Dudley Seth Danoff's Blog, page 5

Surgery Versus Watchful Waiting In Early-Stage Prostate Cancer

The results of a study published in the New England Journal of Medicine showed that surgery for early-stage prostate cancer was no better in saving lives than observation alone over a 10-year period. The study compared radical prostatectomy with watchful waiting in men diagnosed with low-grade localized prostate cancer and concluded that surgery did not significantly prolong the lives of many of the men.

Because prostatic surgery for cancer can produce negative side effects, such as erectile dysfunction and loss of bladder control, determining which men diagnosed with prostate cancer stand to benefit in terms of survival is of critical importance. This new information, if embraced by patients and doctors, may radically change prostate cancer management in the United States, where the majority of early-stage prostate cancers are treated aggressively with surgery or radiation therapy.

As a urologist who treats prostate cancer on an ongoing basis, I have several concerns about the conclusions of this study. First, the average age of the men in this study was 67 years old. It is well known that prostate cancer in older men is far less aggressive than prostate cancer found in men in their 40s and 50s. Second, only about a third of the patients in the study were African American, who have an increased risk of prostate cancer and are often underrepresented in prostate cancer studies.

Third, the study does not address the treatment options for more aggressive cancers or for cancers in men in their 40s, 50s, and early 60s. Any urologic oncologist knows that aggressive treatment in this subset of patients saves lives.

In this study, the early aggressive surgical treatment of prostate cancer was prompted by elevated levels of prostate-specific antigen (PSA). There is no doubt that the reliance of PSA screening, in the years since its introduction, has led to overtreatment of prostate cancer.

PSA screening still remains the best marker for the early diagnosis of prostate cancer, but this study prompts us to look at older patients and treat them less aggressively than younger patients. Even in early-stage prostate cancer, watchful waiting or active surveillance becomes more attractive.

Certainly, this study is an eye-opener and encourages less aggressive treatment in a select group of prostate cancer patients. Urologists have known for some time that some men will do just as well in terms of survival without treatment for their prostate cancer. However, considerable controversy still exists over exactly which of these men can safely opt for no treatment.

Dr. Jonathan Simons, president and CEO of the Prostate Cancer Foundation, said that the foundation is investing in research and development of indicators that could better categorize patients and give urologists and patients a precise plan for curative surgery or radiation and avoidance of over-treating a less aggressive tumor. Unfortunately, these markers are not yet available. Dr. Simons said, “We are tracking with great interest new biomarkers in blood and urine that define which men need surgery that will be curative and which men can safely opt for watchful waiting programs or active surveillance.”

Whether a patient chooses to aggressively treat prostate cancer or take a more conservative approach is a matter that needs to be fairly evaluated by both patient and physician. The final word on the subject has not yet been written. The present study should not be construed as a blanket condemnation of aggressive treatment. Aggressive treatment is still appropriate in certain patients, but at the same time, the number of patients over 65 with low-grade localized prostate cancer who are treated conservatively is growing.

Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).

Read discreetly with the Kindle™ edition of Penis Power™ now available for purchase from Amazon. The Nook Books™ edition from Barnes & Noble and the Sony eReader™ edition from Sony’s Reader Store. Available for under $7.00!

 

 

 

 

Penis Size – Does It Really Matter

One of the most frequently asked questions (often implied) that a busy urologist hears is, “Is my penis big enough, long enough, or wide enough?” Let me set the record straight.

In my more than three decades of practicing urology, I have seen more penises than can fill the Rose Bowl. Most of those penises are accompanied by a wife, girlfriend, or significant other. Never in my practice have I heard a partner ask me, “Dr. Danoff, can you make my partner’s penis bigger, longer, or wider?” But what I have heard is, “Can you make it a little firmer and attach it to a nicer, sweeter guy, preferably a guy with a Platinum American Express Card?” The essential point is that women are less concerned about penis size than men are, and it is generally men who have penis envy, not women.

The myth that size is important is one of the cruelest hoaxes ever perpetrated on mankind. The culture of misinformation has been so deeply embedded in the collective consciousness that men have become extremely sensitive about the length and width of their penises. There is nothing to worry about because one size fits all!

The variation in size among human penises is less than that among hands, fingers, or noses. Penises can be as short as 1 1/2 inches or as long as 9 inches, and those that fall at the extremes are exceedingly few. Variation in penis girth is minimal and ranges between 1 and 1 1/2 inches in diameter when the penis is flaccid. A very tall man might have a longer penis than a short man, just as a tall man will probably have bigger feet and hands than a shorter man. But the difference in penis size between two such men will be far less than that of their other appendages. A short man might wear a size 8 shoe while a tall man might wear a size 13, but the short man’s penis might be only a fraction of an inch shorter than that of a taller man. I have often seen penises on short men that were as big as or bigger than those of most professional basketball players. Most importantly, the variation in the size of the erect penis is far less than that of the flaccid penis.

