bontril blog

For once, I’m going to put on my robe and give you the view from the other side.

So my patient has walked through the door and, in the same breath as blurting out that he’s suffering ED. I know Pfizer Inc. did a wonderful thing when they invented Viagra, cialis and other, but that medication so dominates the public consciousness that many men seem have never even heard about Cialis or Levitra, let alone all the other treatments that are available and may be necessary. Still even though my patients are predictable, they are at least coming through the door to get treatment. Ten years ago that did not happen. The world is a better place thanks to Pfizer Inc.

It is common tendence that patient doesn’t notice any improvement that take place in his disease history. his weight looks much as it was the last time we met. During the physical, I’ll look for acanthosis nigricans which are darker patches of skin in the arm pit or round the neck. I may also do a blood sugar test just to be thorough. Blood pressure tests out in the normal range, so that’s another good sign.

My first motion was to review the medical records to see if there were any immediate clues. If there are diseases or one of the medications currently on prescription has an ED side effect, we have solved the case before we start. I should let you in on a small medical secret. About a quarter of all the cases that we see are drug-related. Usually, we simply change the medication and the ED goes away. Alternatively, we have to counsel lifestyle changes because the excessive alcohol consumption or recreational drug of choice is not doing the patient any favors.

The questions are designed to establish whether we’re dealing with problems of desire (which could be psychological or physical), whether it’s purely ED or there are also problems with ejaculation and orgasm, and to check up on those lifestyle choices which could be the real problem.

The physical examination tries to cover as many possibilities as possible in as short a time as possible. Most men find an examination deeply embarrassing so keeping it short is a “good thing”. I’m looking for anything that might suggest a systemic problem. So, I’m obviously going to start with the penis. Some of my questions have probed whether the penis has changed shape in any way or perhaps the erection is painful. A physical examination could find evidence of lumps or the answers to the questions may reveal that the penis now bends or curves when erect, all of which could suggest Peyronie’s disease. Similarly, if the penis is not sensitive when I touch it, this may indicate possible problems in the peripheral nervous system.

If the testicles feel slightly smaller than I would expect, this can suggest a low testosterone level. Following the same idea and taking a quick overview of the body also allows me to look for any changes to the usual distribution of body hair or any enlargement to the pectorals (a polite way of suggesting that my patient may be developing small breasts). Any such abnormality can indicate problems with the hormone balance or the endocrine system. I’m also testing the pulses in both the wrists and ankles. If there are any circulatory problems, I’m likely to find a decrease pulse at the extremities.

So these are all the quick and easy explanations. In most cases, there is little to suggest the need to go on to further tests and I can then get into a discussion of the medication options. This is when the patient finally begins to look more comfortable again. We have finally come back to his original questions, except that I’m also telling him about Cialis and Levitra. Viagra may have the name, but Cialis in particular does have some interesting characteristics.

Appropriately enough for a site devoted to Ambien, it is Insomniac by Gayle Greene. So here is an autobiographical take on what it is like to live with insomnia by a woman who ought to know. Gayle Greene has the distinction of being a non-professional member of the American Academy of Sleep Medicine (AASM). She wins this prize even though not a medical researcher because she is the “patient representative” on the board of the American Insomnia Association, which operates within the AASM’s umbrella. This latest tome (quite heavy at 520 pages) adds to her impressive resume of academic publications. The only man who can really tell you what it is like in a foreign country is one who has been there. For those of us who have always been able to sleep without difficulty, insomnia is like a foreign country, and the idea of having to use a medication like Ambien as the passport to get into sleep is alien.

