

In a large WHO study involving over 8500 couples from 25 countries, a standardized classification system for categorizing the various causes of male infertility was published. This study clearly showed that the single most common etiology of male infertility belonged to the idiopathic abnormalities of the semen category (25%), followed by varicocele (Cornhaire 1987).

Nevertheless, with our recent understanding of genetic causes, this study is in need of a review. The various causes of male infertility are summarized in Table 4.1. Varicocele is however a debatable cause of male infertility.

Reference

Male Infertility - A Clinical Approach Editors: Gunasekaran, Karthik, Pandiyan, N (Eds.)

The Pharmacokinetics of Sildenafil

Penile erection occurs as a result of the influx of blood into the corpora cavernosa. This influx of blood is the result of the relaxation of smooth muscle of the corpora cavernosa, produced by the increase in cyclic guanosine monophosphate (cGMP) in turn induced by the release of nitric oxide (NO), activating the enzyme guanylate cyclase, during sexual stimulation. Sildenafil is a potent and specific inhibitor of phosphodiesterase type 5 (FD5), the enzyme responsible for degradation of cGMP in the corpus cavernosum. Thus sildenafil enhances the effects of nitric oxide and enhances the erection and maintenance over time. Sildenafil does not act in the absence of sexual stimulation. Sildenafil is characterized by its high specificity for the FD5, presenting weak effects (80-4000 times lower) over other known FD (FD1, FD2, FD3, FD4), the only exception being the FD6.

Sildenafil lowers blood pressure. This effect is dose related and is greater in patients taking nitrates..

Pharmacokinetics
Sildenafil is rapidly absorbed after oral administration in fasting, peak plasma concentrations are reached about one hour after administration (30-120 minutes). Fatty foods delay absorption. The absolute bioavailability is about 40%. The volume of distribution is 105 l. Both sildenafil and its major metabolite N-desmethyl circulate almost completely (96%) bound to plasma proteins. Sildenafil is eliminated primarily by hepatic metabolism (especially 3A4 isoenzyme cytochrome P-450 and secondarily by the 2C9 isoenzyme) and is converted to an active metabolite which is considered responsible for about 20% of the pharmacological effects. The terminal half-life of sildenafil and its major metabolite is about 4 hours. Excretion is mainly in the feces (80% of the administered dose) in the form of metabolites and to a lesser extent (13%) in urine. In patients 65 years or older decreased clearance of sildenafil higher than in younger individuals plasma concentrations was observed. In individuals with mild to moderate alteration not sildenafil pharmacokinetics observed after administration of a single oral dose of 50 mg. In patients with severe renal impairment (creatinine clearance <30 ml / min) decreased clearance of sildenafil and doubling the AUC and peak plasma concentration (Cmax.) Is reported. Decreased clearance of sildenafil, increased AUC (84%) and Cmax was also reported. (47%) in individuals with liver cirrhosis.

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