I have seen men with large penises who are plagued by sexual dysfunction. I have seen men with relatively small penises who represent the quintessence of superpotency. The length and width of a man’s penis is genetically determined at birth. There is no legitimate surgical procedure to make a man’s penis longer or wider. Remember, all of the action is up front. The tip of the penis is the most sensitive part of the male anatomy, and the clitoris, at the entrance to the vagina, is the most sensitive part of a woman’s anatomy.

Today’s media landscape is polluted with countless ads promoting penile growth that promises to increase the length and width of a man’s penis. Not a day goes by where most men are not faced with some kind of advertisement or junk e-mail offering a sure-fire solution for penis enlargement.  The bottom line is that there is no legitimate way to surgically increase the length or width of a human penis. Nor are there any medications that can do the same. I cannot repeat myself enough: these advertisements are all hoaxes and these products are ineffective and can damage your penis. They are designed to prey on the prevailing self-consciousness and self-doubt that plagues men with regards to the way they view their penis and their sexual confidence. From the sincere depths of my urologic heart, I pity the patient who tries to enlarge his penis. Those of my patients who have tried are my saddest patients.

Some of the fascination with large penises can be attributed to the general cultural viewpoint that “bigger is better.” The phallus is a symbol of potency, physical strength, and masculinity. It makes sense that, psychologically, some people conclude that bigger penises are better than smaller ones. The fascination with large penises is not unlike men’s attraction to large breasts or shapely behinds. Finding someone with these features might enhance the sexual experience because it fulfills a fantasy, not because women with large breasts are better in bed or have more hospitable vaginas than women with small breasts. Physiologically and anatomically, what occurs during intercourse has nothing to do with the size of any body part. The orgasm is exactly the same regardless of the physical features of the partners. An experience that may feel different is actually a result of the power of the mind and the emotions.

Your penis is as big as you think it is. Its size can’t be changed. Learn to love it and it will serve you well.

 

Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).

Read discreetly with the Kindle™ edition of Penis Power™ now available for purchase from Amazon. The Nook Books™ edition from Barnes & Noble and the Sony eReader™ edition from Sony’s Reader Store. Available for under $7.00!

 

 

The Truth About Erectile Dysfunction Drugs

Currently, there are four drugs approved by the Food and Drug Administration that can be used to treat erectile dysfunction: Viagra, Levitra, Cialis, and Staxyn. These drugs, known as PDE-5 inhibitors, will enhance performance but will not increase libido. A PDE-5 inhibitor is a chemical that boosts the enzyme that relaxes the smooth muscle cells inside the penis. When combined with sexual excitement, the drug enables the arteries in the penis to widen and the spaces in the erectile chambers to fill with blood. As the veins in the penis expand, they trap blood in the penis for a prolonged period of time.

Multiple clinical trials show that this chain of events creates an excellent erection nearly 80 percent of the time. These drugs seem to be remarkably effective in patients who have a biological reason for their impotence. However, they do not seem to have much impact on men who are getting adequate erections, that is, men who use them as performance-enhancing drugs.

Although all four medications are in the same class of drugs and have the same mechanism of action, they each have slightly different chemical structures and therefore act in slightly different ways.

The first “kid” on the block was Viagra. The usual dose is 50-100 mg. Viagra should be taken one hour prior to sexual activity. One must be sexually stimulated in order for the drug to be effective. So if a man takes the drug and merely looks at the ceiling, nothing will happen! In most cases, Viagra will create an erection firm enough for penetration, and the erection will usually last until orgasm is reached. There is a window of opportunity of up to six hours. Viagra is poorly absorbed on a full stomach, particularly after a fatty meal (and we are talking about a big steak here), so it is best taken before a meal or on a relatively empty stomach.

Levitra is very similar in chemical structure and action to Viagra. The usual dose of Levitra is 10-20 mg. It, too, must be taken about one hour before sexual stimulation. Levitra can be absorbed into the bloodstream, even on a full stomach, and many patients like this feature.

Cialis, which has a standard dose of 10-20 mg, has a much longer chemical half-life and can be effective up to 18 hours after first ingesting the pill. That is not to say that the erection will last 18 hours, but if one is stimulated within the 18-hour window of opportunity, Cialis will usually work very well. Cialis seems to be preferred by the somewhat younger patient with a more active sex life and has been described as the drug for the “weekend warrior.” Cialis also comes in a daily dosage, which is 5 mg. There is no theoretical downside to taking the daily dose if one’s sexual activity warrants it, and many physicians feel there is a beneficial value because it increases coronary artery circulation.

The newest drug on the block is Staxyn. This drug is similar in structure to Levitra. The standard dosage is 10 mg. What makes Staxyn unique is that the tablet is placed on the tongue and is rapidly absorbed orally into the bloodstream. Staxyn has a more rapid onset and a window of opportunity of six or more hours.

It is important that men and women understand that these pills are not aphrodisiacs. They are not sexual cure-alls. They will not work in the absence of desire. Remember that 99 percent of almost all aspects of sexuality (attraction, desire, arousal, and orgasm) reside between the ears. When the brain is stimulated by sexual contact or fantasies, it sends a signal that releases nitrous oxide (commonly known as laughing gas and historically used by dentists for anesthesia) in the penis. The release of nitrous oxide causes the smooth muscles within the penis to relax, allows blood to flow freely into the spongy tissue of the penis, and produces a firm erection. By blocking the breakdown of nitrous oxide, these drugs create a longer period of smooth muscle relaxation in the penis. This mechanism allows the penis to stay erect for a longer period of time.

