Dear Dr G,

First of all, Gong Xi Fa Cai and Happy New Year to your family and all readers celebrating.

I have read with interest all the articles you wrote about “love pills”. I agree that the medication is unavoidable when ageing or unhealthy men are affected by erectile dysfunction.

Although you have provided reasonable scientific evidence that the blue pills are safe, I have several concerns.

You may think these concerns are myths, but I need to put you on the spot to debunk them before

“Chinese Valentine’s Day” or Chap Goh Meh.

First of all, is there evidence that taking too many of the pills at an early age can result in dependency?

Secondly, by taking the pills earlier in life, does it mean higher doses will be needed as we age?

Also, can too many blue pills cause renal failure?

Lastly, I often hear about sudden death associated with taking the pills. Has this happened?

Mythical Mike

Despite decades of clinical use and extensive research, phosphodiesterase type-5 inhibitors (PDE5 inhibitors) remain surrounded by persistent myths. These medications influence blood vessels and sexual function, so they often cause anxiety and attract misinformation.

Concerns about dependency, tolerance, kidney damage and sudden death continue to circulate, even though there is scientific evidence that clears the air. One of the most common fears is that people who use PDE5 inhibitors will become dependent on them. This belief likely arises from confusion with medications that affect the brain’s reward system, such as opioids or sedatives.

PDE5 inhibitors, however, do not act on addiction pathways in the brain. They do not produce cravings, withdrawal symptoms, or chemical dependence. Their action is purely physiological, as they enhance blood vessel relaxation.

When the medication is stopped, the body does not experience withdrawal. Instead, in some cases, individuals may develop psychological reliance because they feel more confident or comfortable when the medication works reliably.

This form of reliance is comparable to using glasses for vision correction rather than a sign of drug addiction. The underlying condition remains unchanged, and the medication simply helps manage its symptoms.

Another widespread misconception is that long-term use inevitably leads to tolerance, meaning the body becomes accustomed to the drug and requires increasing doses. This idea is common with substances such as alcohol or certain pain medications, and it is often incorrectly applied to PDE5 inhibitors.

Long-term clinical studies have shown that these medications maintain their effectiveness over many years without the need for progressively higher doses. When patients report that the medication seems less effective over time, the most likely explanation is progression of the underlying health condition rather than tolerance to the drug.

Erectile dysfunction is frequently linked to ageing, diabetes, high blood pressure and cardiovascular disease. As these conditions worsen, symptoms may become more severe, creating the impression that the medication is losing effectiveness. In reality, the disease may be progressing while the drug’s pharmacological action remains stable.

Concerns about kidney damage represent another enduring myth. Many people think that any medication processed by the body must place strain on the kidneys. PDE5 inhibitors are primarily metabolised by the liver and are then eliminated through both urine and stool.

In individuals with healthy kidney function, these medications are not known to cause kidney damage when used as prescribed. For patients with severe kidney disease, physicians may recommend lower doses because the drug can remain in the bloodstream for a longer period. This adjustment reflects careful medical practice rather than evidence of toxicity.

In fact, ongoing research is exploring whether or not PDE5 inhibitors might offer protective benefits in certain cardiovascular and kidney conditions because of their positive effects on blood vessel health and circulation. Perhaps the most alarming myth is the claim that PDE5 inhibitors can cause sudden death.

This fear gained attention shortly after the first medication in this class became widely available, when media reports highlighted isolated cases of heart attacks occurring during sexual activity. The crucial context often overlooked is that sexual activity itself is a form of physical exertion.

Many individuals who use PDE5 inhibitors are older and may already have cardiovascular disease, which increases the risk of heart events regardless of medication use. Large studies have demonstrated that PDE5 inhibitors do not independently cause sudden death when prescribed appropriately.

The primary safety concern involves combining these medications with nitrate drugs used to treat chest pain. This combination can cause a dangerous drop in blood pressure and is strictly avoided. Some research even suggests that they may improve cardiovascular health by enhancing blood vessel function and circulation.

These myths persist partly because the medications were highly publicised when introduced, and because they are associated with sensitive topics such as sexual health and heart disease. Public discussions often lack the nuance of scientific research, allowing fear to spread more easily than accurate information. Over time, repeated misconceptions can become accepted as fact despite the lack of supporting evidence.

In conclusion, the myths that PDE5 inhibitors cause dependency, tolerance, kidney damage, or sudden death are not supported by scientific research. These medications work by enhancing natural vascular processes and have been studied extensively for decades. When used under proper medical supervision and with attention to contraindications, they have an established safety profile.

Understanding the difference between myth and evidence allows patients to make informed decisions based on science rather than fear. American astronomer Carl Sagan once said: “Extraordinary claims require extraordinary evidence.”

When Dr G is put on the spot to debunk love pill myths before “Chinese Valentine’s Day”, his response is: after 28 years of overwhelming evidence, why are there still extraordinary claims?

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Dear Dr. G,

I am a sixty-year-old man who is reaching an age where it is becoming difficult to achieve a satisfactory erection for regular intimacy with my wife.

I accept that Erectile Dysfunction (ED) is a fact of life for an ageing man and is likely related to diabetes, hypertension and high cholesterol.

My wife agreed for me to try blue pills, and frankly, the pills have saved our marriage.

As our sex life is very regular, the frequent consumption of the pills has become cumbersome and quite expensive.

I recently went to the GP and discussed another ageing problem with my prostate.

He noticed that my frequent blue pills could be replaced by daily pills that can treat my prostate too.

The doctor also highlighted that daily pills can reduce the ups and downs of drug concentration, thereby reducing fluctuations in side effects.

I was curious, as he mentioned the daily dose is also good for other medical conditions.

I would like to put Dr G on the spot for some clarifications.

