Genital ulcers - 2012 review from Am Fam Physician

Here is an excerpt from a review article in the official AAFP journal American Family Physician:

Causes of genital ulcers

Herpes simplex virus (HSV) infection and syphilis are the most common causes of genital ulcers in the U.S.

Other infectious causes include:

- chancroid
- lymphogranuloma venereum (LGV)
- granuloma inguinale (donovanosis)
- secondary bacterial infections
- fungi

Noninfectious etiologies of genital ulcers include:

- sexual trauma
- psoriasis
- Behçet syndrome
- fixed drug eruptions



CDC Streaming Health | This video, produced by Be Smart. Be Well., raises awareness of Sexually Transmitted Diseases (STDs): 1) What are they? 2) Why they matter? and, 3) What can I do about them? Footage courtesy of Be Smart. Be Well. http://www.besmartbewell.com, featuring CDC's Dr. John Douglas, Division of Sexually Transmitted Disease Prevention.

Diagnosis

The following tests should be considered in all patients:

- serologic tests for syphilis and darkfield microscopy or direct fluorescent antibody testing for Treponema pallidum
- culture or polymerase chain reaction test for herpes simplex virus (HSV)
- culture for Haemophilus ducreyi in settings with a high prevalence of chancroid

No pathogen is identified in up to 25% of patients with genital ulcers.

Treatment

The first episode of herpes simplex virus infection is usually treated with 7-10 days of oral acyclovir (5 days for recurrent episodes). Famciclovir and valacyclovir are alternative therapies.

One dose of intramuscular penicillin G benzathine is recommended to treat genital ulcers caused by primary syphilis.

Treatment options for chancroid include a single dose of intramuscular ceftriaxone or oral azithromycin, ciprofloxacin, or erythromycin.

Lymphogranuloma venereum and donovanosis are treated with 21 days of oral doxycycline.

Treatment of noninfectious causes of genital ulcers varies by etiology, of course. Topical wound care for ulcers caused by sexual trauma. Subcutaneous pegylated interferon alfa-2a is considered for ulcers caused by Behçet syndrome.

References:

Diagnosis and management of genital ulcers. Roett MA, Mayor MT, Uduhiri KA. Am Fam Physician. 2012 Feb 1;85(3):254-62.

Unfaithfulness in men may be associated with higher risk of cardiovascular events

The authors of this study from Italy performed an extensive Medline search for “unfaithfulness,”“extramarital affairs,”“infidelity,” and “men.”

How common is unfaithfulness in men?

As expected the results were variable. Some surveys reported that 1.5–4% of married men had extramarital coitus in any given year, others that 23.2% of men have cheated during their current relationship.

Lifetime prevalence of unfaithfulness was between 15% and 50%.

What are the factors related to unfaithfulness?

Men with extramarital affairs more frequently have a dysfunctional primary relationship.

Parenthood and conflicts within the family are associated with a higher risk of having an affair.

Unfaithful men display a higher androgenization, larger testis volume, higher sexual desire, and better sexual functioning.

What are the clinical implications of unfaithfulness in men?

Some studies have suggested that having an extramarital affair could have a negative impact on cardiac morbidity and mortality. Unfaithfulness in men seems to be associated with a higher risk of major cardiovascular events.

References

Fisher AD, Bandini E, Rastrelli G, Corona G, Monami M, Mannucci E, and Maggi M. Sexual and cardiovascular correlates of male unfaithfulness. J Sex Med, 2012.

Image source: OpenClipart.org, public domain.

March Madness Vasectomies: Postop period is "a perfect situation for television", says Cleveland Clinic urologist

Vasectomy is a surgical procedure for male sterilization, and consequently, birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed. This prevents sperm from entering into the seminal stream (ejaculate). You can watch a video how the procedure is done here.



From Cleveland Clinic YouTube channel: A urologist talks about the increase in the number of vasectomies he does this time of year. "Guys get it done, then watch the NCAA Basketball tournament all weekend long." The procedure takes 5-10 minutes. Patients need to ice the area for 2-3 days.

