aging gracefully

Old isn’t always gold Your Health DR GITA MATHAI The Indian population (1.27 billion at present) is projected to overtake that of China in another 10 years, with more births and steadily climbing life expectancy (65 years at present). Between 2000 and 2050, the total population will increase by around 60 per cent but the number of senior citizens (that is, people above the age of 60) will increase by a mind boggling 360 per cent. At that time, they will comprise 20 per cent of the total population. This group is likely to be “feminised” as women tend to outlive men. Also, 70 per cent of the women in that age group would have lost their husbands, whereas only 30 per cent of the men would have lost their wives. Some of these men may remarry, but the majority of women remain single. Many of these old men and women lose their independence and liberty. They are told (often out of kindness) to take rest, relax, watch television and not venture out on to unsafe roads. They may lose control of their resources and suffer neglect or abuse, even though the government has declared that any Indian citizen over the age of 60 is entitled to maintenance from their children. That is all very well in theory but newspapers are inundated with horror stories of abuse, neglect, starvation and even murder. It is a fact that our health deteriorates as we age. “Slowing down” seems a normal process with decline in cognitive skills, muscle strength, and endurance. Finally, the elderly become dependent on caregivers physically and financially. We cannot totally halt this process but it can be slowed down if unhealthy and dangerous behaviour and habits are curtailed while we are still young and fit. Smoking is one of the biggest offenders. It is responsible for bone loss, breathing difficulties, early dementia, heart failure and cancer. No one really likes to look after a wheezy, breathless elder who can barely move around the house. It is a habit that needs to be stopped (not reduced) as soon as possible. Drinking is a double-edged sword, especially as you get older. The drinkers argue that moderate drinking, that is, one drink a day for women or two drinks a day for men, (one drink means 12 fluid ounces of beer, five fluid ounces of wine and 1.5 fluid ounces of 80 per cent proof spirits) has health benefits. It has been credited with a reduction in the risk of getting a heart attack or stroke. It may prevent formation of gallstones and delay diabetes. It may be of benefit in older adults who already have high cholesterol or are at risk for heart disease. Doctors, on the other hand, feel that drinking does not have positive effects for everyone. It can lead to addiction and abuse. Long-term drinking can damage the heart, liver, brain and nervous system. It can lead to personality change. Since the jury is still out, if you do drink do so in moderation and have a day off a week. If you don’t drink, please don’t start. A balanced diet goes a long way towards preserving health. Proteins, fats and carbohydrates should be eaten with four helpings of fruits and vegetables a day. This will keep muscles and bones healthy, prevent constipation, and provide roughage, fibre, vitamins, trace elements and disease fighting anti-oxidants. Regular habits, with at least seven hours of sleep, keeps the brain functioning like a well-oiled machine and gives it enough time to recuperate. As the messages travel again and again through the same internal circuits, the transmission and execution become efficient. The unused areas of the brain tend to atrophy. To prevent this from happening, they need stimulation. Learning a new skill like chess, dancing or music can do this. This may not be possible if a person is house bound and unable to attend a class or a social group. Religious books are usually always available in the house. Committing parts of it to memory and then trying to recall it or learning poetry are excellent ways to stimulate the brain. Crossword puzzles and Sudoku also accomplish this, but then again books need to be provided. The benefits of physical exercise are immeasurable. Regular aerobic activity such as walking, running, jogging, swimming for an hour a day builds muscle and bone strength. This in turn helps balance and that prevents falls and fractures. It also prevents cognitive decline. We owe it to our children to give up unhealthy lifestyles and become physically and mentally fit. That way, we are unlikely to become elderly burdens financially and emotionally. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in Share on emailShare on printShare on facebookShare on twitterMore Sharing Services

