Men's Health Concerns Sourcebook, 3rd Edition 2009

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Concerns
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SOURCEBOOK
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Health Reference Series

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Third Edition
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Concerns
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Basic Consumer Health Information about
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Wellness in Men and Gender-Related Differences
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in Health, Including Facts about Heart Disease,
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Cancer, Traumatic Injury, Other Leading Causes of
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Death in Men, Reproductive Concerns, Sexual Dys-
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function, Disorders of the Prostate, Penis, and Testes,
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Sex-Linked Genetic Disorders, and Other Medical
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and Mental Concerns of Men
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Along with Statistical Data, a Glossary of Related
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Terms, and a Directory of Resources for
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Additional Information
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Edited by
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Sandra J. Judd
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P.O. Box 31-1640, Detroit, MI 48231
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Bibliographic Note
Because this page cannot legibly accommodate all the copyright notices, the Bibliographic
Note portion of the Preface constitutes an extension of the copyright notice.
Edited by Sandra J. Judd
Karen Bellenir, Managing Editor
David A. Cooke, MD, FACP, Medical Consultant
Elizabeth Collins, Research and Permissions Coordinator
Cherry Edwards, Permissions Assistant
EdIndex, Services for Publishers, Indexers
***
Omnigraphics, Inc.
Matthew P. Barbour, Senior Vice President
Kevin M. Hayes, Operations Manager
***
Peter E. Ruffner, Publisher
Copyright © 2009 Omnigraphics, Inc.
ISBN 978-0-7808-1033-4
Library of Congress Cataloging-in-Publication Data

Men's health concerns sourcebook : basic consumer health information about wellness
in men and gender-related differences in health, including facts about heart disease,
cancer, traumatic injury, other leading causes of death in men, reproductive concerns,
sexual dysfunction, disorders of the prostate, penis, and testes, sex-linked genetic
disorders, and other medical and mental concerns of men ; along with statistical data,
a glossary of related terms, and a directory of resources for additional information /
edited by Sandra J. Judd. -- 3rd ed.
p. cm.
Previous ed. edited by Robert Aquinas McNally.
Summary: "Provides basic consumer health information about health conditions of
concern to men, along with tips for maintaining physical and mental wellness. Includes
index, glossary of related terms, and other resources"--Provided by publisher.
Includes bibliographical references and index.
ISBN 978-0-7808-1033-4 (hardcover : alk. paper) 1. Men--Health and hygiene--
Popular works. I. Judd, Sandra J.
RA776.5.M457 2009
613'.04234--dc22
2009024973
Electronic or mechanical reproduction, including photography, recording, or any other in-

formation storage and retrieval system for the purpose of resale is strictly prohibited with-
out permission in writing from the publisher.
The information in this publication was compiled from the sources cited and from other
sources considered reliable. While every possible effort has been made to ensure reliability,
the publisher will not assume liability for damages caused by inaccuracies in the data, and
makes no warranty, express or implied, on the accuracy of the information contained herein.
This book is printed on acid-free paper meeting the ANSI Z39.48 Standard. The infinity
symbol that appears above indicates that the paper in this book meets that standard.
Printed in the United States
Table of Contents
Visit www.healthreferenceseries.com to view A Contents Guide to the
Health Reference Series, a listing of more than 15,000 topics and the
volumes in which they are covered.
Preface ............................................................................................. xi
Part I: Overview of Men’s Health and Wellness

Chapter 1—Men and Life Expectancy .......................................... 3
Section 1.1—Evolutionary Forces
behind Lower Male Life
Expectancy ...................................... 4
Section 1.2—Biological Forces May Aid
Women’s Longevity ......................... 6
Chapter 2—Does Gender Make a Difference

in Health Risks? ......................................................... 7
Chapter 3—Making Decisions about Health Care .................... 17
Section 3.1—Choosing a Doctor ......................... 18
Section 3.2—Tips for Using
Medicines Safely ........................... 23
Section 3.3—How to Get a Second Opinion ...... 24
Chapter 4—Recommended Screenings and Vaccinations

for Men ...................................................................... 27
Section 4.1—Stay Healthy at Any Age:
Men’s Checklist for Health .......... 28
Section 4.2—Colorectal Cancer Screening ........ 31
v
Section 4.3—Prostate Cancer Screening ....... 34
Section 4.4—New Research Questions
Benefit of Annual Prostate
Cancer Screening ....................... 37
Section 4.5—Adult Immunization
Questions and Answers ............. 40
Section 4.6—Facts about the Seasonal
Flu Vaccine ................................. 44
Chapter 5—Self-Examinations Can Lead to Early

Cancer Detection ..................................................... 49
Section 5.1—Skin Cancer
Self-Examination ....................... 50
Section 5.2—Testicular Self-Examination ..... 53
Chapter 6—Nutrition and Wellness .......................................... 55

Section 6.1—Dietary Changes for a
Healthier You ............................. 56
Section 6.2—Diet and Disease ........................ 62
Chapter 7—Managing Your Weight: Avoiding

Overweight and Obesity ......................................... 67
Chapter 8—Physical Activity: Key to a Healthy Lifestyle ....... 85
Chapter 9—How Much Sleep Do We Really Need? .................. 93
Chapter 10—Avoiding Risk Factors for Common
Health Concerns ...................................................... 99
Section 10.1—Alcohol and Its Effects ............ 100
Section 10.2—Health Risks of Smoking
and How to Quit ....................... 110
Section 10.3—Controlling Blood
Cholesterol ............................... 116
Section 10.4—Preventing High Blood
Pressure .................................... 121
Section 10.5—Managing Stress ...................... 126
Chapter 11—Other Behaviors that Can Affect Your Health .... 129
Section 11.1—Aggressive Driving .................. 130
Section 11.2—Drug Abuse .............................. 132
vi
Section 11.3—Anabolic Steroid Use ............... 134
Section 11.4—Dangers of Tanning and
Ultraviolet Rays ....................... 137
Section 11.5—Unsafe Sex ................................ 140
Part II: Leading Causes of Death in Men

Chapter 12—Causes of Death: A Statistical Overview ............ 145
Section 12.1—Leading Causes of Death
for Men of All Ages .................. 146
Section 12.2—A Statistical Look at
Cancer in Men .......................... 149
Section 12.3—Homicide Statistics .................. 150
Chapter 13—Heart Disease ........................................................ 155
Section 13.1—Men and Heart Disease ........... 156
Section 13.2—Coronary Artery Disease ......... 158
Section 13.3—Heart Attack ............................ 167
Section 13.4—Heart Failure ........................... 169
Section 13.5—Cardiac Arrest .......................... 172
Chapter 14—Prostate Cancer ..................................................... 175
Chapter 15—Lung Cancer .......................................................... 185
Chapter 16—Colorectal Cancer .................................................. 193
Chapter 17—Liver Cancer .......................................................... 201
Chapter 18—Other Cancers of Special Concern to Men .......... 213
Section 18.1—Penile Cancer ........................... 214
Section 18.2—Testicular Cancer .................... 220
Section 18.3—Breast Cancer in Men ............. 226
Chapter 19—Accidents and Injuries .......................................... 233
Section 19.1—Safe Steps to Reduce Falls ...... 234
Section 19.2—Preventing Fire-Related
Injuries ..................................... 236
Section 19.3—Preventing Motor Vehicle
Accidents .................................. 241
Section 19.4—Occupational Injuries .............. 250
Section 19.5—Water-Related Injuries
and Water Safety ..................... 256
vii
Chapter 20—Stroke ..................................................................... 263
Chapter 21—Chronic Obstructive Pulmonary Disease ............ 271
Chapter 22—Diabetes ................................................................. 277
Chapter 23—Influenza and Pneumonia .................................... 283
Section 23.1—Influenza .................................. 284
Section 23.2—Pneumonia ............................... 287
Chapter 24—Suicide .................................................................... 293

Chapter 25—Alzheimer Disease ................................................ 301
Chapter 26—Kidney Disease ...................................................... 307
Chapter 27—Chronic Liver Disease and Cirrhosis .................. 311
Part III: Reproductive and Sexual Concerns

Chapter 28—Male Reproductive System ................................... 323
Chapter 29—Circumcision .......................................................... 329
Chapter 30—Preventing Pregnancy .......................................... 333
Section 30.1—Birth Control Methods:
How Well Do They Work? ....... 334
Section 30.2—Condoms: Basic Facts .............. 336
Section 30.3—Vasectomy ................................ 339
Chapter 31—Vasectomy Reversal .............................................. 345

Chapter 32—Infertility................................................................ 351
Chapter 33—Sexually Transmitted Diseases (STDs) .............. 363
Section 33.1—Basic Information
about STDs ............................... 364
Section 33.2—Chancroid ................................. 365
Section 33.3—Chlamydia ................................ 368
Section 33.4—Genital Herpes ......................... 371
Section 33.5—Gonorrhea ................................. 375
Section 33.6—Hepatitis B ............................... 379
Section 33.7—HIV and AIDS .......................... 381
Section 33.8—Human Papillomavirus
(HPV) ........................................ 385
viii
Section 33.9—Pubic Lice (Crabs) .................... 390
Section 33.10—Scabies ...................................... 394
Section 33.11—Syphilis ..................................... 397
Section 33.12—Trichomoniasis ......................... 402
Chapter 34—Sexual Dysfunction ............................................... 405

Section 34.1—Erectile Dysfunction ................ 406
Section 34.2—Premature Ejaculation ............ 412
Section 34.3—Retrograde Ejaculation ........... 417
Chapter 35—Penile Disorders .................................................... 419

Section 35.1—Peyronie Disease ...................... 420
Section 35.2—Balanitis, Phimosis,
Priapism, and Other Penis
Problems ................................... 424
Section 35.3—Penile Trauma ......................... 430
Chapter 36—Non-Cancerous Prostate Disorders ..................... 435

Section 36.1—Benign Prostatic
Hyperplasia .............................. 436
Section 36.2—Prostatitis ................................. 441
Chapter 37—Disorders of the Scrotum and Testicles .............. 447

Section 37.1—Epididymitis and Orchitis ...... 448
Section 37.2—Hydrocele and Inguinal
Hernia ....................................... 453
Section 37.3—Spermatocele ............................ 459
Section 37.4—Testicular Failure .................... 463
Section 37.5—Testicular Torsion .................... 466
Section 37.6—Undescended Testicle .............. 468
Section 37.7—Varicocele ................................. 470
Part IV: Other Common Health Concerns in Men

Chapter 38—Violence and Abuse ............................................... 475
Section 38.1—Violence Is a Concern
for Men ...................................... 476
Section 38.2—Men Can Be Victims
of Sexual Assault ..................... 478
Section 38.3—Are You Being Abused? ........... 480
ix
Chapter 39—Mental Health Concerns ...................................... 483
Section 39.1—Depression in Men ................... 484
Section 39.2—Obsessive-Compulsive
Disorder .................................... 493
Section 39.3—Phobias ..................................... 495
Section 39.4—Posttraumatic Stress
Disorder .................................... 497
Section 39.5—Schizophrenia .......................... 499
Chapter 40—Male Menopause ................................................... 507

Chapter 41—Male Pattern Baldness ......................................... 509
Chapter 42—Sex-Linked Genetic Disorders ............................. 515
Section 42.1—Color Vision Deficiency ........... 516
Section 42.2—Fragile X Syndrome ................. 519
Section 42.3—Hemophilia ............................... 522
Section 42.4—Klinefelter Syndrome .............. 525
Section 42.5—Muscular Dystrophy ................ 527
Chapter 43—Sleep Apnea ........................................................... 543

Chapter 44—Urologic Concerns ................................................. 553
Section 44.1—Kidney Stones .......................... 554
Section 44.2—Urethral Stricture ................... 557
Section 44.3—Urinary Incontinence .............. 561
Chapter 45—“Women’s” Concerns: Men Are at Risk, Too ....... 571

Section 45.1—Body Image Issues ................... 572
Section 45.2—Gynecomastia: A Breast
Disorder in Men ....................... 573
Section 45.3—Osteoporosis in Men ................ 575
Part V: Additional Help and Information

Chapter 46—Glossary of Terms Related to Men’s Health ....... 585
Chapter 47—Directory of Agencies That Provide
Information about Men’s Health ......................... 595
Index ............................................................................................ 605
Preface
About This Book

American men face a staggering array of health concerns. Accord-
ing to the Centers for Disease Control and Prevention, 70 percent of
American men are overweight, a key predictor of future health prob-
lems. Almost 25 percent smoke, another key risk factor. One in five
American men has heart disease, and 29 percent aged twenty and
older suffer from hypertension. More than 11 percent of men face a
limitation in their usual activities due to chronic health conditions.
In addition, the medical concerns men face often differ from those of
most concern to women. Compared with women, nearly twice as many
men die of heart disease, and 50 percent more die of cancer. Men are
also much more likely to commit suicide or to be victims of accidents
and injuries or homicide.
Men’s Health Sourcebook, Third Edition, provides up-to-date infor-
mation on the health conditions of most significance to men. It includes
guidelines for maintaining wellness with facts about recommended
screenings, checkups, and vaccinations. It discusses heart disease, can-
cer, and other leading causes of death in men, and it offers informa-
tion about sexual dysfunction and disorders of the prostate, penis, and
testes. Mental health concerns and sex-linked genetic disorders are also
described, and the book concludes with a glossary of related terms and
a directory of additional resources.
xi
How to Use This Book
This book is divided into parts and chapters. Parts focus on broad
areas of interest. Chapters are devoted to single topics within a part.
Part I: Overview of Men’s Health and Wellness summarizes male

healthcare fundamentals. It discusses the differences in men’s and
women’s life expectancies, includes guidelines for maintaining
wellness, and offers tips for avoiding common risk factors. It details
the screenings, checkups, vaccinations, and self-examinations recom-
mended for men. Information about maintaining a healthy diet, avoid-
ing obesity, and remaining physically active is also included.
Part II: Leading Causes of Death in Men provides facts about the most
common causes of death in men, including heart disease, cancer, ac-
cidents and injuries, diabetes, and lung disease. It includes tips for
avoiding these problems as well as guidelines for their diagnosis and
treatment.
Part III: Reproductive and Sexual Concerns describes the most com-
mon reproductive and sexual disorders among men, including sexu-
ally transmitted diseases, infertility, sexual dysfunction, and disorders
affecting the prostate, penis, and testes. A discussion of how the male
reproductive system works, along with details about preventing preg-
nancy, is also included.
Part IV: Other Common Health Concerns in Men discusses a number

of health concerns of special interest to men, including mental illness
in men, male pattern baldness, sex-linked genetic disorders, and vio-
lence. A chapter is also included that addresses the unique concerns
men face with disorders that may more frequently be associated with
women, such as body image issues and osteoporosis.
Part V: Additional Help and Information includes a glossary of terms

related to men’s health and a directory of organizations able to pro-
vide additional help and support.
Bibliographic Note
This volume contains documents and excerpts from publications
issued by the following U.S. government agencies: Agency for
Healthcare Research and Quality (AHRQ); Bureau of Labor Statistics;
xii
Centers for Disease Control and Prevention (CDC); National Cancer
Institute (NCI); National Heart, Lung, and Blood Institute (NHLBI);
National Highway Transportation Safety Administration (NHTSA);
National Human Genome Research Institute (NHGRI); National In-
stitute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS);
National Institute of Child Health and Human Development (NICHD);
National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK); National Institute of Mental Health (NIMH); National In-
stitute of Neurological Disorders and Stroke (NINDS); National Insti-
tute on Aging (NIA); National Institute on Drug Abuse (NIDA); National
Kidney Disease Education Program (NKDEP); National Women’s
Health Information Center (NWHIC); NIH Senior Health; Substance
Abuse and Mental Health Services Administration (SAMHSA); U.S.
Department of Health and Human Services; U.S. Department of Jus-
tice; and the U.S. Food and Drug Administration (FDA).
In addition, this volume contains copyrighted documents from the
following organizations: A.D.A.M., Inc.; American Chemical Society;
Optometric Association; American Osteopathic Association; American
Urological Association; Andrology Australia; Cleveland Clinic; Domes-
tic Abuse Helpline for Men and Women; Home Safety Council; Hor-
mone Foundation; Men Can Stop Rape; National Foundation for
Infectious Diseases; National Safety Council; National Sleep Founda-
tion; Nemours Foundation; PsychCentral; Royal College of Psychia-
trists; Skin Cancer Foundation; Sudden Cardiac Arrest Association;
University of Iowa Hospitals and Clinics; University of Michigan
Health System; and the University of Michigan News Service.
Acknowledgements
Thanks go to the many organizations, agencies, and individuals
who have contributed materials for this Sourcebook and to medical
consultant Dr. David Cooke and document engineer Bruce Bellenir.
Special thanks go to managing editor Karen Bellenir and permissions
coordinator Liz Collins for their help and support.
About the Health Reference Series

The Health Reference Series is designed to provide basic medical
information for patients, families, caregivers, and the general public.
Each volume takes a particular topic and provides comprehensive
coverage. This is especially important for people who may be dealing
with a newly diagnosed disease or a chronic disorder in themselves
xiii
or in a family member. People looking for preventive guidance, in-
formation about disease warning signs, medical statistics, and risk fac-
tors for health problems will also find answers to their questions in the
Health Reference Series. The Series, however, is not intended to serve
as a tool for diagnosing illness, in prescribing treatments, or as a sub-
stitute for the physician/patient relationship. All people concerned about
medical symptoms or the possibility of disease are encouraged to seek
professional care from an appropriate healthcare provider.
A Note about Spelling and Style

Health Reference Series editors use Stedman’s Medical Dictionary
as an authority for questions related to the spelling of medical terms
and the Chicago Manual of Style for questions related to grammati-
cal structures, punctuation, and other editorial concerns. Consistent
adherence is not always possible, however, because the individual
volumes within the Series include many documents from a wide va-
riety of different producers and copyright holders, and the editor’s
primary goal is to present material from each source as accurately
as is possible following the terms specified by each document’s pro-
ducer. This sometimes means that information in different chapters
or sections may follow other guidelines and alternate spelling authori-
ties. For example, occasionally a copyright holder may require that
eponymous terms be shown in possessive forms (Crohn’s disease vs.
Crohn disease) or that British spelling norms be retained (leukaemia
vs. leukemia).
Locating Information within the Health Reference Series

The Health Reference Series contains a wealth of information about
a wide variety of medical topics. Ensuring easy access to all the fact
sheets, research reports, in-depth discussions, and other material con-
tained within the individual books of the series remains one of our
highest priorities. As the Series continues to grow in size and scope,
however, locating the precise information needed by a reader may
become more challenging.
A Contents Guide to the Health Reference Series was developed to
direct readers to the specific volumes that address their concerns. It
presents an extensive list of diseases, treatments, and other topics of
general interest compiled from the Tables of Contents and major in-
dex headings. To access A Contents Guide to the Health Reference Series,
visit www.healthreferenceseries.com.
xiv
Medical Consultant
Medical consultation services are provided to the Health Reference
Series editors by David A. Cooke, MD, FACP. Dr. Cooke is a graduate
of Brandeis University, and he received his M.D. degree from the Uni-
versity of Michigan. He completed residency training at the Univer-
sity of Wisconsin Hospital and Clinics. He is board-certified in Internal
Medicine. Dr. Cooke currently works as part of the University of Michi-
gan Health System and practices in Ann Arbor, MI. In his free time,
he enjoys writing, science fiction, and spending time with his family.
Our Advisory Board

We would like to thank the following board members for provid-
ing guidance to the development of this series:
Dr. Lynda Baker, Associate Professor of Library and
Information Science, Wayne State University, Detroit, MI
Nancy Bulgarelli, William Beaumont Hospital Library,
Royal Oak, MI
Karen Imarisio, Bloomfield Township Public Library,
Bloomfield Township, MI
Karen Morgan, Mardigian Library, University of Michigan-
Dearborn, Dearborn, MI
Rosemary Orlando, St. Clair Shores Public Library,
St. Clair Shores, MI
Health Reference Series Update Policy

