A Guide for Men - POZitive Attitudes

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Copyright © 2011 by Nelson Vergel

Nelson VergelProgram for Wellness Restoration

PoWeRUSA.orgAuthor of “Built to Survive” and “Testosterone: A Man’s Guide”

Preserving and BoostingPreserving and BoostingSexual Function: Sexual Function: A Guide for MenA Guide for Men

This information (and any accompanying printed This information (and any accompanying printed

material) is not intended to replace the attention or material) is not intended to replace the attention or

advice of a physician or other health care professional. advice of a physician or other health care professional.

Anyone who wishes to embark on any dietary, drug, Anyone who wishes to embark on any dietary, drug,

exercise, or other lifestyle change intended to prevent exercise, or other lifestyle change intended to prevent

or treat a specific disease or condition should first or treat a specific disease or condition should first

consult with and seek clearance from a qualified health consult with and seek clearance from a qualified health

care professional.care professional.

Goals and ObjectivesGoals and Objectives

nn Discuss the most common causes of Discuss the most common causes of Erectile Dysfunction (ED)Erectile Dysfunction (ED)

nn Review a practical evaluation of men Review a practical evaluation of men with EDwith ED

nn Review the treatment optionsReview the treatment options

A Practical Evaluation of Men with EDA Practical Evaluation of Men with EDED QuestionaireED Questionaire³³

nn When you had erections with sexual When you had erections with sexual stimulation, how often were your stimulation, how often were your erections hard enough for penetration?erections hard enough for penetration?

nn How do you rate your confidence that How do you rate your confidence that you could get and keep an erection?you could get and keep an erection?

³The International Index of Erectile Function, Urol 1997;49:822³The International Index of Erectile Function, Urol 1997;49:822--830830

A Practical Evaluation of Men with EDA Practical Evaluation of Men with EDQuestionaire (cont.)Questionaire (cont.)

nn During sexual intercourse, how often During sexual intercourse, how often were you able to maintain your erection were you able to maintain your erection after you had penetrated your partner?after you had penetrated your partner?

nn During sexual intercourse, how difficult During sexual intercourse, how difficult was it to maintain your erection to was it to maintain your erection to completion of intercourse?completion of intercourse?

nn When you attempted sexual When you attempted sexual intercourse, how often was it intercourse, how often was it satisfactory for you?satisfactory for you?

A Practical Evaluation of Men with EDA Practical Evaluation of Men with EDSexual History (cont.)Sexual History (cont.)

nn Do you have any problems with intimacy with Do you have any problems with intimacy with your partner?your partner?

nn Do you have early morning erections?Do you have early morning erections?

nn Do you have erections with selfDo you have erections with self--stimulation?stimulation?

nn Are you able to consistently obtain and Are you able to consistently obtain and maintain an erection sufficient for sexual maintain an erection sufficient for sexual intimacy?intimacy?

nn Does it hurt to have an erection or Does it hurt to have an erection or intercourse?intercourse?

Generated by Foxit PDF Creator © Foxit Softwarehttp://www.foxitsoftware.com For evaluation only.

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A Practical Evaluation of Men with EDA Practical Evaluation of Men with EDSexual History (cont.)Sexual History (cont.)

nn Do you ejaculation sooner than you Do you ejaculation sooner than you would like?would like?

nn Does it take too long to reach an Does it take too long to reach an orgasm?orgasm?

nn Do you fail to reach an orgasm?Do you fail to reach an orgasm?

nn Did your erection problems start Did your erection problems start suddenly or over time?suddenly or over time?

