|
||
|
|
||||
|
THE MEN'S LETTER 8 ©
|
SEPT 2002 |
|||
|
Male Sexual & Reproductive Health
|
|
|||
|
|
||||
|
So much for Procrastinator’s Excuse #1 (and #2, and #3 and perhaps #4 as well.) I’m delighted to inform you of this breakthrough in vasectomy… no needle. Losing the scalpel was the zfirst step in minimally invasive vasectomy, and losing the needle is the next milestone on the road to “gentility”, in my humble opinion. No-Needle Anesthesia (NNA) is accomplished by means of a jet injector that delivers a hypospray of pressurized anesthetic; instantly, painlessly and very effectively. Less than 0.5 cc’s of Xylocaine is required, compared to the 5 to 10 cc’s used with standard needle anesthesia for NSV. The injector works by a spring-loaded piston that delivers the high-pressure, mini-injection of micronized Xylocaine droplets directly through the skin, and diffusing, once it makes contact, down to the vas. All one feels is a gentle, split-second flick against the skin. In addition to the obvious benefits of no pain and no needle, there is the additional advantage that, with so small a volume of anesthetic, there is no distention or ballooning of tissue. That means that the chance of needle-induced bleeding is eliminated and healing is accelerated. The injector has been in use for years; in plastic surgery, gynecology, dentistry, podiatry, other surgical disciplines, not to mention immunizations. It was adapted for vasectomy by an American colleague who has used it on over a thousand patients. There’s a learning curve. Hand positioning and subtle variation in pressure can be critical to success. I’ve been using it in my practice for a number of months with good success. I’m proud to be the first to offer it in Canada. I’ve passed it on to an experienced colleague in Ottawa who is incorporating it into his practice as well. Sound incredulous? I invite you to come and see for yourself. You may want to get one yourself; an injector, that is. It should be great for lumps, bumps, toenail removals, trigger point injections and a host of other minor surgeries and procedures. I should note that with my old “needle” technique, all the patient felt was a little prick and about five seconds of “pressure” up in the gonad, like a menstrual cramp. I’ve always taken great care not to excruciate. Even at that, for some guys the anticipation of getting in touch with his feminine side can be a major procrastinating factor. Talk about fear, the occasional patient would shake so hard before his vasectomy that I would have to shake along with him, just to keep the operative field steady. Many men tell me that the fear of the needle is the one thing that keeps them from a vasectomy, often for years, no matter how masterfully it is administered. Remember: “He who hesitates is pregnant!” Well not actually “he”, “her”. You know what I mean!It just goes to illustrate, once again, that, “Necessity is the mother of invention.” Don’t forget: “Sushi was not invented by the Japanese, Improving compliance with “A token of my congratulations” In most studies up to 50% of vasectomites do not return for semen analysis. In my practice I boast only a 30% “truancy” rate. I mail out a reminder if they haven’t been in for a test by four months, but I’ve recently added an “incentive” to compliance as well….a pen. Not just any pen; it’s one of those electric blue stick pens with the clip that’s in the shape of a squiggle, with a little ball on the end. They’re becoming quite the rage around town, fondly known as the “sperm pen”. This coveted prize is handed out when the patient returns with a negative sperm test, with the announcement of, “Congratulations! You failed!” Whatever works! Of course I also tell him that if his buddy wants a pen too, “He’ll have to earn it the hard way, like you did.”
EngenderHealth, previously known as AVSC International, is the non-profit organization that spearheaded the effort, back in the 80’s that brought No-Scalpel Vasectomy out of China and taught it to the rest of the world. The organization was created in 1943 to bring reproductive healthcare services to men and women in resource-poor areas of the United States. It has since expanded into more than forty under-developed countries. With an established world-wide infrastructure, with a focus on care, and with a long-standing commitment to the concept of “Men as Partners” in family planning, this organization is now at the front line of efforts to stem the growing HIV/AIDS epidemic in Africa and elsewhere. Good work, guys!
Doin’ It for Dad….. I’m happy to say that I took second prize for fundraising, with just over $2000.00, for the Prostate Cancer Walk/Run in June. Most of it came in ten and twenty dollar donations from patients. Another GP took third prize, with $1700, and a third physician personally donated $1000. Thanks to all of you who supported us. That’s a total of almost $5000 from three BC physicians, out of a grand total of $75,000 raised. In other words, three doctors raised 7.5% of the total. Can you imagine if we’d-a-had six or even ten guys turn up! Breast Cancer Runs for the Cure, by comparison, usually raise in the millions. If this doesn’t convince you that we men are an endangered species I don’t what will. Don’t worry. Contrary to public opinion, we too are capable of multi-tasking. We’ll show ‘em next year!