The inaugural book in the Health Reference Series was the first
edition of Cancer Sourcebook published in 1989. Since then, the Se-
ries has been enthusiastically received by librarians and in the medi-
cal community. In order to maintain the standard of providing
high-quality health information for the layperson the editorial staff
at Omnigraphics felt it was necessary to implement a policy of up-
dating volumes when warranted.
Medical researchers have been making tremendous strides, and it
is the purpose of the Health Reference Series to stay current with the
most recent advances. Each decision to update a volume is made on
an individual basis. Some of the considerations include how much new
xv
information is available and the feedback we receive from people who
use the books. If there is a topic you would like to see added to the
update list, or an area of medical concern you feel has not been ad-
equately addressed, please write to:
Editor
Omnigraphics, Inc.
P.O. Box 31-1640
Detroit, MI 48231
E-mail: [email protected]
xvi
Part One
Overview of Men’s
Health and Wellness
Chapter 1
Men and Life Expectancy
Chapter Contents
Section 1.1—Evolutionary Forces behind Lower Male
Life Expectancy ......................................................... 4
Section 1.2—Biological Forces May Aid Women’s Longevity ...... 6
3
Men’s Health Concerns Sourcebook, Third Edition
Section 1.1
Evolutionary Forces behind

Lower Male Life Expectancy
“Evolutionary Forces behind Lower Male Life Expectancy,” reprinted with
permission from the University of Michigan Health System, http://
www.med.umich.edu. Copyright © 2006 Regents of the University of
Michigan.
Despite research efforts to find modern factors that would explain

the different life expectancies of men and women, the gap is actually
ancient and universal, according to University of Michigan research-
ers.
“Women live longer in almost every country, and the sex difference
in lifespan has been recognized since at least the mid-eighteenth cen-
tury,” said Daniel J. Kruger, a research scientist in the U-M School of
Public Health and the Institute for Social Research. “It isn’t a recent
trend; it originates from our deep evolutionary history.”
This skewed mortality isn’t even unique to our species; the men
come up short in common chimps and many other species, Kruger
added.
Kruger and co-author Randolph Nesse, a professor of psychology
and psychiatry and director of the Evolution and Human Adaptation
Program, argue that the difference in life expectancy stems from the
biological imperative of attracting mates.
“This whole pattern is a result of sexual selection and the roles that
males and females play in reproduction,” Kruger said, “Females gen-
erally invest more in offspring than males and are more limited in
offspring quantity, thus males typically compete with each other to
attract and retain female partners.”
For example, in common chimps, the greatest difference in mor-
tality rates for males and females occurs at about thirteen years of
age, when the males are just entering the breeding scene and com-
peting aggressively for social status and females.
From the tail of the peacock to the blinged-out sport utility vehicle,
males compete aggressively for female attention, and that costs them
something. In nature, it means riskier physiology and behavior for the
Men and Life Expectancy
males, such as putting more resources into flashy plumage or engag-
ing in physical sparring.
And even in modern life, where most dueling is a form of enter-
tainment, male behavior and physiology is shortening their life spans
relative to women, Kruger said. In fact, modern lifestyles are actu-
ally exacerbating the gap between male and female life expectancies.
Male physiology, shaped by eons of sexual competition, is putting
the guys at a disadvantage in longevity. Male immune systems are
somewhat weaker, and their bodies are less able to process the fat they
eat, Kruger said. And behavioral causes—smoking, overeating, reck-
less driving, violence—set men apart from most women. “Because
mortality rates in general are going down, behavioral causes of death
are ever more prevalent,” Kruger said.
Looking at human mortality rates sliced by socioeconomic status
shows that the gender gap is affected by social standing. Human males
in lower socioeconomic levels tend to have higher mortality rates than
their higher-status peers. The impact of social standing is greater on
male mortality than on female mortality, Kruger noted, partially be-
cause males who have a relatively lower status or lack a mate engage
in a riskier pattern of behaviors in an attempt to get ahead, he said.
5
Section 1.2
Biological Forces May

Aid Women’s Longevity
Reprinted with permission from “Proteins Could Relate to
Increased Longevity in Women,” June 25, 2008, www.acs.org.
Copyright © 2008 American Chemical Society.
Scientists in Spain and Italy have identified a group of proteins

in laboratory rats that could help explain two enduring medical mys-
teries—why women live longer than men and why calorie restriction
stands as the only proven method of extending longevity. Their study,
which could help scientists understand the biochemical underpinnings
of aging, is scheduled for the July 3, 2008, issue of the American Chemi-
cal Society (ACS)’s monthly Journal of Proteome Research.
In the study, Adamo Valle and colleagues point out that women,
on average, live years longer than men. Previous studies also have
shown that diets extremely low in calories consistently increase maxi-
mum life spans in a wide range of animals. Scientists have speculated
that the explanation may involve hormones, stress, cardiovascular
protection, and other factors.
Using lab rats as stand-ins for humans, the researchers found that
the livers of both female rats and calorie-restricted rats produced dif-
ferent levels of twenty-seven proteins than male rats or those on a
normal diet. The findings suggest that a previously unrecognized set
of cellular pathways may be involved in the longevity boost from be-
ing female and eating a sparse diet, the study says, suggesting that
these insights could lead to new ways of boosting human longevity.
Chapter 2
Does Gender Make a

Difference in Health Risks?
When it comes to health risks, sex does matter. Women are twice
as likely as men to get multiple sclerosis, rheumatoid arthritis, and
migraines. They’re also more likely to get cataracts, hepatitis, and
thyroid disease. Women experience depression about twice as often
as men. And irritable bowel syndrome (IBS) is thought to affect twice
as many women as men. Although men have more heart attacks than
women, more women die within a year after having a heart attack.
“Despite this increased susceptibility to so many diseases, females
across the world have a longer lifespan,” says Joseph Verbalis, M.D.,
clinical director of Georgetown University’s Center for the Study of Sex
Differences, in Washington, D.C. “We don’t know why,” says Verbalis,
“but that’s one of the things we’re trying to find out.”
Researchers are finding that men and women are different in ways
that go beyond their reproductive systems, hormones, and bone struc-
ture. They get many of the same diseases, but they may have differ-
ent symptoms, their diseases may progress differently, and they may
respond differently to treatment. While researchers are working to
discover the underlying causes of these differences, scientists and
regulators at the Food and Drug Administration are working to en-
sure that drugs and medical devices are safe and effective for both
men and women.
Just as one size doesn’t fit all, one treatment or test doesn’t fit all
men or all women. It’s important to test drugs and devices in both
Reprinted from “Does Sex Make a Difference?” U.S. Food and Drug Adminis-
tration, July–August 2005.
7
women and men of different races and ethnicities in clinical trials,
says Margaret Miller, Ph.D., manager of scientific programs in the U.S.
Food and Drug Administration’s (FDA’s) Office of Women’s Health
(OWH).
The FDA has regulations and guidance in place to ensure that both
sexes are represented in clinical trials, that study results are analyzed
by gender, and that medical products are labeled to alert physicians
and patients to any difference in the way men and women respond to
a product. In addition, the agency is supporting research to identify
gender differences that may affect the use of FDA-regulated products.
Gender as a Starting Point

Men and women are different in every organ of the body—even
their skin, says Marianne J. Legato, M.D., a cardiologist and founder
and director of Columbia University’s Partnership for Gender-Specific
Medicine. They are different at the cellular level, and these differences
may influence the amount and type of medicine they need to treat a
disease. “Dosage is not adjustable simply on the basis of body size
anymore,” says Legato. “I think we have to look at a whole variety of
factors in prescribing dosages that are safe on the basis of gender.”
“We know that different people, as individuals, respond to drugs
differently,” says Miller. “People routinely tell me, ‘Oh, that drug
doesn’t do a thing for me.’” Some researchers place priority on study-
ing differences in genetic makeup by individual, not gender, says
Miller. They want to determine the exact sequence of DNA in a
person’s body in order to tailor treatments for that individual. “But
even if the DNA is the same, men and women will express it differ-
ently,” says Miller.
Researchers looking at DNA sequence may think that’s a short-
cut, says Legato, “which it obviously would be if we can take a slice of
people’s DNA and decide whether or not they would react appropri-
ately to any medication to which they’ve not been previously exposed.
That would be the ultimate, but I fear that that’s years away. I think
it would be nice to know the difference between men and women as a
starting point.”
In 2001, the Institute of Medicine (IOM), part of the National Acad-
emy of Sciences, published a report that supported studying poten-
tial gender differences during drug development. The IOM concluded
that “sex matters”; that is, “being male or female is an important ba-
sic human variable that should be considered when designing and
analyzing studies in all areas and at all levels of . . . health-related
Does Gender Make a Difference in Health Risks?
research.” The IOM defined sex-based differences as biologically based
differences in men and women, and described gender-based differences
as distinctions shaped by the cultural and social environment. Gen-
erally, the FDA does not attempt to determine why men are different
from women and refers to any identified difference as a “gender dif-
ference.”
Drugs and Gender Differences

In 1998, the allergy drug Seldane® (terfenadine) was removed from
the market when a safer alternative was approved. It had been dis-
covered that Seldane could cause a life-threatening heart rhythm ir-
regularity when used with certain other drugs. More women took
Seldane, and more were reported to have had this heart arrhythmia,
called torsade de pointes.
Researchers at the Georgetown Center for the Study of Sex Dif-
ferences believe that the male hormone testosterone may protect the
heart from some types of arrhythmia, says Verbalis. In addition, he
says, research has shown that women are at greater risk for torsades
de pointes because of their QT interval—the time it takes for the heart
to relax after it contracts to pump out blood. Women often have a
longer QT interval than men, and taking certain drugs can further
lengthen this interval, thereby increasing the risk of the fatal arrhyth-
mia more in women than in men.
Some drugs are approved to treat a disease based, in part, on pa-
tients’ reporting of the relief of their symptoms. For example,
Zelnorm® (tegaserod maleate) is approved only for women to relieve
the symptoms of IBS. In clinical trials, more women taking Zelnorm
reported relief of their symptoms than those taking an inactive pill
(placebo).
IBS, which is found more commonly in women, produces a variety
of symptoms. “The challenge in the evaluation of a drug for this dis-
ease is to determine if there is a gender difference in the patient’s
perception of symptoms and evaluation of relief of symptoms,” says
Joyce Korvick, M.D., acting director of the FDA’s Division of Gas-
trointestinal and Coagulation Drug Products. “The perception of ‘re-
lief ’ of symptoms in men and women may be very different.”
Because IBS is found more often in women, more women than men
were enrolled in the clinical trials for Zelnorm. But for the nearly three
hundred men with IBS enrolled in the trials, Zelnorm was not shown
to be effective. “More research regarding men and women’s percep-
tions of specific disease symptoms is needed to ensure that differences
9
seen in clinical trials are meaningful to the gender being studied,” says
Korvick.
Another drug, Zoloft® (sertraline hydrochloride), is approved for
both men and women to treat several conditions, including post-
traumatic stress disorder (PTSD). This approval was based on clini-
cal trials in which Zoloft showed little effect in men with PTSD, while
the drug’s benefit over a placebo was clear in the women studied.
“True gender differences in responsiveness may have been one
explanation,” says Thomas Laughren, M.D., team leader for the FDA’s
psychiatric drug products group. “However, it should also be noted that
the types of PTSD differed in the two groups,” he says. Many of the
men in these trials had a long-lasting and treatment-resistant PTSD,
based on military combat experience, compared to many of the women,
who tended to have a more acute form of PTSD, based on recent physi-
cal abuse.
Scientists aren’t sure why some drugs work better in one gender
than in the other. But they do know that differences may occur in the
way men and women absorb certain drugs into the bloodstream, dis-
tribute them to the body’s tissues, break them down, and rid them
from the body. The way the body handles a drug is known as phar-
macokinetics (PK), and was the subject of an FDA study.
FDA researchers examined three hundred drug applications sub-
mitted to the agency between 1994 and 2000. More than half of these
applications contained information on the effect of gender on PK.
The PK was the same for 80 percent of the drugs in which PK was
studied. But for the other 20 percent of the drugs, the PK was dif-
ferent.
“There must be some reason for this difference,” says Miller. “That’s
where research comes in. We want to understand the biology and the
mechanism enough to predict what’s going to be in the 80 percent
group and the 20 percent group. Then we can predict how a product’s
safety or effectiveness will be influenced in each gender.”
Shiew-Mei Huang, Ph.D., deputy director for science in the FDA’s
Office of Clinical Pharmacology and Biopharmaceutics, says that drug
metabolism plays an important role in the way men and women re-
spond to drugs. An enzyme known as cytochrome CYP3A helps me-
tabolize many drugs, and studies have shown that women have more
cytochrome CYP3A in the liver, says Huang. Some drugs or dietary
supplements, for example, St. John’s wort, increase the activity of this
enzyme, which makes the drugs break down faster. This rapid break-
down reduces the amount of the drug in the body, decreasing its ef-
fectiveness in women.
10
The reverse scenario may also occur: A drug could slow down en-
zyme activity, causing too much of the drug to build up in the body
and resulting in more side effects.
But biology can’t explain all the differences in the way men and
women respond to drugs, cautions Huang. Other factors, such as medi-
cation use, must be considered. “A recent survey showed that women,
in all age groups, tend to take more medications, including dietary
supplements, than men,” says Huang. This difference may put women
at more risk for certain drug interactions than men.
Medical Devices and Gender Differences

Men and women may also respond differently to certain medical
devices and the procedures in which they are used. Several FDA stud-
ies have focused on identifying some of these differences.
In 2003 and 2004, FDA researchers studied more than 150,000
people with suspected heart disease and found that women had about
twice the risk of men for local complications after cardiac catheter-
ization. In the catheterization procedure, a slender tube is inserted
into a large artery in the leg (femoral artery) and is threaded up
through the body to the heart to diagnose or treat narrowed heart
arteries that block blood flow.
“The study was done to look at risks associated with hemostasis
devices,” says Dale Tavris, M.D., M.P.H., an FDA epidemiologist spe-
cializing in preventive medicine. These devices are used after cardiac
catheterization to prevent continued bleeding of the femoral artery
where the catheter is inserted.
We don’t know why complications, such as hemorrhaging, occurred
more in women, says Tavris. “There’s speculation that it may be due
to blood vessel size or hormonal differences. And the risk applies
whether or not the hemostasis devices are used.” Further informa-
tion is needed to understand these occurrences, says Tavris, before we
can determine whether any changes to the catheterization procedure
or to hemostasis devices or their labeling are appropriate.
An FDA-sponsored study at Boston University involves men and
women with diabetes who are using blood glucose monitors at home
to test their blood several times a day. Researchers are looking for any
differences in testing blood drawn from the fingertip or from another
part of the body, since newer glucose monitors use blood samples from
alternate body areas. “We found that the fingertip can have a differ-
ent glucose value from an arm or leg, especially when sugar levels are
changing rapidly, for example, after a meal or after exercise,” says Jean
11
Cooper, D.V.M., director of the Division of Chemistry and Toxicology
in the FDA’s Center for Devices and Radiological Health. The study
is continuing to determine whether gender might be a factor in this
difference in glucose values.
The FDA now requires glucose monitors to carry a warning label
cautioning against using alternate sites when glucose levels are chang-
ing rapidly. If a manufacturer can show in clinical trials that its de-
vice doesn’t demonstrate this variance, the warning is not required.
Studies of Both Sexes

In 1977, an FDA guidance said that women able to become preg-
nant should not participate in the early phases of drug studies, with
an exception for studies of potentially life-saving drugs. The exclusion
reflected the concern that if a woman became pregnant, the baby
might have birth defects.
Over more than two decades, the FDA has worked to ensure that
both women and men are represented fairly in clinical trials involv-
ing drugs, biologics such as vaccines and blood products, and medical
devices.
In 1988, the agency issued guidance to drug makers asking that
the safety and effectiveness data in drug applications be analyzed
according to gender, age, and race. And, in 1993, the agency issued
its Guideline for the Study and Evaluation of Gender Differences in
the Clinical Evaluation of Drugs, known as the gender guideline.
When the gender guideline was published, the FDA also revoked
the 1977 restriction on women of childbearing age in early drug stud-
ies and reiterated the need to include patients of both sexes in the
development of drugs, biologics, and medical devices. The guideline
also recommended that drug companies analyze separately men’s and
women’s responses to drugs.
Attention to potential gender differences became part of a larger
agency effort to ensure that the safety and effectiveness of drugs are
adequately studied in people who represent the full range of patients
who could use the drugs when approved. In a 1998 regulation known
as the Demographic Rule, the FDA again addressed the importance
of collecting data on clinical trial volunteers by gender, race, and age.
The regulation required companies to analyze the data to look for
possible differences in effectiveness, safety, and dose-response and to
submit this information in applications for new drugs. It also required
reporting demographic data in annual reports during a drug’s inves-
tigation phase.
12
A regulation in 1999 gave the agency the authority to halt studies
of new drugs to treat life-threatening diseases if clinical trials ex-
cluded women solely because they could become pregnant.
“The Demographic Rule and gender guideline represent our com-
mitment to looking at possible differences in various subgroups’ re-
sponse to drugs, whether men and women, black and white, old and
young,” says Robert Temple, M.D., director of the FDA’s Office of Medi-
cal Policy. “The guidance tells drug sponsors what our expectation is
and what we’re looking for.”
So far, a small number of differences have been found in the way
men and women respond to drugs, says Temple. An FDA study re-
viewed gender-related labeling for 171 new drugs that were approved
for both males and females from 1995 through 1999. Labeling for two-
thirds of the drugs contained some statement about gender, although
only 22 percent described actual gender differences and none of these
differences were considered significant enough to recommend any
change in dosage for one gender.
“But just knowing that is useful information,” says Miller. “You
know you can take these drugs without a higher risk because of your
gender.”
The FDA is also working to revise drug labeling so that both con-
sumers and health care providers can better understand important
information about a drug. A proposed FDA rule will require prescrip-
tion drug labels to contain “highlights” in a prominent place. The high-
lights will discuss the more serious and common side effects and
significant gender differences found in clinical trials.
Continuing Efforts
The FDA’s Office of Women’s Health is funding research within the
agency to examine gender differences—particularly in the areas of heart
disease, obesity, and human immunodeficiency virus (HIV)—that are
important for the agency to consider in regulating medical products.
In one project funded by the OWH, scientists within the FDA’s Cen-
ter for Biologics Evaluation and Research are studying the replica-
tion of HIV, the virus that causes acquired immunodeficiency
syndrome (AIDS), in human blood cells from male and female blood
donors. By infecting the blood cells with HIV in a culture medium and
then adding various sex hormones, scientists are learning more about
the influence of gender on the concentration of the virus. They are also
studying the effect of sex hormones on certain antiviral drugs used
to treat HIV.
13
“Some of the things we’re looking at may affect when treatment
should be started in men and women,” says Andrew Dayton, M.D.,
Ph.D., an FDA research medical officer. And it may give us prelimi-
nary insight into how gender might affect response to HIV treatments,
he adds. This information may help in designing clinical trials to test
the effectiveness of HIV treatments in men and women.
In another initiative, the OWH is developing an innovative knowl-
edge management approach to make better assessments in groups of
people (subpopulations) to protect patient safety. The Demographic
Information and Data Repository (DIDR) was mandated by Congress
in 2002 to monitor the inclusion of women in clinical trials and to
study gender differences and variability in response to medical prod-
ucts.
Katherine Hollinger, D.V.M., M.P.H., a senior health promotions
officer in the OWH, says the DIDR will help the agency to look at
Table 2.1. Gender Differences in Disease Risk

Disorder Gender Differences
Heart attack Men have more, but women are more likely to die
within a year after a heart attack; women tend to get
heart disease seven to ten years later than men
Stroke Women have fewer strokes, but are more likely to
die from them than men; women are generally older
than men when they have a stroke
Depression Twice as common in women
Migraine Three times more common in women
Hearing loss More common in men
Nearsightedness (myopia) More common in women through age sixty
Irritable bowel syndrome More common in women
Cancer Cancer of the lungs, kidneys, bladder, and pancreas
are more common in men; thyroid cancer is more
common in women
Osteoporosis More common in women
Rheumatoid arthritis Two to three times more common in women
Gout More common in men
Lupus Nine times more common in women
Fibromyalgia Nine times more common in women
Source: National Institutes of Health
14
groups of people—including groups characterized by gender, race and
ethnicity, older people, and children—in a more informed way. “It will
allow us to better look at subpopulation issues and differences in drug
response that may affect safety and effectiveness,” says Hollinger. “And
it will allow us to not only track inclusion of women and other popu-
lations in clinical trials, but to monitor the types of trials women, chil-
dren, or the elderly are participating in and identify patterns that are
observed.”
Other benefits of the agency-wide DIDR include helping the agency
to design better studies for new products, enabling more efficient and
informed reviews and approval decisions, and allowing better assess-
ments of product labeling.
Part of the problem in looking at study data to determine subpopu-
lation differences in response to medical products is the lack of stan-
dard approaches and terminology used in individual studies. The
agency is working with the pharmaceutical industry and standards
organizations to establish standardized approaches to labeling, study
data, and study protocols that will be used in the DIDR to protect the
safety of women, men, children, and older people of every race and
ethnicity.
Men, Women, and Heart Disease