The NCAA Men's Division I Basketball Championship is a single-elimination tournament held each spring in the United States, featuring 68 college basketball teams, to determine the national championship in the top tier of college basketball. The tournament, organized by the National Collegiate Athletic Association (NCAA), was created in 1939 by the National Association of Basketball Coaches, is held mostly in March, and it is known informally as March Madness (source: Wikipedia).



Private urology practices advertise on TV their "Vasectomy Madness" campaigns:



CNN RidicuList with Anderson Cooper: Vasectomy and free pizza (video):

The Search for a Male Contraceptive

From the NYT:

Steve Owens had always left birth control to his wife, who took the pill. Then Mr. Owens volunteered to test potential methods that lowered his sperm count so much that “I was not viably able to produce a child,” he said. His count rebounded weeks after stopping each method, and he fathered a daughter between research studies.

Male contraceptives are attracting growing interest from scientists. The most studied approach uses hormones such as testosterone and progestin, which send the body signals to stop producing sperm. While effective and safe for most men, they have not worked for everyone (5% do not respond to treatment). Questions about long term side effects also remain.

Scientists are testing several ways of interrupting sperm production, maturation or mobility:

- hormones (implants, injections, gels or pills) work for 95%

- gamendazole, derived from an anticancer drug, interrupts sperm maturation
- an anti-parasitic drug that blocks production of retinoic acid

- a drug that disables calcium ion channels of sperm

- two drugs, an antihypertensive and an antipsychotic, inhibit ejaculation
- briefly heating the testes with ultrasound can halt sperm production for months

References:

Scientific Advances on Contraceptive for Men. NYTimes.
Image source: The shield and spear of the Roman god Mars, which is also the alchemical symbol for iron, represents the male sex. Wikipedia, public domain.

Persistent Sexual Side Effects Related to Finasteride (Popecia) Use for Male Hair Loss

Finasteride (Propecia) has been associated with reversible adverse sexual side effects in multiple trials for the treatment of male pattern hair loss (MPHL).

This study included 71 otherwise healthy men aged 21–46 years who reported new onset of sexual side effects associated with the temporal use of finasteride, and in which the symptoms persisted for 3 months despite the discontinuation of finasteride.

Patients reported the following new-onset persistent sexual dysfunction associated with the use of finasteride:

- 94% developed low libido
- 92% developed erectile dysfunction
- 92% developed decreased arousal
- 69% developed problems with orgasm

The mean duration of finasteride use was 28 months and the mean duration of persistent sexual side effects was 40 months from the time of finasteride cessation to the interview date.

Physicians treating MPHL should discuss the potential risk of persistent sexual side effects associated with finasteride


Minoxodil - Costco.

References:

Persistent Sexual Side Effects of Finasteride for Male Pattern Hair Loss. Michael S. Irwig MD, Swapna Kolukula. The Journal of Sexual Medicine, 2011.

Gonorrhea Getting Harder to Treat - Antibiotic Resistance Pushing Gonorrhea Toward Superbug Status

Gonorrhea is a common sexually transmitted bacterial infection. If left untreated, gonorrhea can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility in women. Treatment for gonorrhea usually consists of a single dose of one of two antibiotics, cefixime or ceftriaxone.

The current drugs of choice, ceftriaxone and cefixime, are still very effective but there are signs that resistance, particularly to cefixime, is emerging and soon these drugs may not be a good choice.

Only one remaining class of antibiotics is recommended for the treatment of gonorrhea - cephalosporins. Historically, gonorrhea has progressively developed resistance to the antibiotic drugs prescribed to treat it. Thus, it is critical to continuously monitor antibiotic resistance in Neisseria gonorrhoeae.

As a side note that highlights the prevalence of the problem, there are at least 10 songs titled "Gonorrhea" by various artists in the Amazon.com MP3 music store.