doping kids

Foul play Your Health DR GITA MATHAI “This is my son,” said the man, as he walked into my clinic, “He is a district level sprinter. He is to compete at the state interschool athletics meet. Can you give me a certificate saying he is 16 years old? “Don’t you have a birth certificate?” I asked. “Yes,” said the man, “According to that he has completed 19 and will have to compete in another age division”. “Is he 19 years old?” “Yes” confessed the father, “he started school late. Also his coach feels that he is underweight and his muscles are not well developed. He gets tired easily. So he wants him to take these vitamins and supplements.” He produced a plastic bag that contained a mini pharmacy: capsules with vitamins and minerals in mega doses, pills containing anabolic steroids and testosterone, a jar of a “food supplement” with high doses of amino acids and creatine and even injections of long-acting testosterone. Apparently the entire team, including the girls, were on these supplements and injections! Athletes have to practice day in and out for years to build up stamina and muscle to excel in their chosen sport. There are no short-cuts. Some of our young athletes are naturally talented and are spotted by coaches at the school level. Others have parents who pay for coaches and training. After all, if you can compete in a sport at the national level, it will guarantee you a place at college (even with lower marks) and a job under the “sports quota”. In India, the focus is on academics since it is thought to be the only thing that will help a child get a good job. Many parents feel that sports are a waste of time and money. After all, how many Dhonis or Milkha Singhs does the country produce? This means that many talented children do not achieve their potential in sports. So with no access to (or interest from) the talented, coaches look for shortcuts to produce national level athletes. One way is to fudge the age. A 19-year-old always has a good chance of performing better than a 14-year-old. The other is doping. Last year, the International Association of Athletics Federation caught 52 Indians doping. Even more frightening, in last year’s National Schools Championship, 11 student athletes were caught doping. Often the athlete and the parents are ignorant about what is there in the health supplement prescribed by the coach. Creatine powder is one of the things widely used by coaches as it is believed to speed up recovery and increase muscle mass and strength. Since creatine occurs in the body naturally, it is thought to be harmless but the truth is very different. Consuming creatine leads to weight gain and irreparable kidney damage. Steroids and steroid precursors (usually medications ending with “abol”) and DHEA (d ehydroepiandrosterone, a hormone) are misused to better performance. They, however, also cause pimples, damage the heart and liver, precipitate diabetes and high blood pressure and cause short stature by interfering with bone growth. Girls can also develop a deep voice and become hairy and sterile. No one can progress in the chosen field (even if it is only lifting weight in the local gym) without putting in hard work. If you take dangerous supplements as a shortcut to success, you will either be caught or the dangerous side effects will quickly cut short your career and perhaps even your life. If parents and athletes knew what exactly they were consuming in their “health supplements” and what the long-term effects were, most of them would probably decide not to take this “short-cut” and choose to work hard. An athlete’s diet needs to have adequate calories and proteins. The calorific requirement can be roughly calculated by multiplying the ideal weight in pounds by 13. Then add the calories expended in the sport. Running is 350-500 calories an hour, swimming 550-600 and weightlifting 450-500 calories. Depending on the intensity of the training, these calories can be added to the daily requirement. Infants require about 10gm of protein, teenage boys 50gm, girls 46gm, adult males 55gm and women 45gm a day. Meat, fish, eggs, nuts and dairy products are good and healthy sources. Sports is about developing personality, dedication and discipline in children. It is not about winning by any means, fair or foul. It is about instilling ethics, not chasing short-term gains by a devious route at the cost of future health. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in Share on emailShare on printShare on facebookShare on twitterMore Sharing Services