IncidenceIncidence

nn 2020--30 million American men suffer ED30 million American men suffer ED

nn Age dependentAge dependent

–– 2% men age <40 years2% men age <40 years

–– 25% men age 6525% men age 65

–– 75% men >75 years75% men >75 years

nn Not a necessary occurrence of the aging Not a necessary occurrence of the aging processprocess

An Erection Requires a Coordinated An Erection Requires a Coordinated Interaction of Multiple Organ Interaction of Multiple Organ

SystemsSystems

nn PsychologicalPsychological

nn EndocrineEndocrine

nn VascularVascular

nn NeurologicNeurologic

Cause of EDCause of ED

nn Psychogenic Causes:Psychogenic Causes:

–– AnxietyAnxiety

–– DepressionDepression

–– FatigueFatigue

–– GuiltGuilt

–– StressStress

–– Marital DiscordMarital Discord

–– Excessive alcohol consumptionExcessive alcohol consumption

Causes of EDCauses of ED

nn Organic CausesOrganic Causes

–– Cardiovascular diseaseCardiovascular disease

–– Diabetes mellitusDiabetes mellitus

–– Surgery on colon, bladder, prostateSurgery on colon, bladder, prostate

–– Neurologic causes (lumbar disc, MS, CVA)Neurologic causes (lumbar disc, MS, CVA)

–– Hormonal deficiencyHormonal deficiency

Causes of EDCauses of EDRisk FactorsRisk Factors

Massachusetts Male Aging StudyMassachusetts Male Aging Study¹¹

nn Treated heart diseaseTreated heart disease 39%39%

nn Treated diabetesTreated diabetes 28%28%

nn Treated hypertensionTreated hypertension 15%15%

¹Feldman Ha, J Urol 1994; 151:54¹Feldman Ha, J Urol 1994; 151:54--6161


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Causes of EDCauses of EDOther risk Factors Other risk Factors ²²

nn DiabetesDiabetes 27% 27% -- 59%59%

nn Chronic renal failureChronic renal failure 40%40%

nn Hepatic failureHepatic failure 25% 25% -- 70%70%

nn Multiple SclerosisMultiple Sclerosis 71%71%

nn Severe depressionSevere depression 90%90%

nn Other (vascular disease, low HDL, high Other (vascular disease, low HDL, high cholesterol)cholesterol)

²Benet et al. Urol Clinic North Am. 1995; 151:54²Benet et al. Urol Clinic North Am. 1995; 151:54--6161


nn Hormone DeficiencyHormone Deficiency

nn Blockage of Blood VesselsBlockage of Blood Vessels

nn Venous LeakVenous Leak


nn Spinal cord injuries: 5% Spinal cord injuries: 5% -- 80%80%

nn Pelvic and urogenital surgery and Pelvic and urogenital surgery and radiationradiation

nn Substance abuseSubstance abuse

nn Alcohol: >600ml/wkAlcohol: >600ml/wk

nn Smoking amplifies other risk factorsSmoking amplifies other risk factors

nn Medications may be responsible for Medications may be responsible for ~25% of cases of ED~25% of cases of ED

nn Bicycle ridingBicycle riding


Medication:Medication:

nn Most common cause of ED in men >50Most common cause of ED in men >50

nn Many men are polymedicatedMany men are polymedicated

nn Also have coAlso have co--morbid conditionsmorbid conditions


Medications (cont.)Medications (cont.)

nn AntiAnti--hypertensive drugshypertensive drugs

–– All capableAll capable

–– Common: thiazides and beta blockersCommon: thiazides and beta blockers

–– Uncommon: calcium channel blockers, Uncommon: calcium channel blockers, alphaalpha--adrenergic blockers, and ACE adrenergic blockers, and ACE inhibitorsinhibitors



nn CNS drugs:CNS drugs:

–– Antidepressants, tricyclics, SSRIsAntidepressants, tricyclics, SSRIs

–– TranquilizersTranquilizers

–– SedativesSedatives

–– AnalgesicsAnalgesics

nn H1 and H2 receptor blockersH1 and H2 receptor blockers


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nn AnticholinergicsAnticholinergics

nn LHRH agonists (Lupron, Zolladex)LHRH agonists (Lupron, Zolladex)

nn AlcoholAlcohol

nn TobaccoTobacco

nn Drug abuseDrug abuse

nn Estrogens, KetoconazoleEstrogens, Ketoconazole

Treatment OptionsTreatment Options

nn Oral medications Oral medications -- Viagra, Levitra, CialisViagra, Levitra, Cialis

nn Urethral suppositories (MUSE)Urethral suppositories (MUSE)

nn Injection therapy Injection therapy -- Caverject, Trimix, Caverject, Trimix, BimixBimix

nn Vacuum constriction deviceVacuum constriction device

nn SurgerySurgery

nn Sex therapySex therapy

Nonpharmacologic Treatment Nonpharmacologic Treatment OptionsOptions

Lifestyle changes:Lifestyle changes:

nn Reduce fat and cholesterol in dietReduce fat and cholesterol in diet

nn Decrease or limit alcohol consumptionDecrease or limit alcohol consumption

nn Eliminate tobacco use and substance Eliminate tobacco use and substance abuseabuse

nn Weight loss if appropriateWeight loss if appropriate

nn Regular exerciseRegular exercise

MedicationMedication(PDE Inhibitors)(PDE Inhibitors)

Side effects:Side effects:

nn HeadacheHeadache

nn FlushingFlushing

nn DyspepsiaDyspepsia

nn Nasal congestionNasal congestion

nn Visual disturbancesVisual disturbances

nn PriapismPriapism

MedicationMedication(PDE Inhibitors)(PDE Inhibitors)

Contraindications:Contraindications:

nn Organic Nitrites:Organic Nitrites:

–– OralOral

–– SublingualSublingual

nn Severe cardiac diseaseSevere cardiac disease

–– Obtain stress testingObtain stress testing

nn Careful with Careful with NorvirNorvir since it boosts PDE since it boosts PDE blood levelsblood levels

Sexual Dysfunction Oral DrugsSexual Dysfunction Oral Drugs

DrugDrug Onset of Onset of ActionAction

Duration Duration of Activityof Activity

ViagraViagra 60 minutes60 minutes 44--5 hours5 hours

LevitraLevitra 30 minutes30 minutes 44--5 hours5 hours

15 minutes15 minutes 36 hours36 hoursCialisCialis

Side Effects: Heartburn, GI upset, head aches,Side Effects: Heartburn, GI upset, head aches,nasal congestion, flushing, “blue vision” (Viagra only)nasal congestion, flushing, “blue vision” (Viagra only)


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Daily Cialis Use

Free 30 day supply at Cialis.com

Penile Injection TherapyPenile Injection TherapyCaverject, Edex, Tri/BiCaverject, Edex, Tri/Bi--MixMix

nn Mechanism of action: smooth muscle Mechanism of action: smooth muscle vasodilatorvasodilator

nn Administration: 10, 20, 40ugAdministration: 10, 20, 40ug

nn Inject directly into corporeal bodies of Inject directly into corporeal bodies of the penisthe penis

nn Results: 70%Results: 70%--90%90%

nn Dropout rates: 25%Dropout rates: 25%--60%60%

nn Side effects: pain (36%), priapism Side effects: pain (36%), priapism (4%), fibrosis(4%), fibrosis

Trimix (Papavarine+ Phentolamine + alprostadil)

Available by prescription from compounding pharmacies

Other Options for ED

Penile Implants

Vacuum Constriction Devices

Penile ProsthesisPenile Prosthesis

Indications:Indications:

nn Patients who have failed other therapiesPatients who have failed other therapies

nn Peyronie’s diseasePeyronie’s disease

nn Severe vasculogenic diseaseSevere vasculogenic disease

ThreeThree--Piece Inflatable ProsthesisPiece Inflatable Prosthesis

nn Most closely approximates the feel of a Most closely approximates the feel of a natural erectionnatural erection

nn Cylinders expand in girthCylinders expand in girth

nn Some cylinders have the potential to expand Some cylinders have the potential to expand in lengthin length

nn When inflated, it feels more firm and more When inflated, it feels more firm and more full than other prosthetic erectionsfull than other prosthetic erections

nn When deflated, it feels softer and more When deflated, it feels softer and more flaccid with better conceal ability than with flaccid with better conceal ability than with other prosthetic devicesother prosthetic devices


