Circumcision FAQ

Q-What are reasons for doing circumcision?

Newborn circumcision consists of removal of the foreskin to near the coronal sulcus performed in early infancy (before age 2 months). The procedure prevents phimosis, paraphimosis, and balanoposthitis. Meatitis is more common in circumcised boys. There is no evidence that meatitis leads to stenosis of the urethral meatus.
It is particularly important that uncircumcised boys be taught careful penile cleansing. As the boy grows, cleansing of the distal portion of the penis is facilitated by gently, never forcibly, retracting the foreskin only to the point where resistance is met. Full retraction may not be achieved until age 3 years or older.
A small percentage of boys who are not circumcised as newborns will later require the procedure for treatment of phimosis, paraphimosis, or balanoposthitis. When performed after the newborn period, circumcision may be a more complicated procedure.

The follow up is a summary of factors relating to neonatal circumcision, which may be considered by parents before deciding on the procedure.

Religious

Traditional, cultural, and religious factors play a role in the decision made by parents, paediatrician, obstetrician, or family practitioner on behalf of a son. The final decision by parents is based on true informed consent. It is advantageous for discussion to take place well in advance of delivery, when the capacity for clear response is more likely.

Prevention of Phimosis

Phimosis is tightness of foreskin with inability to retract for hygiene. It is very common in newborn period. It resolves in few children as they grow, but persists in many. Circumcision should be done in infancy or at least before boy starts school.

Faciliation of Hygiene

Circumcision, properly performed, eliminates much of the need for careful penile hygiene. If circumcision is not performed, lifelong penile hygiene is required. Factors such as climate, the social and emotional reaction of prospective parents to penile cleansing, and the ability to understand and facilitate good hygiene, etc. should be taken into account when deciding whether circumcision should be performed.

Urinary Tract Infections

Studies conducted at US Army hospitals involving more than 200,000 men showed a greater than tenfold increase in urinary tract infections in uncircumcised compared with circumcised male infants; moreover, as the rate of circumcision declined throughout the years, the incidence of urinary tract infection increased. In another army hospital study, infants were examined in the first month of life and it was concluded that the high incidence of urinary tract infection in uncircumcised boys was accompanied by a similarly increased incidence of other significant infection, including bacteremia and meningitis26; Still another recent army hospital study lends support to a 1986 hypothesis that circumcision prevents preputial bacterial colonization and thus protects male infants against urinary tract infection..

Sexually Transmitted Diseases

There is higher risk of gonococcal and nonspecific urethritis in uncircumcised men,29,30 Published reports suggest that chancroid, syphilis, human papillomavirus, and herpes simplex virus type 2 infection are more frequent in uncircumcised men, .29,30,32-34

Cancer of the Penis

This condition occurs almost exclusively in uncircumcised men.12-14 In five major reported series since 1932, not one man had been circumcised neonatally.11, 15-19 The predicted lifetime risk of cancer of the penis developing in an uncircumcised man has been estimated at 1 in 600 men in the United States20
Factors other than circumcision are important in the etiology of penile cancer. The incidence of penile cancer is related to hygiene. In developing nations with low standards of hygiene, the incidence of cancer of the penis in uncircumcised men is 3 to 6 per 100,000 men per year22. The decision not to circumcise a male infant must be accompanied by a lifetime commitment to genital hygiene to minimize the risk of penile cancer developing. Poor hygiene, lack of circumcision, and certain sexually transmitted diseases all correlate with the incidence of penile carcinoma.

Cancer of the Prostate

There is presently no convincing scientific evidence to substantiate the assertion that circumcision reduces the eventual incidence of cancer of the prostate.

Cervical Carcinoma

There appears to be a strong correlation between squamous cell carcinoma of the cervix and sexually transmitted diseases. Human papillomavirus types 16 and 18 are the viruses most commonly associated with cancer of the cervix 35-38; Herpes simplex virus type 2 has also been linked with cervical cancer.36, 39 Although human papillomavirus types 16 and 18 are also associated with cancer of the penis,23,37 evidence linking uncircumcised men to cervical carcinoma is inconclusive. The strongest predisposing factors in cervical cancer are a history of intercourse at an early age and multiple sexual partners. The disease is virtually unknown in nuns and virgins.

Balanitis and Venereal Disease

Balanitis is infection of the glans.
Posthitis is infection of the foreskin. It occurs only in uncircumcised males.
Balanoposthitis is infection of both the glans and the foreskin. It is very painful. If this occurs, staged surgical corrections may be necessary - first a dorsal slit to allow inflammation to subside, and then a secondary circumcision. .
If Circumcision leaves foreskin remnants, which partially cover the glans, then any of these conditions may occur also in circumcised males.
Adequate studies to determine the relationship between circumcision and the incidence of venereal disease have not been performed.

Surgical Risk and Aftermaths

Circumcision is a surgical procedure that requires careful aseptic technique, systemized postoperative observation, and evaluation after discharge from the hospital.

Q-What Anaesthesia is required for circumcision?

Local Anesthesia

Dorsal penile nerve block using no more than 1cc lidocaine (without epinephrine) in appropriate doses (3 to 4 mg/kg)
Ring Block 1%-2% Lidocaine around root of penis

General Anesthesia

I.V. anaesthesia-using injectable medicines
Inhalation anaesthesia-using anaesthetic gases.

Q-What are the techniques of performing circumcision?

Circumcision is a safe surgical procedure if performed carefully by a trained, experienced operator using strict aseptic technique. The procedure should be performed only on a healthy, stable infant.
Various techniques are available . Precise method used depends on condition of penis & Surgeon’s preference.
Clamp techniques (eg, Gomco or Mogen clamps)-Metallic clamps are used
Plastibell (disposable plastic devise) give equally good results
Free hand surgical excision of skin followed by stitching

Q-when circumcision should not be done?