Heart disease is the leading cause of death in the United States
for both men and women, according to the American Heart Associa-
tion. “But the normal heart is different in men and women,” says
Marianne J. Legato, M.D., a cardiologist and founder and director of
Columbia University’s Partnership for Gender-Specific Medicine.
“Women’s hearts beat faster, even during sleep,” she says. And women
have different proteins in the heart cells.
“Some data suggest that the whole physiology of the coronary ar-
teries and what keeps them open and what causes them to go into
spasm might be significantly different in men and women,” says
Legato, adding that some women have had heart attacks without any
of the fatty buildup of plaque seen in the coronary arteries in most
people with heart attacks.
And the symptoms of a heart attack may be different. “Twenty
percent of women will not have the ‘typical symptoms’ of chest pain
radiating down the left arm,” says Legato, “but will instead describe
nausea, profound sweating, and shortness of breath and pain in the
upper abdomen.”
15
Chapter 3
Making Decisions
about Health Care
Chapter Contents
Section 3.1—Choosing a Doctor .................................................... 18
Section 3.2—Tips for Using Medicines Safely ............................. 23
Section 3.3—How to Get a Second Opinion ................................. 24
17
Section 3.1
Choosing a Doctor
“Choosing a Doctor,” Excerpted from Your Guide to Choosing Quality Health
Care, AHRQ Publication No. 99-0012, July 2001, Agency for Healthcare
Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/qnt/.
Reviewed by David A. Cooke, M.D., March 2009.
It is important to choose your doctor with care, because quality

varies. For example, the Pacific Business Group on Health asked pa-
tients of California doctors’ groups how they rated their care. The re-
sults? More than 80 percent of the patients said they were satisfied
with their care. But fewer than two-thirds were happy with the ease
of getting that care.
This section can help you choose a primary care doctor who will
meet your needs and give you quality care. The information also may
be useful in choosing any specialists you might need. Primary care
doctors are specially trained to serve as your main doctor over the
long term. They provide your medical and health care, help you stay
healthy, and help to manage your care. Your primary care doctor can
refer you to specialists (doctors who treat only certain parts of the
body, conditions, or age groups) if you need them.
Quick Check for Quality

Look for a doctor who:
• is rated to give quality care;
• has the training and background that meet your needs;
• takes steps to prevent illness—for example, talks to you about
quitting smoking;
• has privileges at the hospital of your choice;
• is part of your health plan, unless you can you afford to pay extra;
• encourages you to ask questions;
• listens to you;
18
Making Decisions about Health Care
• explains things clearly;
• treats you with respect.
Doctors and Health Plans

If you already are in a health plan, your choices may be limited to
doctors who participate in the plan. But if you have a choice of plans,
you may want to first think about which doctor(s) you would like to
use. Then, you may be able to choose a plan that has your choice of
doctor(s).
Decide What You Want and Need in a Doctor

What is most important to you in a doctor? A few ideas are listed
below. Add your own to create a list that will help you choose a doctor
who is right for you:
• My doctor must be highly rated by a consumer or other group.
You will want to find out who did the ratings. Is the information
reliable? Who collected it? Does the group have something to
gain from the ratings?
• My doctor needs to have experience with my condition(s). Re-
search shows that doctors who have a lot of experience with a
condition tend to have better success with it.
• I want a doctor who has privileges (is permitted to practice) at
the hospital of my choice.
• My doctor must be part of my health plan.
Make a List of Doctors

• If you are in a managed care plan, check the plan’s list of doc-
tors first. Ask doctors or other health professionals who work
with doctors, such as hospital nurses. Check the “Physician Se-
lect” service of the website of the American Medical Association.
This can give you lists of doctors, by specialty, who practice near
you. You can also check on training and board certification:
http://www.ama-assn.org/aps/amahg.htm.
• Call a doctor referral service at a hospital. But keep in mind
that these services usually refer you to any of the doctors on the
staff of that hospital. The services do not have information on
the quality of care these doctors provide.
19
• Some local medical societies offer lists of doctors who are mem-
bers. Again, these lists do not have information on the quality of
care these doctors provide.
• Ask family, friends, neighbors, and co-workers.
Check on Quality
Once you have a list of doctors, there are several ways to check on
their skills and knowledge, and the quality of care they provide:
• Find out if a consumer or other group has rated doctors in the
area where you live. Again you will want to find out how reli-
able the ratings are.
• Information on doctors in some states is available on the inter-
net at http://www.docboard.org. This website is run by Adminis-
trators in Medicine—a group of state medical board directors.
• The American Board of Medical Specialties (800-733-2267) can
tell you if the doctor is board certified. “Certified” means that
the doctor has completed a training program in a specialty and
has passed an exam (board) to assess his or her knowledge, skills,
and experience to provide quality patient care in that specialty.
Primary care doctors also may be certified as specialists. You can
also check the Website at http://www.certifacts.org. (While board
certification is a good measure of a doctor’s knowledge, it is pos-
sible to receive quality care from doctors who are not board cer-
tified.)
• Call the American Medical Association (AMA) at 312-464-5000
for information on training, specialties, and board certification
about many licensed doctors in the United States. This informa-
tion also can be found in “Physician Select” at AMA’s Website:
http://www.ama-assn.org/aps/amahg.htm.
Contact the Doctors’ Offices

When you have found a few names of doctors you might want to
try, call their offices. The first thing to find out is whether the doctor
is covered by your health plan and is taking new patients. If the doc-
tor is not covered by your plan, are you prepared to pay the extra
costs?
Below are some questions you might want to ask the office man-
ager or other staff. You may have some additional questions. Note that
20
some of these items might have more to do with the health plan than
with the doctor’s office.
Things to find out from the office staff:
• Which hospitals does the doctor use?
• What are the office hours (when is the doctor available and
when can I speak to office staff)?
• Does the doctor or someone else in the office speak the language
that I am most comfortable speaking?
• How many other doctors “cover” for the doctor when he or she is
not available? Who are they?
• How long does it usually take to get a routine appointment?
• How long might I need to wait in the office before seeing the
doctor?
• What happens if I need to cancel an appointment? Will I have to
pay for it anyway?
• Does the office send reminders about prevention tests?
• What do I do if I need urgent care or have an emergency?
• Does the doctor (or a nurse or physician assistant) give advice
over the phone for common medical problems?
You may also want to talk briefly with the doctor by phone or in
person. Ask if you are able to do this and if there is a charge.
The next step is to schedule a visit with your top choice. During
that first visit you will learn a lot about just how easy it is to talk
with the doctor. You will also find out how well the doctor might meet
your medical needs. Ask yourself, did the doctor:
• give me a chance to ask questions?
• really listen to my questions?
• answer in terms I understood?
• show respect for me?
• ask me questions?
• make me feel comfortable?
• address the health problem(s) I came with?
• ask me my preferences about different kinds of treatments?
• spend enough time with me?
21
Trust your own reactions when deciding whether this doctor is the
right one for you. But you also may want to give the relationship some
time to develop. It takes more than one visit for you and your doctor
to get to know each other.
Once You Leave the Doctor’s Office, Follow Up

• If you have questions, call.
• If your symptoms get worse, or if you have problems with your
medicine, call.
• If you had tests and do not hear from your doctor, call for your
test results.
• If your doctor said you need to have certain tests, make appoint-
ments at the lab or other offices to get them done.
• If your doctor said you should see a specialist, make an appoint-
ment.
Urgent or Emergency Care Centers

What if you get sick at night, on a holiday, or over the weekend?
You can’t get to your doctor, but you are not sick enough to go to the
emergency room. There may be an “urgent” or “emergency” care cen-
ter near you. These centers are open long hours every day to handle
problems that are not life threatening. But they are no substitute for
a regular primary care doctor.
To make sure an urgent or emergency care center provides quality care,
call your health plan or visit the center to find out the following things:
• If your health plan will cover your care there.
• If it is licensed. Then check to see if it is accredited by a group
such as the Joint Commission on Accreditation of Healthcare Or-
ganizations (telephone 630-792-5800; Website http://www.jcaho
.org) or the Accreditation Association for Ambulatory Healthcare
(telephone 847-853-6060; Website http://www.aaahc.org). The ac-
creditation certificate should be posted in the facility.
• How well trained and experienced the center’s health care pro-
fessionals are.
• If the center is affiliated with a hospital. If it is not, find out
how the center will handle any emergency that could happen
during your visit.
22
Section 3.2
Tips for Using Medicines Safely

Reprinted from “Check Your Medicines: Tips for Using Medicines
Safely,” Agency for Healthcare Research and Quality, AHRQ Publication
No. 08-M044-A, April 2008.
Take a List or a Bag with All Your Medicines When You

Go to Your Doctor’s Office, the Pharmacy, or the
Hospital
Include all prescription and over-the-counter medicines, vitamins,
and herbal supplements that you use. If your doctor prescribes a new
medicine, ask if it is safe to use with your other medicines. Remind
your doctor and pharmacist if you are allergic to any medicines.
Ask Questions about Your Medicines

Ask questions and make sure you understand the answers. Choose
a pharmacist and doctor you feel comfortable talking with about your
health and medicines. Take a relative or friend with you to ask ques-
tions and remind you about the answers later. Write down the an-
swers.
Make Sure Your Medicine Is What the Doctor Ordered

Does the medicine seem different than what your doctor wrote on
the prescription or look different than what you expected? Does a re-
fill look like it is a different shape, color, or size than what you were
given before? If something seems wrong, ask the pharmacist to double-
check it. Most errors are first found by patients.
Ask How to Use the Medicine Correctly

Read the directions on the label and other information you get with
your medicine. Have the pharmacist or doctor explain anything you
do not understand. Are there other medicines, foods, or activities (such
23
as driving, drinking alcohol, or using tobacco) that you should avoid
while using the medicine? Ask if you need lab tests to check how the
medicine is working or to make sure it doesn’t cause harmful side ef-
fects.
Ask about Possible Side Effects

Side effects can occur with many medicines. Ask your doctor or
pharmacist what side effects to expect and which ones are serious.
Some side effects may bother you but will get better after you have
been using the medicine for a while. Call your doctor right away if
you have a serious side effect or if a side effect does not get better. A
change in the medicine or the dose may be needed.
Section 3.3
How to Get a Second Opinion

Reprinted from “Tools to Help You Build a Healthier Life: How to
Get a Second Opinion,” National Women’s Health Information Center,
October 2006.
Even though doctors may get similar medical training, they can
have their own opinions and thoughts about how to practice medicine.
They can have different ideas about how to diagnose and treat condi-
tions or diseases. Some doctors take a more conservative, or tradi-
tional, approach to treating their patients. Other doctors are more
aggressive and use the newest tests and therapies. It seems like we
learn about new advances in medicine almost every day.
Many doctors specialize in one area of medicine, such as cardiol-
ogy or obstetrics or psychiatry. Not every doctor can be skilled in us-
ing all the latest technology. Getting a second opinion from a different
doctor might give you a fresh perspective and new information. It
could provide you with new options for treating your condition. Then
you can make more informed choices. If you get similar opinions from
two doctors, you can also talk with a third doctor.
24
Tips: What to Do
Ask your doctor for a recommendation: Ask for the name of
another doctor or specialist, so you can get a second opinion. Don’t
worry about hurting your doctor’s feelings. Most doctors welcome a
second opinion, especially when surgery or long-term treatment is
involved.
Ask someone you trust for a recommendation: If you don’t

feel comfortable asking your doctor for a referral, then call another
doctor you trust. You can also call university teaching hospitals and
medical societies in your area for the names of doctors. Some of this
information is also available on the Internet.
Check with your health insurance provider: Call your insur-

ance company before you get a second opinion. Ask if they will pay
for this office visit. Many health insurance providers do. Ask if there
are any special procedures you or your primary care doctor need to
follow.
Ask to have medical records sent to the second doctor: Ask

your primary care doctor to send your medical records to the new
doctor. You need to give written permission to your current doctor to
send any records or test results to a new doctor. You can also ask for
a copy of your own medical records for your files. Your new doctor can
then examine these records before your office visit.
Learn as much as you can: Ask your doctor for information you
can read. Go to a local library. Search the Internet. Find a teaching
hospital or university that has medical libraries open to the public.
The information you find can be hard to understand, or just confus-
ing. Make a list of your questions, and bring it with you when you see
your new doctor.
Do not rely on the Internet or a telephone conversation:

When you get a second opinion, you need to be seen by a doctor. That
doctor will perform a physical examination and perhaps other tests.
The doctor will also thoroughly review your medical records, ask you
questions, and address your concerns.
25
Chapter 4
Recommended Screenings
and Vaccinations for Men
Chapter Contents
Section 4.1—Stay Healthy at Any Age: Men’s Checklist
for Health ................................................................. 28
Section 4.2—Colorectal Cancer Screening .................................. 31
Section 4.3—Prostate Cancer Screening ..................................... 34
Section 4.4—New Research Questions Benefit of Annual
Prostate Cancer Screening ..................................... 37
Section 4.5—Adult Immunization Questions and Answers ....... 40
Section 4.6—Facts about the Seasonal Flu Vaccine ................... 44
27
Section 4.1
Stay Healthy at Any Age:

Men’s Checklist for Health
Excerpted from “Men: Stay Healthy at Any Age—Your Checklist
for Health,” Agency for Healthcare Research and Quality, AHRQ
Publication No. 07-IP006-A, February 2007.
What can you do to stay healthy and prevent disease? You can get
certain screening tests, take preventive medicine if you need it, and
practice healthy behaviors.
Top health experts from the U.S. Preventive Services Task Force
suggest that when you go for your next checkup, you should talk to
your doctor or nurse about how you can stay healthy no matter what
your age.
The most important things you can do to stay healthy are as fol-
lows:
• Get recommended screening tests.
• Be tobacco free.
• Be physically active.
• Eat a healthy diet.
• Stay at a healthy weight.
• Take preventive medicines if you need them.
Screening Tests for Men: What You Need and When

Screening tests can find diseases early, when they are easier to
treat. Health experts from the U.S. Preventive Services Task Force
have made recommendations, based on scientific evidence, about test-
ing for the conditions below. Talk to your doctor about which ones
apply to you and when and how often you should be tested.
Obesity: Have your body mass index (BMI) calculated to screen
for obesity. (BMI is a measure of body fat based on height and weight.)
You can also find your own BMI with the table in chapter 7.
28
Recommended Screenings and Vaccinations for Men
High cholesterol: Have your cholesterol checked regularly start-
ing at age thirty-five. If you are younger than thirty-five, talk to your
doctor about whether to have your cholesterol checked if any of the
following are true:
• You have diabetes.

• You have high blood pressure.
• Heart disease runs in your family.
• You smoke.
High blood pressure: Have your blood pressure checked at least

every two years. High blood pressure is 140/90 or higher.
Colorectal cancer: Have a test for colorectal cancer starting at

age fifty. Your doctor can help you decide which test is right for you.
If you have a family history of colorectal cancer, you may need to be
screened earlier.
Diabetes: Have a test for diabetes if you have high blood pressure
or high cholesterol.
Depression: Your emotional health is as important as your physi-

cal health. If you have felt “down,” sad, or hopeless over the last two
weeks or have felt little interest or pleasure in doing things, you may
be depressed. Talk to your doctor about being screened for depression.
Sexually transmitted infections: Talk to your doctor to see

whether you should be tested for gonorrhea, syphilis, chlamydia, or
other sexually transmitted infections.
Human immunodeficiency virus (HIV): HIV is the virus that

can cause acquired immunodeficiency syndrome (AIDS). Talk to your
doctor about HIV screening if any of the following are true:
• You have had sex with men since 1975.

• You have had unprotected sex with multiple partners.
• You have used or now use injection drugs.
• You exchange sex for money or drugs or have sex partners who do.
• You have past or present sex partners who are HIV-infected, are
bisexual, or use injection drugs.
29
• You are being treated for sexually transmitted diseases.
• You had a blood transfusion between 1978 and 1985.
Abdominal aortic aneurysm: If you are between the ages of

sixty-five and seventy-five and have ever smoked (one hundred or
more cigarettes during your lifetime), you need to be screened once
for abdominal aortic aneurysm, which is an abnormally large or swol-
len blood vessel in your abdomen.
Daily Steps to Health

Don’t smoke: If you do smoke, talk to your doctor about quitting.
Your doctor or nurse can help you. And, you can also help yourself.
For tips on how to quit, go to chapter 10.
Be physically active: Walking briskly, mowing the lawn, danc-

ing, swimming, and bicycling are just a few examples of moderate
physical activity. If you are not already physically active, start small
and work up to thirty minutes or more of moderate physical activity
most days of the week.
Eat a healthy diet: Emphasize fruits, vegetables, whole grains,

and fat-free or low-fat milk and milk products; include lean meats,
poultry, fish, beans, eggs, and nuts; and eat foods low in saturated fats,
trans fats, cholesterol, salt (sodium), and added sugars.
Stay at a healthy weight: Balance calories from foods and bev-

erages with calories you burn off by your activities. To prevent gradual
weight gain over time, make small decreases in food and beverage
calories and increase physical activity.
Drink alcohol only in moderation: If you drink alcohol, have

no more than two drinks a day. (A standard drink is one 12-ounce
bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces
of 80-proof distilled spirits.)
Should You Take Medicines to Prevent Disease?

Aspirin
Ask your doctor about taking aspirin to prevent heart disease if
any of the following are true:
30
• You are older than forty-five
• You are younger than forty-five and:
• have high blood pressure;
• have high cholesterol;
• have diabetes;
• smoke.
Immunizations
Stay up-to-date with your immunizations:
• Have a flu shot every year starting at age fifty. If you are
younger than fifty, ask your doctor whether you need a flu
shot.
• Have a pneumonia shot once after you turn sixty-five. If you are
younger, ask your doctor whether you need a pneumonia shot.
Section 4.2
Colorectal Cancer Screening

Reprinted from “Colorectal Cancer: Basic Facts on Screening,”
U.S. Centers for Disease Control and Prevention, January 2006.
What is Colorectal Cancer?

Colorectal cancer is cancer that occurs in the colon or rectum.
Sometimes it is called colon cancer, for short. The colon is the large
intestine or large bowel. The rectum is the passageway that connects
the colon to the anus.
It’s the Second Leading Cancer Killer

Colorectal cancer is the second leading cancer killer in the United
States, but it doesn’t have to be. If everybody age fifty or older had
31
regular screening tests, at least one-third of deaths from this cancer
could be avoided. So if you are fifty or older, start screening now.
Who Gets Colorectal Cancer?

• Both men and women can get colorectal cancer.
• Colorectal cancer is most often found in people fifty and older.
• The risk for getting colorectal cancer increases with age.
Are You at High Risk?

Your risk for colorectal cancer may be higher than average if ei-
ther of the following are true:
• You or a close relative have had colorectal polyps or colorectal
cancer.
• You have inflammatory bowel disease.
People at high risk for colorectal cancer may need earlier or more
frequent tests than other people. Talk to your doctor about when you
should begin screening and how often you should be tested.
Screening Saves Lives

If you’re fifty or older, getting a screening test for colorectal can-
cer could save your life. Here’s how:
• Colorectal cancer usually starts from polyps in the colon or rec-
tum. A polyp is a growth that shouldn’t be there.
• Over time, some polyps can turn into cancer.
• Screening tests can find polyps, so they can be removed before
they turn into cancer.
• Screening tests can also find colorectal cancer early. When it is
found early, the chance of being cured is good.
Colorectal Cancer Can Start With No Symptoms

People who have polyps or colorectal cancer sometimes don’t have
symptoms, especially at first. This means that someone could have pol-
yps or colorectal cancer and not know it. That is why having a screen-
ing test is so important.
32
What Are the Symptoms?