CDCStreamingHealth | April 16, 2010: This video, produced by Be Smart. Be Well., raises awareness of Sexually Transmitted Diseases (STDs): 1) What are they? 2) Why they matter? and, 3) What can I do about them? Footage courtesy of Be Smart. Be Well. http://www.besmartbewell.com, featuring CDC's Dr. John Douglas, Division of Sexually Transmitted Disease Prevention.

References:

Gonorrhea Getting Harder to Treat. WebMD.
Sex infection gonorrhea risks becoming "superbug". Reuters.
Antibiotic Resistant Gonorrhea. CDC.

Sexually Transmitted Diseases (STDs) - Diagnosis and Management Slideshow from Medscape http://goo.gl/uzwA

Clinical Pearls in Men's Health - Mayo Clinic Proceedings Video

Dr. Thomas Beckman discusses his July 2010 Mayo Clinic Proceedings concise review on 3 cases involving men's health.

Erectile dysfunction is a strong predictor of death in men with cardiovascular disease

From CNN:

Men with cardiovascular disease and ED were twice as likely to die from all causes than men who did not have erectile dysfunction. And those with ED were 1.6 times more likely to suffer from a serious cardiovascular problem such as a heart attack or stroke.

Erectile dysfunction is something that regularly should be addressed in the medical history of patients; it might be a symptom of early atherosclerosis.

Men with ED who are going to a general practitioner or a urologist need to be referred for a cardiology workup to determine existing cardiovascular disease and proper treatment. ED is an early predictor of cardiovascular disease.

References:
Study: Erectile dysfunction may indicate heart disease, death risk - CNN.com.

ED, Depression, Heart Disease: Does the Existence of One Component of This Triad Necessitate Inquiring the Other Two? http://goo.gl/EKvKl

Image source: Viagra (sildenafil), Wikipedia, GNU Free Documentation License.

P.S.A. testing can’t detect prostate cancer, says its discoverer

Richard J. Ablin in the NYTimes:

"Approved by the Food and Drug Administration in 1994, the P.S.A. test’s popularity has led to a hugely expensive public health disaster. It’s an issue I am painfully familiar with — I discovered P.S.A. in 1970.

The annual bill for P.S.A. screening is at least $3 billion, with much of it paid for by Medicare and the Veterans Administration.

As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t."

References:
The Great Prostate Mistake. NYTimes.
Image source: Wikipedia, public domain.

Sexual life expectancy is longer for men than women

A BMJ study of middle aged and older adults showed that men were more likely than women to be sexually active, report a good quality sex life, and be interested in sex.

These gender differences increased with age and were greatest among the 75 to 85 year old group: 38.9% of men compared with 16.8% of women were sexually active, 70.8% versus 50.9% of those who were sexually active had a good quality sex life, and 41.2% versus 11.4% were interested in sex.

People in very good or excellent health were 1.5 to 1.8 times more likely to report an interest in sex than those in poorer health. At age 30, sexually active life expectancy was 34.7 years for men and 30.7 years for women compared with 14.9 to 15.3 years for men and 10.6 years for women at age 55.

At age 55, men in very good or excellent health on average gained 5-7 years of sexually active life compared with their peers in poor or fair health. Women in very good or excellent health gained 3-6 years compared with women in poor or fair health.

References:

Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ 2010;340:c810.

Image source: OpenClipart.org, public domain.

Rock star Ozzy Osbourne to CNN: "Between drugs and STDs, I'm lucky to be alive today"

"Ozzy Osbourne, the former front man of rock group Black Sabbath, says that after decades of living a life of drugs and sex, he's lucky to be alive today.

Osbourne described how he often played a dangerous game when it came to using drugs and having promiscuous sex. "With the drugs, it nearly killed me on a daily basis -- I did a lot of heavy drug taking for a long time and I survived it by the grace of God.

Answering a viewer's question on whether he realized his power to change people's lives, Osbourne replied with shock. "When you're on the inside looking, you don't see it that way," Osbourne said. "But I suppose you're right. I do -- I do have the power to change people's lives."

References:
Ozzy Osbourne: I'm living on borrowed time. CNN.