Remember, these drugs are not desire drugs—they are capacity drugs. They do not create desire; rather, these medications give a man the capacity to exercise his sexual potential.

Love making, and sex in general, is much more than an erect penis simply interacting with someone else’s body for the sole purpose of having an orgasm and releasing sexual tension. The sexual experience must go far beyond its physical characteristics. It must involve intimacy, sensuality, and an emotional connection based on respect and caring.

Couples with problems in their interpersonal relationships should not turn to these drugs as a quick-fix solution. These drugs are designed to help individuals revive and maintain the sexual aspects of a healthy, intimate relationship. They should not be used as a substitute for resolving conflicts. Communication and discussion are certainly more valuable than any medicine, but these medicines are undoubtedly a great way to help communicate affection to your partner!

Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).

Read discreetly with the Kindle™ edition of Penis Power™ now available for purchase from Amazon. The Nook Books™ edition from Barnes & Noble and the Sony eReader™ edition from Sony’s Reader Store. Available for under $7.00!

 

Masturbation – The Real Story

Let me state loudly and clearly that there is nothing wrong with masturbation. It is normal behavior that should not elicit any form of shame or embarrassment. Masturbation is not harmful and cannot be overdone. The only limiting factor is the possible irritation or abrasion of the skin of the penis. But, from my perspective, masturbation should be the “court of last resort” for most men.

Naturally, every man is alone at times without a partner available to relieve his sexual tension. Under such circumstances, masturbation is certainly better than no sexual activity at all. But men who cannot get through a day without servicing themselves or who are obsessed with watching pornography (especially in today’s world of cyberspace and cybersex) need to reexamine their view of sex. Not only does pornography present a completely unrealistic view of sex in general, it has the potential to instill unhealthy habits that can jeopardize future intimate relationships.

In short, masturbation will do in a pinch, but it is no substitute for the real thing. Given its negative connotations, too much masturbation can increase levels of self-doubt (even though, within limits, it causes no physical damage). A man cannot help feeling a bit inadequate if he has to resort to performing in mono when he would rather perform in stereo.

Mutual masturbation is another matter entirely. Couples who know how to use their hands and fingers with the artistry of a violinist can fill a bedroom with fantastically erotic music. It is fine to let your hands do the talking, but masturbation is much more satisfying if the conversation is between two people.

Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press).

Read discreetly with the Kindle™ edition of Penis Power™ now available for purchase from Amazon. The Nook Books™ edition from Barnes & Noble and the Sony eReader™ edition from Sony’s Reader Store. Available for under $7.00!

 

A Tried-And-True Technique For Delaying Orgasm

In the context of my busy urologic practice, I am often asked if there is any way to make male orgasms last longer. This area is one where men are jealous of women. I call it Venus Envy. For reasons unknown, nature designed humans so that women can experience prolonged wavelike orgasms, while men can experience brief and thunderous orgasms, five to seven seconds in duration. Wouldn't it be great, men dream, if we could make that ecstatic sensation last a full minute? Five minutes? An hour? So far, no one has come up with a way to prolong orgasm. However, we have found ways to delay it.

I will go out on a limb and predict that we will find a way to prolong male orgasms somehow, someday. With sex being studied by more scientists than ever before, I believe that researchers will eventually accomplish what most men have been unable to achieve on their own. When that day comes, it will be a great one for men.

In the meantime, many excellent techniques can be employed to delay orgasms in men, prolong the pleasurable sensation that sexual stimulation embodies, and delay ejaculatory inevitability.

With sufficient stimulation to an erect penis, the reflex action of ejaculation is eventually triggered. The amount of time it takes for ejaculation to occur depends on the individual and on the circumstances. The sensation of pleasure involved also may vary with different encounters. A man might experience fireworks and ejaculate very quickly, or he might require an extended period of stimulation in order to achieve climax. The differences in the intensity and pleasure of orgasm are mediated in the brain. These differences entail psychological and emotional factors, such as love, romance, fantasy, physical chemistry, and the level of physical and emotional passion that precedes the orgasm.

What takes place physically during ejaculation is always the same (with minor variations), whether a man is masturbating in a closet or making love under a tropical waterfall with the partner of his dreams.

When a certain level of excitement is reached, a complex chain of nerve impulses signals the muscles in the pelvic floor to contract. (These muscles are located in the perineum, the area between the back of the scrotum and the bottom of the rectum.) These pelvic contractions are accompanied by muscle contractions in other parts of the body, such as the lower back and abdomen, and an increase in the heart and respiratory rates. All of these reflexes make ejaculation a whole-body phenomenon.

When the contractions of the perineal muscles forcibly start to move the semen on its route to the penis, men feel the sensations that tell them they are about to ejaculate. From this point on, ejaculation is inevitable. It is a pure reflex that cannot be stopped. Any effort to delay ejaculation has to be made prior to this point of no return.