I find this case very perplexing. I was getting a haircut and the barber related this story; that of a 35 year-old friend of his who was taking Propecia for male pattern baldness, and that it resulted in ED. “Presumably the ED resolved when he stopped the Propecia.” I surmised. “Don’t know. He’s still taking it.” was the reply. I was amazed that a man would continue to suffer ED, just to prevent hair loss. I would bet his doctor doesn’t know! This case demonstrates that Body Dysmorphic Disorder (a.k.a. The Adonis Syndrome) can have serious medical consequences. It also shows the extent to which our society places esthetic demands not only on women, but increasingly, on men as well. RISK-TAKING NEWS….. A population that takes risks is a population at risk, by definition! The Workers’ Compensation Board of BC reported 168 job fatalities last year. 161 of them were men. While some of this can be explained by more men working in hi-risk occupations, there is also an element of the different attitudes men and women have when it comes to caution and attention to safety. ( Attention Deficit Disorder doesn’t end when you leave school.) 80% of the spinal cord injuries, MVA’s, homicides, and suicides are men. Male bravado, risk-taking, thrill seeking, carelessness, aggressiveness are not only a function of testosterone. They are socially and culturally programmed from a very early age. Are there ways to activate mens’ attention and intention in effective, male-specific modes of communication? Sure, the marketers have served up lame and nerdy stereotype images, but nobody’s taken a serious and interested look at how and what men really think, feel, need and want. How else will we ever know? On June 28th I went rollerblading and wore a helmet, for the first time. Stupid as they look, I will never rollerblade without one again. I’ve never had a serious fall. I’ve always been confidant that I never will. I still am, but so is every other guy, until it happens. What changed me? … a thirteen year-old kid who usually wears a helmet but didn’t one day that week. He fell off his skateboard and died. Stupid truth: “Nothing ever happens till it happens.” We men are confident, young and old, that we won’t get hurt. True, the wind rushing through your hair doesn’t feel the same with a helmet, but that’s Marlboro Country thinking. Why cant those marketing gurus serve us up images of “wind rushing through helmet”? Perhaps safety needs to be sold to men and boys by men and boys. After all, they can hear it a million times from their mothers but it’s like water off a duck’s back. ERECTILE DYSFUNCTIONOLGY NEWS I forgot to mention it last letter, but whenever I prescribe Viagra I tell the patient to find the dose that seems to work, and then try it at half-dose. That way he can find the lowest effective dose for him. This accomplishes a few things. First, it reinforces the concept that, “It’s like your nose; everybody’s is different!” More important, it also demonstrates that you, the physician, is more concerned with his biochemical and financial well-being than you are with enhancing the market value of your Pfizer shares. After all, are we here for the patient, or is the patient here for us? Of course you know the answer to that one, but in sexual medicine, as in most other walks of life, it is very important to keep up the illusion. MORE TALES FROM THE ERECTILE DYSFUNCTIONOLOGIST’S COUCH The treatment of ED can be remarkably simple if you take a good sexual history. To most non-physicians the term INTROMISSION probably conjures up the image of a capuccino and an oat-fudge bar between sets at the Orpheum or the Vogue. When I was a child they had yo-yo contests on the stage at intromission time. For doctors, however, the word is defined as the act of inserting the penis into the vagina. The recent 71 year-old gentleman in question presented with the history of a reasonably strong erection, but one that disappeared predictably just before intromission, not an uncommon complaint in a man his age. Veno-occlusive dysfunction is likely at play here, but there was another, more treatable factor to be gleaned from the history The key question to keep asking the patient as he tells his story is, “So what happens next?” It seems that in the current case, at the moment of truth, (a.k.a. intromission), she would call a time-out to apply lubricant to her vagina, and that delay was enough to cause his already marginal erection to fade, “never the twain to meet again”, as it were. Solution? Simple! Have her put the lubricant on him, not herself. No joke! It worked. Sorry Pfizer! “RANDOM THOUGHTS ON SEXUAL DYSFUNCTION & DEPRESSION…. or Add another ”S” to your S.I.G. E. C.A.P.S. For those who have forgotten, or never knew, “Sige caps” is a nemonic doctors are taught to remember the eight features of depression: Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidality. We really ought to add one more “feature” to the depression list. This one’s not just a feature, it’s a major CAUSE of depression in men!! You guessed it: Sexual, and particularly erectile, dysfunction!! It’s unfortunate that psychiatrists, and GP’s who diagnose and treat depression are often reluctant to broach the subject of erections when the patient first presents depressed or anxious, because it really should be one of the first questions asked. When ED is diagnosed and treated it can even CURE the depression and obviate the need for anti-depressants, which, as we know, often worsens sexual dysfunction even further. (good grammar, huh?) And while we’re still on the subject of uncovering stupid but simple truths, let me say a few words about libido, or lack thereof. Illibido syndrome, I like to call it. Some try