"Researchers studying Ozzy Osbourne's DNA found that the singer is descendant of Neanderthals" http://goo.gl/7Fa8

Related:

Erectile Dysfunction Treatment: Alternatives to Pills

From the NYTimes:

30 million men in U.S. experience erectile dysfunction (ED), 30% of men in their 50s, more than 50% of those in their 60s.

One Viagra pill, the most common way to treat erection problems, costs about $15. Viagra, Cialis and Levitra do not work for about half of the men with ED.

After 2 years of significant lifestyle changes (and no meds), 58% of the men with ED had normal erectile function.

Self-administered injections of alprostadil for ED cost $35; a "cocktail" of alprostadil, papaverine, phentolamine.

References:

For Common Male Problem, Hope Beyond a Pill. NYTimes.
Extracorporeal Shock Wave Therapy - New Treatment for Erectile Dysfunction Poorly Responsive to PDE5 Inhibitors http://goo.gl/h7SOh
Erectile Dysfunction Medications Related to Transient Amnesia, FDA Warns

Men who use ED drugs have higher rates of STDs, particularly HIV infection - Ann Intern Med http://goo.gl/UH78

ED, Depression, Heart Disease: Does the Existence of One Component of This Triad Necessitate Inquiring the Other Two? http://goo.gl/EKvKl
Image source: Viagra (sildenafil), Wikipedia, GNU Free Documentation License.

Prostate cancer screening: What is new?

From the Cleveland Clinic Journal of Medicine (CCJM):

PSA has low specificity. Most men with “elevated” PSA do not have prostate cancer.

There is no PSA level below which risk of cancer is zero. No PSA cutoff level is clinically useful.

PCPT risk calculator uses 7 variables to calculate the risk of having high-grade prostate cancer.

Men with a higher body mass index have lower PSA levels, statins also lower PSA levels.

Two large trials of PSA screening came to opposite conclusions in 2009: Europe vs. U.S. - benefit vs. no benefit.

New prostate cancer markers under study: Urinary PCA3, Serum EPCA-2, Gene fusions.

There is an ongoing debate whether 5-alpha reductase inhibitors should be used by all men at risk of prostate CA or only by those at high risk.

References:
What’s new in prostate cancer screening and prevention? CCJM, 2009.
Erectile dysfunction after prostate removal for prostate cancer
Image source: Wikipedia, public domain.

Infertile men three times more likely to develop testicular cancer

Over his lifetime, a man's risk of testicular cancer is 1 in 250 ( 0.4 percent). It is most common among males aged 15-35 years.


Micrograph of a seminoma. Image source: Nephron, Creative Commons Attribution ShareAlike 3.0, Wikipedia.

A few facts from a recent study reported by Reuters:

• Infertile men are nearly three times more likely to develop testicular cancer than those who are fertile.
  
  
• Certain forms of male infertility associated with faulty DNA repair which is also associated with development of tumors.
  
  
• During the last 30-50 years, there has been a continued increase in the incidence of testicular germ cell cancers.
  
  
• During the same period, there is evidence of a decline in semen quality and fertility in industrialized nations.

References:
Study finds infertility-testicular cancer link. Reuters.
Testicular cancer, from Wikipedia, the free encyclopedia.

Simple urine test for sarcosine detects prostate cancer

Sarcosine is the N-methyl derivative of glycine. It is a natural amino acid found in muscles and other body tissues. Sarcosine was first isolated and named by the German chemist Justus von Liebig in 1847, while Jacob Volhard first synthesized it in 1862. Image source: Wikipedia, public domain.



Glycine (Gly) is the smallest of the 20 amino acids commonly found in proteins. Image source: Wikipedia, public domain.

A simple urine test for sarcosine could be used to detect prostate cancer and might help avoid the need for biopsies.

Adding sarcosine to benign prostate cells made them behave like cancer cells:

"Any time they did anything that increased production [of sarcosine], the cells became highly mobile," says Beecher. The cells started to move so much they could get themselves into a sample of gelatine under their own force — a behaviour that cancerous cells also show."