Firstly, can you please tell me how the daily dose of the hard pills works?

What are the pros and cons as compared to on-demand dosing?

Can the medications truly be used for other medical conditions?

Lastly, if I choose to take the pills on a daily basis, will I suddenly have Happy Valentines every night?

Regards

Valentine Vincent

The history of phosphodiesterase type-5 (PDE5) inhibitors began in the late twentieth century, when research initially aimed at treating angina unexpectedly prompted a shift in focus toward sexual medicine and vascular physiology. In 1998, sildenafil became the first PDE5 inhibitor approved for erectile dysfunction, marking a turning point in both medical treatment and public awareness of sexual health. PDE5 inhibitors are widely associated with the treatment of erectile dysfunction, yet their medical significance extends far beyond this original purpose. Over time, their use has evolved from occasional, “as-needed” dosing to daily low-dose therapy designed to provide continuous physiological benefits.

Understanding the mechanism of PDE5 inhibitors helps explain why daily dosing can be effective. These medications inhibit the phosphodiesterase type 5 enzyme, which normally degrades cyclic guanosine monophosphate (cGMP). This molecule plays a crucial role in relaxing smooth muscle and widening blood vessels. By preventing the breakdown of cGMP, PDE5 inhibitors maintain blood vessel relaxation for longer periods, thereby improving circulation and tissue oxygenation. Although this effect is best known for improving erectile function, it also affects blood flow to the prostate, bladder, lungs, and other organs.

Daily dosing has demonstrated notable effectiveness in the treatment of erectile dysfunction, particularly for individuals with persistent symptoms or those who prefer spontaneity in sexual activity. Rather than planning medication use around specific occasions, patients taking daily therapy maintain a consistent level of medication in their system. This approach may improve baseline erectile function and reduce anxiety related to performance. Continuous treatment may also support long-term vascular health in penile tissue by improving oxygenation and reducing episodes of hypoperfusion. Hence, it is known to be effective for “penile rehabilitation” following the trauma of surgical intervention, such as radical prostatectomy for the treatment of prostate cancer.

Beyond sexual health, daily PDE5 inhibitor therapy has shown effectiveness in managing urinary symptoms caused by benign prostatic hyperplasia, a condition involving enlargement of the prostate gland. The medications relax smooth muscle in the bladder and prostate, thereby reducing urinary urgency, improving urine flow, and decreasing nocturnal urination. For patients experiencing both erectile dysfunction and urinary symptoms, daily dosing offers the advantage of treating multiple conditions with a single medication. Another important medical application is pulmonary arterial hypertension, a serious disorder characterised by narrowed blood vessels in the lungs. PDE5 inhibitors improve exercise tolerance and help reduce pulmonary blood pressure, illustrating the broader significance of their effects on the circulatory system.

The advantages of daily therapy include stable drug levels in the bloodstream and reduced fluctuations associated with higher, intermittent doses. Continuous dosing may produce more consistent therapeutic effects and may improve treatment adherence for individuals managing chronic conditions. However, these benefits must be weighed against potential side effects and the need for ongoing medical supervision.

The most common side effects of PDE5 inhibitors are generally mild and are associated with their vasodilatory effects. Headaches, facial flushing, nasal congestion, indigestion, and mild dizziness are among the most frequently reported symptoms. Some individuals experience muscle or back pain, particularly with longer-acting medications. These effects often diminish as the body adjusts to treatment. More serious risks are rare but important to consider. Because these drugs lower blood pressure, they must never be combined with nitrate medications used for heart disease, as this combination can cause a dangerous drop in blood pressure. In rare cases, individuals may experience changes in vision or hearing, and prolonged erections lasting several hours require immediate medical attention. Drug interactions with certain antibiotics, antifungals, and heart medications also require careful management by healthcare professionals.

Research into PDE5 inhibitors continues to expand, with scientists exploring their potential role in cardiovascular disease, circulation disorders such as Raynaud’s phenomenon, and other conditions related to vascular function. These ongoing investigations highlight the possibility that the medications may offer broader health benefits than initially recognised, potentially including the treatment of altitude sickness in both men and women.

In conclusion, daily-dose PDE5 inhibitors represent a significant evolution in pharmacology. What began as an accidental discovery during research on heart disease has evolved into a versatile therapeutic approach for several chronic conditions. Daily therapy offers consistent effectiveness and improved convenience, though it requires awareness of possible side effects and careful medical oversight. As scientific understanding of vascular health continues to develop, PDE5 inhibitors may play an increasingly important role in future medical treatments. American actress Mae West once said, “Sex is emotion in motion.” Men contemplating switching from “Valentine” pills to a daily dose for sexual benefits and beyond often put Dr G on the spot for his opinion. His view is: “Sexual health treatment is also evolution in motion!”

So, take advantage of this evolution and enjoy Happy Daily Valentines!

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Dear Dr. G,

I am a 30-year-old man whose life crumbled after being diagnosed with testicular cancer two years ago. During an intimate moment, my wife noticed a lump in my right testicle. At first, I wasn’t worried about testicular cancer, as I never believed that cancer could happen to young men. However, as the lump grew bigger and my concern increased, I decided to see a doctor.

I was horrified when the doctors informed me that the painless lump was likely cancerous. They advised me to have my testicle removed as soon as possible. I am grateful that the operation was successful and the cancer was completely removed.

Two years later, during my medical check-up following the surgery, I received the good news that there was no recurrence of the cancer. I was somewhat taken aback when the doctors mentioned the possibility of a testicular prosthesis. Initially, I thought it was a joke until I researched more about testicular prosthetics.

I want to understand the necessity of having a prosthesis to fill an empty scrotal sac. What exactly are testicular prostheses, and what materials are they made from? How common are such prostheses, and who typically receives them? What are the pros and cons of having a prosthesis? Is there a genuine need to fake an empty sack with a prosthesis?