Circumcision is contraindicated in an unstable or sick infant.
Genital anomalies-Infants with genital anomalies, including hypospadias, should not be circumcised because the foreskin may later be needed for surgical correction of the anomalies.
Bleeding disorders. Appropriate laboratory studies should be performed when there is a family history of bleeding disorders.
Unstable infant. Wait till he is stabilised. Infants who have demonstrated an uncomplicated transition to extrauterine life are considered stable. Signs of stability include normal feeding and elimination and maintenance of normal body temperature without an incubator or radiant warmer.
Neonatal illness -A period of observation may allow for recognition of abnormalities or illnesses (eg, hyperbilirubinemia, infection, or manifest bleeding disorder) .That should be treated before elective circucision
Premature infant. It is prudent to wait until a premature infant meets criteria for discharge before performing circumcision.
Immediate neonatal period --or until complete neonatal physical adoption has occurred (usually 12 to 24 hours). The avoidance of circumcision in the delivery room is particularly important because neonatal disease is not always apparent at birth.

Q-what are the complications of circumcision?

Ans - Circumcision is a surgical procedure involving anaesthesia.Like any other surgery complications may occur.
The exact incidence of postoperative complications is unknown,50 but large series indicate that the rate is low, approximately 0.2% to 0 6%.44,45,51,52
The most common complications are local infection and bleeding. Deaths attributable to newborn circumcision are rare; there were no deaths in 500,000 circumcisions in New York City52 or in 175,000 circumcisions in US Army hospitals.51
Complications due to local anesthesia are rare and consist mainly of hematomas and local skin necrosis.41,46-49,54.
Newborns circumcision is a rapid and generally safe procedure when performed by an experienced operator. It is an elective procedure to be performed only if an infant is stable and healthy. Infants respond to the procedure with transient behavioral and physiologic changes.

Q-What happens after circumcision

procedure

One of the advantages of Circumcision by our technique is that, you need not make frequent visits to hospital for follow up. If any minor problem arises you can yourself manage it at home as per advice given below. But if you feel there is a problem you are not able to cope with, then immediately bring the child to us for proper assessment and management.

Q.1. There is a swelling of change?

Ans. Usually some swelling wil be there due to anaesthesic injection and presence of device. It will decrease after wards. If swelling is increasing contact us

.
Q 2. There is colour change?

Ans. Some redish or bluish spot may be appear at injection site. There is nathing to worry. It wil disappear with time. Skin over the ring wil turn black. It is norml course of event, don’t worry.

Q 3. There are blebs on penis?

Ans. Due toallergy to a
ntiseptic. Rash may develop. Contact us for advice or treatment.

Q 4. Child complain of pain?

Ans. Some children complain of mild pain while passing urine. Give the prescribed medicine regularly if pain persists, contact us.

Q 5. Child has difficulty in passing urine?

Ans. Child wil pass urine freely and painlessly. Some children hold urine due to fear. Give him plenty of fulids to drink. Wash with warm water or make the child sit in a tub of warm water. He wil pass urine. In case difficulty persists,contact us.

Q 6. There is pus formation?

Ans. Dried up ointment and scab may appear like pus. Wash it well and apply ointment. In case there is some discharge contact us.

Q 7. Child has fever?

Ans. There wil not be any fever after circumcision. If temperature is >100f, then there is some othere problem. Contact us for assessment @ treatment.

Q 8. There is bleeding?

Ans. Blood may ooz from injection site,press the part with cotton.it wil stop. Some bleeding may occur at the time of seperation of ring. Wash it with clean cotton,bleeding wil stop. If bleeding persists,bring the child to hospital.

Q 9 Ans. Ring has not seperated?

Ans. The plastiblell ring wil separates and falls off on its own after healing of wounds. Attempt to remove it prematurely wil cause pain and bleeding. So leave it alone and don’t try to pull it. In case it has not separated by 15 days,then bring the child for ring removal

Q 10 Is adult cicumcision different from child circumcision?

Yes. In adults plastibell cannot  be applied. Circumcision is done by Excision and suture.Absorble stitches will be applied.which will dissolve later on.

Q 11 How much rest is required after adult circumcision?

adults need no hospitalisation.Circumcision is done on out patient basis. Person can walk home immediately after the procedure.Even at home there is no need for bed rest.You can walk about.

FAQ - Female Sex Problems

Q – What are the types of sexual problems in

female?

Ans - Female sexual dysfunction is generally divided into four categories:

1. Low sexual desire. You have poor libido, or lack of sex drive. This is the most common type of sexual disorder among women.

2. Sexual arousal disorder. Your desire for sex might be intact, but you're unable to become aroused or maintain arousal during sexual activity.

3. Orgasmic disorder. You have persistent or recurrent difficulty in achieving orgasm after sufficient sexual arousal and ongoing stimulation.

4. Sexual pain disorder. You have pain associated with sexual stimulation or vaginal contact.

Most sexual problems in women overlap more than one category. With increased information about the complicated nature of female sexual response, a new view has emerged — one that focuses on sexual response as a complex interaction of many components affecting intimacy, including your physiology, emotions, experiences, beliefs, lifestyle and relationships. If any one of these components is affected, sexual drive, arousal or satisfaction may be affected.

Q—What are treatment options for female sexual disorders?

Ans - Treatment may involve treating the underlying medical or hormonal condition contributing to sexual dysfunction, as well as addressing emotional and relationship issues that result or contribute to the dysfunction. In some cases,
Female sexual dysfunction can be treated by taking specially prescribed medications. But quite often, successful treatment requires no medications.
Nonmedical treatment for female sexual dysfunction
Improve your sexual health by making healthy lifestyle choices and enhancing communication with your partner.