making babies

Making a baby

Your Health DR GITA MATHAI

ON YOUR PART....  Make sure your immunisations against rubella (R-vac) and Hepatitis B are complete and up to date  Take folic acid supplements (5mg a day ) to ensure proper development of the nervous system in the foetus  Reduce stress, by taking up yoga, meditation or Tai chi  Exercise for an hour a day even if both the husband and wife are of ideal body weight At any given time, 12 per cent of married couples in India are trying unsuccessfully to have children. A majority of them have had arranged marriages. The pressure on the couple (especially the woman) to procreate is tremendous. If they haven’t conceived within 4- 6 months of marriage, many can be found in doctors’ offices, anxious and depressed. A couple is considered relatively infertile only if they have been married at least a year, the woman menstruates regularly, the man has a normal sperm count, they have had regular and frequent intercourse during this period and still haven’t conceived. This automatically excludes couples who are together only every fortnight or once a month. Women ovulate only once in 28 days (if they have regular cycles). Once the egg leaves the ovary, it survives for 12-24 hours. After ejaculation, sperms survive for 3-5 days. This means that there is a very small window in a month when pregnancy is possible. Work, travel, illness, social and religious functions all make it very possible for the “fertile period” to be missed completely. A person can have intercourse only on weekends for months on end and still manage to miss the “fertile days”. It is possible to approximately calculate fertile days (the egg is released 14 days before the next period) and make sure they are not missed. The downside is that women do not function like machines and the length of their menstrual cycles can vary. There are many specialised fertility centres all over India, which offer expensive and high tech solutions, intrauterine insemination (IUI) and IVF (in vitro fertilisation) being two that are much advertised. Before attending one of these centres and embarking on an expensive journey, there are a few simple interventions that can be tried. Check the BMI (body mass index) of both the husband and wife. Women with a BMI of 35 were found to be 25 per cent less likely to achieve a spontaneous pregnancy. If the BMI goes up to 40, the chances fall to below 40 per cent, despite regular menstruation. If the BMI is more than 25 in either partner, then the first thing to do is get it down with strict diet and exercise. Even before the weight begins to drop, the chemicals released by the body during regular and consistent exercise improves chances of conception by 50 per cent. Men with a BMI of 30 or more are also relatively infertile. Both partners need to stop smoking or using tobacco in any form and stop consuming alcohol. A physician needs to be consulted without waiting for the mandatory year if you are an older couple (more than 35), if the woman’s periods are irregular, painful, there is endometriosis or symptoms of pelvic infection. In men, a visit to the doctor is recommended if there is a history of having been treated for diseases such as gonorrhea, prostate or cancer, or surgery for varicocele, hernia or hydrocele. If reasons for infertility are analysed, in 33 per cent of the cases the woman has a problem, in 33 per cent it is the male and in 33 per cent no cause can be identified. Men may not have children because their sperm count is low, the sperms are abnormal, there are ejaculation problems, over exposure to chemicals or heat in the workplace has harmed sperm, or as a side effect of hernia, hydrocele or varicocele, sexually transmitted diseases or previous cancer treatment. Women’s infertility may stem from ovulation problems, polycystic ovaries, hormonal problems (thyroid, prolactin), abnormalities in the shape of the uterus or cervix, blocked fallopian tubes, endometriosis or premature menopause. Evaluation for causes of infertility need to be done on a step-by-step basis after a complete physical check up by a doctor. Once a specific diagnosis is arrived, interventions can be suggested. Tests and treatment take time and can be expensive and uncomfortable. Even after a particular line of treatment is suggested and followed it takes a whole month (one menstrual cycle) before there is even a suspicion that the treatment may have been successful. Switching doctors and clinics every few months because of anecdotes about success or turning to different systems of medicine will not ensure success. Instead, there will only be duplication of tests and procedures as each doctor attempts to give you a baby. Even in the best of hands success rates all over the world have not crossed 50 per cent. Do not let that depress you. Some couples eventually become pregnant after they have actually “given up” on treatment. Also, there are other options available today like adoption and surrogacy. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.

metabolic syndrome X

Not sweet

YOUR HEALTH / DR GITA MATHAI

Diabetes has reached epidemic proportions in India. Exact figures are difficult to come by but screening studies place the numbers at between 10 and 20 per cent of the total population. These, of course, are only the people with frank diabetes. It does not take into account pre-diabetics, those with mildly elevated sugars who may eventually become full-blown diabetics. Nor does it consider the gestational diabetics — pregnant women who are diabetic during pregnancy but may recover completely after delivery. Unfortunately, diabetes affects systems all over the body, particularly if it is undiagnosed or uncontrolled. In the brain, it may lead to strokes or an earlier onset of cognitive decline, with memory loss and unreasonable behaviour. The eyes can develop cataract, muscles can become weak and the blood pressure can rise. In the heart it can lead to myopathy, blocked vessels or heart attacks. The kidneys can begin to malfunction and the nerves develop neuropathy with tingling numbness and weakness. Many diabetics remain undiagnosed as they have limited access to medical care or have not got themselves evaluated . Others have more faith in alternate systems of medicine. Many of these systems emphasise a “symptom based” approach to diagnosis and treatment. Individual symptoms such as weakness, frequent urination or loss of weight are treated. The main disease (diabetes) remains undiagnosed. Although diabetes is a dangerous disease, evolution has not wiped out the genes responsible for it. This is because it was originally a survival mechanism . Before large-scale storage of food was available, people (particularly women) needed to store food as fat in their bodies to tide them over in lean times (famines). People with the ability to do this were more likely to survive and pass on the genes to their offspring. People prone to diabetes have a similar metabolism that can efficiently convert food to fat and store it. Now that food is plentiful, these genes have become detrimental. They cause the metabolic syndrome X and this eventually leads to diabetes. The International Diabetes Federation has defined “the metabolic syndrome X” as the presence of central obesity — a waist-:hip ratio greater than 0.90 in males and 0.85 in females, or BMI 30 kg/m 2 . (The waist hip ratio can be measured in inches or centimetres by measuring the narrowest part of the waist and the widest part of the hip. The BMI is the weight in kg divided by the height in meter squared.) In addition, any two of the following should be present: Triglycerides more than 150mg/dL HDL cholesterol 40 mg/dL (1.03 mmol/L) in males, < 50 mg/dL (1.29 mmol/L) in females. A blood pressure reading of 135/85 or higher A fasting blood sugar value more than 100 mg/dL To avoid diabetes, the total calories consumed should not exceed that which is required by the body. The number of calories we need is based on our body weight, level of activity and the thermic effect of food (TEF) or the calories required to digest the food that we eat. About 60-70 per cent of the calories we eat goes towards supporting life. To find calorific requirement in males multiply body weight in pounds by 10 and then add double the body weight. In adult females multiply the body weight by 10, add the body weight. (1 pound = 2.2.kg) In addition calories are burnt during physical activity. This can be added to the above value. The TEF is a flat 10 per cent of the total calories consumed. So eat sensibly and exercise for an hour daily. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