In order to delay reaching this point of ejaculatory inevitability, one must get extremely close to the threshold of ejaculatory inevitability and then halt all stimulation and relax all muscles of the perineum and lower back before resuming direct stimulation. With practice, this process can be done multiple times, but it takes a considerable amount of mental, physical, and emotional discipline. Though not medically correct, this technique is sometimes labeled "the continuous male orgasm." The trick, of course, is to reach a high level of excitation prior to ejaculatory inevitability, back off, reach a higher level of excitability prior to ejaculatory inevitability, back off, and continue this exercise for as long as possible.

A good idea is to start with gentle self-stimulation. One can bring himself to the edge and then back off and repeat the process. The key is to get very close to ejaculatory inevitability and then completely relax all of the sexual organ muscles and cease stimulation to the penis. This exercise, of course, can also be done with a partner, but the principle is the same. Some of my patients use this approach and combine it with the "squeeze" technique, which involves a sharp squeeze of the tip of the penis just prior to ejaculatory inevitability. This maneuver will set the clock back, and then the process starts again. Another approach is called the Valsalva maneuver. Again, one is brought close to the point of ejaculatory inevitability and then increases abdominal pressure by bearing down as if one were having a bowel movement (without, of course, having one). This increased intra-abdominal pressure will have the same effect as pelvic relaxation and the squeeze technique.

These techniques will not create a state of continuous orgasm but will merely prolong the period of sexual excitation prior to ejaculatory inevitability. Learning to resist the temptation of orgasm, which is not easy to do, can prolong the period of sexual excitation. The key thought should be "get close, relax, get closer, relax, and so forth." With practice, the stop-and-go approach will delay orgasms, increase the period of high-level sexual excitement, and bring a broad smile to all involved.

 

Brand-Name Drugs Versus Generic Equivalents– A Moral Dilemma

We are all aware of many high-priced drugs, some costing more than $10,000 a month for treatment, that have radically altered the course of a patient's illness. We are also aware of a huge market in generic-equivalent drugs, many of which are similar in chemical composition and effect to their high-priced cousins.

Over the past several years, India has become the world's largest producer of cheap, lifesaving generic medicines, which are distributed to impoverished countries around the world.

But in the United States and most European countries, many medicines with recognizable brand names are protected by patents and cannot be manufactured or distributed as generic equivalents. Despite this protection, India has, for many years, mass-produced the generic equivalents of many expensive and effective drugs to the poorest countries around the world by circumventing patent regulations. Most of the major manufacturers have, until recently, looked the other way. Presently, however, there is a case in front of the Indian Supreme Court involving the drug Gleevec, a breakthrough cancer treatment for people with a deadly form of leukemia manufactured by the Swiss drug company Novartis. Novartis is trying to stop the Indian supply chain of inexpensive generics by forcing the Indian government to recognize the patent of this drug in particular and, by inference, all brand-name drugs, thereby blocking distribution.

The particular case of Novartis and Gleevec presents a moral and business conundrum. The drug company is trying to stop Indian manufacturers from producing generic knockoffs and claims that the violation of patents and copyright laws would not allow Novartis to pursue research and development to create newer and better drugs. The Indian government, on the other hand, claims that if the large drug companies, like Novartis, prevail in the lawsuit, the worldwide supply of inexpensive medicine to treat cancer, AIDS and HIV, and other diseases would disappear.

The moral dilemma for a company like Novartis, a major worldwide developer and manufacturer of innovative (and expensive) drugs, is that in order to develop these drugs, the company must be profitable. These profits would then, in large part, go toward research and development and hopefully new and far-reaching discoveries. However, the high cost denies millions of patients, particularly AIDS and HIV patients in poorer countries, access to these drugs.

At the heart of the matter is the Indian government's denial of the patent for Gleevec and similar drugs made by Western drug manufacturers. The Obama administration and the Pharmaceutical Research and Manufacturers of America, a drug industry lobby group, are applying considerable pressure on the Indian government to relent in the dispute. Their desire is that the Indian government agree to grant patents to generics in situations similar to that involving Gleevec.

Clearly, the drug companies would like to increase their investment in India, for both distribution and manufacturing, as sales in the emerging markets would then compensate for the expected decreased business in the United States and Western Europe.

Although Gleevec, originally approved by the Food and Drug Administration in 2001, can cost about $70,000 a year in the United States, Novartis insists that it offers hefty discounts in poor and underdeveloped countries. By comparison, the Indian generic version costs about $2,500 a year.

The question for a company like Novartis is, How do you balance the high cost of a drug and the need for a hefty profit in order to continue research and development against the worldwide need for generics across a wide swath of countries unable to afford the brand-name drugs?

The burden falls squarely on India, a country that exports about $10 billion worth of generic medicines per year. Doctors Without Borders estimates that 80 percent of the generic AIDS drugs it supplies to an estimated 170,000 people in Africa are made in India. Without a change in the patent laws, a humanitarian disaster is imminent.