1. Communicate with your partner. Open and honest communication with your partner can enhance your emotional and sexual intimacy. Some couples never talk about sex, while others are less inhibited. Even if you're not used to communicating about your likes and dislikes, learning to do so and providing feedback in a nonthreatening manner can set the stage for greater sexual intimacy. It may be difficult to resolve differences in sexual desire with your partner. Communicating your feelings can help in this matter.

2. Make healthy lifestyle changes.

3. Avoid drinking excessive amounts of alcohol, stop smoking,

4. Exercise regularly

5. And make time for leisure and relaxation.

6. All the abovemeasures are as important for your sexual health as for your overall health. Too much alcohol blunts your sexual responsiveness. Cigarette smoking restricts blood flow. Decreased blood flow to your sexual organs can lead to decreased sexual arousal or orgasm. Regular aerobic exercise can increase your stamina, improve your body image and elevate your mood. Learning to relax amid the stresses of your daily life can enhance your ability to focus on the sexual experience and attain better arousal and orgasm.

7. Strengthen pelvic muscles. Pelvic floor exercises can help with some arousal and orgasm problems. Doing Kegel exercises strengthens the muscles involved in pleasurable sexual sensations. To perform these exercises, tighten your pelvic muscles as if you're stopping your stream of urine. Hold for a count of five, relax and repeat. Do these exercises several times a day.
Your doctor also may recommend exercising with vaginal weights. By using a series of five weights, each increasingly heavier, that you hold in place in your vagina, you can strengthen pelvic floor muscles. You gradually work up to heavier weights as your muscle tone improves.

8. Seek counselling. Talking with a sex therapist or counsellor skilled in addressing sexual concerns can benefit you whether your condition is due to emotional factors or not, since even sexual problems that are hormonal in origin can affect your emotional health and intimacy with your partner. Evaluation with a sex therapist typically includes a review of your sexual identity, beliefs and attitudes; relationship factors including intimacy and attachment; communication and coping styles; and your overall emotional health. Therapy often includes education about sexual response and techniques, ways to enhance intimacy with your partner, and recommendations for reading materials or couples exercises.

Medical treatment for female sexual dysfunction

Effectively treating sexual dysfunction often requires addressing an underlying medical condition or hormonal change that's affecting your sexuality.
Medical conditions that can contribute to sexual dysfunction include depression or anxiety, diabetes, cardiovascular and neurological diseases, pelvic or abdominal surgery, and cancers. Vulnerable hormonal times in a woman's life occur during pregnancy and the postpartum period, while using hormonal birth control methods, and during perimenopause and menopause.
Therefore, to treat the underlying condition, medical therapy for sexual dysfunction might include:

9. Adjusting or changing medications that have sexual side effects

10. Treating thyroid problems or other hormonal conditions

11. Optimising treatment for depression or anxiety

12. Strengthening pelvic floor muscles

13. Trying strategies recommended by your doctor to help with pelvic pain or other pain problems

If your doctor feels you might benefit from a hormonal treatment, possible therapies include:

1. Estrogen therapy. Estrogens are important in maintaining the health of vaginal and external genital tissues. Replacing estrogen can improve sexual function in a number of ways, including increasing the tone and elasticity of vaginal tissues, increasing vaginal blood flow, enhancing lubrication, and having a positive effect on brain function and mood factors that impact sexual response. Localized estrogen therapy in the form of a vaginal cream, gel or tablet can help with sexual In some changes due to menopause.

2. Progestin therapy. Progestins generally are prescribed to balance estrogen's effect on the uterus and not to treat sexual dysfunction.

3. Androgen therapy. Androgens include male hormones, such as testosterone. Testosterone is important for sexual function in women as well as men, although testosterone occurs in much lower amounts in a woman. Androgen therapy for sexual dysfunction is controversial. Some studies show a benefit for women who have low testosterone levels and develop sexual dysfunction, for instance after surgical menopause due to removal of the ovaries. In these women, testosterone therapy reportedly improved libido, arousal and sexual thoughts. No standard, FDA-approved testosterone preparation exists for treating female sexual dysfunction. Testosterone therapy may be given as a cream or gel patch applied to your skin. Sometimes, testosterone is given as a pill or injection.

Possible side effects for women on testosterone therapy include acne, excess body hair (hirsutism), enlargement of the clitoris, and mood or personality changes such as aggressiveness or hostility. Also, excessive amounts of testosterone can decrease high-density lipoprotein (HDL) cholesterol (the "good" cholesterol) or cause an abnormal rise in liver enzymes in the blood.

Hormonal therapies won't resolve sexual problems that have other causes beyond those factors related to hormones. Because the issues surrounding female sexual dysfunction are usually complex and multifaceted, even the best medications are unlikely to work if other emotional or social factors remain unresolved.

Emerging treatments

Research is on to assess the effectiveness of sildenafil (Viagra), tadalafil (Cialis) and other drugs in female sex disorders.

FAQ Male Sex Problems

Q—What types of sexual problems are seen in males?

Ans - Men may have various problems related to sex.
1. Low desire (libido)
2. Problems of erection (Erectile Dysfunction)
3. Problems of Ejaculation—Early, Delayed or Absent ejaculation.
4. Sexual Pain Syndromes.

Q What is Premature Ejaculation & What can be done about it?

Ans - Premature ejaculation ia condition where a man ejaculates during intercourse sooner than he or his partner wishes.

Causes

Premature ejaculation is commonest sexual problem in males.
It is often caused by Psychological &Social factors. It is only rarely caused by a physical or structural problem of the body( Organic cause).
Premature ejaculation early in a relationship is most often caused by anxiety and overstimulation. Other psychological factors such as guilt may also be relevant. The condition usually improves without formal treatment if cause is Psychogenic .