Some people with colorectal polyps or colorectal cancer do have
symptoms. They may include the following:
• Blood in or on your stool (bowel movement).
• Pain, aches, or cramps in your stomach that happen a lot and
you don’t know why.
• A change in bowel habits, such as having stools that are nar-
rower than usual.
• Losing weight and you don’t know why.
If you have any of these symptoms, talk to your doctor. These symp-
toms may also be caused by something other than cancer. However,
the only way to know what is causing them is to see your doctor.
Types of Screening Tests

There are several different screening tests that can be used to find
polyps or colorectal cancer. Each one can be used alone. Sometimes
they are used in combination with each other. Talk to your doctor
about which test or tests are right for you and how often you should
be tested.
Fecal occult blood test or stool test: For this test, you receive a
test kit from your doctor or health care provider. At home, you put a small
piece of stool on a test card. You do this for three bowel movements in a
row. Then you return the test cards to the doctor or a lab. The stool
samples are checked for blood. This test should be done every year.
Flexible sigmoidoscopy: For this test, the doctor puts a short, thin,
flexible, lighted tube into your rectum. The doctor checks for polyps or
cancer inside the rectum and lower third of the colon. This test should
be done every five years.
Fecal occult blood test plus flexible sigmoidoscopy: Your doc-

tor may ask you to have both tests. Some experts believe that by us-
ing both tests, there is a better chance of finding polyps or colorectal
cancer.
Colonoscopy: This test is similar to flexible sigmoidoscopy, except

the doctor uses a longer, thin, flexible, lighted tube to check for polyps
33
or cancer inside the rectum and the entire colon. During the test, the
doctor can find and remove most polyps and some cancers. This test
should be done every ten years. Colonoscopy may also be used as a
follow-up test if anything unusual is found during one of the other
screening tests.
Double contrast barium enema: This test is an x-ray of your

colon. You are given an enema with a liquid called barium. Then the
doctor takes an x-ray. The barium makes it easy for the doctor to see
the outline of your colon on the x-ray to check for polyps or other ab-
normalities. This test should be done every five years.
Will Insurance or Medicare Pay for Screening Tests?

Many insurance plans and Medicare help pay for colorectal can-
cer screening tests. Check with your plan to find out which tests are
covered for you.
Section 4.3
Prostate Cancer Screening

“Prostate Cancer Screening,” is reprinted with permission from
www.urologyhealth.org, © 2006 American Urological Association, Inc.
All rights reserved.
Currently, digital rectal examination (DRE) and prostate specific

antigen (PSA) are used for prostate cancer detection. The age at which
time screening for prostate cancer should begin is not known with
certainty. However, most experts agree that healthy men over the age
of fifty should consider prostate cancer screening with a DRE and PSA
test. Screening should occur earlier, at age forty, in those who are at
a higher risk of prostate cancer, such as African-American men or
those with a family history of prostate cancer. Men who are concerned
about their future risk of prostate cancer should be screened to as-
sess their baseline risk for developing the disease.
34
Digital rectal exam (DRE): The DRE is performed with the man
either bending over, lying on his side, or with his knees drawn up to
his chest on the examining table. The physician inserts a gloved fin-
ger into the rectum and examines the prostate gland, noting any
abnormalities in size, contour, or consistency. DRE is inexpensive, easy
to perform, and allows the physician to note other abnormalities such
as blood in the stool or rectal masses, which may allow for the early
detection of rectal or colon cancer. However, DRE is not the most ef-
fective way to detect an early cancer, so it should be combined with a
PSA test.
Prostate specific antigen test: The PSA test is usually per-

formed in addition to DRE and increases the likelihood of prostate
cancer detection. The test measures the level of PSA, a substance pro-
duced only by the prostate, in the bloodstream. The PSA should be
less than 1.0 ng/ml The median for men in their forties is 0.7 ng/ml.
If the PSA is higher than the age-specific median, the risk of devel-
oping prostate cancer and the risk of having an aggressive form of
the disease are increased. Accordingly, the patient might be well ad-
vised to have more frequent screening to detect a rise in the PSA level
over time.
This blood test can be performed in a clinical laboratory, hospital,
or physician’s office and requires no special preparation on the part
of the patient. Ideally, the test should be taken before a digital rectal
examination is performed or any catheterization or instrumentation
of the urinary tract. Furthermore, because ejaculation can transiently
elevate the PSA level for twenty-four to forty-eight hours, men should
abstain from sexual activity for two days prior to having a PSA test.
A tourniquet or rubber strap is tied around the upper arm to mildly
restrict the flow of blood and keep blood in the vein. Then, a needle
with a tube-like container attached is inserted into a vein, usually in
the bend of the elbow or the top of the hand. After a sufficient sample
of blood is obtained, the needle is withdrawn, a bandage is placed on
the puncture site, and firm pressure is held until the bleeding stops.
The entire test takes less than five minutes and produces only mild
discomfort. After, the patient may experience slight bruising at the
puncture site.
Very little PSA escapes from a healthy prostate into the blood-
stream, but certain prostatic conditions can cause larger amounts of
PSA to leak into the blood. One possible cause of a high PSA level is
benign (noncancerous) enlargement of the prostate, otherwise known
as BPH. Inflammation of the prostate, called prostatitis, is another
35
common cause of PSA elevation, as is recent ejaculation. Prostate
cancer is the most serious possible cause of an elevated PSA level. The
frequency of PSA testing remains a matter of some debate. The Ameri-
can Urological Association (AUA) encourages men to have annual PSA
testing starting at age fifty. The AUA also recommends annual PSA
testing for men over the age of forty who are African American or have
a family history of the disease (for example, a father or brother who
was diagnosed with prostate cancer), or for those who are interested
in an early risk assessment. Some experts have suggested that men
with an initial normal DRE and PSA level of less than 2.5 ng/ml can
have PSA testing performed every two years. However, a disadvan-
tage of infrequent testing is that it limits the ability to detect a rap-
idly rising PSA level that can signal aggressive prostate cancer.
Recently, several refinements have been made in the PSA blood test
in an attempt to determine more accurately who has prostate cancer
and who has false-positive PSA elevations caused by other conditions
like BPH. These refinements include PSA density, PSA velocity, PSA
age-specific reference ranges and use of free-to-total PSA ratios. Such
refinements may increase the ability to detect cancer and these should
be discussed with your physician.
Currently, it is recommended that both a DRE and PSA test be used
for the early detection of prostate cancer. It is important to realize
that in most cases an abnormality in either test is not due to cancer
but to benign conditions, the most common being BPH or prostatitis.
For instance, it has been shown that only 18 to 30 percent of men with
serum PSA values between 4 and 10 ng/ml have prostate cancer. This
number rises to approximately 42 to 70 percent for those men whose
PSA values exceeding 10 ng/ml.
36
Section 4.4
New Research Questions Benefit

of Annual Prostate Cancer Screening
Excerpted from “U.S. Cancer Screening Trial Shows No
Early Mortality Benefit from Annual Prostate Cancer Screening,”
National Cancer Institute, March 18, 2009.
Six annual screenings for prostate cancer led to more diagnoses

of the disease, but no fewer prostate cancer deaths, according to a
major new report from the Prostate, Lung, Colorectal, and Ovarian
(PLCO) Cancer Screening Trial, a seventeen-year project of the Na-
tional Cancer Institute (NCI), part of the National Institutes of
Health. The PLCO was designed to provide answers about the effec-
tiveness of prostate cancer screening.
“What this report tells us is that there may be some men who are
diagnosed with prostate cancer and have the side-effects of treatment,
such as impotence and incontinence, with little chance of benefit,” said
John E. Niederhuber, M.D., director of the NCI. “Clearly, we need a
better way of detecting prostate cancer at its earliest stages and as
importantly, a method of determining which tumors will progress.
Many of the molecular studies we’re currently sponsoring will hope-
fully yield new, better ways of definitively classifying which men need
treatment and which can consider watchful waiting. Until we have
developed and verified a new test’s benefits and harms, as we have
done with the PLCO, regular visits to your doctor to monitor your
health are still strongly recommended.”
Results appeared online March 18, 2009, in the New England Jour-
nal of Medicine, to coincide with presentation of the data at the Eu-
ropean Association of Urology meeting in Stockholm, Sweden. The
print version of the results appeared in the March 26, 2009, issue.
NCI does not have a recommendation about prostate cancer screen-
ing. The U.S. Preventive Services Task Force, whose recommendations
are considered the gold standard for clinical preventive services, re-
cently concluded that there is insufficient evidence to assess the bal-
ance of benefits and harms of prostate cancer screening in men younger
37
than age seventy-five and recommended against prostate cancer
screening in men age seventy-five and older.
There were 76,693 men in the PLCO trial that was conducted at
ten centers around the United States. Of the men in the trial, 38,343
were randomly assigned to screening with annual prostate-specific
antigen (PSA) tests for six rounds and digital rectal exams (DRE) for
four rounds. The other 38,350 men were randomly assigned to usual
care, but received no recommendations for or against annual prostate
cancer screening.
Of those men who were screened annually, 85 percent had PSA
tests and 86 percent had DREs. Men in the usual-care arm sometimes
had these tests as well, due to the growing public acceptance of such
screening. Screening by PSA in this usual-care group increased from
40 percent at the beginning of the study to 52 percent of men by the
last screening year, and screening with DRE ranged from 41 percent
initially to 46 percent by the last screening year. Men in the screen-
ing arm were referred to their usual health care provider for follow-
up testing for prostate cancer if their PSA level was greater than 4.0
nanograms per milliliter (ng/mL) or if a DRE found an abnormality.
This report includes data for all participants at seven years after
they joined the trial and for 67 percent of participants at ten years
after they joined the trial. Other important findings are as follows.
At seven years, 22 percent more prostate cancers were diagnosed
in the screening arm. This excess is continuing to be observed in data
collected up to ten years (currently a 17 percent excess).
The vast majority of men in both groups who developed prostate
cancer were diagnosed with relatively early stage II (out of four stages,
of which IV is late stage) disease, and the number of later-stage cases
was similar in the two groups. However, using the Gleason scoring
system, which assesses tumor aggressiveness, men in the usual-care
group had more prostate cancers that fell into the Gleason 8 to 10
range, which marks them as more aggressive. The smaller number of
men with prostate cancer with a Gleason score of 8 to 10 in the inter-
vention group may eventually lead to a mortality difference between
men in the two groups but data analyzed so far have not shown such
a difference.
Men in both groups who were diagnosed with prostate cancer at
the same stage received similar treatments for their disease. This
reflects the PLCO study design policy of not mandating specific thera-
pies.
At seven years, fifty deaths were attributable to prostate cancer
in the screening group and forty-four deaths were attributable in the
38
usual-care group. Through year ten, there were ninety-two prostate
cancer deaths in the screening group and eighty-two in the usual-care
group. The difference between the numbers of deaths in the two groups
was not statistically significant. Thus there was no detectable mor-
tality benefit for screening vs. usual-care.
Given the uncertainties about the mortality benefits of PSA test-
ing, NCI has been pursuing many avenues to find new ways of screen-
ing for prostate cancer, including several sets of biomarkers that are
being validated in its Early Detection Research Network (EDRN),
some using specimens from PLCO’s biorepository of tissue and blood.
Some examples of the marker tests include using microstrands of RNA
to detect disease, examining changes in genes such as GSTP1, and
imaging of proteins in prostate cancer tissue.
“NCI wants to understand why some prostate cancers are lethal
even when found early by annual screening, and what approaches can
be used to identify these more aggressive cancers when they can be
effectively treated,” said Christine Berg, M.D., NCI leader of the PLCO
trial and senior author of the study. “The PLCO biorepository is an
invaluable resource for such research, with nearly three million bio-
logical samples collected from our participants. Our hope is that
through all aspects of the PLCO, we will gather the information that
tells us whom to treat aggressively and whom to avoid overtreating.”
Another report in this same online publication of the NEJM [New
England Journal of Medicine] is from the large European Random-
ized Study of Screening for Prostate Cancer (ERSPC), which shows a
20 percent reduction in the rate of death from prostate cancer but with
a high risk of overdiagnosis. In the ERSPC, unlike the PLCO trial,
men were referred for follow-up testing if their PSA level was 3.0 ng/
mL or higher and were also screened, on average, every four years as
opposed to annually in the PLCO.
“Approaches such as lowering the threshold for what is considered
an abnormal PSA level to 3.0 ng/mL will diagnose more cases, but it
is not at all clear that it will identify the prostate cancers that are
more likely to lead to a man’s death,” said Berg.
The PLCO data are being made public now because the study’s
Data and Safety Monitoring Board (DSMB), an independent review
committee that meets every six months saw a continuing lack of evi-
dence that screening reduces death due to prostate cancer as well as
the suggestion that screening may cause men to be treated unneces-
sarily. The DSMB also supports continued follow-up of all participants
so that every participant is tracked for at least thirteen years from
entry onto the trial.
39
The PLCO is a large-scale clinical trial, sponsored and run by NCI’s
Division of Cancer Prevention, begun in 1992 to determine whether
certain cancer screening tests can help reduce deaths from prostate,
lung, colorectal and ovarian cancer. The underlying rationale for the
trial is that screening for cancer may enable doctors to discover and
treat the disease earlier.
Nearly 155,000 women and men between the ages of fifty-five and
seventy-four have joined the PLCO trial. At entry, participants were
assigned at random to one of two study groups: One group received
routine health care from their health providers. The other received a
series of exams to screen for prostate, lung, colorectal, and ovarian
cancers. Screening of participants ended in late 2006. Follow-up of
participants is anticipated to continue for several more years.
Section 4.5
Adult Immunization Questions and Answers

Excerpted from “Adult Immunization Questions and Answers,”
© 2008 National Foundation for Infectious Diseases (www.nfid.org).
Reprinted with permission.
Are there vaccines that protect against communicable dis-

eases for adults?
Yes! Vaccinations are readily available for such common adult ill-
nesses as influenza (flu), pneumococcal disease, herpes zoster
(shingles), human papillomavirus (HPV), pertussis (whooping cough),
hepatitis A, and hepatitis B. Vaccinations against less common dis-
eases such as measles, mumps, rubella (German measles), tetanus
(lockjaw), diphtheria, and varicella (chickenpox) are also needed by
some adults. The Centers for Disease Control and Prevention’s (CDC)
recommendations clearly identify people who are at risk for these dis-
eases and who should be immunized to prevent these diseases and
their complications. Consult your healthcare provider or local health
department regarding your own immunization status as well as cur-
rent immunization recommendations.
40
Which vaccinations do adults need?

All adults require tetanus and diphtheria (Td) immunizations at
ten-year intervals throughout their lives. Adults who deferred Td
boosters during 2001 and early 2002 because of vaccine shortages
should get back on track—the supply problems have been resolved.
Additionally, adults younger than sixty-five years of age should sub-
stitute a tetanus, diphtheria, acellular pertussis (Tdap) vaccination
for one Td booster.
Adults born after 1956 who are not immune to measles, mumps,
or rubella should be immunized.
Women twenty-six years of age or younger should be immunized
against human papillomavirus (HPV), the virus that causes about 70
percent of all cervical cancer cases in the United States.
All adults sixty-five years of age or older, as well as persons two to
sixty-four years of age who have diabetes or chronic heart, lung, liver,
or kidney disorders need protection against pneumococcal disease, and
should consult their healthcare providers regarding this vaccine.
Influenza vaccination is recommended for all adults fifty years of
age or older, women who will be pregnant during influenza season, and
residents of long-term care facilities, as well as for all children six
months through eighteen years of age, and persons who have certain
chronic medical conditions. Other individuals who should seek annual
influenza immunization include healthcare workers and those who live
with or provide care for high-risk persons, including those who live with
or who provide care for infants younger than six months of age.
Hepatitis B vaccine is recommended for adults in certain high-risk
groups, such as healthcare workers and public safety workers exposed
to blood on the job; household and sex contacts of persons with chronic
hepatitis B virus (HBV) infection; sexually active people who are not
in long-term, mutually monogamous relationships; people seeking
evaluation or treatment for sexually transmitted disease (STD); men
who have sex with men; injection drug users; travelers to countries
where HBV infection is common; people with end-stage renal disease;
and human immunodeficiency virus (HIV)–infected persons. Hepati-
tis B vaccine is also recommended for anyone seeking protection from
HBV infection. To increase vaccination rates among people at highest
risk for HBV infection, hepatitis B vaccine is recommended for all adults
in the following settings: STD treatment facilities, HIV testing and
treatment facilities, facilities providing drug-abuse treatment and pre-
vention services, healthcare settings targeting services to injection-drug
users or men who have sex with men, correctional facilities, end-stage
41
renal disease programs and facilities for chronic hemodialysis patients,
and institutions and nonresidential daycare facilities for persons with
developmental disabilities.
Hepatitis A vaccine is recommended for adults in certain high-risk
groups, including travelers to countries where hepatitis A is common,
people with chronic liver disease, people who have blood clotting-
factor disorders such as hemophilia, men who have sex with men, and
users of injection and non-injection illegal drugs.
Varicella vaccine is recommended for all adults who have not had
chickenpox and have not been immunized previously against chicken-
pox, including teachers of young children and daycare workers, residents
and staff in institutional settings, military personnel, nonpregnant
women of childbearing age, international travelers, healthcare work-
ers, and family members of immunocompromised persons.
Meningococcal vaccination is recommended for adults (not previ-
ously immunized with the meningococcal conjugate vaccine) with asple-
nia or terminal complement deficiencies, who will be first-year college
students living in dormitories, who are military recruits or certain labo-
ratory workers, or who will be traveling to or living in countries in
which meningococcal disease is common. The vaccine is also recom-
mended for administration to all adolescents eleven to eighteen years
of age.
Adults sixty years of age and older should receive a single dose of
zoster vaccine whether or not they report a prior episode of herpes
zoster (shingles). Persons with chronic medical conditions may be
vaccinated unless a contraindication or precaution exists for their
condition.
Where can I obtain my vaccinations?

Vaccinations should be available from family doctors and internists.
Additionally, your city or county health department or local hospital
may hold clinics to administer influenza, pneumococcal, hepatitis A,
and hepatitis B vaccines. Many pharmacies offer these and other
immunizations. Clinics may also be available in shopping malls, gro-
cery stores, senior centers, and other community settings.
How often do I need to be immunized?

Immunizations for pneumococcal disease (except for patients at
particular risk for pneumococcal complications), measles, mumps, and
rubella are usually administered once, and offer protection for life. A
42
single pneumococcal revaccination is recommended for persons who
were vaccinated prior to age sixty-five. Some persons born after 1956
may require a second measles and mumps vaccination. Women twenty-
six years of age and younger should receive three doses of the HPV
vaccine to prevent cervical cancer. Influenza vaccine must be admin-
istered yearly because the strains in the vaccine are updated nearly
every year and because protection from the vaccine does not last from
year to year. Additional booster doses of tetanus and diphtheria vac-
cines (usually given as a combination Td vaccine) are required every
ten years to maintain immunity against these diseases. One of these
booster doses should be the tetanus, diphtheria, acellular pertussis
(Tdap) vaccine, for adults younger than sixty-five years of age. Two
doses of hepatitis A are needed six to twelve months apart to ensure
long-term protection. Hepatitis B vaccine is usually administered in
three doses given over a six-month period. Two doses of chickenpox
vaccine are recommended for people thirteen years old or older who
have not had the disease or been immunized. One dose of zoster vac-
cine is recommended for persons sixty years of age and older.
Are there side effects to these vaccines?