Yours truly,

Faking Freddie

A testicular prosthesis is offered when a patient desires restoration of scrotal appearance after losing a testicle. These occur following an Orchiectomy for cancer, trauma or torsion requiring surgical removal and severe infection or abscess requiring orchiectomy. Undescended testis (cryptorchidism), where the

testicle is absent or atrophic (Congenital anorchia), may also require a testicular prosthesis. Testicular prosthesis is also inserted for Cosmetic or Psychological Reasons. Patients with significant body-image concerns intend to reduce psychological impact, such as shame, anxiety, or altered self-image. Therefore,

testicular prostheses have become an important component of urological reconstructive care. Their primary purpose is to restore the cosmetic appearance of the scrotum after the loss or absence of a testicle. This is helping many patients regain confidence, body image, and psychological well-being.

Although testicular prosthesis is highly beneficial, it remains underused. Only 25–35% of men undergoing orchiectomy are offered a prosthesis at the time of surgery. Implantation rates vary by region, with higher insertion in North America, Australia, and Europe, and lower in Asia, due to cultural factors and

lower awareness. Satisfaction rates are 90–95% among patients who receive an implant. Barriers to Uptake are usually a lack of counselling or awareness, and stigma or embarrassment.

The concept of replacing a missing testicle dates back more than a century. Early attempts started in the early 1900s, when surgeons experimented with glass balls, silver, gold, paraffin, and ivory implants. These materials often caused infection, extrusion, or severe inflammation and were eventually abandoned. In the Mid-20th century, plexiglas spheres were introduced. They were more inert, but still rigid and uncomfortable. The first silicone gel–filled testicular prosthesis was introduced in 1993, representing a major leap in biocompatibility and comfort. Smooth or textured silicone shells filled with saline became the new standard, reducing concerns about silicone gel leakage. Today, most prostheses are silicone elastomer shells filled with silicone gel or saline, depending on regulatory and regional preferences. These are anatomically shaped and available in multiple sizes.

Sizing is both an art and a science. Measurement of the contralateral testis, for length, width, and firmness, is the usual practice. In bilateral absence, use standard anatomical averages for age. Assessing scrotal volume is crucial with the Orchidometer: a tight, small scrotum requires a smaller prosthesis, while a lax scrotum allows a larger, more natural feel. Many surgeons perform intraoperative sizing and evaluate cosmetic fit using natural hang and symmetry. The general sizing principles aim to match the existing testicle in unilateral cases. In bilateral implants, aim for normal adult size. A small testicle is 12-16 mL equivalent, medium size is 18–20 mL equivalent, and lastly, large is 22-25 mL equivalent. A well-sized implant should look natural and be comfortable long-term.

Testicular prosthesis is considered safe and well-tolerated. The rejection rates are low, and long-term durability and minimal maintenance are required. The surgical risk includes infection rates of 1–3%. This is usually associated with hematoma or scrotal swelling. The infection can result in pain or discomfort. In the longer term, complications such as extrusion can also occur, although this is rare with modern devices. Malposition or high-riding implant and Implant rupture. The need for replacement is usually when the lifespan is> 15–20 years. There is no evidence that prostheses increase cancer risk or interfere with cancer surveillance or tumour markers.

Testicular prostheses provide an excellent option for men who have lost a testicle or were born without one. They improve body image, scrotal symmetry, and psychological well-being with minimal long-term risk. Although the concept dates back more than a century, modern silicone and saline devices are safe,

comfortable, and highly effective. Despite their benefits, they are often underused because patients are not made aware of the option. With appropriate counselling, individualised sizing, and proper surgical technique, satisfaction rates are extremely high. Men facing empty scrotal sacs contemplating faking it with a prosthesis often put Dr G on the spot for opinion. His advice is: “Losing the authentic testicle for cancer is unavoidable, but modern prosthesis can still fake it almost to perfection!”

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Dear Dr G,

In the spirit of Pink October, I am hoping you can help me with some troubling matters on my chest.

I am a female university student in my early twenties.

As far as I can remember, I have had two moles on each side of my chest, next to my nipples.

Although a bit unsightly, these two lumps were not troubling at all.

Things began to change after I started my puberty.

I noticed the moles have become bulkier and darker in colour.

During my menstruation, the lumps are somewhat uncomfortable.

Another observation is when I am aroused during sexual intercourse: I noticed the lump to be more prominent and sensitive.

My partner tells me these lumps are likely to be two extra nipples.

I have never heard of such nonsense and would like to put Dr G on the spot to set the record straight.

Is there such a thing as an extra nipple? Why does it appear?

How many types of extra nipples are there, and where do they usually appear?

Can anything be done about my extra nipples? They are rather unsightly.

Lastly, can men get extra nipples, too?

Incidentally, why do men have nipples when they are functionless?

I am so confused. Please help me get this double trouble off my chest.

Yours truly,

Erogenous Ernie

A supernumerary nipple occurs when an extra nipple or nipples appear, in addition to the pair of nipples in the usual location. In medical terms, this is also known as ectopic nipples, accessory nipples, vestigial nipples, or triple nipples.‌ Such a phenomenon is relatively common, occurring in between 1% and 5% of the population.

Extra nipples in humans are completely harmless, and many people with an extra nipple may not realise that they have one, as they are often mistaken for moles. Extra nipples form during development in the womb, appearing along the milk line, or the mammary ridge. This location, anywhere between the armpits and groin, is where breast tissues potentially develop and regress in mammals.

In human embryogenesis, the mammary ridge appears as a narrow skin thickening in both sexes during the first seven weeks of pregnancy. As this occurs before sexual differentiation, this explains why men have nipples too. After the initial development of the milk line, they go into regression. Most humans have two nipples, but in some cases, additional ones will develop, usually growing along the milk line.