The case before the Indian Supreme Court gets a little sticky because it involves a principle of Indian patent law that prohibits a new form of a substance from receiving a patent unless the formation significantly improves the medicine's efficacy. This position was aimed at preventing a widespread practice among pharmaceutical companies known as evergreening, wherein the company makes minor changes of existing drugs and earns new patents. Evergreening can theoretically provide many additional years of patent protection from generic competition. At present, India's patent law does not define efficacy or say how it should be measured.

In the end, the key to the case before the court and the moral conundrum to be solved is to interpret the law in a way that balances the need for innovation against public health concerns.

 

Dr. Danoff’s Top Ten Myths About Sex

Having practiced urology for more than 30 years and having examined more men than can fill the Rose Bowl, I have heard every myth conceivable with regard to sex and would like to share my top 10 myths with you (in no particular order):

 

Myth #1. Size Matters!

 

The unique size of every man’s penis is determined at birth by the size of the corpora cavernosa—the two chambers within the shaft of the penis that fill with blood during an erection. There is no medical or surgical way to increase the length or width of the penis. Since the power of the mind has the most significant influence over sexuality, the only advantage a man with a large penis might have is that he thinks he has an advantage. “Think big and you will be big” is the most important message for a man to know about size. What really matters is the size of a man’s self-esteem and the size of his heart, not the size of his penis. Even if penis size did matter, nothing can be done about it. I have asked the wives and girlfriends of many of my patients about penis size. Not one of them has asked, “Dr. Danoff, can you make my man’s penis longer or wider?” But what they have asked is if I could “make it a bit firmer and attach it to a nicer, more pleasant, and generous guy!” Remember, contact of the tip of the penis (the most sensitive part) against the clitoris, the most up-front structure in the vagina, leads to orgasm. In most cases, size is irrelevant.

 

Myth #2. Withdrawal before ejaculation is a good method of birth control.

 

This “pullout” method, also known as the rhythm method, is a very poor form of birth control. As a man approaches a climax, ejaculatory fluid, which contains a considerable number of sperm, will seep preceding orgasm. The sperm can easily come in contact with the uterus and result in pregnancy. One in five couples who use the pullout method as their only form of birth control over the course of a year will conceive a child.

 

Myth #3. Premature ejaculation affects only younger men.

 

Although premature ejaculation is quite common in younger men at the outset of sexual maturity, many older men also find it to be an issue. Premature ejaculation affects about 30 percent of men at some time in their life. It can often be related to sexual inactivity for long periods of time or psychological factors. On the other hand, the ability to delay ejaculation can be learned. A number of treatments for premature ejaculation are readily available. Early ejaculation in men who are in their 30s or older may be a symptom of erectile dysfunction or fatigue. In older men, premature ejaculation can be a function of poor cardiovascular conditioning, depression, or neurologic symptoms. In younger men, it can be a symptom of anxiety. Early ejaculation is correctable and treatable in all age brackets.

 

Myth #4. A real headache is a good reason to avoid sex.

 

While many women, and some men, have feigned a headache to get out of sex, intercourse actually relieves minor aches and pains, including headaches. Oxytocin and other good endorphins released during sexual activity and orgasm are responsible for pain relief and general mood elevation.

 

Myth #5. Most men don’t last long in bed.

 

Surveying my patients revealed that the optimal length of sex is 3 to 13 minutes, not including foreplay. Each couple has its own time averages, which depend on each individual and, of course, other factors, including energy levels and sexual desire. Many of my patients think that everyone else is having better, longer, and more sex than they are, when in reality this belief is generally untrue. The key factor for most of my patients is mutual sexual satisfaction, unrelated to the clock at the bedside.

 

Myth #6. Great sex comes naturally!

 

Great sex is not an Olympic sport. It is not a contest. It does not come with an instruction manual. The key to great sex is mutual communication. Each partner must show a willingness to try new techniques and positions. The key is agreeing on what both partners find pleasurable. The physical chemistry often seen on television shows or in a movie suggests that when two lovers meet, sparks fly and mind-blowing sex naturally flows. But in the real world, great sex is not always that easy.

 

Myth #7. Sexually transmitted diseases (STDs) can be contracted from a public toilet seat.

 

Organisms that cause the most common STDs, like gonorrhea and Chlamydia, can survive only for a very short time, and the toilet seat is a highly unlikely transmitter. Public restrooms are undoubtedly a host to a number of germs, from those that cause the common cold to hepatitis A. But catching an STD in a public restroom is extremely rare. To contract an STD, the organism would have to come in direct contact with the urethra or enter through an open wound, a circumstance that is certainly possible but highly unlikely.

 

Myth #8. Viagra and similar drugs are the holy grail for men with erectile dysfunction.

 

The class of drugs known as PDE5 inhibitors, which include Viagra, Cialis, Levitra, and Staxyn, make up a billion-dollar industry in the United States alone. These drugs increase blood flow to the penis and create a firm erection, particularly in men who have diminished blood flow or an inability to sustain an erection long enough to complete intercourse. While many men benefit greatly from the use of these drugs, many younger men abuse them to enhance performance. This practice is a dangerous precedent. These drugs are drugs of performance, not drugs of desire. Many older men with serious cardiovascular conditions require a more aggressive form of treatment, which might include injection therapy or perhaps even a penile prosthesis. The “little blue pill” is not the answer for everyone. Although safe in most instances, these drugs are not without serious side effects or dire consequences if used inappropriately.