Vaccines are among the safest medical products available. Some
common side effects are a sore arm or low-grade fever. As with any
medical product, there are very small risks that serious problems
could occur after getting a vaccine. However, the potential risks as-
sociated with the diseases these vaccines prevent are much greater
than the potential risks associated with the vaccines themselves.
What vaccines do I need if I’m traveling abroad?
Contact your healthcare provider or the public health department

as early as possible to check on the vaccinations you may need. Vac-
cines against certain diseases such as hepatitis A, hepatitis B, yellow
fever, and typhoid fever are recommended for different countries. The
time required to receive all vaccinations will depend on whether you
need one dose or a series of doses. A variety of books are available from
libraries and bookstores providing information on specific vaccines re-
quired by different countries as well as general health measures for
travelers. Up-to-date information on immunization recommendations
for international travelers is available from the Centers for Disease
Control and Prevention.
43
Section 4.6
Facts about the Seasonal Flu Vaccine

Reprinted from “Key Facts about Seasonal Flu Vaccine,”
U.S. Centers for Disease Control and Prevention, July 16, 2008.
The single best way to protect against the flu is to get vaccinated
each year.
There are two types of vaccines:
• The “flu shot”: An inactivated vaccine (containing killed
virus) that is given with a needle, usually in the arm. The flu
shot is approved for use in people older than six months, in-
cluding healthy people and people with chronic medical condi-
tions.
• The nasal-spray flu vaccine: A vaccine made with live,
weakened flu viruses that do not cause the flu (sometimes
called LAIV for “live attenuated influenza vaccine” or FluMist®).
LAIV (FluMist®) is approved for use in healthy people two to
forty-nine years of age who are not pregnant.
Each vaccine contains three influenza viruses—one A (H3N2) vi-

rus, one A (H1N1) virus, and one B virus. The viruses in the vaccine
change each year based on international surveillance and scientists’
estimations about which types and strains of viruses will circulate in
a given year.
About two weeks after vaccination, antibodies that provide protec-
tion against influenza virus infection develop in the body.
When to Get Vaccinated

Yearly flu vaccination should begin in September or as soon as
vaccine is available and continue throughout the influenza season,
into December, January, and beyond. This is because the timing and
duration of influenza seasons vary. While influenza outbreaks can
happen as early as October, most of the time influenza activity peaks
in January or later.
44
Who Should Get Vaccinated

In general, anyone who wants to reduce their chances of getting
the flu can get vaccinated. However, it is recommended by the Ad-
visory Committee on Immunization Practices (ACIP) that certain
people should get vaccinated each year. They are either people who
are at high risk of having serious flu complications or people who
live with or care for those at high risk for serious complications.
During flu seasons when vaccine supplies are limited or delayed,
ACIP makes recommendations regarding priority groups for vacci-
nation.
People who should get vaccinated each year are as follows:
• Children aged six months up to their nineteenth birthday

• Pregnant women
• People fifty years of age and older
• People of any age with certain chronic medical conditions
• People who live in nursing homes and other long-term care fa-
cilities
• People who live with or care for those at high risk for complica-
tions from flu, including health care workers, household con-
tacts of persons at high risk for complications from the flu, or
household contacts and out of home caregivers of children less
than six months of age (these children are too young to be vacci-
nated)
Use of the Nasal Spray Flu Vaccine

It should be noted that vaccination with the nasal-spray flu vac-
cine is always an option for healthy people two to forty-nine years of
age who are not pregnant.
Who Should Not Be Vaccinated

There are some people who should not be vaccinated without first
consulting a physician. These include the following:
• People who have a severe allergy to chicken eggs

• People who have had a severe reaction to an influenza vaccina-
tion
45
• People who developed Guillain-Barré syndrome (GBS) within
six weeks of getting an influenza vaccine
• Children less than six months of age (influenza vaccine is not
approved for this age group)
• People who have a moderate-to-severe illness with a fever (they
should wait until they recover to get vaccinated)
Vaccine Effectiveness
The ability of flu vaccine to protect a person depends on the age
and health status of the person getting the vaccine, and the similar-
ity or “match” between the virus strains in the vaccine and those in
circulation. Testing has shown that both the flu shot and the nasal-
spray vaccine are effective at preventing the flu.
Vaccine Side Effects (What to Expect)

Different side effects can be associated with the flu shot and LAIV.
The Flu Shot

The viruses in the flu shot are killed (inactivated), so you cannot
get the flu from a flu shot. Some minor side effects that could occur
are as follows:
• Soreness, redness, or swelling where the shot was given

• Fever (low grade)
• Aches
If these problems occur, they begin soon after the shot and usu-
ally last one to two days. Almost all people who receive influenza
vaccine have no serious problems from it. However, on rare occasions,
flu vaccination can cause serious problems, such as severe allergic
reactions. As of July 1, 2005, people who think that they have been
injured by the flu shot can file a claim for compensation from the
National Vaccine Injury Compensation Program (VICP).
LAIV (FluMist®)
The viruses in the nasal-spray vaccine are weakened and do not
cause severe symptoms often associated with influenza illness. (In
46
clinical studies, transmission of vaccine viruses to close contacts has
occurred only rarely.)
In children, side effects from LAIV (FluMist®) can include the fol-
lowing:
• Runny nose
• Wheezing
• Headache
• Vomiting
• Muscle aches
• Fever
In adults, side effects from LAIV (FluMist®) can include the fol-
lowing:
• Runny nose
• Headache
• Sore throat
• Cough
47
Chapter 5
Self-Examinations Can Lead

to Early Cancer Detection
Chapter Contents
Section 5.1—Skin Cancer Self-Examination ............................... 50
Section 5.2—Testicular Self-Examination .................................. 53
49
Section 5.1
Skin Cancer Self-Examination

Reprinted from “Self-Examination: How to Spot Skin Cancer,” “Warning
Signs: The ABCDEs of Melanoma,” and “The Ugly Duckling Sign: An
Early Melanoma Recognition Tool,” © 2008 Skin Cancer Foundation (www
.skincancer.org). Reprinted with permission.
Self-Examination
Coupled with a yearly skin exam by a doctor, self-examination of
your skin once a month is the best way to detect the early warning
signs of basal cell carcinoma, squamous cell carcinoma, and mela-
noma, the three main types of skin cancer. Look for a new growth or
any skin change.
What you’ll need: a bright light; a full-length mirror; a hand mir-
ror; two chairs or stools; a blow dryer.
Examine head and face, using one or both mirrors. Use blow dryer
to inspect scalp.
Check hands, including nails. In full-length mirror, examine elbows,
arms, underarms.
Focus on neck, chest, torso. Women: Check under breasts.
With back to the mirror, use hand mirror to inspect back of neck,
shoulders, upper arms, back, buttocks, legs.
Sitting down, check legs and feet, including soles, heels, and nails.
Use hand mirror to examine genitals.
Melanoma, the deadliest form of skin cancer, is especially hard to
stop once it has spread (metastasized) to other parts of the body. But
it can be readily treated in its earliest stages.
Warning Signs: The ABCDEs of Melanoma

Moles, brown spots, and growths on the skin are usually harm-
less—but not always. Anyone who has more than one hundred moles
is at greater risk for melanoma. The first signs can appear in one or
more of these moles. That’s why it’s so important to get to know your
skin very well, so you can recognize any changes in the moles on your
50
Self-Examinations Can Lead to Early Cancer Detection
body. Look for the ABCDEs of melanoma, and if you see one or more,
make an appointment with a dermatologist immediately.
Asymmetry: If you draw a line through the mole, the two halves
will not match, meaning it is asymmetrical, a warning sign for mela-
noma.
Border: The borders of an early melanoma tend to be uneven. The

edges may be scalloped or notched.
Color: Having a variety of colors is another warning signal. A

number of different shades of brown, tan, or black could appear. A
melanoma may also become red, white, or blue.
Diameter: Melanomas usually are larger in diameter than the size

of the eraser on your pencil (1/4 inch or 6 mm), but they may some-
times be smaller when first detected.
Evolving: Any change—in size, shape, color, elevation, or another

trait, or any new symptom such as bleeding, itching, or crusting—
points to danger.
Prompt action is your best protection. Common moles and mela-

nomas do not look alike.
Table 5.1. Characteristics of Benign and Malignant Skin Growths

Benign Malignant
Symmetrical Asymmetrical
Borders are even Borders are uneven
One shade Two or more shades
Smaller than 1/4 inch Larger than 1/4 inch
The Ugly Duckling Sign: An Early Melanoma

Recognition Tool
A recently developed early detection tool can improve early diag-
nosis critical to the successful treatment of melanoma.
For many years, the early warning signs of melanoma have been
identified by the acronym “ABCDE” (A stands for asymmetry, B stands
51
for border, C for color, D for diameter, and E for evolving or changing
was recently added.). While the ABCDE rule helps detect many mela-
nomas, there are a group of melanomas that do not manifest the
ABCDE features. Recently, several melanoma specialists developed
a new method of sight detection for skin lesions which could be mela-
noma.
This new method of sight detection for skin lesions is based on the
concept that these melanomas look different—i.e., “the ugly duck-
ling”—compared to surrounding moles. Thus, during skin self exami-
nation, patients and physicians should be looking for lesions that
manifest the ABCDEs and for lesions that look different compared
to surrounding moles.
As reported in the December 2007 issue of The Melanoma Letter,
a publication of the Skin Cancer Foundation, an approach combining
the ABCDEs and the “Ugly Duckling” technique should improve the
chances of early detection of all types of melanoma. In the article “The
‘Ugly Duckling’ Sign: An Early Melanoma Recognition Tool For Cli-
nicians and the Public” by Dr. Alon Scope and Dr. Ashfaq A. Marghoob
of Memorial Sloan Kettering Cancer Center (New York, N.Y.), the
premise of the ugly duckling sign is that the patient’s “normal” moles
resemble each other, like siblings.
The doctors suggest thinking of “the ugly duckling” mole, a.k.a. “the
outlier,” as the lesion that, at a given moment in time, looks or feels
different than the patient’s other moles, or that over time, changes
differently than the patient’s other moles. The “ugly duckling” meth-
odology may be especially useful in the detection of nodular melanoma,
a dangerous type of melanoma, which notoriously lacks the classic
ABCDE signs.
52
Self-Examinations Can Lead to Early Cancer Detection
Section 5.2
Testicular Self-Examination
“How to Perform a Testicular Self-Examination,” August 2008, reprinted
with permission from www.kidshealth.org. Copyright © 2008 The Nemours
Foundation. This information was provided by KidsHealth, one of the larg-
est resources online for medically reviewed health information written
for parents, kids, and teens. For more articles like this one, visit www
.KidsHealth.org, or www.TeensHealth.org.
The testicular self-examination (TSE) is an easy way for guys to

check their own testicles to make sure there aren’t any unusual lumps
or bumps—which can be the first sign of testicular cancer.
Although testicular cancer is rare in teenage guys, overall it is the
most common cancer in males between the ages of fifteen and thirty-
five. It’s important to try to do a TSE every month so you can become
familiar with the normal size and shape of your testicles, making it
easier to tell if something feels different or abnormal in the future.
Here’s what to do:
• It’s best to do a TSE during or right after a hot shower or bath.
The scrotum (skin that covers the testicles) is most relaxed then,
which makes it easier to examine the testicles.
• Examine one testicle at a time. Use both hands to gently roll
each testicle (with slight pressure) between your fingers. Place
your thumbs over the top of your testicle, with the index and
middle fingers of each hand behind the testicle, and then roll it
between your fingers.
• You should be able to feel the epididymis (the sperm-carrying
tube), which feels soft, rope-like, and slightly tender to pressure,
and is located at the top of the back part of each testicle. This is
a normal lump.
• Remember that one testicle (usually the right one) is slightly
larger than the other for most guys—this is also normal.
• When examining each testicle, feel for any lumps or bumps
along the front or sides. Lumps may be as small as a piece of
rice or a pea.
53
• If you notice any swelling, lumps, or changes in the size or color
of a testicle, or if you have any pain or achy areas in your groin,
let your doctor know right away.
Lumps or swelling may not be cancer, but they should be checked

by your doctor as soon as possible. Testicular cancer is almost always
curable if it is caught and treated early.
54
Chapter 6
Nutrition and Wellness
Chapter Contents
Section 6.1—Dietary Changes for a Healthier You .................... 56
Section 6.2—Diet and Disease ...................................................... 62
55
Section 6.1
Dietary Changes for a Healthier You

Reprinted from “Finding Your Way to a Healthier You,”
U.S. Department of Agriculture, April 5, 2005.
Feel Better Today, Stay Healthy for Tomorrow

The food and physical activity choices you make every day affect your
health—how you feel today, tomorrow, and in the future. The science-
based advice of the Dietary Guidelines for Americans, 2005 highlights
how make smart choices from every food group, find your balance be-
tween food and physical activity, and get the most nutrition out of your
calories.
You may be eating plenty of food, but not eating the right foods that
give your body the nutrients you need to be healthy. You may not be
getting enough physical activity to stay fit and burn those extra calo-
ries. This chapter is a starting point for finding your way to a healthier
you.
Eating right and being physically active aren’t just a “diet” or a
“program”—they are keys to a healthy lifestyle. With healthful hab-
its, you may reduce your risk of many chronic diseases such as heart
disease, diabetes, osteoporosis, and certain cancers, and increase your
chances for a longer life.
The sooner you start, the better for you, your family, and your fu-
ture.
Make Smart Choices from Every Food Group

The best way to give your body the balanced nutrition it needs is
by eating a variety of nutrient-packed foods every day. Just be sure
to stay within your daily calorie needs.
A healthy eating plan is one that does the following:
• Emphasizes fruits, vegetables, whole grains, and fat-free or low-
fat milk and milk products
• Includes lean meats, poultry, fish, beans, eggs, and nuts
56
• Is low in saturated fats, trans fats, cholesterol, salt (sodium),
and added sugars.
Don’t Give in When You Eat Out and Are on the Go

It’s important to make smart food choices and watch portion sizes
wherever you are—at the grocery store, at work, in your favorite res-
taurant, or running errands. Try these tips:
• At the store, plan ahead by buying a variety of nutrient-rich

foods for meals and snacks throughout the week.
• When grabbing lunch, have a sandwich on whole-grain bread
and choose low-fat/fat-free milk, water, or other drinks without
added sugars.
• In a restaurant, opt for steamed, grilled, or broiled dishes in-
stead of those that are fried or sautéed.
• On a long commute or shopping trip, pack some fresh fruit,
cut-up vegetables, string cheese sticks, or a handful of un-
salted nuts—to help you avoid impulsive, less healthful snack
choices.
Mix Up Your Choices within Each Food Group

Focus on fruits: Eat a variety of fruits—whether fresh, frozen,
canned, or dried—rather than fruit juice for most of your fruit choices.
For a two-thousand-calorie diet, you will need two cups of fruit each
day (for example, one small banana, one large orange, and 1/4 cup of
dried apricots or peaches).
Vary your veggies: Eat more dark green veggies, such as broc-
coli, kale, and other dark leafy greens; orange veggies, such as car-
rots, sweet potatoes, pumpkin, and winter squash; and beans and peas,
such as pinto beans, kidney beans, black beans, garbanzo beans, split
peas, and lentils.
Get your calcium-rich foods: Get three cups of low-fat or fat-

free milk—or an equivalent amount of low-fat yogurt and/or low-fat
cheese (1½ ounces of cheese equals one cup of milk)—every day. For
kids aged two to eight, it’s two cups of milk. If you don’t or can’t con-
sume milk, choose lactose-free milk products or calcium-fortified foods
and beverages.
57
Make half your grains whole: Eat at least 3 ounces of whole-
grain cereals, breads, crackers, rice, or pasta every day. One ounce is
about 1 slice of bread, 1 cup of breakfast cereal, or ½ cup of cooked
rice or pasta. Look to see that grains such as wheat, rice, oats, or corn
are referred to as “whole” in the list of ingredients.
Go lean with protein: Choose lean meats and poultry. Bake it,
broil it, or grill it. And vary your protein choices—with more fish,
beans, peas, nuts, and seeds.
Know the limits on fats, salt, and sugars: Read the Nutrition
Facts label on foods. Look for foods low in saturated fats and trans
fats. Choose and prepare foods and beverages with little salt (sodium)
or added sugars (caloric sweeteners).
Find Your Balance between Food and Physical Activity

Becoming a healthier you isn’t just about eating healthy—it’s also
about physical activity. Regular physical activity is important for your
overall health and fitness. It also helps you control body weight by
balancing the calories you take in as food with the calories you ex-
pend each day. Here are some tips:
• Be physically active for at least thirty minutes most days of the
week.
• Increasing the intensity or the amount of time that you are
physically active can have even greater health benefits and
may be needed to control body weight. About sixty minutes a
day may be needed to prevent weight gain.
• Children and teenagers should be physically active for sixty
minutes every day, or most every day.
Consider this: If you eat one hundred more food calories a day than
you burn, you’ll gain about one pound in a month. That’s about ten
pounds in a year. The bottom line is that to lose weight, it’s impor-
tant to reduce calories and increase physical activity.
Get the Most Nutrition out of Your Calories

There is a right number of calories for you to eat each day. This num-
ber depends on your age, activity level, and whether you’re trying to
gain, maintain, or lose weight. You could use up the entire amount on
58
a few high-calorie items, but chances are you won’t get the full range
of vitamins and nutrients your body needs to be healthy.
Choose the most nutritionally rich foods you can from each food
group each day—those packed with vitamins, minerals, fiber, and
other nutrients but lower in calories. Pick foods like fruits, vegetables,
whole grains, and fat-free or low-fat milk and milk products more of-
ten.
Nutrition: Know the Facts, Use the Label

Most packaged foods have a Nutrition Facts label. For a healthier
you, use this tool to make smart food choices quickly and easily. Try
these tips:
• Keep these low: saturated fats, trans fats, cholesterol, and so-
dium.
• Get enough of these: potassium, fiber, vitamins A and C, cal-
cium, and iron.
• Use the % Daily Value (DV) column when possible: 5 per-
cent DV or less is low, 20 percent DV or more is high.
Check servings and calories: Look at the serving size and how
many servings you are actually consuming. If you double the servings
you eat, you double the calories and nutrients, including the % DVs.
Make your calories count: Look at the calories on the label and
compare them with what nutrients you are also getting to decide
whether the food is worth eating. When one serving of a single food
item has more than 400 calories per serving, it is high in calories.
Don’t sugarcoat it: Since sugars contribute calories with few, if

any, nutrients, look for foods and beverages low in added sugars. Read
the ingredient list and make sure that added sugars are not one of
the first few ingredients. Some names for added sugars (caloric sweet-
eners) include sucrose, glucose, high fructose corn syrup, corn syrup,
maple syrup, and fructose.
Know your fats: Look for foods low in saturated fats, trans fats,
and cholesterol to help reduce the risk of heart disease (5% DV or less
is low, 20% DV or more is high). Most of the fats you eat should be
polyunsaturated and monounsaturated fats. Keep total fat intake
between 20 percent and 35 percent of calories.
59
Reduce sodium (salt), increase potassium: Research shows
that eating less than 2,300 milligrams of sodium (about 1 tsp of salt)
per day may reduce the risk of high blood pressure. Most of the so-
dium people eat comes from processed foods, not from the saltshaker.
Also look for foods high in potassium, which counteracts some of
sodium’s effects on blood pressure.
Figure 6.1. Nutrition Facts Label
60
Play It Safe with Food

Know how to prepare, handle, and store food safely to keep you and
your family safe:
• Clean hands, food-contact surfaces, fruits, and vegetables. To

avoid spreading bacteria to other foods, meat and poultry should
not be washed or rinsed.
• Separate raw, cooked, and ready-to-eat foods while shopping,
preparing, or storing.
• Cook meat, poultry, and fish to safe internal temperatures to
kill microorganisms.
• Chill perishable foods promptly and thaw foods properly.
Table 6.1. Safe Cooking and Holding Temperatures for Foods

180° F Whole poultry
170° F Poultry breasts
165° F Stuffing, ground poultry, reheat leftovers
160° F Meats (medium), egg dishes, pork, and ground meats
145° F Beef steaks, roasts, veal, lamb (medium rare)
140° F Hold hot foods
41°–139° F DANGER ZONE
40° F Refrigerator temperatures
0° F Freezer temperatures
About Alcohol
If you choose to drink alcohol, do so in moderation. Moderate drink-
ing means up to one drink a day for women and up to two drinks for
men. Twelve ounces of regular beer, 5 ounces of wine, or 1.5 ounces of
80-proof distilled spirits count as a drink for purposes of explaining
moderation. Remember that alcoholic beverages have calories but are
low in nutritional value.
Generally, anything more than moderate drinking can be harmful
to your health. Some people, or people in certain situations, shouldn’t
drink at all. If you have questions or concerns, talk to your doctor or
healthcare provider.
61
Section 6.2
Diet and Disease

Reprinted from “Diet and Disease,”
© 2009 A.D.A.M., Inc. Reprinted with permission.
There are nutritional and dietary elements that have proven re-
lationships to certain diseases or conditions. For additional informa-
tion on U.S. Food and Drug Administration (FDA)–approved health
claims, refer to nutrition labeling.
Calcium and Osteoporosis

Calcium is one of the most important minerals for human life. The
body uses it to form and maintain healthy bones and teeth. Calcium
also plays a vital role in nerve conduction, muscle contraction, and
blood clotting.
Osteoporosis is a disease in which the calcium content of bones is
very low. In this disease, calcium and phosphorus, which are normally
present in the bones, become reabsorbed back into the body. This pro-
cess results in brittle, fragile bones that are easily broken.
Getting enough calcium in the diet throughout childhood and puberty
is one key to preventing osteoporosis. A person who does not get enough
calcium growing up will not have sturdy bones. An older person who
consumes a low-calcium diet is also at great risk for osteoporosis.
The recommended dietary allowances (RDA) for calcium are based
on age, gender, and hormonal factors. Many foods, such as some veg-
etables, contain calcium. However, milk and dairy products are some
of the best food sources. Calcium may also be obtained by taking supple-
ments.
Fiber and Cancer

Dietary fiber is found in plant foods, where it occurs in two forms:
soluble and insoluble. Soluble fiber attracts water and turns to gel
during digestion. This process slows digestion and the rate of nutri-
ent absorption from the stomach and intestine.
62
Soluble fiber is found in oat bran, barley, nuts, seeds, dried beans
and legumes, lentils, peas, and some fruits and vegetables. Insoluble
fiber also adds bulk (fiber) to the stool. It is found in wheat bran, veg-
etables, and whole grains.
A diet high in fiber is thought to reduce the risk of cancers of the
rectum and colon.
Fruits, Vegetables, and Cancer