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Penile ProsthesisPenile ProsthesisInsurance ReimbursementInsurance Reimbursement

nn Covered by most companies, including Covered by most companies, including MedicareMedicare

nn No coNo co--payment for men with Medicare payment for men with Medicare supplemental insurancesupplemental insurance

Future ED Products

§ Intracavernous Bone Marrow Stem-cell Injection

§ Udenafil (Zydena®)

§ Avanafil

§ LY2452473

§ SK-3530

Signs and Symptoms of Low Testosterone

ØØ Loss of muscle mass and strength Loss of muscle mass and strength

ØØ Loss of libido and erectile dysfunctionLoss of libido and erectile dysfunction

ØØ Depression Depression

ØØ Lethargy (fatigue, lack of focus)Lethargy (fatigue, lack of focus)

ØØ Bone lossBone loss

ØØ Some regression of secondary sexual Some regression of secondary sexual characteristics (body hair loss, etc)characteristics (body hair loss, etc)

ØØ Low or no sperm countLow or no sperm count

Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987

Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html

Testosterone and AgingTestosterone and Aging


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Testosterone Deficiency (Hypogonadism)

• Normal levels in blood:

Men... Total test. 300-1100 ng/dL,

Free test. 5 - 21 ng/dL

Women... Total test. 10-50 ng/dL

Free test. 0.10-0.85 ng/dL

• Symptoms of testosterone deficiency:

Fatigue, low or lack of sex drive, poor appetite,

loss of muscle mass & strength, depression

Albumin-bound T38%

Free T2%

SHBG-bound T60%

T = testosteroneOnly 2% is free testosteroneand 98% is bound

Testosterone Fractions in the Blood

(binds testosterone)

TestosteroneReplacement Benefits

Sexual function

Mentalfocus

Stamina and Bone Strength

LeanBodyMass

Testosterone Options

Injections

Patch

Pellets

Buccal

Gels

Gels


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Potentially Approved in the Next 12-24 Months

The Top 10 Mistakes Made by Men The Top 10 Mistakes Made by Men on Testosteroneon Testosterone

ØØ Using “street sources” of testosteroneUsing “street sources” of testosterone

ØØ Not exploring what testosterone option is best Not exploring what testosterone option is best

ØØ Not using the right doseNot using the right dose

ØØ Cycling on and off testosteroneCycling on and off testosterone

Ø Stopping testosterone abruptly due to an unrelated side effect

Ø Not knowing how to manage potential side effects

ØØ Having a life style that is not “testosterone friendly”Having a life style that is not “testosterone friendly”

ØØ Not reading or staying “networked” with other patientsNot reading or staying “networked” with other patients

Ø Not switching doctors when you have to

Ø Poor compliance

The HPT Axis

Potential Side Effects

Polycythemia

Benign Prostatic Enlargement

Acne

Gynecomastia Increased BP

Testicular AtrophyDecreased sperm count


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For More Information:TestosteroneWisdom.com

For More InformationFor More Informationnn More details in “Built To Survive” and More details in “Built To Survive” and

”Testosterone”Testosterone-- A Man’s Guide” A Man’s Guide” www.amazon.comwww.amazon.com or any bookstoreor any bookstore

nn Email:Email:

Nelson Nelson VergelVergel –– [email protected]@yahoo.com

nn Websites:Websites:

www.powerusa.comwww.powerusa.com

www.testosteronewisdom.comwww.testosteronewisdom.com

www.facialwasting.orgwww.facialwasting.org

www.TheBody.comwww.TheBody.com

nn Join my Internet discussion group by sending a blank Join my Internet discussion group by sending a blank email to email to [email protected]@yahoogroups.com


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