 

Myth #9. Certain foods or substances are aphrodisiacs.

 

Aphrodisiacs, named for the Greek goddess of sensuality and love, theoretically increase libido and put people in the mood for love. Oysters, dark chocolate, strawberries, rhinoceros horn, and tiger penis have been touted as aphrodisiacs for decades. No scientific evidence supports the validity of claims that foods or herbs can actually cause arousal. It is possible that certain foods, fragrances, or visual stimuli can trigger an erotic memory and thus increase desire. These substances may appear to be aphrodisiacs, but arousal would occur only on an individual basis.

 

Myth #10. Men care less about birth control responsibility than women do.

 

A large number of fertile men see me for an elective vasectomy. Men have often taken the brunt of women’s complaints regarding whose responsibility birth control is. The real issue is that women have several options available to them—patches, implants, diaphragms, the pill, the injection, IUDs, female condoms, and tubal ligation—while men have only vasectomy, condoms, withdrawal, and possibly (on the horizon) the male pill to choose from. Therefore, in the majority of cases, responsibility for birth control nearly always falls on a woman by default. Among my patients, condom use is still the main form of contraception, followed closely by the pill. My experience indicates that equal responsibility should be and usually is operative in matters of birth control

 

Dr. Danoff's Top Ten Myths About Sex

Having practiced urology for more than 30 years and having examined more men than can fill the Rose Bowl, I have heard every myth conceivable with regard to sex and would like to share my top 10 myths with you (in no particular order):

 

Myth #1. Size Matters!

 

The unique size of every man's penis is determined at birth by the size of the corpora cavernosa—the two chambers within the shaft of the penis that fill with blood during an erection. There is no medical or surgical way to increase the length or width of the penis. Since the power of the mind has the most significant influence over sexuality, the only advantage a man with a large penis might have is that he thinks he has an advantage. "Think big and you will be big" is the most important message for a man to know about size. What really matters is the size of a man's self-esteem and the size of his heart, not the size of his penis. Even if penis size did matter, nothing can be done about it. I have asked the wives and girlfriends of many of my patients about penis size. Not one of them has asked, "Dr. Danoff, can you make my man's penis longer or wider?" But what they have asked is if I could "make it a bit firmer and attach it to a nicer, more pleasant, and generous guy!" Remember, contact of the tip of the penis (the most sensitive part) against the clitoris, the most up-front structure in the vagina, leads to orgasm. In most cases, size is irrelevant.

 

Myth #2. Withdrawal before ejaculation is a good method of birth control.

 

This "pullout" method, also known as the rhythm method, is a very poor form of birth control. As a man approaches a climax, ejaculatory fluid, which contains a considerable number of sperm, will seep preceding orgasm. The sperm can easily come in contact with the uterus and result in pregnancy. One in five couples who use the pullout method as their only form of birth control over the course of a year will conceive a child.

 

Myth #3. Premature ejaculation affects only younger men.

 

Although premature ejaculation is quite common in younger men at the outset of sexual maturity, many older men also find it to be an issue. Premature ejaculation affects about 30 percent of men at some time in their life. It can often be related to sexual inactivity for long periods of time or psychological factors. On the other hand, the ability to delay ejaculation can be learned. A number of treatments for premature ejaculation are readily available. Early ejaculation in men who are in their 30s or older may be a symptom of erectile dysfunction or fatigue. In older men, premature ejaculation can be a function of poor cardiovascular conditioning, depression, or neurologic symptoms. In younger men, it can be a symptom of anxiety. Early ejaculation is correctable and treatable in all age brackets.

 

Myth #4. A real headache is a good reason to avoid sex.

 

While many women, and some men, have feigned a headache to get out of sex, intercourse actually relieves minor aches and pains, including headaches. Oxytocin and other good endorphins released during sexual activity and orgasm are responsible for pain relief and general mood elevation.

 

Myth #5. Most men don't last long in bed.

 

Surveying my patients revealed that the optimal length of sex is 3 to 13 minutes, not including foreplay. Each couple has its own time averages, which depend on each individual and, of course, other factors, including energy levels and sexual desire. Many of my patients think that everyone else is having better, longer, and more sex than they are, when in reality this belief is generally untrue. The key factor for most of my patients is mutual sexual satisfaction, unrelated to the clock at the bedside.

 

Myth #6. Great sex comes naturally!

 

Great sex is not an Olympic sport. It is not a contest. It does not come with an instruction manual. The key to great sex is mutual communication. Each partner must show a willingness to try new techniques and positions. The key is agreeing on what both partners find pleasurable. The physical chemistry often seen on television shows or in a movie suggests that when two lovers meet, sparks fly and mind-blowing sex naturally flows. But in the real world, great sex is not always that easy.

 

Myth #7. Sexually transmitted diseases (STDs) can be contracted from a public toilet seat.