Symptoms

Ejaculation happens before the individual or couple would like ,that is prematurely.
This may range from before penetration to a point just after penetration, and may leave the couple feeling unsatisfied.

Signs and tests

Abnormal findings are unlikely to be found on examination.Lab reports are also usually normal. Useful information is more likely to be obtained by discussion between person or the couple & healthcare provider.

Treatment

Practice and relaxation will help you deal with the problem. Some men try to distract themselves by thinking non-sexual thoughts to avoid becoming excited too fast.

Some helpful techniques include the following:

The "stop and start" method:

1. This technique involves sexual stimulation until the man recognizes that he is about to ejaculate. The stimulation is then removed for about thirty seconds and then may be resumed. The sequence is repeated until ejaculation is desired, the final time allowing the stimulation to continue until ejaculation occurs.

2. Can be done by man himself or with the help of his partner.

The "squeeze" method:

This technique involves sexual stimulation until the man recognizes that he is about to ejaculate. At that point, the man or his partner gently squeezes the end of the penis (where the glans meets the shaft) for several seconds, till urge to ejaculate passes away.Withhold further sexual stimulation for about 30 seconds, and then resume stimulation. The sequence may be repeated by the person or couple until ejaculation is desired. The final time allowing the stimulation to continue until ejaculation occurs.

Drugs

Antidepressants such as Fludac and other selective serotonin reuptake inhibitors (SSRIs) may be helpful because they have a common side effect of prolonging the time it takes to achieve ejaculation.

Local anesthetic creams,such as Xylocaine, may be applied to the penis to decrease stimulation. Decreased feeling in the penis may prolong the time before ejaculation.

Condom use may also have this effect for some men.Initially double condoms may be used.

Evaluation by an andrologist,urologist,surgeon, sex therapist, psychologist, or psychiatrist may be required for some couples.

Prognosis

In most cases, the man is able to learn ejaculatory control through education and practice of the simple techniques outlined. Chronic premature ejaculation may be a sign of anxiety or depression, both of which could be helped by psychiatric intervention.

Complications

1. Inferility - Very early ejaculation, occurring prior to entry into the vagina, may prohibit a desired pregnancy.

2. Marital Discord - A continued lack of ejaculatory control may lead to sexual dissatisfaction on the part of either or both partners and may be a factor in sexual tension or discord in the relationship.

Professional help

Call for an appointment with your health care provider if premature ejaculation is causing a problem and does not respond to techniques such as those described above.

Don’t fall prey to Quacks.

Don’t be misled by wellmeaning but uninformed relatives & friends.

Prevention

There is no prevention for this disorder, though relaxation can reduce the likelihood of its occurrence.

Q-. What is Erectile Dysfunction (Impotence)?

Male erectile dysfunction is defined as "the inability to achieve or maintain an erection sufficient for sexual intercourse”. It is one of the most common sexual dysfunctions in men. Although erectile dysfunction can be primarily psychogenic in origin, most patients have an organic disorder, commonly with some psychogenic overlay. Some men assume that erectile failure is a natural part of the aging process and tolerate it; for others it is devastating. Withdrawal from sexual intimacy because of fear of failure can damage relationships and have a profound effect on overall wellbeing for the couple.

Erectile dysfunction often accompanies chronic illnesses, such as diabetes mellitus, heart disease, hypertension, and a variety of neurological diseases, physicians from many medical disciplines may be required for management of these patients

Q How common is Erectile Dysfunction?

The Massachusetts male aging study, studied men aged 40 to 70 years and found some degree of impotence (Erectile dysfunction) was present in 52 per cent of the men studied. Mild in 17.1%, moderate in 25.2%, and complete in 9.6%
5% of men at 40 years of age and 15% at 70 years of age reported complete impotence;
However, a higher prevalence of complete impotence was seen in men with concomitant illnesses. Erectile dysfunction is more common with advancing age, and since the aged population will increase, its prevalence will continue to rise

Q What is required for Erection?

In the flaccid state, the smooth muscle cells of the penile arteries and the corpora cavernosa are in a state of tone (contraction). Relaxation of the smooth muscle (arterial and cavernosal) causes increased inflow of blood into the lacunar spaces of the corpora cavernosa (fig 1).6 The arterial pressure expands the relaxed trabecular walls, thus expanding the tunica albuginea with subsequent elongation and compression of the draining venules. This mechanism of veno-occlusion restricts the outflow of blood through these channels. After ejaculation or cessation of the erotic stimuli, the smooth muscle surrounding the arteries and the lacunar spaces contracts. The inflow of blood is reduced and the venous drainage of the corporeal spaces is opened, returning the penis to the flaccid state. Erection of the penis is thus a haemodynamic event under the control of the autonomic nervous system.7 Coordination of the neuronal activity from psychogenic stimuli occurs in the hypothalamus while reflexogenic erection involves a polysynaptic coordination in the sacral parasympathetic centres.8

Fig 1. Hypothetical mechanism of penile erection, adapted from Krane et al2

Several neurotransmitters are involved in penile erection. A principal neural mediator of penile smooth muscle relaxation, and therefore of erection, is nitric oxide.The importance of this pathway is shown by the clinical finding that selective inhibitors of phosphodiesterase-5 (which breaks down cyclic guanosine monophosphate) facilitate erection.11

Normal erectile function requires the coordination of psychological, hormonal, neurological, vascular, and cavernosal factors. Alteration in any one of these factors is sufficient to cause erectile dysfunction. Not uncommonly, a combination of factors is involved.

Q What are the causes of Erectile Dysfunction (Impotence)?