The ectopic nipples may appear with or without the accessory glandular tissues. When the supernumerary nipple appears alone, it is termed polythelia. However, when an extra nipple is connected to the breast tissues and glands, it is known as polymastia.

Supernumerary nipples can be classified into six categories depending on their existence with or without the pigmented skin around the nipple (areola) and the underlying breast tissues. The existence of areola and glandular tissues will also be influenced by hormonal changes and sexual stimulation.

The male and female breasts and areolae develop similarly in the fetus and have the same number of nerve endings. At puberty, male breasts remain rudimentary, but female breasts develop further into adulthood. The influence of estrogen and progesterone determines the degree of enlargement of both breasts. Therefore, even the third nipple will experience some degree of change in engorgement and sensitivity during the menstrual cycle.

The human breasts, especially the nipples, are highly sensitive with erogenous zones for both men and women, and the number of nerve endings of the breast is similar irrespective of size. The tactile stimulation often has a heightened sensitivity and stimulation that can generate sexual arousal and excitement. Nipple stimulation is a common, but less talked about, mode of human sexual practice, either by itself or as part of a sexual experience with a partner.

Engorged nipples are typically a prominent indicator of female sexual arousal; similarly, male breasts may protrude and become erect when erotically inclined. Such sexual sensitivity may also apply to the ectopic nipple. Supernumerary nipples are essentially harmless. Some scientific publications link the condition with kidney cancers and end-stage renal diseases; however, such associations are exceedingly rare.

Most individuals with ectopic nipples are oblivious to their additional nipples. However, some may be bothered by them and request surgical removal for cosmetic purposes. The removal process itself is usually a minor outpatient procedure under local anaesthesia, with minimal complications. The embryological development of a human being is a curious form of creation.

Some may be scarred with a disabling malfunction of an organ, others may just be oblivious of a variation of the norm, such as a harmless supernumerary mammary gland.

Charlie Chaplin famously said: “I do not have much patience with a thing of beauty that must be explained to be understood. If it does need additional interpretation by someone other than the creator, then I question whether it fulfilled its purpose”

When Dr G is put on the spot by troubled men and women, with a mole-like lesion on their chests and curious about a possible extra nipple, his view is: “The extra nipple is just like a thing of beauty that needs no explanation nor understanding. Questioning whether it fulfils its purpose is pointless, as the additional interpretation by the creator is lacking. Why interfere with nature when the double trouble may just actually be doubly pleasurable?”

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Dear Dr. G,

I’m a 42-year-old who has been married for many years. After the pandemic, I admit I’m not in the best shape, but my blood pressure and blood sugar levels are under control with medication. Since gaining weight, I’ve noticed I’ve started developing “moobs” (man boobs). My wife has also noticed that my chest has grown compared to before. Family and colleagues joke that I need a bra, and while I laugh it off, I feel embarrassed and self-conscious about these changes.

I’m not someone who is overly concerned with appearance, but I find it unsettling for men to develop breasts. My doctor explained that this condition, called gynecomastia, is linked to hormonal changes. I’m concerned because I thought I was too young for such changes.

What are the causes of gynecomastia? Can this be part of aging process?

Can I get rid of them with medicine? Or are there surgeries that can rectify the problem.

Finally, these moobs are really affecting my self-confidence. Do you think I should have surgery to get rid of them?

Yours truly,

Booby Bob

The excessive growth of the male breast tissue is a common benign disorder also known as gynecomastia. Common slangs or derogatory terms such as man boobs or moobs are often used, which can cause tremendous distress in men. Gynecomastia can involve one or both breasts. Such excessive growth of breast tissue is generally caused by endocrine disturbances, which can be physiological in different stages of men’s life.

Nearly all male newborns develop gynecomastia and typically resolve naturally. Persistent adolescent breast swelling is documented in 70% of teenage boys, which can be a source of embarrassment and distress, in addition to other growing pain.

Another physiological cause of breast tissue growth also commonly affects men above the age of 50, known as senile gynecomastia. The prevalence of senile gynecomastia is believed to be under-reported. In older men, gynecomastia is thought to be associated with the natural decline in testosterone. The rise in prevalence of gynecomastia in recent years is not fully understood. The use of anabolic steroids, pesticides and plastics that mimic estrogen has been widely implicated.

Other causes of gynecomastia can be due to organ failure. Men with liver impairment or cirrhosis can result in defective hormonal metabolism. This is a well-established cause of gynecomastia. Apart from poorly functioning liver, renal impairment, testicular failure and hypothyroidism can also directly and indirectly affect the testosterone and estrogen balance in men. This can lead to excessive breast tissue growth.

Certain medications are also well recognised to induce excessive breast tissue growth in men. These include cardiac medications such as digoxin. Other common medications such as antifungal and antibiotics may also interfere with liver function and sexual hormone metabolism. Lastly, medications that directly impact testosterone production such as 5 alpha reductase inhibitors utilised for hair growth and prostate enlargement will also directly suppress male hormone production and inducing male breasts.

Although gynecomastia is generally not life threatening, the swellings in the chest can cause mild discomfort and emotional embarrassment amongst affected men and heightened anxiety about breast cancer. Breast cancers indeed affect men too, but this is exceedingly rare. However, in some rare cases of gynecomastia, the etiology can derive from hormone producing cancerous cells, especially in the testicles.

Gynecomastia is generally treated conservatively, as they post no medical or oncological threats. Men with mild cases of man boobs are assured and advised to exercise with a balanced diet. Moderate or severe cases may require medical or surgical interventions. There are medications prescribed to tackle gynecomastia on an “off label” basis. These are the same medications used for breast cancer such as Tamoxifen. However, the success in breast tissue reduction with the medication is not consistent.