to distinguish libido, or “horniness”, from other types of lack of desire. Libido is said to be a testosterone function, while low desire is more of a moody, touchy, feely typathing, therefore not likely “hormonal”. I think this distinction is a little academic. In either case it behooves to test testosterone, because andropause can present with predominantly affective symptoms, like low desire, or with “sexual” symptoms like low libido, and either can be present with or without ED. To convolute matters even further, ED can result in low desire on it’s own, without depression or andropause. I don’t know what neurotransmitter is responsible, probably adrenaline, but some kind of negative feedback inhibition results when the “don’t start what you can’t finish” self-talk begins, as it always does, whenever erections flail, whatever the cause. In other words, having ED is enough to dampen anyone’s desire, even if it wasn’t terribly flawed to begin with. Testosterone is not likely to fix that. DELAYED EJACULATION I am starting to see this complaint more frequently in my ED practice. There is very little written on it in the literature. When it’s the result of an SSRI, Viagra is said to be of help. Other than that I’ve been at a loss to know what to do to help these guys. You’d think that a guy would be happy to “go forever”. That’s not the case. They are frustrated and unsatisfied. Their partners often feel somehow inadequate. As with ED, the resultant feelings of anxiety, spectating, and disconnection from their own pleasure can be difficult to overcome. As with ED, these men require a physical assessment to rule out prostatic, neurologic, vascular and endocrine disease. Don’t forget that delayed ejaculation, diminished force, decrease volume, and darkening of the semen, are all possible signs of hypogonadism, in addition to low libido. Age and neuro-degenerative processes may be at play as well. One could make a case for the neuropathic effect of diabetes on the pudendal nerve, for example. Combine this with the fact that older couples tend to have limited and traditional sexual repertoires, so he may be thrusting too deep in the vagina to get the sensory stimulation he needs under the circumstances. Some experts thing that suggesting that he thrust more shallowly can facilitate ejaculation. There is also a subset of younger patients with “DE”. (Looks like we just coined another one). These men seem to have conditioned themselves early on, to ejaculate only to their own, often forceful, hand stimulation. The stress this puts on a young relationship can be extreme. She often feels she can’t “satisfy” her man. Treatment is sensate focus exercises, to learn to refocus on pleasure, and away from performance. You can’t put the car in gear before the engine’s turned on, in other words; get the head turned on before trying to engage the penis. Is there a broader message here for the rest of us as well? After all, we do live in a demography! Everyone pays lip service to the aging and demanding “boomers” and the strain they will be placing on resources in the coming years, but nothing really illustrates the magnitude of the situation like the following statistic from UN projections on global population changes. Within the next twenty years the number of elderly (over age 75) will triple, while the number of children (under age 18) will diminish, from the current 30%, to a mere 20% of the world’s population. Wow! Just think of all the Viagra and testosterone they (we) are gonna need in the next twenty years! The guy must be some kind of a leptomaniac Simpleton that I am, I thought leptin was only an adipocyte secreted hormone discovered by positional cloning of the obesity (ob) gene, that messages the brain on energy stores, hunger, satiety and the like. Little did I realize until reading this review that leptin is also a crucial hormone/cytokine in the processes of inflammation, angiogenesis, hematopoesis, immune function and even reproduction (and therefore sexual function). Leptin is expressed in a number of non-adipose tissues including pituitary, skeletal muscle and gastric fundus. Leptin receptors (OB-Rs) are plentiful in hypothalamic, anterior pituitary, ovarian and testicular tissues. Nutritional/leptin regulation of reproduction is a complex and multi-faceted interaction, probably designed to stop women from getting pregnant when the food was in short supply. Estrogens induce, while androgens suppress leptin production. Turns out that leptin also affects androgens and estrogens, through its significant role in the modulation of the hypothalamic-pituitary-gonadal axis. You may or may not recall me spouting in the last Men’s Letter about leptin and Omnirexia Nervosa, and that epidemic of obesity that the government has finally decided to social engineer out of us and our children. Well little did I know then that Mr. Leptin would also be implicated in all those other hungers plaguing our poor unsuspecting reptilian brains! Love is indeed, a many splintered thing!. And finally, introducing……
You will soon be hearing more about this clinic which will be opening Downtown in October, with two GP’s, five consultants and a clinical counselor, and a nurse. It is a pilot project to deliver gender-specific care to men. We’ll be starting with a number of male sexual and reproductive services, and then moving into programs for cardiovascular and other risk modification, psycho-social dysfunctions, prostate health, etc. Hopefully we shall evolve in time to include other areas which legitimately fall under the umbrella of men’s health. You can check us out at www.xyhealth.ca Barry Rich MD Inc. Over 5000 happy vasectomites served to date! |
||||
|
|
||||
|
||||