Ans - There are several possible causes for ED.What it is in a given case requires assessment by a doctor. Some of the important causes are:-

Chronic systemic illness

Diabetes mellitus, heart disease, and hypertension are all commonly associated with erectile dysfunction. Complete impotence has also been observed to increase with the severity of depression; almost 90% of severely depressed men report complete impotence. Peripheral vascular disease leading to insufficient arterial blood supply is another common cause. In addition, an association between low plasma concentrations of high-density lipoprotein and erectile dysfunction has been found. Other diseases such as peptic ulcer, arthritis, and allergy are also associated with an increased prevalence of erectile dysfunction.

Hormonal factors

The fall in free serum testosterone and increases in concentrations of sex hormone binding globulin with aging may be associated with loss of libido and reduced frequency of erection, but restoration of normal testosterone concentrations does not usually improve sexual function.
Patients with hyperprolactinaemia, frequently associated with low testosterone values, can develop low libido and erectile dysfunction by unknown mechanisms.

Local conditions

Poor blood supply as a result of congenital malformations or trauma is a less common cause of erectile dysfunction that can affect the young male.

Peyronie's disease is a specific condition of the penis in which the development of fibrous plaques in the tunica albuginea, sometimes extending into the erectile tissue, may cause pain (in the early inflammatory stage) and penile deviation, making coitus impossible.

Inability to retain pressurised blood in the corpus cavernosum follows disruption of the veno-occlusive mechanism, which can be caused by Peyronie's disease, congenital, or the result of trauma or surgery.

Drug induced erectile dysfunction

Around 25% of erectile failure seen in clinic patients is caused by medication. Erectile dysfunction may affect 10-20% of patients taking thiazide diuretics, and to a lesser extent, patients who are using blocking drug (Propanolol, Atenolol etc)

Erectile dysfunction commonly complicates antidepressant treatment with both monoamine oxidase (MAO)inhibitors and tricyclic antidepressants. Benzodiazepines and selective serotonin reuptake inhibitors(SSRI) have been reported to cause erectile failure, decreased libido, or ejaculatory problems.

Cimetidine, digoxin, and metoclopramide cause erectile dysfunction, as do anabolic steroids, either through a direct effect on penile tissues or through suppression of normal androgen production.

Up to 75% of patients in alcohol rehabilitation programmes have erectile dysfunction. In chronic alcohol abusers erectile failure may be the result of a combination of psychogenic and organic factors (for example, neuropathy).

Psychogenic causes

Psychogenic influences are the most likely causes of intermittent erectile failure in young men. Anxiety about "performance" may result in inhibitory sympathetic nervous system activity, and anticipatory anxiety can make the condition self-perpetuating. A psychogenic component is often present in older men, secondary to an organic cause. Underlying relationship problems are a common cause of erectile failure

Q—How is Erectile Dysfunction diagnosed?

Your medical and sexual history should be told, and details of any concomitant medication, tobacco and alcohol consumption, and the presence of risk factors for erectile dysfunction (for example, vascular or surgical) should be informed. Preservation of nocturnal and early morning erections generally means that there is no organic basis for erectile dysfunction. The quality of erections during sleep can be assessed with portable home devices (such as Rigiscan) that measure changes in penile girth and rigidity, or in a sleep laboratory.

Measurement of blood pressure, palpation of peripheral pulses, and a neurological examination will be undertaken, including the bulbocavernous reflex and anal sphincter tone. The secondary sexual characteristics will be examined for signs of hypogonadism and any local abnormality in the external genitalia will be noted. The penis will be palpated for Peyronie's plaques and the testes examined for size and consistency. Further investigations are likely to be guided by the clinical findings, but should include measurement of free testosterone and prolactin concentrations. Vascular assessment may also be required.

Q –How is Erectile Dysfunction treated?

Ans--Treatment modality chosen in a given case depends on the cause of the problem. One or more of following may be required.

Psychosexual counseling

Patients who have a sizeable psychogenic component require psychosexual counseling. Since an organic element is present in most patients, this approach is increasingly being used in conjunction with drugl treatment.

Hormonal therapy

Testosterone may improve erectile dysfunction in some patients with diagnosed hypogonadism. Transdermal formulations of testosterone and dihydro-testosterone, or as oral formulations of testosterone are used.

Hyperprolactinaemia is usually managed with bromocryptine or similar drugs. Less commonly, surgery is used to remove tumours secreting prolactin.

Drug treatment

Drugs that are currently available have limited effectiveness.Some of the drugs given orally are

Trazodone, given as a single agent, has been effective in some studies, but not others. Side effects such as sleepiness and gastrointestinal discomfort are common and limit its use.

Yohimbine has a modest effect on psychogenic, but not on organic, erectile dysfunction.

New drugs, such as inhibitors of phosphodiesterase-5 that affect the breakdown of cyclic guanosine monophosphate are more effective. Trials of one such drug, Sildenafil, have shown a response rate of around 90% in men with erectile dysfunction of no known organic cause. In diabetic subjects with clear organic erectile dysfunction, sildenafil showed a 50% response rate. This drug is generally well tolerated, and has no appreciable effect on pulse rate or blood pressure. The dopaminergic agonist, apomorphine, produced a 60% response rate after subcutaneous injection in men with psychogenic erectile dysfunction. However, patients reported a large number of side effects. Recent formulations (a sublingual, sustained release tablet), minimise these side effects. Phentolamine, widely used for intracavernosal injection treatment, has been tried orally. A buccal preparation with a shorter onset of action has also been used with a success rate of 30-40%. Injectable drugs In those patients who show inadequate response to tablets injections may be used. The most common treatment is self-injection of prostaglandin E1 into the corpora cavernosa (fig 2).