Radiation and surgery, such as liposuction and mastectomy have also been carried out to help men cope with such embarrassment. However, the interventions are invasive and may not get the optimal results in many men.

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Dear Dr G,

I understand that your August articles have focused on the impact of ageing on sexual health.

While my question isn’t directly about sex, I believe that thinning hair can affect one’s sex appeal and might be related to sex hormones.

I am a man in my late 40s, and I don’t consider myself to be a miserable middle-aged man.

However, noticing my thinning hair is making me quite unhappy.

Admittedly, I haven’t been living healthily lately and am troubled by diabetes and hypertension.

Otherwise, I believe I am doing reasonably well.

My wife asked me to see the doctor for an explanation and solution.

Frankly, I believe she is concerned that, as a woman nearing menopause, she might also experience hair loss.

I feel too embarrassed to consult a doctor about something I consider vain, so I thought it would be best to ask Dr G for some answers.

Firstly, can you tell me why men lose hair? Is this related to ageing?

I am also confused why men and some women have hair loss problems too?

Do hormones and genes play a part in hair loss and graying?

Can you suggest any lifestyle changes that can slow down hair loss?

Finally, what treatment would you recommend for reversing the diminishing crowning glory?

Yours truly,

Thinning Thomas

Hair is often described as a “crown of glory,” tied closely to identity, confidence, and self-expression. However, as men and women age, hair undergoes noticeable changes in thickness, density, colour, and growth pattern.

Hair loss, or alopecia, becomes increasingly common with advancing age, though its causes and patterns differ between men and women.

Understandably, these changes can affect an individual’s perceived attractiveness and lead to diminishing self-confidence in relationships and sexual contexts.

The exact physiology of hair growth is not fully understood. Each hair follicle cycles through three main phases: anagen (growth), catagen (transition), and telogen (resting). With age, the duration of the growth phase shortens, while the resting phase lengthens. This results in slower hair growth, thinner strands, and reduced overall density. The hair shaft itself may become more fragile, while pigment-producing cells (melanocytes) decline, leading to greying. Therefore, age related hair thinning and greying is almost inevitable.

For men, the most common cause of age-related hair loss is androgenetic alopecia, often called male pattern baldness. It is strongly influenced by genetics and hormones, particularly dihydrotestosterone (DHT), which shrinks hair follicles over time. Men usually notice thinning at the temples and crown, which can progress to complete baldness on the top of the scalp while preserving hair at the back and sides. This may begin as early as the late teens or twenties, but it becomes more pronounced with age, affecting up to 80% of men by age 70. Other contributing factors include reduced blood flow to the scalp, chronic illnesses, stress, and nutritional deficiencies, which may amplify the loss. Therefore, the thinning of the crown of glory is not strictly age-related.

In women, hair thinning with age is also common, however the pattern is different. Women typically experience diffuse thinning across the scalp, with widening of the part-line, but rarely complete baldness. Female hair loss becomes more noticeable after menopause, when estrogen that helps to protect against follicle shrinkage declines. This allows the effects of androgens to become more pronounced. Aside from hormonal shifts, women may also be affected by chronic medical conditions such as thyroid disease, iron deficiency, autoimmune disorders, stress, or the cumulative effect of hairstyling practices. Therefore, all those hair sprays may not do the luscious hairs any big favour.

Shared age-related factors in both sexes are also noted. Scalp blood flow decreases with age, leading to weaker follicle support. Hair often becomes coarser, drier, and more brittle, as one gets older. After shedding, follicles also take longer to re-enter the growth phase. Lastly, common age-related conditions like diabetes, cardiovascular disease, or treatments such as chemotherapy also contribute to hair thinning.

Although ageing-related hair loss cannot always be prevented, several approaches can help slow the process or improve hair density. Medical therapies such as topical Minoxidil are equally efficacious for both men and women, finasteride can also be used to reduce dihydrotestosterone effects on hair follicles. Lastly, hormone therapy for post-menopausal women in some cases can also help to rejuvenate hair growth. Procedural options including hair transplantation remains a reliable long-term solution and platelet-rich plasma (PRP) therapy may also stimulate follicle activity.

Lifestyle and supportive care are also important. Balanced nutrition with adequate protein, iron, zinc, and vitamin D, gentle hair care practices to reduce breakage, and stress reduction, since chronic stress can worsen hair loss.

Ageing inevitably influences hair growth and density, with men more prone to patterned baldness and women experiencing diffuse thinning, especially after menopause. While some loss is a natural part of ageing, advances in medical and cosmetic treatments, coupled with healthy lifestyle choices, can help maintain fuller, healthier hair for longer. Ultimately, acceptance and self-confidence play just as vital a role as treatment in navigating age-related hair changes.

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Dear Dr G,

I have turned 60 and am a healthy chap who exercises and watches his diet regularly.

Shortly after my 60th birthday, I started waking up at night to urinate. However, I often struggle to drain the pipe and only have a weak stream and dribbling.

Although it only used to happen at night, the problem is now affecting me in daytime.

I also get sudden urges to urinate and I have been caught out where I could not make it to the toilet in time!

Additionally, despite having a strong libido, I am having difficulty maintaining an erection during sex.

My urologist reckons I suffer from benign prostatic hyperplasia (BPH).

What exactly is BPH and why is urinary flow affected?

I read somewhere prostate size is affected by testosterone – is there a direct correlation of the hormone’s levels in the body and prostate enlargement?

How does prostate enlargement cause erectile dysfunction?

Is this all to do with the ageing process and can I avoid this at all?

Yours truly,

Ageing Adam

The prostate is a walnut-sized gland located between the bladder and the rectum. It surrounds the urethra and plays a key role in male fertility by producing seminal fluid.