 

Organisms that cause the most common STDs, like gonorrhea and Chlamydia, can survive only for a very short time, and the toilet seat is a highly unlikely transmitter. Public restrooms are undoubtedly a host to a number of germs, from those that cause the common cold to hepatitis A. But catching an STD in a public restroom is extremely rare. To contract an STD, the organism would have to come in direct contact with the urethra or enter through an open wound, a circumstance that is certainly possible but highly unlikely.

 

Myth #8. Viagra and similar drugs are the holy grail for men with erectile dysfunction.

 

The class of drugs known as PDE5 inhibitors, which include Viagra, Cialis, Levitra, and Staxyn, make up a billion-dollar industry in the United States alone. These drugs increase blood flow to the penis and create a firm erection, particularly in men who have diminished blood flow or an inability to sustain an erection long enough to complete intercourse. While many men benefit greatly from the use of these drugs, many younger men abuse them to enhance performance. This practice is a dangerous precedent. These drugs are drugs of performance, not drugs of desire. Many older men with serious cardiovascular conditions require a more aggressive form of treatment, which might include injection therapy or perhaps even a penile prosthesis. The "little blue pill" is not the answer for everyone. Although safe in most instances, these drugs are not without serious side effects or dire consequences if used inappropriately.

 

Myth #9. Certain foods or substances are aphrodisiacs.

 

Aphrodisiacs, named for the Greek goddess of sensuality and love, theoretically increase libido and put people in the mood for love. Oysters, dark chocolate, strawberries, rhinoceros horn, and tiger penis have been touted as aphrodisiacs for decades. No scientific evidence supports the validity of claims that foods or herbs can actually cause arousal. It is possible that certain foods, fragrances, or visual stimuli can trigger an erotic memory and thus increase desire. These substances may appear to be aphrodisiacs, but arousal would occur only on an individual basis.

 

Myth #10. Men care less about birth control responsibility than women do.

 

A large number of fertile men see me for an elective vasectomy. Men have often taken the brunt of women's complaints regarding whose responsibility birth control is. The real issue is that women have several options available to them—patches, implants, diaphragms, the pill, the injection, IUDs, female condoms, and tubal ligation—while men have only vasectomy, condoms, withdrawal, and possibly (on the horizon) the male pill to choose from. Therefore, in the majority of cases, responsibility for birth control nearly always falls on a woman by default. Among my patients, condom use is still the main form of contraception, followed closely by the pill. My experience indicates that equal responsibility should be and usually is operative in matters of birth control

 

Robotic Surgery For Prostate Cancer Gets A Bad Wrap

A new study from Duke University Medical Center, led by Dr. Judd W. Moul, a prostate surgeon, suggests that men's expectations of laparoscopic robot-assisted prostatectomy may be too high. The study found that of 171 men facing prostate cancer surgery, those having robotic surgery expected a shorter hospital stay and a quicker return to their usual physical activity and sex life. Dr. Moul points out that those hopes may not be realistic. I disagree with this observation.

In my nearly 40 years of practicing urology and participating in thousands of surgical operations for prostate cancer, I have seen no technique, piece of equipment, drug, imaging device, or surgical procedure that has been more innovative than the introduction of laparoscopic robot-assisted prostatectomy. It is certainly true that the experience and skill of the robotic surgeon is the key element to the success of this breakthrough procedure. But assuming that the procedure is performed by an experienced robotic surgeon, when comparing robotic surgery with open surgery in terms of the precise definition of surgical anatomy, field magnification, blood loss, and nerve and continence preservation, there is no contest!

Among many other advantages, the laparoscopic robot-assisted prostatectomy requires no large incision (resulting in less pain), the surgical field is magnified, the blood loss is negligible, and the natural tremor of the surgeon (who can often become fatigued) is eliminated. These advantages all allow a more exacting and anatomically correct attachment between the bladder neck and the urethra after the prostate has been removed.

In my experience at Tower Urology at Cedars-Sinai Medical Center in Los Angeles, the overwhelming majority of our patients experience essentially no postoperative pain, are discharged to moderate activity on the first postoperative day, need to wear a urinary catheter for about five days (much shorter than with open surgery), have nearly perfect continence from the start, and have an excellent return of sexual function (usually dependent on the degree, if any, of preoperative erectile dysfunction).

It is true that the robotic equipment is expensive and that many hospitals heavily promote this approach with aggressive marketing. But claims that robotic surgery is better than the old-fashioned way are true, based on my experience. Surgeons who still cling to the illusion that open surgery is better often say that, by using their hands, they get a tactile feel of the organs and nerve bundles, a benefit impossible with the robotic approach. Although there is no tactile feel using the robot, this loss is more than compensated by the magnification of the surgical field and the ability of the robotic arm to rotate 360 degrees and angulate in a manner much more efficient than the ability of any human wrist, hand, or arm.