Fig 2. Vasoactive drugs such as Papaverine or alprostadil can be injected into the penis or administered by applicator

This treatment is highly effective approximately 80% of impotent men benefit from it. It is relatively safe, with only a small risk of priapism and formation of painless penile fibrotic lesions (8-9% after two years).16

Alprostadil (prostaglandin E1) has also been administered into the urethra in men with erectile dysfunction from several causes (fig 2). Erection sufficient to allow intercourse was achieved by more than 40% of men, and home treatment reports indicate a good safety profile. This treatment will probably be tried as an initial step, and those who fail will then be managed with intracavernosal injections.

Mechanical devices

The simplest and least expensive treatment is a vacuum constriction device shown in figure 3. Air is pumped out of the cylinder with the hand held pump to create a vacuum and cause an erection. The constriction band is then pulled off the cylinder onto the base of the erect penis and the cylinder is removed. This treatment is reliable and has few adverse effects when used properly It is often accepted by older patients in a longstanding relationship, whereas younger patients may prefer to try other treatments.

Penile prostheses are surgically implanted devices that provide penile rigidity (fig 3)

With the two piece inflatable prosthesis, the pump and reservoir are in the scrotum and are used to inflate the cylinders into the erect position. The cylinders are then deflated by pressing a valve at the base of the pump to return the fluid to the reservoir.

In a three piece inflatable prosthesis, the pump is in the scrotum and the reservoir is in the abdomen. Penile prostheses are usually recommended when other treatments fail.

Semirigid, malleable rods can also be inserted into the penis to provide penile erection.

Fig 3. Vacuum Device and Penile prostheses to produce erection

Vascular surgery

Arterial reconstructive surgery is sometimes indicated in men with arterial occlusive disease,The best results are obtained in young patients with isolated arterial lesions following trauma.

Venous surgery, with extensive ligation of the veins that drain the corpora cavernosa, is sometimes used as the last resort before the implantation of a penile prosthesis in young men with veno-occlusive disease. The results are generally poor as only 30% of patients report long term improvement.

Conclusions

Although the ideal treatment for erectile dysfunction has not yet been found, important advances have been made. Greater openness in society has stimulated research and made it easier for patients to seek help. However, doctors are generally reluctant to discuss the topic with their patients.So if you have any sexual concerns bring it to notice of your doctor.

FAQ - Diabetic Foot

Q-Why Diabetics have foot problems

People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications.

Foot problems most often happen when there is

1- nerve damage, also called neuropathy, which results in loss of feeling in your feet.
2- Poor blood flow in the foot.
3- Changes in the shape of your feet or toes leading to abnormally high pressures.

Q-What is Neuropathy

Although it can hurt, diabetic nerve damage can also lessen your ability to feel pain, heat, and cold. Loss of feeling often means you may not feel a foot injury. You could have a tack or stone in your shoe and walk on it all day without knowing. You could get a blister and not feel it. You might not notice a foot injury until the skin breaks down and becomes infected.
Nerve damage can also lead to changes in the shape of your feet and toes. Ask your health care provider about special therapeutic shoes, rather than forcing deformed feet and toes into regular shoes.

Q--What happens to foot skin in diabetes?

Diabetes can cause changes in the skin of your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that the nerves that control the oil and moisture in your foot no longer work. After bathing, dry your feet and seal in the remaining moisture with a thin coat of plain petroleum jelly, an unscented hand cream, or other such products.

Do not put oils or creams between your toes. The extra moisture between toes can lead to infection. So dry the web spaces with cotton or tissues.
Also, don't soak your feet - that can dry your skin.

Q-What is significance of Calluses?

Calluses occur more often and build up faster on the feet of people with diabetes. This is because there are high-pressure areas under the foot. Too much callus may mean that you will need therapeutic shoes and inserts.
Calluses, if not trimmed, get very thick, break down, and turn into ulcers (open sores). Never try to cut calluses or corns yourself - this can lead to ulcers and infection. Let your health care provider cut your calluses. Also, do not try to remove calluses and corns with chemical agents(corn caps etc). These products can burn your skin. Using a pumice stone every day will help keep calluses under control. It is best to use the pumice stone on wet skin. Put on lotion right after you use the pumice stone.

Q-Tell about Foot Ulcers

Ulcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Remember, even though some ulcers do not hurt, every ulcer should be seen by your health care provider right away. Neglecting ulcers can result in infections, which in turn can lead to loss of a limb.
What your health care provider will do varies with your ulcer. Your health care provider may take x-rays of your foot to make sure the bone is not infected. The health care provider may clean out any dead and infected tissue. You may need to go into the hospital for this. Also, the health care provider may culture the wound to find out what type of infection you have, and which antibiotic will work best. Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot. Your health care provider may put a special shoe, brace, or cast on your foot to protect it. If your ulcer is not healing and your circulation is poor, your health care provider may need to refer you to a vascular surgeon. Good diabetes control is important. High blood glucose levels make it hard to fight infection. After the foot ulcer heals, treat your foot carefully. Scar tissue under the healed wound will break down easily. You may need to wear special shoes after the ulcer is healed to protect this area and to prevent the ulcer from returning.

Q What is vasculopathy and role poor circulation in diabetic foot?

Poor circulation (poor blood flow) can make your foot less able to fight infection and to heal. Diabetes causes blood vessels of the foot and leg to narrow and harden. You can control some of the things that cause poor blood flow.
Don't smoke - smoking makes arteries harden faster.

Also, follow your health care provider's advice for keeping your blood pressure and cholesterol under control.
If your feet are cold, you may be tempted to warm them. Unfortunately, if your feet cannot feel heat, it is easy for you to burn them with hot water, hot water bottles, or heating pads. The best way to help cold feet is to wear warm socks.