The prostate starts off small in size at birth (1.5 g). Only during early puberty does it become active, producing ejaculate and increasing in size via an androgen-dependent pubescent growth phase from 10g to an average of 20g in young adults.

A second selective growth phase of the inner zones occurs in approximately 50% of men by age 50, and 90% of men above 80.

The aetiology is pathologically recognised as BPH and clinically noted as benign prostatic enlargement (BPE) inducing bladder outlet obstruction (BOO).

The exact cause of BPH is not fully understood but age-related hormonal shifts, chronic inflammation and genetic predisposition are known to play roles. BPH commonly affects men with advancing age. The gradual overgrowth results in the compression of the urethra and obstructs it. Symptoms of this include poor urinary flow, hesitancy in initiation, dribbling and straining at the end.

Additionally, the post-void residual urine also results in frequent urination – both daytime and night time – and in severe cases also causes urgency and incontinence.

Scientists know of testosterone’s importance in prostate development and pathology but the exact cause and effects of this non-cancerous enlargement is largely unknown. However, castrated men do not experience problems associated with BPH.

The process of BPH, however, continues as men age, despite the fact their serum testosterone decreases by approximately 2%–3% annually.

On the other hand, some men do not encounter BPH despite testosterone replacement therapy. In fact, many studies demonstrate there is no significant correlation between serum testosterone levels with BPH in many individuals.

The real hormonal change responsible for BPH is the increase in the active component of dihydrotestosterone (DHT). This active form of testosterone induces proliferation of the prostate gland cells.

Several other factors have been also identified as potential contributors to BPH. These include hormonal imbalance, particularly the ratio between oestrogen and testosterone is considered more significant in the development of BPH. Genetic factors also play a role in predisposing certain individuals to BPH. Lastly, lifestyle choices, such as a sedentary lifestyle, obesity, smoking and excessive alcohol consumption, have been associated with an increased risk of BPH.

As for erectile dysfunction (ED), an enlarged prostate can exert pressure on the urethra and disrupt normal blood flow. The blood vessels responsible for engorging the penis during sexual arousal can be impeded, leading to difficulties in achieving and maintaining an erection.

While BPH itself does not directly cause ED, its presence and associated symptoms can indirectly contribute to the development of this condition. The frustration and anxiety caused by the urinary symptoms associated with BPH can also negatively impact a man’s sexual confidence and performance.

Fortunately, various treatment options are available to address both prostate enlargement and ED. Lifestyle changes, medication or surgical procedures may be recommended depending on the severity of symptoms. In fact, oral medications such as long-acting Phosphodiesterase 5 Inhibitors (PDE5-I) are common medications that can resolve both issues at the same time.

If such treatment fails, there are surgical options such as the gold standard of transurethral resection of the prostate (TURP), laser prostatectomy and open or robotic prostatectomy for very large prostates.

BPH is a complex condition influenced by multiple factors rather than testosterone levels alone. While the connection between testosterone and BPH remains elusive, research continues to shed light on the mechanisms at play. Having knowledge of the pathogenesis and effective treatment strategies allows men to take proactive steps to maintain overall health and enjoy a fulfilling sex life, despite the ageing prostate.

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Dear Dr G,

I read with interest your recent articles on infections of various sexual organs.

I hope you can also help me with my dilemma in the pelvis.

I have been suffering from prostatitis since my early thirties, and the condition has been a real pain in my life.

It all started with an episode of a urinary tract infection after fasting during Ramadan.

I was admitted to the hospital for intravenous antibiotics, which took a good week before the fever subsided.

I started urinating normally again without a burning sensation, and as I thought my ordeal was over, I began having intermittent pain in the groin, exacerbated by ejaculation.

I constantly face issues of pelvic discomfort and intermittent difficulties in urination.

The pain on ejaculation has a real dampening impact on my sex life, as I have been depriving myself of sexual activities to avoid the pain.

I also started facing problems of premature ejaculation and erectile dysfunction following the diagnosis of prostatitis.

My wife tells me the sexual dysfunctions are all in my mind and asked me to seek help from the psychiatrists. Instead, I went to a urologist for an opinion.

The urologist reckons I now suffer from prostadynia secondary to chronic prostatitis. Apparently, this can also cause my sexual dysfunctions, such as erectile dysfunction and premature ejaculation.

I would like to put Dr G on the spot for some clarification on prostatitis.

Exactly what is prostadynia, and how is it related to prostatitis?

What are the usual symptoms of prostatitis?

How can prostate inflammation result in sexual dysfunction?

I am really troubled by the chronicity of my prostate inflammation.

I am feeling hopeless with all the pain; I am deeply helpless.

Yours truly,

Hopeless and Helpless Hussain

Prostatitis is caused by inflammatory changes in the prostate. It can be broadly divided into Acute and Chronic Prostatitis. Acute Bacterial Prostatitis (ABP) is caused by a bacterial infection associated with severe symptoms of pain in the lower abdomen, fever, and difficulty urinating.

On the other hand, Chronic Bacterial Prostatitis (CBP) is a persistent low-grade bacterial infection that lasts for several months or even years. The symptoms are similar to ABP but tend to be less severe and long-lasting. Chronic prostatitis can also be due to non-infective causes.

Non-infective prostatitis is mostly associated with unidentifiable aetiology. Lastly, asymptomatic Inflammatory Prostatitis (AIP) is usually discovered incidentally during a biopsy. Although prostatitis is generally not life-threatening, it is one of the commonest reasons why men seek help from healthcare providers.

This is reported to constitute about 20% of all General Practitioners’ consultations for young men in the United States. On the other hand, “prostadynia” is a medical term derived from the words “prosta,” describing the prostate, and “dynia,” depicting the pain. These are common symptoms presented by men under the umbrella of conditions generally known as Pelvic Pain Syndrome.