violent children

Violent child

DR GITA MATHAI

The media seem to be overflowing with tales of violence. There are stories on robbery, kidnapping, rape and murder. While such crimes have become more visible now, the truth is that they have always been around. What is worrying is the rise in violent crimes committed by children and adolescents all over the world, not just in India. The middle class and the rich of this country like to think that such crimes are only committed by the economically disadvantaged and that “their children” are safe in “good” private schools. Nothing could be farther from the truth. The wealthy are just better at concealing the incidents, hushing them up and paying off the victims. Now, however, that is no longer the case. Under increased media glare, the crimes get exposed even if the criminal is rich, well connected or a juvenile. Children are becoming violent because of several factors. Often, both parents work so there is no one to keep an eye on the children when they return from school. Most are left to the care of uneducated domestic helps. (The old loyal breed of ayahs is now practically non-existent). They may be sent to “tuitions”, but they have no hobbies, do not read much and even when they play with friends they are unsupervised. The television is often used as a babysitter. Children watch two to three hours of TV a day unsupervised. Many of the serials and movies have adult content with sex, violence, stereotyping of women and lawlessness. They glorify a violent solution to everyday problems and often portray it as the only alternative. Authority is downplayed. Success needs to be achieved at any cost. The actors are seldom injured. Even when sustaining trauma or death, they mysteriously reappear in other episodes or different serials. The lines between the virtual and real world become blurred in the child’s mind. Blood and gore appear commonplace. The child becomes insensitised to violence and ceases to feel empathy for the victim. They may even begin to identify with the “villain”. Unfortunately, violence eventually ceases to horrify. It seems an ideal way to solve problems. The lines between right and wrong become blurred and the end appears to justify the means. Children as young as three or four may exhibit violent behaviour. Sometimes, the preschool may not report it. Even if it does, parents do not take it seriously. They blame the school, or feel that the child will grow out of it. A child in danger of developing violent behaviour has certain characteristics. He or she is impulsive, demanding, physically aggressive and throws temper tantrums if thwarted. He or she may destroy property and be cruel to animals. Violent behaviour is more likely to develop in children if there is marital discord, alcoholism or domestic violence. The child sees violence as a solution to problems and imitates elders. Also, alcohol may be available in the house, leading to experimentation, especially in older children. In these situations the lines between a genetic predisposition to violence and environmental factors like upbringing become blurred. If a child shows violent behaviour, excessive punishment or expulsion is not the solution, though it may keep other members of the school safe. The child needs evaluation and counselling. If the problem is alcoholism, marital discord and violence in the home, the parents need counselling and treatment. This may be difficult as they as adults have developed this pattern of behaviour with callous disregard for the consequences on their family or society. It is very important to spend time with children and monitor their movies, television programmes and computer games. It is important to not allow certain programmes or games, even if there is peer pressure and the oft-repeated complaint, “everyone else gets to watch it”. Limiting television viewing has other positive fallouts. Children have more time to study, read, play sports and pursue hobbies. Structured physical activity such as a game or sport and regular exercise helps to vent frustration and anger in a healthy fashion. Interest in sports means the child is likely to spend time outdoors. He or she is more likely to avoid cigarettes, alcohol and drugs. He or she also develops a sense of self- worth. They do not need to boost this with bullying or violence. As parents and caregivers, we can only lead by example. That means we too must give up violent programmes, exercise regularly and learn to peacefully co-exist with our families, neighbours and society. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

sons of viagra

Sons of Viagra

It won’t “get up” or “stay up,” confessed the shifty eyed man refusing to look his doctor in the eye.  His wife was equally uncomfortable, though it was a toss up as to who was more embarrassed, the doctor or the patient! 