No surgical procedure should be approached as a "walk in the park." Since there are only two surgical approaches to removal of the prostate, laparoscopic robot-assisted prostatectomy and incisional prostatectomy, the choice seems obvious, assuming that the procedure is performed by an experienced robotic surgeon. Of course, many men with early-stage prostate cancer decide to hold off on treatment. Many prostate cancers are slow-growing and may never advance. More and more men are opting for watchful waiting or active surveillance as a modality of treatment. This decision is entirely justified.

However, if the patient and his urologist decide that prostatic surgery is the best course of action, robot-assisted laparoscopic prostatectomy by an experienced robotic team is both revolutionary in the annals of urologic surgery and unequaled in results.

 

Finally, A Rational Reason To Recommend Circumcision

The concept of "to be or not to be," circumcised that is, is both ageless and fraught with emotional, religious, psychological, medical, and moral issues. All sides have argued both for and against circumcision with a high degree of emotion and ill-conceived prejudice.

Finally, several reliable medical studies have shown that circumcising adult heterosexual men is one of the most effective therapies against HIV and AIDS. These studies pointed out that by merely circumcising these men, the chance of infection decreases by 60 percent or more. Circumcision is believed to protect heterosexual men because the foreskin has a type of cell that attracts the virus and literally delivers it to the immune system—which HIV attacks.

With these findings in mind, the World Health Organization (WHO) has focused on the devastating HIV and AIDS problems in Africa and has been desperately searching for a method of performing assembly-line circumcisions. The need for mass circumcisions has now become obvious in South Africa, particularly in the province of KwaZulu-Natal, which has South Africa's highest AIDS rate. Zulu's King Goodwill Zwelithini has ordered that all Zulu men be circumcised, reversing 200 years of tradition.

To meet the goal of circumcising 20 million African men by 2015, a quick-fix circumcision must be found. To date, only about 600,000 have been "clipped." African countries are critically short of surgeons, even a skilled surgeon takes about 15 minutes to perform a circumcision, and as far as I know, there is no "Mohels Without Borders." All humor aside,  with these obstacles in mind, WHO and the Bill & Melinda Gates Foundation have been looking for a ring device that could be used by a trained nurse to perform assembly-line circumcisions.

Several weeks ago, the Food and Drug Administration approved such a device called PrePex, invented in 2009 by four Israelis after they heard an appeal for doctors to perform mass circumcisions in Africa. The initial safety studies indicate that PrePex is faster, less painful, and more bloodless than any of its current rivals. The technology—a rubber band—is extremely simple and nonthreatening. PrePex uses a ringlike device that is slipped inside the band and placed around the penis to block blood flow to the foreskin. After about a week, the dead foreskin falls off or can be clipped off. A spokesman from PrePex compared the process to the stump of an umbilical cord shriveling up and dropping off a few days after it is clamped. The procedure uses a topical anesthetic cream and is free of any bleeding. The device can be put in place and removed by a nurse after about three days of training.

WHO is also examining the Shang Ring, a plastic device consisting of two rings that was developed in China. However, this method requires cutting off the excess foreskin beyond the clamp. The circumciser (nurse or physician) must inject anesthetics directly into the penis and groin, wait for them to take effect, create a sterile surgical field, and be trained in minor surgery. Although faster than a surgical circumcision, the Shang Ring is not fast enough for the purpose of circumcising millions of men.

Preliminary studies from Rwanda's health ministry noted that the PrePex device had been used to circumcise nearly 600 men and that only two men experienced moderate complications. One complication was fixed with a single suture, and one man required a new ring and rubber band in a slightly different spot. This complication rate of 0.34 percent is about one-tenth the typical complication rate of surgical circumcision.

Utilizing the PrePex system in Rwanda, two-nurse teams could perform the procedure in about three minutes. The best surgical assembly lines—a practice being pioneered in Africa with American taxpayer support—can complete the circumcision in about seven minutes per patient, but only by getting six nurses and a surgeon into a tight team.

Theoretically, three two-nurse teams could circumcise about 400 men a day, rather than the 60-80 a busy surgical team now circumcises in Africa. Furthermore, the surgeon involved could be doing something more surgically relevant.

According to Dr. Jason Reed, an epidemiologist in the global AIDS division of the Centers for Disease Control and Prevention, most American AIDS dollars for circumcisions go toward an operating room with lights and an instrument sterilizer. Instead of circumcisions, these hospitals are more likely to use the operating room for other procedures without regard to HIV and AIDS prevention.

In addition to the ease of application and effectiveness, the PrePex device does not require any anesthesia, a benefit that provides a real advantage. On a 10-point pain scale, the men reported an average of only about 1 when the ring was placed and only 3 when it was removed.

Rwanda is currently training about 150 two-nurse teams. Rwanda may serve as a role model for the rest of Africa because the country's health-care system is well organized, government corruption scandals are rare, and health care is heavily supported by donor funds.

There are a number of other clamp devices on the market, including the Tara Klamp, manufactured in Malaysia since the 1990s; Ali's Klamp, a Turkish device currently being tested in Kenya; and the SmartKlamp device, approved by the Food and Drug Administration in 2004. But the PrePex device clearly seems to have an edge over the others and may offer a revolutionary breakthrough to assembly-line circumcisions and AIDS prevention involving tens of millions of men worldwide.