Some people feel pain in their calves when walking fast, up a hill, or on a hard surface. This condition is called intermittent claudication. Stopping to rest for a few moments should end the pain. If you have these symptoms, you must stop smoking. Work with your health care provider to get started on a walking program. Some people can be helped with medication to improve circulation.
Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walk in sturdy, good-fitting, comfortable shoes. Don't walk when you have open sores.

Q-Why diabetic feet are amputated?

People with diabetes are far more likely to have a foot or leg amputated than other people. The problem? Many people with diabetes have artery disease, which reduces blood flow to the feet. Also, many people with diabetes have nerve disease, which reduces sensation. Together, these problems make it easy to get ulcers and infections that may lead to amputation. Most amputations are preventable with regular care and proper footware. For these reasons, take good care of your feet and see your health care provider right away about foot problems. Ask about prescription shoes . Always follow your health care provider's advice when caring for ulcers or other foot problems. One of the biggest threats to your feet is smoking. Smoking affects small blood vessels. It can cause decreased blood flow to the feet and make wounds heal slowly. A lot of people with diabetes who need amputations are smokers.

What can I do to prevent diabetic foot problems?

Every person with diabetes - with or without any of these risk factors - should take proper care of their feet. Routine foot inspection and preventive care can minimize or prevent foot problems. Below are things to make sure you ask your doctor about:

1. You should have a thorough foot examination by a professional at least once a year. This includes checking the sense of feeling and the pulses in your feet. (See box.)
2. Ask for a risk evaluation. Specific follow-up and treatment will be based on what risk category your feet are in. Ask for special instructions for people with high-risk feet, if applicable.
3. If you have lost some sensation in your feet, they should be visually inspected at every visit. Take off your shoes and socks at every visit and make sure this happens.
4. Ask your provider to check your footwear to make sure that the style and fit are appropriate for the condition of your feet. Ask if special shoes would help your feet stay healthy.

Components of a good foot exam:

At least once a year, everyone with diabetes should have a thorough foot examination. It should include an assessment of:

1. Protective sensation - using a monofilament or vibratory sensation test
2. Foot structure
3. Biomechanics - including any limits in joint mobility or problems with gait and balance
4. Vascular status - including questions about painful walking and determination of pulses in your feet
5. Skin integrity - especially between your toes and on the ball of your foot
6. Increased pressure on the soles of your feet; areas of warmth, redness, or callus formation may be indicative of tissue damage

Many diabetes treatment programs operate regular foot clinics to help patients with routine foot care and to make sure that preventive measures are taken. Some pharmacists specializing in diabetes care offer similar programs. Be sure to take advantage of any foot care programs that are available to you.

Q What Preventive foot care should I do?

Of course, the best way to prevent foot problems is to keep your blood glucose under control. But there are also specific things you should do EVERY DAY to make sure your feet stay fit. Here are some of them:

1. Examine your feet EVERY DAY to look for cuts, sores, blisters, redness, etc. If you have anything of that nature, and it doesn't heal in a day or two, notify your doctor. If you have trouble seeing or reaching your feet, ask someone to help, or use a mirror to help you see better.
2. Wash your feet EVERY DAY with lukewarm water and mild soap. Dry them carefully and thoroughly with a soft towel. Dust your feet with talcum powder, which will help keep them dry.
3. Don't soak your feet - this will make your skin too dry.
4. If you have dry skin on your feet, use a moisturizing lotion to prevent cracking - but NEVER use a lotion or cream between your toes, as this can lead to infection.
5. If you have corns or calluses, DO NOT cut them, don't use corn plasters or liquid corn and callus removers - they can damage your skin. Check with your doctor or foot care specialist who may advise you to use a pumice stone to smooth calluses or corns.
6. Keep your toenails trimmed. Trim them with toenail clippers after you have washed and dried your feet. Trim the nails following the shape of your toes, and smooth them with an emery board or nail file. Don’t cut into the corners of the nail, which could trigger an ingrown toenail. If your nails are very thick or yellowed, have a foot care specialist trim them.
7. Don't go barefoot - not even indoors. Always wear socks, stockings, or nylons with your shoes to help avoid blisters and sores. Choose soft socks made of cotton, wool, or a cotton-polyester blend, which will help keep your feet dry. Avoid mended socks or those with seams, which can rub to cause blisters.
8. Avoid wearing socks or hose that are too tight around your legs. Knee-high or thigh-high stockings as well as elasticised men's dress socks can constrict circulation to your legs and feet.

Q-What is the proper footwear for diabetics?

Choosing the right footwear is an important part of foot care, since poorly fitted shoes are involved in as many as half of serious foot problems. Here are some tips for choosing the best footwear:

1. Wear well-cushioned walking shoes or athletic shoes. If you have foot deformities such as hammertoes or bunions, you may need extra-wide shoes or depth shoes. Depth shoes have more room in them to allow for different shaped feet and toes or for special inserts made to fit your feet. If problems are severe, custom-moulded shoes are available.
2. Don't wear shoes with high heels or pointed toes. They can create pressure, which might contribute to bone and joint disorders as well as diabetic ulcers.
3. Don't wear open-toed shoes or sandals with a strap between the first two toes. They increase the chance that you'll injure a toe.
4. When you buy new shoes, be sure your feet are properly measured and fitted. Your feet can change size and shape, so an experienced shoe fitter should measure them whenever you get new shoes. Shoes should fit both the length and width of your foot, with room for your toes to wiggle freely.
5. Your new shoes should be sturdy and comfortable. They should have leather or canvas uppers, which breathe to keep your feet from getting sweaty. Avoid vinyl or plastic shoes, because they don't stretch or breathe.
6. When you get new shoes, break them in gradually so you won't get blisters.
7. Shake your shoes before you put them on. Even a small pebble in your shoe can lead to problems.

Q-What Special care is required for high-risk conditions?