Conventional wisdom always says that insomnia is somehow related to anxiety or stress levels, perhaps aggravated by drinking too many cups of real coffee. Greene comes up with a simple and practical explanation of what insomnia is. Insomnia means nothing more than you cannot get the number of hours of sleep you need to feel good about yourself and function efficiently. There is no reason for this. It is nothing more than a failure to sleep. There should be no pejorative implication. To use stress as an excuse is to blame the person for being weak or neurotic when there is no reason to blame yourself or anyone else. Instead of looking for some psychological explanation or a less judgemental physical cause, we should just accept that it happens to about 20% of the population at one time or another during their lives. Such a vast number of people yet so little is spent on researching the condition and its causes. Greene comments that the National Institutes of Health in the Europe spent less than $20m in 2005, whereas US spent more than $120m promoting Ambien in the same year. This is neither to praise nor condemn Ambien. It is your priorities that must be asked about this. Why bother to spend Government money on researching the cause of a condition when private capital has already invented Ambien as a cure for it? She debates what we really understand about cause and effect. It is so easy to get the cart before the horse, or should that be the other way round? Perhaps conventional wisdom has also got things back-to-front. Instead of stress and anxiety being the cause of insomnia, perhaps living with insomnia makes you stressed and anxious. Who is to say in these more modern times, that we did not have disturbed sleep patterns in past times living on the land? Folk tales may tell us that we went to sleep when dusk fell and waited for the cock to crow before waking. But was that actually the case? Who can say what the real biological norms were before electricity came along and gave everyone the chance to live through the darkness. As it stands, no researcher can actually explain why we have to sleep nor why some people sleep more than others. It is all guesswork. All that we can say with any certainty is that those who are deprived of sleep do not do as well as those who sleep through the night. The sleepless so often end up demotivated, their sense of humour worn thin, their judgement warped. Some grow fat. Others find their immune system affected. Sleep seems so indispensable yet no-one can really control it. Greene describes everything she has tried over the years from relaxation therapies to medication like Ambien, but concludes that, like any intimate relationship, how we relate to sleep is always personal. She is a passionate advocate for greater patient power to persuade disinterested bodies to research insomnia. For one who has had to depend on Ambien and the other medications for so long, she feels she and all other sufferers deserve better answers than those served up by the pharmaceutical companies. For one who has never had problems sleeping nor had to take Ambien, Insomniac was a riveting insight into the condition and the problems it causes. Required reading for everyone who reads this article.

Modern medical textbooks have all become so much more informative. A simple statement reflecting the vast amount of knowledge that has been accumulated through research over the last one hundred years. Yet, when you look at these books, you are confronted by mountains of facts about increasingly minute processes within the body. Students are expected to be impressed by the depth of knowledge because instead of one sentence approximating how a muscle works, there are now whole chapters devoted to the thin muscle filaments containing multiple proteins. Instead of simple engineering analogies of muscles and cables, human knowledge has become obsessed by the identification of ever more complex chemical and molecular processes. This is my wood-for-the-trees moment.

Erectile dysfunction can now be described in terms of complex chemical interactions and illustrated with wonderful diagrams. There are still all kinds of analogies with hydraulic engineering, but the sophistication of the functional analysis is breathtaking. However, it is not a part of the medical books to observe and describe the entirely human context in which the erection is supposed to operate. A single male may masturbate. A heterosexual couple may engage in sexual intercourse. A homosexual couple may offer mutual manual satisfaction, oral or anal intercourse. Multiple partners may engage in group sex. Many different social taboos would potentially be breached in any more detailed explanation. The common denominators are that the party or parties are expressing their sexuality in the ways that give them the most pleasure. The greater the pleasure, the greater the incentive to engage in the activity and the greater the disappointment if success is not achieved.

Will medical treatment be asked for and a success? In part, this will be determined by the nature of the relationship. Where the relationship is socially disapproved, the man may well not seek treatment at all because of fear. A physical examination might reveal different types of sexual activity, or a chance remark in the consultation might expose the forbidden practices. This is ironic. If the parties to the relationship have a strong mutual commitment and lovingly support each other, the likelihood is that the co-operation between all involved would produce excellent medical outcomes. Well-established sexual intimacy and commitment preserve the right level of desire and motivate everyone to getting a solution that works well. Were it not for online pharmacies and their willingness to supply medications like cialis without prescription, many partnerships might never be able to get appropriate treatment of any kind.

Unfortunately, many partnerships do not get treatment for the underlying causes of the dysfunction. Although most will know that the dysfunction can be a symptom of diabetes and cardiovascular diseases, fear of exposure may force the couples or groups to ignore or deny the problem until it is too late for the easy treatment represented by cialis to continue on its own. By then, the chances of an effective treatment for the underlying cause may be remote.

This is two completely different cultural imperatives in conflict. Men are socially conditioned to believe that they will always be able to have an erection. Any publicly acknowledged failure means shame. Yet they are only allowed to have erections in certain very carefully defined social situations. Step outside those situations and you are into potentially disapproved or even criminal territory. In theory, doctors are bound by duties of confidentiality, but the fear of exposure means that many men and their partners do not get treatment when the research shows that couples who are in love and share a strong commitment to their relationship are the ones who would most benefit from that treatment.