Sarcosine should be looked at as a possible drug target in prostate cancer

References:
Prostate cancer marker found in urine. Nature | doi:10.1038/news.2009.94.
Sarcosine, from Wikipedia, the free encyclopedia.

Related:
Researchers identify new prostate cancer marker detectable in urine. Helen Jaques.

Video: Horror story - Candiru, the Toothpick Fish

See the BBC video on YouTube (embedding disabled by request):

"The Candiru fish, or Toothpick fish, is a natural parasite commonly found living inside Amazonian Catfish. Watch this short video from BBC wildlife show 'Weird Nature' to learn how this small fish has become a horror story in its own right when introduced to humans."


Candiru, also known as canero or toothpick fish, are parasitic freshwater catfish found in the Amazon River. They have a reputation among the natives as the most feared fish in its waters, even over piranha. They are eel-shaped and translucent, making them almost impossible to see in the water. Candiru grow to a size of 6 inches (~15 cm) in length and have barbels around the head, together with short, backward pointing spines on the gill covers.

The Candirú lies in wait at the river's murky bottom, searching for its next host by sampling/sniffing the water for expelled chemicals, such as urea and ammonia from the gills of other fish. Once having detected a fish in the vicinity, with a burst of speed the Candirú darts towards the gill cavity and lodges itself in place with its spines. Then, with usually fatal consequences for its victim, the Candirú begins to gnaw a hole towards a major blood vessel and gorges itself for no more than a few minutes. It will then dislodge itself and sink back to the river bed in order to digest its food and wait for its next meal.

This fish is also known to attack humans and animals and swim into an orifice (the vagina, anus, or even the penis—and deep into the urethra). Because of spines protruding from the fish, it is almost impossible to remove except through surgery. It locates its human targets when people urinate near the fish.


Parasites - Candiru fish.

References:
Candiru, from Wikipedia, the free encyclopedia.
Image source: Candiru, Vandellia cirrhosa, Wikipedia, public domain.

Distinguished British doctor admits 34 years later: BMJ case report of 'cello scrotum' was a hoax

A distinguished doctor, now a member of Britain's House of Lords, invented the fake disease "cello scrotum" 34 years ago and published a single paragraph case report in the BMJ.

Baroness Elaine Murphy, a former Professor of Psychiatry at Guy's Hospital, has confessed to manufacturing a medical condition which only existed in her imagination.

In 1974, the young Dr Murphy claimed to have discovered "cello scrotum", a painful affliction which only affected male players of the instrument.

The spoof letter was written in response to an earlier one about "guitar nipple" from a Dr P Curtis, which the young Dr Murphy thought likely also to be a spoof.

See the original BMJ case report of 'cello scrotum' from 1974: a scanned PDF file.

The Murphy family sent a card to Dr Curtis addressed to "The inventor of guitar nipple from the discoverers of cello scrotum."

Medscape listed both "cello scrotum" and "guitar nipple" in the review of Maladies in Musicians.

References:
Letter: Cello scrotum. J M Murphy. Br Med J. 1974 May 11; 2(5914): 335.
Exposed: the myth of cello scrotum. The Independent.
Cello scrotum? It’s a load of . . . nonsense, admits Baroness Murphy. The Times.
Exposed: The medical myth of 'cello scrotum' The Daily Mail.
Image source: Wikipedia, public domain.

Erectile Dysfunction Medications Related to Transient Amnesia, FDA Warns

According to WebMD:

All three erectile dysfunction drugs -- Cialis, Levitra, and Viagra -- now list rare reports of transient global amnesia on their labels.

What is transient global amnesia (TGA)?

TGA is a brief episode amnesia lasting less than 24 hours, without causing other problems. TGA has been a well-described phenomenon for more than 40 years.