If you do have any of the high-risk conditions, there are specific things you should do to keep your feet healthy.
1. If you have neuropathy or evidence of increased pressure on the soles of your feet, wear well-cushioned walking shoes or athletic shoes.
2. If you have lost some sensation in your feet, be sure to carefully inspect them often to identify any problems early.
3. If you have calluses, have a foot care specialist treat them.
4. If you have bony deformities such as hammertoes or bunions, you may need extra-wide shoes or depth shoes. In extreme cases, custom-moulded footwear may be needed.
5. Promptly treat minor skin conditions such as dry skin or athlete's foot to keep them from progressing.
6. Have a complete foot examination every 3 to 6 months.
A formal, comprehensive program has been developed at the Gillis W. Long Hansen's Disease Center in Carville, LA, known as the "LEAP program" for Lower Extremity Amputation Prevention. It consists of 5 relatively simple activities:
7. Annual foot screening to identify people who have lost protective sensation
8. Patient education in self-management, with emphasis on proper foot care
9. Daily self-inspection of the foot
10. Appropriate footwear selection
11. Management of simple foot problems such as dry skin, nail and callus care, and basic wound management

In a number of large clinical centers where formal preventive care programs such as this have been implemented, the rate of amputations has been reduced by as much as 85%.

FAQ Infertility

Quick Facts About Infertility

1. Infertility is NOT an inconvenience; it is a disease of the reproductive system that impairs the body's ability to perform the basic function of reproduction.
2. Infertility affects men and women equally.
3. Most infertility cases -- 85% to 90% -- are treated with conventional medical therapies such as medication or surgery.
4. While vital for some patients, in vitro fertilization and similar treatments account for less than 3% of infertility services, and about (or approximately) seven hundredths of one percent (0.07%) of U.S. health care costs.

Q: What is Infertility?

A: Infertility is a disease of the reproductive system that impairs one of the body's most basic functions: the conception of children. Conception is a complicated process that depends upon many factors: on the production of healthy sperm by the man and healthy eggs by the woman; unblocked fallopian tubes that allow the sperm to reach the egg; the sperm's ability to fertilize the egg when they meet; the ability of the fertilized egg (embryo) to become implanted in the woman's uterus; and sufficient embryo quality.
Finally, for the pregnancy to continue to full term, the embryo must be healthy and the woman's hormonal environment adequate for its development. When just one of these factors is impaired, infertility can result.

Q: What Causes Infertility?

A: No one can be blamed for infertility any more than anyone is to blame for diabetes or leukemia. In rough terms, about one-third of infertility cases can be attributed to male factors, and about one-third to factors that affect women. For the remaining one-third of infertile couples, infertility is caused by a combination of problems in both partners or, in about 20 percent of cases, is unexplained.
The most common male infertility factors include azoospermia (no sperm cells are produced) and oligospermia (few sperm cells are produced). Sometimes, sperm cells are malformed or they die before they can reach the egg. In rare cases, infertility in men is caused by a genetic disease such as cystic fibrosis or a chromosomal abnormality.
The most common female infertility factor is an ovulation disorder. Other causes of female infertility include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a sometimes painful condition causing adhesions and cysts). Congenital anomalies (birth defects) involving the structure of the uterus and uterine fibroids are associated with repeated miscarriages.

Q: How is Infertility Diagnosed?

A: Couples are generally advised to seek medical help if they are unable to achieve pregnancy after a year of unprotected intercourse. The doctor will conduct a physical examination of both partners to determine their general state of health and to evaluate physical disorders that may be causing infertility. Usually both partners are interviewed about their sexual habits in order to determine whether intercourse is taking place properly for conception.
If no cause can be determined at this point, more specific tests may be recommended. For women, these include an analysis of body temperature and ovulation, x-ray of the fallopian tubes and uterus, and laparoscopy. For men, initial tests focus on semen analysis.

Q: How is Infertility Treated?

A: Most infertility cases -- 85 to 90 percent -- are treated with conventional therapies, such as drug treatment or surgical repair of reproductive organs.

Q: What is In Vitro Fertilization?

A: In infertile couples where women have blocked or absent fallopian tubes, or where men have low sperm counts, in vitro fertilization (IVF) offers a chance at parenthood to couples who until recently would have had no hope of having a "biologically related" child.
In IVF, eggs are surgically removed from the ovary and mixed with sperm outside the body in a Petri dish ("in vitro" is Latin for "in glass"). After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are dividing into cells. These fertilized eggs (embryos) are then placed in the women's uterus, thus bypassing the fallopian tubes.

Q: Is In Vitro Fertilization Expensive?

A: Like other extremely delicate medical procedures, IVF involves highly trained professionals with sophisticated laboratories and equipment, and the cycle may need to be repeated to be successful. While IVF and other assisted reproductive technologies are not inexpensive.

Q: Does In Vitro Fertilization Work?

A: Yes. Since 1985, when counting began, through the end of 2006, almost 500,000 babies have been born in the United States as a result of reported Assisted Reproductive Technology procedures (IVF, GIFT, ZIFT, and combination procedures). IVF currently accounts for more than 99% of ART procedures with GIFT, ZIFT and combination procedures making up the remainder. The average live delivery rate for IVF in 2005 was 31.6 percent per retrieval--a little better than the 20 per cent chance in any given month that a reproductively healthy couple has of achieving a pregnancy and carrying it to term. In 2002, approximately one in every hundred babies born in the US was conceived using ART and that trend continues today.

Surgery FAQ

Q—What is treatment for hernia?

Ans - There is no medical therapy for hernia. Most cases will require surgical repair(few selected cases may be left alone).Surgery involves the repair of defect either with sutures or some prosthetic mesh implant.
Surgery can be performed by conventional open method or by laparoscope.