Eating more fruits and vegetables helps provide a good supply of
fiber, vitamin A, vitamin C, beta carotene and other carotenoids, and
valuable substances called phytochemicals. Studies have shown that
a diet high in these nutrients and fiber can reduce the risk of devel-
oping cancers of the stomach, colon, rectum, esophagus, larynx, and
lung.
Vitamin C and beta carotene, which forms vitamin A, are antioxi-
dants. As such, they protect body cells from oxidation, a process that
can lead to cell damage and may play a role in cancer.
In addition to nutrients that are needed for normal metabolism,
plant foods also contain phytochemicals, plant chemicals that may
affect human health. There are hundreds of phytochemicals, and their
exact role in promoting health is still uncertain. However, a growing
body of evidence indicates that phytochemicals may help protect
against cancer.
To get these benefits, eat more fruits and vegetables that contain
vitamins A and C and beta carotene. These include dark-green leafy
vegetables such as spinach, kale, collards, and turnip greens. Citrus
fruits, such as oranges, grapefruit, and tangerines, are also high in
antioxidants. Other red, yellow, and orange fruits and vegetables or
their juices are also healthful choices. Note: Juicing removes the fi-
ber.
Fiber and Coronary Heart Disease

Some fiber, especially soluble fiber, binds to lipids such as choles-
terol. The fiber then carries the lipids out of the body through the stool.
This lowers the concentration of lipids in the blood and may reduce
the risk of coronary heart disease.
Fat and Cancer

A diet high in fat has been shown to increase the risk of cancers of
the breast, colon, and prostate. A high-fat diet does not necessarily
63
cause cancer. Rather, it may promote the development of cancer in
people who are exposed to cancer-causing agents.
A diet high in fat may promote cancer by causing the body to se-
crete more of certain hormones that create a favorable environment
for certain types of cancer. Breast cancer is one of these hormone-
influenced cancers. High-fat diets also may change the characteris-
tics of the cells to make them more vulnerable to cancer-causing
agents.
To reduce fat in the diet, choose lean cuts of beef, lamb, and pork
as well as skinless poultry and fish. Baking, broiling, poaching, and
steaming are recommended cooking methods. Choose skim or low-fat
milk and dairy products, as well as low-fat salad dressings.
Saturated Fat, Cholesterol, and Coronary Heart Disease

Eating too much saturated fat is one of the major risk factors for
heart disease. A diet high in saturated fat causes cholesterol, a soft,
waxy substance, to build up in the arteries. Eventually, the arteries
harden and narrow. The result is an increased pressure in the arter-
ies as well as strain on the heart to maintain adequate blood flow
throughout the body.
Because of its high calorie content, too much dietary fat also in-
creases the risk of heart disease in that it increases the likelihood that
a person will become obese. Obesity is another risk factor for heart
disease.
Sodium and Hypertension

Sodium is a mineral that helps the body regulate blood pressure.
Sodium is also commonly known as salt. It also plays a role in the
proper functioning of cell membranes, muscles, and nerves. Sodium
concentration in the body is mainly controlled by the kidneys, adre-
nal glands, and the pituitary gland in the brain.
The balance between dietary intake and kidney excretion through
urine determines the amount of sodium in the body. Only a small
amount of sodium is lost through the stool or sweat. The amount of
sodium in urine is controlled by the steroid hormone aldosterone.
Water and sodium are also related. Retention of more sodium is fol-
lowed by retention of more fluid, and vice versa.
Sodium-sensitive individuals may experience high blood pressure
from too much sodium in the diet. The American Heart Association
has developed specific guidelines for sodium intake. Dietary changes
64
may be helpful. Sodium intake may have little effect in persons with-
out high blood pressure, but it may have a profound effect in sodium-
sensitive individuals. Blood pressure is often controlled by diuretics
that cause sodium excretion in the urine.
Alcohol
Alcohol use increases the risk of liver cancer. When combined with
smoking, alcohol intake also increases the risk of cancers of the mouth,
throat, larynx, and esophagus. In addition, alcohol intake is associ-
ated with an increased risk of breast cancer in women.
Alcohol is processed by the liver into energy for the body. Contin-
ued and excessive use of alcohol can damage the liver in various ways,
including the development of a fatty liver. A fatty liver can lead to
cirrhosis of the liver.
Alcohol can damage the lining of the small intestine and stomach,
where most nutrients are digested. As a result, alcohol can impair the
absorption of essential nutrients. Alcohol also increases the body’s
need for some nutrients, and interferes with the absorption and stor-
age of other nutrients.
Continued and excessive use of alcohol can result in an increase
in blood pressure. Chronic heavy drinking also can cause damage to
the heart muscle (cardiomyopathy). In addition, stroke is associated
with both chronic heavy drinking and binge drinking.
If you choose to drink alcohol, do so in moderation—no more than
two drinks per day for a man, one per day for a woman.
Nitrates and Cancer

Countries in which people eat a lot of salt-cured, smoked, and nitrite-
cured foods have a high rate of cancer of the stomach and esophagus.
Examples of such foods include bacon, ham, hot dogs, and salt-cured fish.
Eat salted, smoked, or cured foods only on occasion.
65
Chapter 7
Managing Your Weight:

Avoiding Overweight and
Obesity
What Are Overweight and Obesity?

The terms “overweight” and “obesity” refer to a person’s overall
body weight and where the extra weight comes from. Overweight is
having extra body weight from muscle, bone, fat, and/or water. Obe-
sity is having a high amount of extra body fat. The most useful mea-
sure of overweight and obesity is the body mass index (BMI). BMI is
based on height and weight and is used for adults, children, and teens.
Millions of Americans and people worldwide are overweight or
obese. Being overweight or obese puts you at risk for many diseases
and conditions. The more body fat that you carry around and the more
you weigh, the more likely you are to develop heart disease, high blood
pressure, type 2 diabetes, gallstones, breathing problems, and certain
cancers.
A person’s weight is a result of many factors. These factors include
environment, family history and genetics, metabolism (the way your
body changes food and oxygen into energy), behavior or habits, and
other factors.
Certain things, like family history, can’t be changed. However, other
things—like a person’s lifestyle habits—can be changed. You can help
prevent or treat overweight and obesity if you do the following things:
• Follow a healthful diet, while keeping your calorie needs in mind

Excerpted from “Overweight and Obesity,” National Heart Lung and Blood
Institute, National Institutes of Health, May 2008.
67
• Be physically active
• Limit the time you spend being physically inactive
Weight loss medicines and surgery also are options for some people
who need to lose weight if lifestyle changes don’t work.
Outlook
Reaching and staying at a healthy weight is a long-term challenge
for people who are overweight or obese. But it also can be a chance to
lower your risk of other serious health problems. With the right treat-
ment and motivation, it’s possible to lose weight and lower your long-
term disease risk.
What Causes Overweight and Obesity?

Energy Balance
For most people, overweight and obesity are caused by not having
energy balance. Weight is balanced by the amount of energy or calo-
ries you get from food and drinks (this is called energy IN) equaling
the energy your body uses for things like breathing, digesting, and
being physically active (this is called energy OUT).
Energy balance means that your energy IN equals your energy
OUT. To maintain a healthy weight, your energy IN and OUT don’t
have to balance exactly every day. It’s the balance over time that helps
you maintain a healthy weight:
• The same amount of energy IN and energy OUT over time =
weight stays the same
• More IN than OUT over time = weight gain
• More OUT than IN over time = weight loss
Overweight and obesity happen over time when you take in more
calories than you use.
Other Causes
Physical inactivity: Many Americans aren’t very physically ac-
tive. There are many reasons for this. One reason is that many people
spend hours in front of TVs and computers doing work, schoolwork,
and leisure activities. In fact, more than two hours a day of regular
TV viewing time has been linked to overweight and obesity.
68
Managing Your Weight: Avoiding Overweight and Obesity
Other reasons for not being active include: relying on cars instead
of walking to places, fewer physical demands at work or at home be-
cause modern technology and conveniences reduce the need to burn
calories, and lack of physical education classes in schools for children.
People who are inactive are more likely to gain weight because they
don’t burn up the calories that they take in from food and drinks. An
inactive lifestyle also raises your risk for heart disease, high blood
pressure, diabetes, colon cancer, and other health problems.
Environment: Our environment doesn’t always help with healthy

lifestyle habits; in fact, it encourages obesity. Some reasons are as
follows:
• Lack of neighborhood sidewalks and safe places for recreation:
Not having area parks, trails, sidewalks, and affordable gyms
makes it hard for people to be physically active.
• Work schedules: People often say that they don’t have time to be
physically active, given the long hours at work and the time
spent commuting back and forth to work.
• Oversized food portions: Americans are surrounded by huge food
portions in restaurants, fast food places, gas stations, movie the-
aters, supermarkets, and even home. Some of these meals and
snacks can feed two or more people. Eating large portions means
too much energy IN. Over time, this will cause weight gain if it
isn’t balanced with physical activity.
• Lack of access to healthy foods: Some people don’t live in neigh-
borhoods that have supermarkets that sell healthy foods such
as fresh fruits and vegetables. Or if they do, these items are of-
ten too costly.
• Food advertising: Americans are surrounded by ads from food
companies. Often children are the targets of advertising for high-
calorie, high-fat snacks and sugary drinks. The goal of these ads
is to sway people to buy these high-calorie foods, and often they
do.
Genes and family history: Studies of identical twins who have

been raised apart show that genes have a strong influence on one’s
weight. Overweight and obesity tend to run in families. Your chances
of being overweight are greater if one or both of your parents are over-
weight or obese. Your genes also may affect the amount of fat you store
in your body and where on your body you carry the extra fat.
69
Because families also share food and physical activity habits, there
is a link between genes and the environment. Children adopt the hab-
its of their parents. So, a child with overweight parents who eat high-
calorie foods and are inactive will likely become overweight like the
parents. On the other hand, if a family adopts healthful food and
physical activity habits, the child’s chance of being overweight or obese
is reduced.
Health conditions: Sometimes hormone problems cause over-

weight and obesity. These problems include the following:
• Underactive thyroid (also called hypothyroidism): This is a con-

dition in which the thyroid gland doesn’t make enough thyroid
hormone. Lack of thyroid hormone will slow down your metabo-
lism and cause weight gain. You’ll also feel tired and weak.
• Cushing syndrome: This is a condition in which the body’s adre-
nal glands make too much of the hormone cortisol. Cushing syn-
drome also can happen when people take high levels of medicines
such as prednisone for long periods of time. People with Cushing
syndrome gain weight and have upper-body obesity, a rounded
face, fat around the neck, and thin arms and legs.
• Polycystic ovarian syndrome (PCOS): This is a condition that af-
fects about 5 to 10 percent of women of childbearing age. Women
with PCOS often are obese, have excess hair growth, and have re-
productive and other health problems due to high levels of hor-
mones called androgens.
Medicines: Certain medicines, such as corticosteroids (for ex-

ample, prednisone), antidepressants (for example, Elavil®), and medi-
cines for seizures (for example, Neurontin®), may cause you to gain
weight. These medicines can slow the rate at which your body burns
calories, increase your appetite, or cause your body to hold on to ex-
tra water—all of which can lead to weight gain.
Emotional factors: Some people eat more than usual when they
are bored, angry, or stressed. Over time, overeating will lead to weight
gain and may cause overweight or obesity.
Smoking: Some people gain weight when they stop smoking. One
reason is that food often tastes and smells better. Another reason is
because nicotine raises the rate at which your body burns calories,
70
so you burn fewer calories when you stop smoking. However, smok-
ing is a serious health risk, and quitting is more important than pos-
sible weight gain.
Age: As you get older, you tend to lose muscle, especially if you’re
less active. Muscle loss can slow down the rate at which your body
burns calories. If you don’t reduce your calorie intake as you get older,
you may gain weight. Midlife weight gain in women is mainly due to
aging and lifestyle, but menopause also plays a role. Many women gain
around five pounds during menopause and have more fat around the
waist than they did before.
Pregnancy: During pregnancy, women gain weight so that the

baby gets proper nourishment and develops normally. After giving
birth, some women find it hard to lose the weight. This may lead to
overweight or obesity, especially after a few pregnancies.
Lack of sleep: Studies find that the less people sleep, the more
likely they are to be overweight or obese. People who report sleeping
five hours a night, for example, are much more likely to become obese
compared to people who sleep seven to eight hours a night.
People who sleep fewer hours also seem to prefer eating foods that
are higher in calories and carbohydrates, which can lead to overeat-
ing, weight gain, and obesity over time. Hormones that are released
during sleep control appetite and the body’s use of energy. For ex-
ample, insulin controls the rise and fall of blood sugar levels during
sleep. People who don’t get enough sleep have insulin and blood sugar
levels that are similar to those in people who are likely to have dia-
betes.
Also, people who don’t get enough sleep on a regular basis seem to
have high levels of a hormone called ghrelin (which causes hunger)
and low levels of a hormone called leptin (which normally helps to
curb hunger).
What Are the Health Risks of Overweight and Obesity?

Being overweight or obese isn’t a cosmetic problem. It greatly raises
the risk in adults for many diseases and conditions.
Heart disease: This condition occurs when a fatty material called
plaque builds up on the inside walls of the coronary arteries (the ar-
teries that supply blood and oxygen to your heart). Plaque narrows
71
the coronary arteries, which reduces blood flow to your heart. Your
chances for having heart disease and a heart attack get higher as your
body mass index (BMI) increases. Obesity also can lead to congestive
heart failure, a serious condition in which the heart can’t pump
enough blood to meet your body’s needs.
High blood pressure (hypertension): This condition occurs

when the force of the blood pushing against the walls of the arteries
is too high. Your chances for having high blood pressure are greater
if you’re overweight or obese.
Stroke: Being overweight or obese can lead to a buildup of fatty

deposits in your arteries that form a blood clot. If the clot is close to
your brain, it can block the flow of blood and oxygen and cause a
stroke. The risk of having a stroke rises as BMI increases.
Type 2 diabetes: This is a disease in which blood sugar (glucose)

levels are too high. Normally, the body makes insulin to move the blood
sugar into cells where it’s used. In type 2 diabetes, the cells don’t re-
spond enough to the insulin that’s made. Diabetes is a leading cause
of early death, heart disease, stroke, kidney disease, and blindness.
More than 80 percent of people with type 2 diabetes are overweight.
Abnormal blood fats: If you’re overweight or obese, you have a

greater chance of having abnormal levels of blood fats. These include
high amounts of triglycerides and low-density lipoprotein (LDL) cho-
lesterol (a fat-like substance often called “bad” cholesterol), and low
amounts of high-density lipoprotein (HDL) cholesterol (often called
“good” cholesterol). Abnormal levels of these blood fats are a risk for
heart disease.
Metabolic syndrome: This is the name for a group of risk fac-

tors linked to overweight and obesity that raise your chance for heart
disease and other health problems such as diabetes and stroke. A
person can develop any one of these risk factors by itself, but they tend
to occur together. Metabolic syndrome occurs when a person has at
least three of these heart disease risk factors:
• A large waistline. This is also called abdominal obesity or

“having an apple shape.” Having extra fat in the waist area
is a greater risk factor for heart disease than having extra fat
in other parts of the body, such as on the hips.
72
• Abnormal blood fat levels, including high triglycerides and low
HDL cholesterol.
• Higher than normal blood pressure.
• Higher than normal fasting blood sugar levels.
Cancer: Being overweight or obese raises the risk for colon, breast,
endometrial, and gallbladder cancers.
Osteoarthritis: This is a common joint problem of the knees, hips,

and lower back. It occurs when the tissue that protects the joints
wears away. Extra weight can put more pressure and wear on joints,
causing pain.
Sleep apnea: This condition causes a person to stop breathing for

short periods during sleep. A person with sleep apnea may have more
fat stored around the neck. This can make the breathing airway
smaller so that it’s hard to breathe.
Reproductive problems: Obesity can cause menstrual irregular-

ity and infertility in women.
Gallstones: These are hard pieces of stone-like material that form

in the gallbladder. They’re mostly made of cholesterol and can cause
abdominal or back pain. People who are overweight or obese have a
greater chance of having gallstones. Also, being overweight may re-
sult in an enlarged gallbladder that may not work properly.
How Are Overweight and Obesity Diagnosed?

Body Mass Index
The most common way to find out whether you’re overweight or
obese is to figure out your body mass index (BMI). BMI is an estimate
of body fat and a good gauge of your risk for diseases that occur with
more body fat. The higher your BMI, the higher your risk of disease.
BMI is calculated from your height and weight. You can use Table 7.1
to figure out your BMI.
Use this table to learn your BMI. First, find your height on the far
left column. Next, move across the row to find your weight. Once
you’ve found your weight, move to the very top of that column. This
number is your BMI.
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Table 7.1. Body Mass Index for Adults

Height 21 22 23 24 25 26 27 28 29 30 31
4'10" 100 105 110 115 119 124 129 134 138 143 148
5'0" 107 112 118 123 128 133 138 143 148 153 158
5'1" 111 116 122 127 132 137 143 148 153 158 164
5'3" 118 124 130 135 141 146 152 158 163 169 175
5'5" 126 132 138 144 150 156 162 168 174 180 186
5'7" 134 140 146 153 159 166 172 178 185 191 198
5'9" 142 149 155 162 169 176 182 189 196 203 209
5'11" 150 157 165 172 179 186 193 200 208 215 222
6'1" 159 166 174 182 189 197 204 212 219 227 235
6'3" 168 176 184 192 200 208 216 224 232 240 248
Note: Weight is measured with underwear but no shoes.
Table 7.2. What Does Body Mass Index Mean?

BMI
18.5–24.9 Normal weight
25.0–29.9 Overweight
30.0–39.9 Obese
40.0 and above Extreme obesity
Although BMI can be used for most men and women, it does have
some limits:
• It may overestimate body fat in athletes and others who have a
muscular build.
• It may underestimate body fat in older persons and others who
have lost muscle.
Waist Circumference
Health care professionals also may take your waist measurement.
This helps to screen for the possible health risks that come with over-
weight and obesity in adults. If you have abdominal obesity and most
74
of your fat is around your waist rather than at your hips, you’re at
higher risk for heart disease and type 2 diabetes. This risk goes up
with a waist size that is greater than thirty-five inches for women or
greater than forty inches for men.
You, too, may want to measure your waist size. To do so correctly,
stand and place a tape measure around your middle, just above your
hipbones. Measure your waist just after you breathe out.
How Are Overweight and Obesity Treated?