 Men seldom discuss personal problems. It requires a great deal of courage for a man to sit face to face with a medical practitioner confess that his “manhood” is malfunctioning, and he has impotence. Fortunately, more couples are now coming out of the closet, and seeking treatment

A single failure is not erectile dysfunction or impotence. It is a medical problem when there is a persistent failure 75% of the time over a period of 3 months.

About 90% of the urban Indian males develop impotence at some time in their lives.

Rather than have this embarrassing problem evaluated, many men visit the friendly neighbourhood pharmacist, who supplies them with OTC (over the counter ) sidenafil citrate  (common trade name—Viagra) at black market rates. Others prefer alternative medicine laced with dangerous high doses of heavy metals with supposed aphrodisiac properties. Some form long lines in front of the paanwala for his overpriced mysterious “break- the- cot” paan.

Sexual dysfunction is a disease like any other. It needs to be scientifically evaluated and diagnosed before embarking on treatment. The cause may be organic or psychological. 

 The organic dysfunction is better, as, once the cause is treated the impotence resolves. It can be caused by uncontrolled diabetes, hypertension, a high cholesterol, low male hormone levels, abnormal genitalia, chronic liver or kidney disease, spinal cord abnormalities disease or degeneration, and as an aftermath of prostate surgery. Sometimes it is an unexplained side effect of certain medications.

Inadequately and improperly controlled diabetes causes a dysfunction of the autonomic nerves. This affects vascular channels all over the body, particularly and obviously in the penis. Attention to the prescribed diet, regular exercise and adherence to the medication prescribed will usually cure the problem. Uncontrolled diabetes also alters the sex hormone ratios, particularly testosterone, affecting both desire and performance.

Smoking is rightly blamed for a host of diseases. Not only is the quality of the semen in the ejaculate poor, leading to sub fertility, the compromised penile blood supply leads to impotence.

High triglycerides block blood vessels reduces blood supply just when it is needed the most.

Removal of the prostrate may damage the nerves, leading to erectile dysfunction. If men take female hormones for cancer, impotence may occur.

Diseases tumours and degeneration of the spinal cord can lead to impotence.

Sex is not a mechanical action. It is a higher function involving the release of chemicals and neurotransmitters from the brain. A loving cooperative partner and expert counselling can produce vast improvement even if there is a disease process affecting function.

Many medications are touted as miracle cures for impotence. Sidenafil releases neurochemical transmitters with cause expand blood vessels. It takes at least 30 minutes to act and the effect lasts only for 4 hours. The environment also has to be conducive ( not while watching comedy shows) otherwise it will not work. Viagra has side effects. It can produce visual disturbances so driving after taking the tablet is not advised. All blood vessels may be uniformly dilated  and this may produce low blood pressure. It interacts with commonly used medications.

 “Sons of Viagra” or superior versions like varderafil and tadalafil are now available. The onset of action is faster, more specific and long lasting (up to 12 hours). This produces spontaneity, and reduces anxiety. That alone may improve performance.

Hormone replacement is indicated for low testosterone levels.

There are other safer lesser known centrally acting apomophine derivatives that can be placed under the tongue, and do not react with other medications or food. Unfortunately they take around 10 minutes to act (during this time speech may be difficult). Also sometimes up to 6 doses are needed before any effect is seen.

For the brave hearted, there are injections into the penis. These are self administered (may turn off the partner) and the technique has to be carefully learnt to prevent infections and local side effects.

Medicated gels can be directly applied inside the urethra but then again the person cannot lie down or sit for 20 minutes.

A specially designed suction apparatus can be used to  produce an erection.

Penile implants made of silicone can be used but are not very popular as the erection is permanent.