Men with prostadynia often describe discomfort upon ejaculations. This can range from transient mild discomfort that is a bit of a nuisance to severe intense climactic pain that may last for days. Although the causes of prostadynia are generally associated with the inflammations of the prostate, other medical conditions such as pelvic radiation and occluded spermatic ducts can also result in painful ejaculation in men.

Prostatitis is well recognised to affect sexual function in men. Men can be affected by weakened erections, painful ejaculation, premature ejaculation, and declining libido. In a recent study of more than 11,000 men presented with prostadynia, men with such symptoms are noted to have a 50% risk of suffering from premature ejaculation, a 30% risk of erectile dysfunction, and a 20% risk of diminished libido.

Although the exact mechanism of prostatitis causing sexual dysfunction is unknown, the inflammation is thought to cause swelling and disruption of blood flow, disrupting the physiology of erections and ejaculations.

On the other hand, painful and bloody ejaculation is also well-recognised to have an adverse psychological impact on men, causing erectile dysfunction. The treatment option for prostatitis is mainly antibiotics for bacterial-induced ABP and CBP.

Appropriate longer-term antibiotics are often prescribed for chronic bacterial prostatitis, while pain relievers and anti-inflammatories are necessary to manage pain and discomfort. Other important medications such as alpha blockers, 5 alpha-reductase inhibitors, NSAIDs, and PDE5-I are often necessary to manage the symptoms.

However, it is also crucial to take into account that some of these medications can further exacerbate sexual dysfunctions such as retrograde ejaculations and lowered libido.

In addition, lifestyle changes such as regular physical exercise, stress reduction techniques, and avoiding triggers like alcohol and caffeine may provide some relief. Other treatments such as pelvic floor exercises and relaxation techniques can also help to relieve pain.

The bacterial and nonbacterial inflammatory changes of the prostate and its association with chronic prostatitis often generate uncertainty for both the suffering men and their treating physicians.

Moreover, the chronicity of prostatic inflammation forming an unwanted alliance with sexual dysfunction such as erectile dysfunction, ejaculatory derangement, and dwindling libido is another form of uncertainty and hopelessness.

Despite the sense of despair for the sufferer, the reality is that a healthier and active lifestyle can potentially suppress the symptoms and progression of prostatitis in the long term. The Swiss poet and philosopher, Henri-Federic Amiel, once said: “Uncertainty is the refuge of hope.”

When Dr G is put on the spot for his opinion on the hopelessness of prostatitis and the helpless sequelae of sexual dysfunction, his opinion is: “A healthier lifestyle is the hope that sees the end of helpless refuge and uncertainty!”

The post Prostatitis and its impact on men’s sexual health appeared first on George Lee.my.

Dear Dr G

I have a very embarrassing issue I hope you can resolve for me.

I am in my early twenties and started having a sexual relationship while at university; I think I began encountering the problem of premature ejaculation since I first became intimate.

While there were occasions when I could last longer, I generally do not last very long.

My inability to have a satisfying sexual relationship has a huge impact on my self-confidence both inside and outside the bedroom.

I feel like I have been short-changed in life.

I am now embarking on another relationship.

I have been quite open with my girlfriend and told her about my “shortcomings.”

She seems to understand my predicament and suggested I should seek help.

Truthfully, I am really not sure I suffer from PE and hope to put Dr G on the spot for better clarification.

First of all, can you tell me how long men last in bed?

And if I do suffer from PE, how quickly do I ejaculate?

Incidentally, what tests do you do to make the diagnosis?

What sort of timing is ideal for sex?

What is considered too long and too short?

Do men who suffer from PE make bad lovers?

Please help.

Yours truly,

Short-changed Sam

There is no uniform consensus on the cut-off definition of timing to define “premature” in PE. A consensus of experts at The International Society of Sexual Medicine (ISSM) has agreed that men in the 95th percentile of complaining about early ejaculation or rapid climax tend to reach orgasm around one minute from penetration.

On the other hand, The International Classification of Diseases (ICD-10) has a different view and applies 15 seconds as the cut-off point for the diagnosis. Experts at the Kinsey Institute highlighted that the timing of sex is not just variable from different individuals, but also varies between different partners and the degree of arousal during sexual encounters.

In fact, Kinsey himself observed up to 75% of men ejaculated within two minutes of penetration at least half of the time, and many couples can still experience satisfaction with such an interval. With such a big variation in timings, what constitutes a normal interval of intercourse? The measurement of the timing of sex is done with a scientific method called Intravaginal Ejaculation Latency Time (IELT).

The time it takes for men to ejaculate from the point of penetration is technically a research tool, whereby the partner is instructed to start the stopwatch upon penetration and record the reading when climax is achieved.

Although this may seem primitive and artificial in nature, the IELT can give a rough estimate of what is the duration of “normal” and “abnormal” intervals of intercourse in most sexual relationships.

Multinational research has been conducted using IELT to measure what is considered a “normal” duration of performance in a typical man. One study done on 491 heterosexual men in various European countries revealed the median IELT for all participants was 5.4 minutes. The study demonstrated IELT tends to decrease with age.

Men aged 18 to 30 tend to last 6.5 minutes, while men above 50 can only sustain 4.3 minutes, and condoms did also not influence the timing of IELT. Another study done in North America investigating the ideal timing of sex revealed the average coitus timing is 7 minutes. The couples tend to perceive 1 to 2 minutes as being too short, 3 to 7 minutes as adequate, 7 to 13 minutes as desirable, and 13 to 30 minutes as too long.

Contrary to what is portrayed in pornography; “typical” men would last between 5 to 8 minutes in a “typical” sexual encounter. Premature ejaculation (PE) is a well-recognised sexual dysfunction when a man experiences orgasm and ejaculates “shortly” after penetration.