Successful treatments for weight loss include setting goals and
making lifestyle changes such as eating fewer calories and being more
physically active. Drug therapy and weight loss surgery are also op-
tions for some people if lifestyle changes don’t work.
Set Realistic (“Do-able”) Goals

Setting the right weight loss goals is an important first step to los-
ing and maintaining weight:
• Lose just 5 to 10 percent of your current weight over six
months. This will lower your risk for heart disease and other
conditions.
• The best way to lose weight is slowly. A weight loss of one to
two pounds a week is do-able, safe, and will help you keep off
the weight. It also will give you the time to make new, healthy
lifestyle changes.
• If you’ve lost 10 percent of your body weight, have kept it off
for six months, and are still overweight or obese, you may want
to consider further weight loss.
Lifestyle Changes
For long-term weight loss success, it’s important for you and your
family to make lifestyle changes:
• Focus on energy IN (calories from food and drinks) and energy
OUT (physical activity).
• Follow a healthy eating plan.
• Learn how to adopt more healthful lifestyle habits.
Over time, these changes will become part of your everyday life.
75
Calories
Cutting back on calories (energy IN) will help you lose weight. To
lose one to two pounds a week, adults should cut back their calorie
intake by 500 to 1,000 calories a day:
• In general, 1,000 to 1,200 calories a day will help most women
lose weight safely.
• In general, 1,200 to 1,600 calories a day will help most men lose
weight safely. This calorie range is also suitable for women who
weigh 165 pounds or more or who exercise routinely.
These calorie levels are a guide and may need to be adjusted. If

you eat 1,600 calories a day but don’t lose weight, then you may want
to cut back to 1,200 calories. If you’re hungry on either diet, then you
may want to boost your calories by 100 to 200 a day. Very-low-calorie
diets of less than 800 calories a day shouldn’t be used unless your
doctor is monitoring you.
Healthy Eating Plan

A healthy eating plan gives your body the nutrients it needs ev-
ery day. It has enough calories for good health, but not so many that
you gain weight.
A healthy eating plan also will lower your risk for heart disease
and other conditions. A plan low in total, saturated, and trans fat;
cholesterol; and sodium (salt) will help to lower your risk for heart
disease. Cutting down on fats and added sugars also can help you
eat fewer calories and lose weight. Healthful foods include the fol-
lowing:
• Fat-free and low-fat milk and milk products such as low-fat yo-
gurt, cheese, and milk.
• Lean meat, fish, poultry, cooked beans, and peas.
• Whole-grain foods such as whole wheat bread, oatmeal, and
brown rice. Other grain foods like pasta, cereal, bagels, bread,
tortillas, couscous, and crackers.
• Fruits, which can be canned (in juice or water), fresh, frozen, or
dried.
• Vegetables, which can be canned (without salt), fresh, frozen, or
dried.
76
Canola or olive oils and soft margarines made from these oils are
heart healthy. They should be used in small amounts because they’re
high in calories. Unsalted nuts, like walnuts and almonds, also can
be built into a healthful diet as long as you watch the amount you
eat, because nuts are high in calories.
Foods to limit: Foods that are high in saturated and trans fats
and cholesterol raise blood cholesterol levels and also may be high in
calories. These fats raise the risk of heart disease, so they should be
limited.
Saturated fat is found mainly in the following:
• Fatty cuts of meat such as ground beef, sausage, and processed
meats such as bologna, hot dogs, and deli meats
• Poultry with the skin
• High-fat milk and milk products like whole-milk cheeses, whole
milk, cream, butter, and ice cream
• Lard, coconut, and palm oils found in many processed foods
Trans fat is found mainly in the following:

• Foods with partially hydrogenated oils such as many hard mar-
garines and shortening
• Baked products and snack foods such as crackers, cookies,
doughnuts, and breads
• Food fried in hydrogenated shortening such as French fries and
chicken
Cholesterol is found mainly in the following:

• Egg yolks
• Organ meats such as liver
• Shrimp
• Whole milk or whole-milk products, including butter, cream,
and cheese
Limiting foods and drinks with added sugars, like high-fructose

corn syrup, is important. Added sugars will give you extra calories
without nutrients like vitamins and minerals. Added sugars are found
in many desserts, canned fruit packed in syrup, fruit drinks, and
77
nondiet drinks. Check the nutrition label on food packages for added
sugars like high-fructose corn syrup. Drinks with alcohol also will add
calories, so it’s a good idea to watch alcohol intake.
Portion size: A portion is the amount of food that you choose to eat
for a meal or snack. It’s different from a serving, which is a measured
amount of food and is noted on the nutrition label on food packages.
Anyone who has eaten out lately is likely to notice how big the
portions are. In fact, they’re oversized. These ever-larger portions have
changed what we think of as normal.
Cutting back on portion size is a good way to help you eat fewer
calories and balance your energy IN.
Food weight: Studies have shown that we all tend to eat a con-
stant “weight” of food. Ounce for ounce, our food intake is fairly con-
stant. Knowing this, you can lose weight if you eat foods that are lower
in calories and fat for a given measure of food. For example, replac-
ing a full-fat food product that weighs two ounces with one that’s the
same weight but lower in fat helps you cut back on calories. Another
helpful practice is to eat foods that contain a lot of water, like veg-
etables, fruits, and soups.
Physical Activity
Staying active and eating fewer calories will help you lose weight
and keep the weight off over time. Physical activity also will benefit
you in other ways. It will do the following:
• Lower the risk of heart disease, diabetes, and cancers (such as

breast, uterus, and colon)
• Strengthen your lungs and help them to work better
• Strengthen your muscles and keep your joints in good condition
• Slow bone loss
• Give you more energy
• Help you to relax and cope better with stress
• Allow you to fall asleep more quickly and sleep more soundly
• Give you an enjoyable way to share time with friends and family
In general, adults should follow these guidelines in relation to

physical activity:
78
• For overall health and to lower the risk of disease, aim for at
least thirty minutes of moderate-intensity physical activity most
days of the week.
• To help manage body weight and prevent gradual weight gain,
aim for sixty minutes of moderate-to-vigorous-intensity physical
activity most days of the week.
• To maintain weight loss, aim for at least sixty to ninety minutes
of daily moderate-intensity physical activity.
Many people lead inactive lives and may not be motivated to do

more physical activity. Some people may need help and supervision
when they start a physical activity program to avoid injury.
If you’re obese, or if you haven’t been active in the past, start physi-
cal activity slowly and build up the intensity a little at a time. When
starting out, one way to be active is to do more “everyday” activities
such as taking the stairs instead of the elevator and doing household
chores and yard work. The next step is to start walking, biking, or
swimming at a slow pace, and then build up the amount of time you
exercise or the intensity level of the activity.
To lose weight and gain better health, it’s important to get moderate-
intensity physical activity. Choose activities that you enjoy and that
fit into your daily life. A daily, brisk walk is an easy way to be more
active and improve your health. Use a pedometer to count your daily
steps and keep track of how much you’re walking. Try to increase the
number of steps you take each day.
Other examples of moderate-intensity physical activity include danc-
ing, bicycling, gardening, and swimming. For greater health benefits,
try to step up your level of activity or the length of time you’re active.
For example, start walking for ten to fifteen minutes three times a week,
and then build up to brisk walking for sixty minutes, five days a week.
You also can break up the amount of time that you’re physically active
into shorter amounts, such as fifteen minutes at a time.
Behavioral Changes
Changing your behaviors or habits around food and physical ac-
tivity is important for losing weight. The first step is to understand
the things that lead you to overeat or have an inactive lifestyle. The
next step is to change these habits.
The list below gives you some simple tips to help build healthier
habits.
79
Change your surroundings: You may be more likely to overeat
when watching TV, when treats are available in the office break room,
or when you’re with a certain friend. You also may not be motivated
to take the exercise class you signed up for. But you can change these
habits. Here are some things you can do:
• Instead of watching TV, dance to music in your living room or go

for a walk.
• Leave the office break room right after you get a cup of coffee.
• Bring a change of clothes to work. Head straight to the exercise
class on the way home from work.
• Put a note on your calendar to remind yourself to take a walk or
go to your activity class.
Keep a record: A record of your food intake and the amount of

physical activity that you do each day will help to inspire you. You also
can keep track of your weight. For example, when the record shows
that you’ve been meeting your goal to be more active, you’ll want to
keep it up. A record is also an easy way to track how you’re doing, es-
pecially if you’re working with a registered dietitian or nutritionist.
Seek support: Ask for help or encouragement from your friends,

family, and health care provider. You can get support in person,
through e-mail, or by talking on the phone. You also can join a sup-
port group.
Reward success: Reward your success for meeting your weight

loss goals or other achievements with something you would like to do,
not with food. Choose rewards that you’ll enjoy, such as a movie, a
music CD, an afternoon off from work, a massage, or personal time.
Weight Loss Medicines

Weight loss medicines approved by the Food and Drug Adminis-
tration (FDA) may be an option for some people. If you’re not success-
ful at losing one pound a week after six months of using lifestyle
changes, medicines may help. These medicines should be used only
as part of a program that includes diet, physical activity, and behav-
ioral changes.
Weight loss medicines may be suitable for adults who are obese (a
BMI of 30 or greater). People who have BMIs of 27 or greater and a
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risk for heart disease and other health conditions also may benefit
from medicines.
The FDA has approved two prescription weight loss medicines for
long-term use: sibutramine (Meridia®) and orlistat (Xenical®). These
medicines cause a weight loss between four and twenty-two pounds,
although some people lose more weight. Most of the weight loss oc-
curs within the first six months of taking the medicine.
Sibutramine (Meridia): This medicine sends signals to your

brain to curb your appetite. Sibutramine raises blood pressure and
pulse. You shouldn’t take it if you have high blood pressure or a his-
tory of heart disease or stroke.
Orlistat (Xenical): This medicine reduces the absorption of fats,

fat calories, and vitamins A, D, E, and K by the body. Orlistat can re-
sult in mild side effects such as oily and loose stools.
The FDA also has approved Alli®, an over-the-counter weight loss
aid for adults. Alli is the lower-dose form of orlistat. It’s meant to be
used along with a reduced-calorie, low-fat diet and physical activity. In
studies, most people taking Alli lost five to ten pounds over six months.
Like orlistat, Alli reduces the absorption of fats, fat calories, and
vitamins A, D, E, and K to promote weight loss. It also has similar side
effects to orlistat. If you’re taking orlistat or Alli, you should take a
multivitamin at bedtime due to the possible loss of some vitamins. You
also should talk to your doctor before starting Alli if you’re taking blood-
thinning medicines or being treated for diabetes or thyroid disease.
Combined with healthy eating and physical activity, these medi-
cines can help people lose weight. If you think you would benefit from
the prescription medicines sibutramine or orlistat, talk to your doc-
tor. People taking these medicines need regular checkups with their
doctors, especially in the first year after starting the medicine. Dur-
ing checkups, your doctor will check your weight, blood pressure, and
pulse and order laboratory tests. He or she also will discuss any medi-
cine side effects and answer your questions.
Over-the-Counter Products
Over-the-counter (OTC) products often claim that a person taking
them will lose weight. The FDA doesn’t regulate these products be-
cause they’re considered dietary supplements, not medicines. How-
ever, many of these products have serious side effects and aren’t
generally recommended. A few OTC products include the following:
81
• Ephedra (also called Ma-huang): Ephedra comes from plants
and has been sold as a dietary supplement. The active ingredient
in the plant is called ephedrine. Ephedra can cause short-term
weight loss. It also has serious side effects. It causes high blood
pressure and stresses the heart. In fact, because ephedra poses
a serious health risk, the FDA has advised people to stop using
dietary supplements that contain it.
• Chromium: This is a mineral that’s sold as a dietary supple-
ment to reduce body fat. While studies haven’t found any weight
loss benefit from chromium, there are few serious side effects
from taking it.
• Diuretics and herbal laxatives: These products cause you to
lose water weight, not fat. They also can lower your body’s potas-
sium levels, which may cause heart and muscle problems.
• Hoodia: Hoodia is a cactus that is native to Africa. It’s sold in
pill form as an appetite suppressant. However, there is no firm
evidence that hoodia works. No large-scale research has been
done on humans to show whether hoodia is effective or safe.
Weight Loss Surgery

Weight loss surgery may be an option for people with extreme obe-
sity (BMI of 40 or greater) when other treatments have failed. It’s
also an option for people with a BMI of 35 or greater who have life-
threatening conditions such as the following:
• Severe sleep apnea (a condition in which your breathing stops
or gets very shallow while you’re sleeping)
• Obesity-related cardiomyopathy (diseases of the heart muscle)
• Severe type 2 diabetes
There are two common weight loss surgeries:
• Banded gastroplasty: For this surgery, a band or staples are

used to create a small pouch at the top of your stomach. This sur-
gery limits the amount of food and liquids the stomach can hold.
• Roux-en-Y gastric bypass: For this surgery, a small stomach
pouch is created with a bypass around part of the small intestine
where most of the calories you eat are absorbed. This surgery
limits food intake and reduces the calories your body absorbs.
82
Weight loss surgery can improve your health and weight. However,
the surgery can be risky depending on your overall health. There are
few long-term side effects with gastroplasty; however, you must limit
your food intake dramatically. Roux-en-Y gastric bypass has more side
effects. These include nausea, bloating, diarrhea, and faintness (which
are all part of a condition called dumping syndrome). After Roux-en-Y
gastric bypass, multivitamins and minerals may be needed to prevent
nutrient deficiencies.
Lifelong medical follow-up is needed after both surgeries. A moni-
toring program both before and after surgery also is advised to help
you with diet, physical activity, and coping skills.
If you think you would benefit from weight loss surgery, talk to your
doctor. Ask whether you’re a candidate for the surgery and discuss
the risks, benefits, and what to expect.
Weight Loss Maintenance

Maintaining your weight loss over time can be a challenge. For
adults, weight loss is a success if you lose at least 10 percent of your
initial weight and you don’t regain more than six or seven pounds in
two years. You also must keep a lower waist circumference—at least
two inches lower than your waist circumference before you lost weight.
After six months of keeping off the weight, you can think about
losing more if the following are true:
• You’ve already lost 5 to 10 percent of your body weight

• You’re still overweight or obese
The key to further weight loss or to maintain your weight loss is

to continue with lifestyle changes. Adopt these changes as a new way
of life. However, if you want to lose more weight, you may need to eat
fewer calories and increase your activity level. For example, if you eat
1,600 calories a day but don’t lose weight, you may want to cut back
to 1,200 calories.
Adults should aim for sixty to ninety minutes of daily moderate-
intensity physical activity.
How Can Overweight and Obesity Be Prevented?

Staying at a healthy weight and preventing overweight and obe-
sity can be achieved through living a healthy lifestyle. Because life-
time habits begin in childhood, it’s important for parents and families
83
to create habits that encourage healthy food choices and physical ac-
tivity early in life.
84
Chapter 8
Physical Activity:
Key to a Healthy Lifestyle
Physical Activity and Health

The Benefits of Physical Activity
Regular physical activity is one of the most important things you
can do for your health. It can help:
• control your weight;

• reduce your risk of cardiovascular disease;
• reduce your risk for type 2 diabetes and metabolic syndrome;
• reduce your risk of some cancers;
• strengthen your bones and muscles;
• improve your mental health and mood;
• improve your ability to do daily activities and prevent falls, if
you’re an older adult;
• increase your chances of living longer.
If you’re not sure about becoming active or boosting your level of

physical activity because you’re afraid of getting hurt, the good news
Excerpted from the following documents from the Centers for Disease Con-
trol and Prevention: “Physical Activity and Health,” December 3, 2008; “How
Much Physical Activity Do Adults Need?” December 17, 2008; and “Adding Physi-
cal Activity to Your Life,” January 15, 2009.
85
is that moderate-intensity aerobic activity, like brisk walking, is gen-
erally safe for most people.
Start slowly. Cardiac events, such as a heart attack, are rare dur-
ing physical activity. But the risk does go up when you suddenly be-
come much more active than usual. For example, you can put yourself
at risk if you don’t usually get much physical activity and then all of
a sudden do vigorous-intensity aerobic activity, like shoveling snow.
That’s why it’s important to start slowly and gradually increase your
level of activity.
If you have a chronic health condition such as arthritis, diabetes,
or heart disease, talk with your doctor to find out if your condition
limits, in any way, your ability to be active. Then, work with your doc-
tor to come up with a physical activity plan that matches your abili-
ties. If your condition stops you from meeting the minimum guidelines,
try to do as much as you can. What’s important is that you avoid be-
ing inactive. Even sixty minutes a week of moderate-intensity aero-
bic activity is good for you.
The bottom line is, the health benefits of physical activity far out-
weigh the risks of getting hurt.
Control Your Weight

Looking to get to or stay at a healthy weight? Both diet and physi-
cal activity play a critical role in controlling your weight. You gain
weight when the calories you burn, including those burned during
physical activity, are less than the calories you eat or drink. When it
comes to weight management, people vary greatly in how much physi-
cal activity they need. You may need to be more active than others to
achieve or maintain a healthy weight.
To maintain your weight: Work your way up to 150 minutes of

moderate-intensity aerobic activity, 75 minutes of vigorous-intensity
aerobic activity, or an equivalent mix of the two each week. Strong
scientific evidence shows that physical activity can help you main-
tain your weight over time. However, the exact amount of physical
activity needed to do this is not clear since it varies greatly from per-
son to person. It’s possible that you may need to do more than the
equivalent of 150 minutes of moderate-intensity activity a week to
maintain your weight.
To lose weight and keep it off: You will need a high amount
of physical activity unless you also adjust your diet and reduce the
86
Physical Activity: Key to a Healthy Lifestyle
number of calories you’re eating and drinking. Getting to and stay-
ing at a healthy weight requires both regular physical activity and a
healthy eating plan.
Reduce Your Risk of Cardiovascular Disease

Heart disease and stroke are two of the leading causes of death in
the United States. But following the guidelines and getting at least
150 minutes a week (2 hours and 30 minutes) of moderate-intensity
aerobic activity can put you at a lower risk for these diseases. You can
reduce your risk even further with more physical activity. Regular
physical activity can also lower your blood pressure and improve your
cholesterol levels.
Reduce your Risk of Type 2 Diabetes and Metabolic Syn-

drome
Regular physical activity can reduce your risk of developing type
2 diabetes and metabolic syndrome. Metabolic syndrome is a condi-
tion in which you have some combination of too much fat around the
waist, high blood pressure, low high-density lipoprotein (HDL) cho-
lesterol, high triglycerides, or high blood sugar. Research shows that
lower rates of these conditions are seen with 120 to 150 minutes
(2 hours to 2 hours and 30 minutes) a week of at least moderate-
intensity aerobic activity. And the more physical activity you do, the
lower your risk will be.
Already have type 2 diabetes? Regular physical activity can help
control your blood glucose levels.
Reduce Your Risk of Some Cancers

Being physically active lowers your risk for two types of cancer:
colon and breast. Research shows that the following is true:
• Physically active people have a lower risk of colon cancer than

do people who are not active.
• Physically active women have a lower risk of breast cancer than
do people who are not active.
Improve your quality of life: If you are a cancer survivor, re-

search shows that getting regular physical activity not only helps give
you a better quality of life, but also improves your physical fitness.
87
Strengthen Your Bones and Muscles

As you age, it’s important to protect your bones, joints, and muscles.
Not only do they support your body and help you move, but keeping
bones, joints, and muscles healthy can help ensure that you’re able
to do your daily activities and be physically active. Research shows
that doing aerobic, muscle-strengthening, and bone-strengthening
physical activity of at least a moderately intense level can slow the
loss of bone density that comes with age.
Hip fracture is a serious health condition that can have life-
changing negative effects, especially if you’re an older adult. But re-
search shows that people who do 120 to 300 minutes of at least
moderate-intensity aerobic activity each week have a lower risk of hip
fracture.
Regular physical activity helps with arthritis and other conditions
affecting the joints. If you have arthritis, research shows that doing
130 to 150 (2 hours and 10 minutes to 2 hours and 30 minutes) a week
of moderate-intensity, low-impact aerobic activity can not only improve
your ability to manage pain and do everyday tasks, but it can also
make your quality of life better.
Build strong, healthy muscles. Muscle-strengthening activities can
help you increase or maintain your muscle mass and strength. Slowly
increasing the amount of weight and number of repetitions you do will
give you even more benefits, no matter your age.
Improve Your Mental Health and Mood

Regular physical activity can help keep your thinking, learning,
and judgment skills sharp as you age. It can also reduce your risk of
depression and may help you sleep better.
Improve Your Ability to Do Daily Activities and Prevent

Falls
A functional limitation is a loss of the ability to do everyday ac-
tivities such as climbing stairs, grocery shopping, or playing with your
grandchildren.
How does this relate to physical activity? If you’re a physically
active middle-aged or older adult, you have a lower risk of functional
limitations than people who are inactive.
Already have trouble doing some of your everyday activities? Aero-
bic and muscle-strengthening activities can help improve your abil-
ity to do these types of tasks.
88
Are you an older adult who is at risk for falls? Research shows that
doing balance and muscle-strengthening activities each week along
with moderate-intensity aerobic activity, like brisk walking, can help
reduce your risk of falling.
Increase Your Chances of Living Longer

Science shows that physical activity can reduce your risk of dying
early from the leading causes of death, like heart disease and some
cancers. This is remarkable in two ways:
• Only a few lifestyle choices have as large an impact on your
health as physical activity. People who are physically active for
about seven hours a week have a 40 percent lower risk of dying
early than those who are active for less than 30 minutes a week.
• You don’t have to do high amounts of activity or vigorous-
intensity activity to reduce your risk of premature death. You
can put yourself at lower risk of dying early by doing at least
150 minutes a week of moderate-intensity aerobic activity.
How Much Physical Activity Do Adults Need?