Sex involves two people and impotence is a problem involving a couple. It has to be tackled together. Andrologists (urologists with an interest and training) and psychiatrists can often achieve miracles. Amateur treatment or that of a single partner alone is often unsuccessful despite herbal medicines, alternative therapy and “the sons of Viagra.”

help

Sons of Viagra

It won’t “get up” or “stay up,” confessed the shifty eyed man refusing to look his doctor in the eye.  His wife was equally uncomfortable, though it was a toss up as to who was more embarrassed, the doctor or the patient! 

 Men seldom discuss personal problems. It requires a great deal of courage for a man to sit face to face with a medical practitioner confess that his “manhood” is malfunctioning, and he has impotence. Fortunately, more couples are now coming out of the closet, and seeking treatment

A single failure is not erectile dysfunction or impotence. It is a medical problem when there is a persistent failure 75% of the time over a period of 3 months.

About 90% of the urban Indian males develop impotence at some time in their lives.

Rather than have this embarrassing problem evaluated, many men visit the friendly neighbourhood pharmacist, who supplies them with OTC (over the counter ) sidenafil citrate  (common trade name—Viagra) at black market rates. Others prefer alternative medicine laced with dangerous high doses of heavy metals with supposed aphrodisiac properties. Some form long lines in front of the paanwala for his overpriced mysterious “break- the- cot” paan.

Sexual dysfunction is a disease like any other. It needs to be scientifically evaluated and diagnosed before embarking on treatment. The cause may be organic or psychological. 

 The organic dysfunction is better, as, once the cause is treated the impotence resolves. It can be caused by uncontrolled diabetes, hypertension, a high cholesterol, low male hormone levels, abnormal genitalia, chronic liver or kidney disease, spinal cord abnormalities disease or degeneration, and as an aftermath of prostate surgery. Sometimes it is an unexplained side effect of certain medications.

Inadequately and improperly controlled diabetes causes a dysfunction of the autonomic nerves. This affects vascular channels all over the body, particularly and obviously in the penis. Attention to the prescribed diet, regular exercise and adherence to the medication prescribed will usually cure the problem. Uncontrolled diabetes also alters the sex hormone ratios, particularly testosterone, affecting both desire and performance.

Smoking is rightly blamed for a host of diseases. Not only is the quality of the semen in the ejaculate poor, leading to sub fertility, the compromised penile blood supply leads to impotence.

High triglycerides block blood vessels reduces blood supply just when it is needed the most.

Removal of the prostrate may damage the nerves, leading to erectile dysfunction. If men take female hormones for cancer, impotence may occur.

Diseases tumours and degeneration of the spinal cord can lead to impotence.

Sex is not a mechanical action. It is a higher function involving the release of chemicals and neurotransmitters from the brain. A loving cooperative partner and expert counselling can produce vast improvement even if there is a disease process affecting function.

Many medications are touted as miracle cures for impotence. Sidenafil releases neurochemical transmitters with cause expand blood vessels. It takes at least 30 minutes to act and the effect lasts only for 4 hours. The environment also has to be conducive ( not while watching comedy shows) otherwise it will not work. Viagra has side effects. It can produce visual disturbances so driving after taking the tablet is not advised. All blood vessels may be uniformly dilated  and this may produce low blood pressure. It interacts with commonly used medications.

 “Sons of Viagra” or superior versions like varderafil and tadalafil are now available. The onset of action is faster, more specific and long lasting (up to 12 hours). This produces spontaneity, and reduces anxiety. That alone may improve performance.

Hormone replacement is indicated for low testosterone levels.

There are other safer lesser known centrally acting apomophine derivatives that can be placed under the tongue, and do not react with other medications or food. Unfortunately they take around 10 minutes to act (during this time speech may be difficult). Also sometimes up to 6 doses are needed before any effect is seen.

For the brave hearted, there are injections into the penis. These are self administered (may turn off the partner) and the technique has to be carefully learnt to prevent infections and local side effects.

Medicated gels can be directly applied inside the urethra but then again the person cannot lie down or sit for 20 minutes.

A specially designed suction apparatus can be used to  produce an erection.

Penile implants made of silicone can be used but are not very popular as the erection is permanent.

Sex involves two people and impotence is a problem involving a couple. It has to be tackled together. Andrologists (urologists with an interest and training) and psychiatrists can often achieve miracles. Amateur treatment or that of a single partner alone is often unsuccessful despite herbal medicines, alternative therapy and “the sons of Viagra.”