Historically, this is referred to as ejacultio praecox, which is in Latin translated as “early booming of ejaculation.” According to the ISSM, premature ejaculation is a sexual dysfunction that is not just dependent on the timing of intercourse. Men with PE often describe the feeling of having no control over the ejaculatory trigger.

In addition, they also report emotional and relationship distress, even to the extent of sexual relationship avoidance due to embarrassment. Premature ejaculation may seem like a trivial matter between the sheets, but it is well recognised to have a significant adverse impact on self-confidence and relationships.

In reality, the timing of ejaculation should not be a yardstick for the measurement of the quality of a lover. Instead, rapid ejaculation should be considered a variation of a norm, as the timing of sex is a spectrum that can be influenced by many factors.

From an evolutionary viewpoint, most male mammals ejaculate quickly during intercourse, prompting some biologists to consider the real “heroes” are rapid ejaculators who evolved into men’s genetic makeup to increase the chances of passing their genes.

When Dr G is often put on the spot by men who are bothered by being short-changed in the timing of sex and aspire to be the “heroes” like others, his response is to seek help from doctors for the many treatments that might help with prolonging the shortcomings.

The post Short-changed in Intimacy appeared first on George Lee.my.

Dear Dr. G,

I understand you are featuring ways to kick bad habits as a New Year’s Resolution for the benefit of better sexual health in men.

I hope to put Dr G on the spot for help to kick my bad habit of cigarette smoking.

I started smoking when I was 16 years old.

Although I have been cutting down on the number of cigarettes I smoke every year, it has still been ten years since I started.

I am sure all that cigarette is not doing my overall and sexual health any good.

I am convinced cigarette smoking can result in ED (Erectile Dysfunction), cancers and heart diseases in the long run.

Although I don’t have problems with erection (yet), I am determined to kick the habit this year and switch to vape as a better alternative.

I have read somewhere that although the e-cigarette itself is not exactly healthy, it is comparatively the lesser of the two evils.

My only concern is e-cigarettes can cause harm to my health, too.

Therefore, I am keen to put Dr G on the spot for some clarification.

Can you tell me what exactly e-cigarette is and what’s the difference with vaping?

Is it true that e-cigarettes contain less toxin and cause less harm?

Do you think it is sensible to use e-cigarettes to stop smoking?

Is there scientific evidence linking e-cigarettes with sexual dysfunction in men?

I have a feeling you are going to tell me my e-cigarette theory is all smoke and mirrors. However, I still look forward to your opinions.

Yours truly,

Vaping Vincent

Electronic nicotine delivery systems (ENDS), also known as e-cigarettes, are battery-powered devices that heat a liquid, creating vapours for inhalation. When e-cigarettes first became available in many countries, the liquids contained nicotine and a range of chemicals to add flavour. Some countries, like Singapore, have entirely banned vaping, while others, such as Australia, require that all nicotine vaping products be purchased only with a doctor’s prescription. For the rest of the world, ENDS are legally accessible.

Vaping is often marketed as a better alternative to smoking cigarettes. When e-cigarettes are used by smokers instead of traditional cigarettes, there is evidence of a slight improvement in an individual’s short-term health. Evidence suggests individuals who use e-cigarettes are likely to be smoking cigarettes, too. Therefore, diseases caused by smoking are unlikely to be reduced by e-cigarettes if cigarette smoking continues. In addition, many diseases take a long time to develop. Therefore, just because there is currently no proof that vaping causes disease, this is not proof that it is safe. Laboratory studies indicate that regular vaping is likely to have detrimental effects on your health, primarily affecting lung function.

Strong public health campaigns and strict regulation in many countries worldwide have seen rates of tobacco smoking almost halve over the last three decades. However, the number of people vaping or using e-cigarettes every day has grown from 6% in 2016 to 9% in 2019, especially among the youth. This trend is sounding alarm bells for many health experts globally. Quitting smoking can be difficult, so the best option is not to vape or smoke at all. Many people use e-cigarettes to try and stop smoking, to reduce the number of cigarettes smoked or to avoid restarting a smoking habit as a gentle cessation strategy. Although evidence suggests ex-smokers who use nicotine e-cigarettes are more likely to not smoke than those who use other nicotine replacement options such as patches, gum, lozenges, mouth sprays, inhalators and intranasal sprays. However, most studies showing this effect have a moderate or high level of bias.

E-cigarettes are also well-known to be addictive. This may impact the relationship and intimacy with partners who do not smoke or vape. There is also plenty of evidence to suggest nicotine impairs normal erectile function and negatively affects male sexual performance. Erectile Dysfunction is twice as common among men who vape every day compared to those who have never vaped. This is likely due to nicotine acting as a vasoconstrictor, resulting in poor circulation to the penis. In addition to impairment of sexual health, e-cigarettes are also noted to have an adverse impact on the reproductive health of men. One Italian study revealed that men who vape for more than two years are shown to have smaller testicles compared to men who do not use e-cigarettes. Other studies also demonstrated that ENDS can also result in male infertility, as sperm quality is noted to deteriorate as vaping continues.

The use of ENDS (Electronic nicotine delivery systems) seems to be associated with erectile dysfunction independent of age, cardiovascular disease and other risk factors. The causative adversity on reproductive health in men is also apparent. While ENDS remain under evaluation for harm reduction and smoking cessation potential, ENDS users should be informed about the possible association between ENDS use and erectile dysfunction and male infertility. Men contemplating New Year’s resolution of smoking cessation by vaping and considering this to be the lesser of the two evils often put Dr G on the spot for his opinion.

His opinion is: “The smoke and mirrors of ENDS is evident. Complete cessation should be the be-all and ENDS-all approach!”

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