Diagnostic requirements for TGA include:

- The attack was witnessed and reported as being a definite loss of recent memory (anterograde amnesia).
- There was an absence of clouding of consciousness.
- There were no focal neurological signs or deficits during or after the attack.
- There were no features of epilepsy, and the patient did not have any recent head injury or active epilepsy
- The attack resolved within 24 hours

The underlying cause of TGA is unclear. It may be due to venous congestion of the brain, leading to ischemia of the hippocampus (involved with memory, shown in the image above). The ischemia may be triggered by immersion in cold water, sexual activity, severe emotional stress and vigorous exertion.

The prognosis of TGA is very good but the annual recurrence rate is 4-5%.

There is no proof that the erectile dysfunction drugs actually cause transient global amnesia, which can happen for various reasons, and can be triggered by the sexual encounter itself.

However, FDA required that all erectile dysfunction drugs must list the TGA warning on their labels in the "Post-Marketing" section.

Note: All those ready to make "such a convenient excuse" jokes must be aware that TGA can be a very disturbing experience for the patient.

References:

Cialis, Viagra Labels to Note Amnesia. WebMD.
Hodges JR, Warlow CP Syndromes of transient amnesia: towards a classification; a study of 153 cases. Neurosurg Psychiatry 1990;53:834–43.
Transient global amnesia, from Wikipedia, the free encyclopedia.
Transient Global Amnesia. eMedicine.
Sex, then amnesia...and it's no soap opera. CNN, 2009.
Image source: Hippocampus, from Wikipedia, public domain.

Related reading:

“Forgettable” Sex: A Case of Transient Global Amnesia Presenting to the Emergency Department http://goo.gl/6Rfrt
How sex and stress made one man lose his memory. The Daily Mail, 04/2010.

Men who use ED drugs have higher rates of STDs, particularly HIV infection - Ann Intern Med http://goo.gl/UH78

ED, Depression, Heart Disease: Does the Existence of One Component of This Triad Necessitate Inquiring the Other Two? http://goo.gl/EKvKl

Clinical Case: Staphylococcus Aureus Prostatic Abscess and More

A 50 yo male with type 2 diabetes mellitus was admitted with complaints of dysuria and non-specific abdominal pain for 1 week, accompanied by malaise followed by fevers and chills.


Figure 1. Computed tomography scan of the pelvis: The seminal vesicles are enlarged and demonstrate fluid attenuation internally. The right seminal vesicle measures approximately 3 cm in size. This fluid attenuation extends into the prostate, which is also heterogeneous and mildly enlarged. There are surrounding inflammatory changes of the perivesical fat. The urinary bladder shows minimal thickening of the wall. Delayed images show no obvious intraluminal abnormalities with further opacification of the urinary bladder.


Figure 2. Trans-esophageal echocardiogram: a vegetation in the anterior leaflet of mitral valve; doppler shows no significant mitral valve regurgitation.

Read more in Staphylococcus Aureus Prostatic Abscess Complicated By Infective Endocarditis at Clinical Cases and Images.

The author of this clinical case is Moises Auron, M.D. from the Department of Hospital Medicine, Cleveland Clinic.

Cell phones do not cause brain tumors but may decrease male fertility

A study of 361 men seen at Cleveland Clinic found an association between heavy cell phone use and sperm quality: the more hours the men spent on their cell phones each day, the lower their sperm count and the greater the percentage of abnormal sperm.

The study was observational and did not mention if decreasing the cell phones use led to improvement in the sperm parameters.

According to the authors, the research shows a strong association of cell phone use with decreased semen quality but does not prove a cause-and- effect relationship. A larger follow-up study is currently underway.

References:
Effect of cell phone usage on semen analysis in men attending infertility clinic: an observational study. Agarwal A, Deepinder F, Sharma RK, Ranga G, Li J. Fertil Steril. 2008 Jan;89(1):124-8. Epub 2007 May 4.
Heavy cell phone use tied to poorer sperm quality. Reuters.
Japanese study clears mobiles of brain cancer risk. Reuters.
Image source: OpenClipArt.org, public domain.

Related:
'Cancer link' to heavy mobile use. BBC, 02/2008.
Cancer and cell phones. Paging Dr. Gupta, 06/2008.

Updated: 06/14/2008