Physical activity is anything that gets your body moving. Accord-
ing to the 2008 Physical Activity Guidelines for Americans, you need
to do two types of physical activity each week to improve your health—
aerobic and muscle-strengthening.
For Important Health Benefits

Adults need at least:
• Two hours and 30 minutes (150 minutes) of moderate-intensity
aerobic activity (i.e., brisk walking) every week and muscle-
strengthening activities on two or more days a week that work
all major muscle groups (legs, hips, back, abdomen, chest, shoul-
ders, and arms); or
• One hour and 15 minutes (75 minutes) of vigorous-intensity
aerobic activity (i.e., jogging or running) every week and muscle-
strengthening activities on two or more days a week that work
all major muscle groups (legs, hips, back, abdomen, chest, shoul-
ders, and arms); or
• An equivalent mix of moderate- and vigorous-intensity aerobic
activity and muscle-strengthening activities on two or more days
89
a week that work all major muscle groups (legs, hips, back, ab-
domen, chest, shoulders, and arms).
Ten minutes at a time is fine: We know 150 minutes each week

sounds like a lot of time, but you don’t have to do it all at once. Not
only is it best to spread your activity out during the week, but you
can break it up into smaller chunks of time during the day, as long as
you’re doing your activity at a moderate or vigorous effort for at least
ten minutes at a time.
For Even Greater Health Benefits

Adults should increase their activity to:
• Five hours (300 minutes) each week of moderate-intensity aero-
bic activity and muscle-strengthening activities on two or more
days a week that work all major muscle groups (legs, hips, back,
abdomen, chest, shoulders, and arms); or
• Two hours and 30 minutes (150 minutes) each week of vigorous-
intensity aerobic activity and muscle-strengthening activities on
two or more days a week that work all major muscle groups (legs,
hips, back, abdomen, chest, shoulders, and arms); or
• An equivalent mix of moderate- and vigorous-intensity aerobic
activity and muscle-strengthening activities on two or more days
a week that work all major muscle groups (legs, hips, back, ab-
domen, chest, shoulders, and arms).
More time equals more health benefits: If you go beyond 300

minutes a week of moderate-intensity activity, or 150 minutes a week
of vigorous-intensity activity, you’ll gain even more health benefits.
Aerobic Activity—What Counts?

Aerobic activity or “cardio” gets you breathing harder and your
heart beating faster. From pushing a lawn mower, to taking a dance
class, to biking to the store—all types of activities count, as long as
you’re doing them at a moderate or vigorous intensity for at least ten
minutes at a time.
Intensity is how hard your body is working during aerobic activ-
ity.
How do you know if you’re doing light-, moderate-, or vigorous-
intensity aerobic activities? For most people, light daily activities such
90
as shopping, cooking, or doing the laundry don’t count toward the
guidelines. Why? Your body isn’t working hard enough to get your
heart rate up.
Moderate-intensity aerobic activity means you’re working hard
enough to raise your heart rate and break a sweat. One way to tell is
that you’ll be able to talk, but not sing the words to your favorite song.
Here are some examples of activities that require moderate effort:
• Walking fast
• Doing water aerobics
• Riding a bike on level ground or with few hills
• Playing doubles tennis
• Pushing a lawn mower
Vigorous-intensity aerobic activity means you’re breathing hard

and fast, and your heart rate has gone up quite a bit. If you’re work-
ing at this level, you won’t be able to say more than a few words with-
out pausing for a breath. Here are some examples of activities that
require vigorous effort:
• Jogging or running
• Swimming laps
• Riding a bike fast or on hills
• Playing singles tennis
• Playing basketball
You can do moderate- or vigorous-intensity aerobic activity, or

a mix of the two each week. A rule of thumb is that one minute of
vigorous-intensity activity is about the same as two minutes of
moderate-intensity activity.
Muscle-Strengthening Activities—What Counts?

Besides aerobic activity, you need to do things to strengthen your
muscles at least two days a week. These activities should work all the
major muscle groups of your body (legs, hips, back, chest, abdomen,
shoulders, and arms).
To gain health benefits, muscle-strengthening activities need to be
done to the point where it’s hard for you to do another repetition with-
out help. A repetition is one complete movement of an activity, like
91
lifting a weight or doing a sit-up. Try to do eight to twelve repetitions
per activity that count as one set. Try to do at least one set of muscle-
strengthening activities, but to gain even more benefits, do two or
three sets.
There are many ways you can strengthen your muscles, whether
it’s at home or the gym. You may want to try the following:
• Lifting weights
• Working with resistance bands
• Doing exercises that use your body weight for resistance (i.e.,
push-ups, sit-ups)
• Heavy gardening (i.e., digging, shoveling)
• Yoga
92
Chapter 9
How Much Sleep

Do We Really Need?
Our Sleep Needs

What the Research Says about Sleep Duration
The first thing experts will tell you about sleep is that there is no
“magic number.” Not only do different age groups need different
amounts of sleep, but sleep needs are also individual. Just like any
other characteristics you are born with, the amount of sleep you need
to function best may be different for you than for someone who is of
the same age and gender. While you may be at your absolute best
sleeping seven hours a night, someone else may clearly need nine
hours to have a happy, productive life. In fact, a 2005 study confirmed
the fact that sleep needs vary across populations, and the study calls
for further research to identify traits within genes that may provide
a “map” to explain how sleep needs differ among individuals.
Another reason there is “no magic number” for your sleep results
from two different factors that researchers are learning about: a
person’s basal sleep need—the amount of sleep our bodies need on a
regular basis for optimal performance—and sleep debt, the accumu-
lated sleep that is lost to poor sleep habits, sickness, awakenings due
to environmental factors, or other causes. Two studies suggest that
“Our Sleep Needs” is excerpted from “How Much Sleep Do We Really Need?”
and the “Sleep Needs over the Life Cycle” table is excerpted from “Let Sleep Work
for You,” © 2007 National Sleep Foundation (www.sleepfoundation.org). Reprinted
with permission.
93
healthy adults have a basal sleep need of seven to eight hours every
night, but where things get complicated is the interaction between
the basal need and sleep debt. For instance, you might meet your basal
sleep need on any single night or a few nights in a row, but still have
an unresolved sleep debt that may make you feel more sleepy and less
alert at times, particularly in conjunction with circadian dips, those
times in the twenty-four-hour cycle when we are biologically pro-
grammed to be more sleepy and less alert, such as overnight hours
and mid-afternoon. You may feel overwhelmingly sleepy quite suddenly
at these times, shortly before bedtime, or feel sleepy upon awakening.
The good news is that some research suggests that the accumulated
sleep debt can be worked down or “paid off.”
Though scientists are still learning about the concept of basal sleep
need, one thing sleep research certainly has shown is that sleeping
too little can not only inhibit your productivity and ability to remem-
ber and consolidate information, but lack of sleep can also lead to se-
rious health consequences and jeopardize your safety and the safety
of individuals around you.
For example, short sleep duration is linked with:
• increased risk of motor vehicle accidents;
• increase in body mass index—a greater likelihood of obesity due
to an increased appetite caused by sleep deprivation;
• increased risk of diabetes and heart problems;
• increased risk for psychiatric conditions including depression
and substance abuse;
• decreased ability to pay attention, react to signals, or remember
new information.
According to researchers Michael H. Bonnet and Donna L. Arand,

“There is strong evidence that sufficient shortening or disturbance of
the sleep process compromises mood, performance and alertness and
can result in injury or death. In this light, the most common-sense
‘do no injury’ medical advice would be to avoid sleep deprivation.”
On the other hand, some research has found that long sleep dura-
tions (nine hours or more) are also associated with increased morbidity
(illness, accidents) and mortality (death). Researchers describe this
relationship as a “U-shaped” curve, where both sleeping too little and
sleeping too much may put you at risk. This research found that vari-
ables such as low socioeconomic status and depression were signifi-
cantly associated with long sleep. Some researchers argue that these
94
How Much Sleep Do We Really Need?
other variables might be the cause of the longer sleep: the fact that
individuals with low socioeconomic status are more likely to have un-
diagnosed illnesses because of poor medical care explains the relation-
ship between low socioeconomic status, long sleep, and morbidity/
mortality. Researchers caution that there is not a definitive conclu-
sion that getting more than nine hours of sleep per night is consis-
tently linked with health problems and/or mortality in adults, while
short sleep has been linked to both these consequences in numerous
studies.
“Currently, there is no strong evidence that sleeping too much has
detrimental health consequences, or even evidence that our bodies will
allow us to sleep much beyond what is required,” says Kristen L.
Knutson, Ph.D., Department of Health Studies, University of Chicago.
“There is laboratory evidence that short sleep durations of four to five
hours have negative physiological and neurobehavioral consequences.
We need similar laboratory and intervention studies to determine
whether long sleep durations (if they can be obtained) result in physi-
ological changes that could lead to disease before we make any rec-
ommendations against sleep extension.”
But a key question is how much is too much or too little. Research-
ers Shawn Youngstedt and Daniel Kripke reviewed two surveys of
more than one million adults conducted by the American Cancer So-
ciety and found that the group of people who slept seven hours had
less mortality after six years than those sleeping both more and less.
The group of people who slept shorter amounts and those who slept
longer than eight hours had an average mortality risk that was
greater, but the risk was higher for longer sleepers. Youngstedt and
Kripke argue that for those who would normally sleep longer than
eight hours, restricting their sleep may actually be healthier for them,
just as eating less than one’s appetite may be healthier in a more sed-
entary society.
Though research cannot pinpoint an exact amount of sleep need
by people at different ages, Table 9.1 identifies the “rule-of-thumb”
amounts most experts have agreed upon. Nevertheless, it’s important
to pay attention to your own individual needs by assessing how you
feel on different amounts of sleep. Are you productive, healthy, and
happy on seven hours of sleep? Or does it take you nine hours of qual-
ity ZZZs to get you into high gear? Do you have health issues such as
being overweight? Are you at risk for any disease? Are you experienc-
ing sleep problems? Do you depend on caffeine to get you through the
day? Do you feel sleepy when driving? These are questions that must
be asked before you can find the number that works for you.
95
Table 9.1. Sleep Needs over the Life Cycle

Infants/babies (including naps)
0 to 2 months 10.5 to 18.5 hours
2 to 12 months 14 to 15 hours
Toddlers/Children (including naps)
12 to 18 months 13 to 15 hours
18 months to 3 years 12 to 14 hours
3 to 5 years 11 to 13 hours
5 to 12 years 9 to 11 hours
Adolescents 8.5 to 9.5 hours
Adults/Older Persons 7 to 9 hours
Source: “Let Sleep Work for You,” © 2007 National Sleep Foundation. Reprinted
with permission.
What You Can Do

To begin a new path toward healthier sleep and a healthier life-
style, begin by assessing your own individual needs and habits. See
how you respond to different amounts of sleep. Pay careful attention
to your mood, energy, and health after a poor night’s sleep versus a
good one. Ask yourself, “How often do I get a good night’s sleep?” If
the answer is “not often”, then you may need to consider changing your
sleep habits or consulting a physician or sleep specialist.
To pave the way for better sleep, experts recommend that you and
your family members follow these sleep tips:
• Establish consistent sleep and wake schedules, even on weekends.
• Create a regular, relaxing bedtime routine such as soaking in
a hot bath or listening to soothing music—begin an hour or more
before the time you expect to fall asleep.
• Create a sleep-conducive environment that is dark, quiet, com-
fortable, and cool.
• Sleep on a comfortable mattress and pillows.
• Use your bedroom only for sleep and sex (keep “sleep stealers”
out of the bedroom—avoid watching TV, using a computer, or
reading in bed).
96
How Much Sleep Do We Really Need?
• Finish eating at least two to three hours before your regular
bedtime.
• Exercise regularly during the day or at least a few hours before
bedtime.
• Avoid caffeine and alcohol products close to bedtime and give up
smoking.
If you or a family member are experiencing symptoms such as

sleepiness during the day or when you expect to be awake and alert,
snoring, leg cramps or tingling, gasping or difficulty breathing during
sleep, prolonged insomnia, or another symptom that is preventing you
from sleeping well, you should consult your primary care physician or
sleep specialist to determine the underlying cause. You may also try
keeping a sleep diary to track your sleep habits over a one- or two-
week period and bring the results to your physician.
Most importantly, make sleep a priority. You must schedule sleep
like any other daily activity, so put it on your “to-do list” and cross it
off every night. But don’t make it the thing you do only after every-
thing else is done—stop doing other things so you get the sleep you
need.
97
Chapter 10
Avoiding Risk Factors for

Common Health Concerns
Chapter Contents
Section 10.1—Alcohol and Its Effects ........................................ 100
Section 10.2—Health Risks of Smoking and How to Quit ....... 110
Section 10.3—Controlling Blood Cholesterol ............................ 116
Section 10.4—Preventing High Blood Pressure ........................ 121
Section 10.5—Managing Stress .................................................. 126
99
Section 10.1
Alcohol and Its Effects

Reprinted from “Alcohol: Frequently Asked Questions” and
“Excessive Alcohol Use and Risks to Men’s Health,” Centers for
Disease Control and Prevention, August 6, 2008.
Alcohol: Frequently Asked Questions

What Is Alcohol?
Ethyl alcohol, or ethanol, is an intoxicating ingredient found in
beer, wine, and liquor. Alcohol is produced by the fermentation of yeast,
sugars, and starches.
How Does Alcohol Affect a Person?

Alcohol affects every organ in the body. It is a central nervous sys-
tem depressant that is rapidly absorbed from the stomach and small
intestine into the bloodstream. Alcohol is metabolized in the liver by
enzymes; however, the liver can only metabolize a small amount of
alcohol at a time, leaving the excess alcohol to circulate throughout
the body. The intensity of the effect of alcohol on the body is directly
related to the amount consumed.
Why Do Some People React Differently to Alcohol Than

Others?
Individual reactions to alcohol vary, and are influenced by many
factors, including but not limited to the following:
• Age
• Gender
• Race or ethnicity
• Physical condition (weight, fitness level, etc.)
• Amount of food consumed before drinking
• How quickly the alcohol was consumed
100
Avoiding Risk Factors for Common Health Concerns
• Use of drugs or prescription medicines
• Family history of alcohol problems
What Is a Standard Drink in the United States?

A standard drink is equal to 13.7 grams (0.6 ounces) of pure alco-
hol or:
• twelve ounces of beer;
• eight ounces of malt liquor;
• five ounces of wine;
• one and a half ounces, or a “shot,” of 80-proof distilled spirits or
liquor (e.g., gin, rum, vodka, or whiskey).
Is Beer or Wine Safer to Drink Than Liquor?

No. One 12-ounce beer has about the same amount of alcohol as
one 5-ounce glass of wine, or a 1.5-ounce shot of liquor. It is the amount
of ethanol consumed that affects a person most, not the type of alco-
holic drink.
What Does Moderate Drinking Mean?

There is no one definition of moderate drinking, but generally the
term is used to describe a lower risk pattern of drinking. According
to the Dietary Guidelines for Americans,1 drinking in moderation is
defined as having no more than one drink per day for women and no
more than two drinks per day for men. This definition is referring to
the amount consumed on any single day and is not intended as an
average over several days.
Is It Safe to Drink Alcohol and Drive?

No, alcohol use slows reaction time and impairs judgment and co-
ordination, which are all skills needed to drive a car safely.2 The more
alcohol consumed, the greater the impairment.
What Does It Mean to Be Above the Legal Limit for Drinking?

The legal limit for drinking is the alcohol level above which an indi-
vidual is subject to legal penalties (e.g., arrest or loss of a driver’s license).
Legal limits are measured using either a blood alcohol test or a
breathalyzer.
101
Legal limits are typically defined by state law, and may vary based
on individual characteristics such as age and occupation.
All states in the United States have adopted 0.08 percent (80 mg/
dL) as the legal limit for operating a motor vehicle for drivers aged
twenty-one years or older. However, drivers under age twenty-one
years are not allowed to operate a motor vehicle with any level of al-
cohol in their system.
Note: Legal limits do not define a level below which it is safe to
operate a vehicle or engage in some other activity. Impairment due
to alcohol use begins to occur at levels well below the legal limit.
How Do I Know If It’s Okay to Drink?

The current Dietary Guidelines for Americans1 recommend that if
you choose to drink alcoholic beverages, you do not exceed one drink
per day for women and two drinks per day for men. These guidelines
also specify that there are some people who should not drink alcoholic
beverages at all, including the following:
• Children and adolescents

• Individuals of any age who cannot limit their drinking to low
levels
• Women who may become pregnant or who are pregnant
• Individuals who plan to drive, operate machinery, or take part
in other activities that require attention, skill, or coordination
• Individuals taking prescription or over-the-counter medications
that can interact with alcohol
• Individuals with certain medical conditions
• Persons recovering from alcoholism
What Do You Mean by Heavy Drinking?

For men, heavy drinking is typically defined as consuming an aver-
age of more than two drinks per day. For women, heavy drinking is typi-
cally defined as consuming an average of more than one drink per day.
What Is Binge Drinking?

According to the National Institute on Alcohol Abuse and Alcohol-
ism, binge drinking is defined as a pattern of alcohol consumption that
brings the blood alcohol concentration (BAC) level to 0.08 percent or
102
above. This pattern of drinking usually corresponds to five or more
drinks on a single occasion for men or four or more drinks on a single
occasion for women, generally within about two hours.3
What Is the Difference between Alcoholism and Alcohol

Abuse?
Alcoholism or alcohol dependence is a diagnosable disease char-
acterized by several factors, including a strong craving for alcohol,
continued use despite harm or personal injury, the inability to limit
drinking, physical illness when drinking stops, and the need to in-
crease the amount drunk to feel the effects.4
Alcohol abuse is a pattern of drinking that results in harm to one’s
health, interpersonal relationships, or ability to work. Certain mani-
festations of alcohol abuse include failure to fulfill responsibilities at
work, school, or home; drinking in dangerous situations, such as while
driving; legal problems associated with alcohol use; and continued
drinking despite problems that are caused or worsened by drinking.
Alcohol abuse can lead to alcohol dependence.4
What Does It Mean to Get Drunk?

“Getting drunk” or intoxicated is the result of consuming excessive
amounts of alcohol. Binge drinking typically results in acute intoxi-
cation.
Alcohol intoxication can be detrimental to health for a variety of
reasons, including, but not limited to, the following:
• Impaired brain function resulting in poor judgment, reduced
reaction time, loss of balance and motor skills, or slurred speech
• Dilation of blood vessels causing a feeling of warmth but result-
ing in rapid loss of body heat
• Increased risk of certain cancers, stroke, and liver diseases
(e.g., cirrhosis), particularly when excessive amounts of alcohol
are consumed over extended periods of time
• Damage to a developing fetus if consumed by pregnant women5
• Increased risk of motor-vehicle traffic crashes, violence, and
other injuries
Coma and death can occur if alcohol is consumed rapidly and in

large amounts because of depression of the central nervous system.
103
How Do I Know If I Have a Drinking Problem?

Drinking is a problem if it causes trouble in your relationships, in
school, in social activities, or in how you think and feel. If you are con-
cerned that either you or someone in your family might have a drink-
ing problem, consult your personal health care provider.
What Can I Do If I or Someone I Know Has a Drinking

Problem?
Consult your personal health care provider if you feel you or some-
one you know has a drinking problem. Other resources include the
National Drug and Alcohol Treatment Referral Routing Service avail-
able at 800-662-HELP. This service can provide you with information
about treatment programs in your local community and allow you to
speak with someone about alcohol problems.6
What Health Problems Are Associated with Excessive Alco-

hol Use?
Excessive drinking, in the form of either heavy drinking or binge
drinking, is associated with numerous health problems, including but
not limited to the following:
• Chronic diseases such as liver cirrhosis (damage to liver cells);
pancreatitis (inflammation of the pancreas); various cancers, in-
cluding liver, mouth, throat, larynx (the voice box), and esopha-
gus; high blood pressure; and psychological disorders
• Unintentional injuries, such as motor-vehicle traffic crashes,
falls, drowning, burns, and firearm injuries
• Violence, such as child maltreatment, homicide, and suicide
• Harm to a developing fetus, such as fetal alcohol spectrum dis-
orders, if a woman drinks while pregnant
• Sudden infant death syndrome (SIDS)
• Alcohol abuse or dependence
I’m Young—Is Drinking Bad for My Health?

Yes.7,8 Studies have shown that alcohol use by youth and young
adults increases the risk of both fatal and nonfatal injuries.9,10,11 Re-
search has also shown that youth who use alcohol before age fifteen
104
are five times more likely to become alcohol dependent than adults
who begin drinking at age twenty-one.12 Other consequences of youth
alcohol use include increased risky sexual behaviors, poor school per-
formance, and increased risk of suicide and homicide.13,14,15
Is It Okay to Drink When Pregnant?

No, there is no safe level of alcohol use during pregnancy. Women
who are pregnant or plan on becoming pregnant should refrain from
drinking alcohol.16 Several conditions, including fetal alcohol syn-
drome disorders, have been linked to alcohol use during pregnancy.
Women of childbearing age should also avoid binge drinking to reduce
the risk of unintended pregnancy and potential exposure of a devel-
oping fetus to alcohol.
References
1. United States Department of Agriculture and United States
Department of Health and Human Services. In: Dietary Guide-
lines for Americans. Chapter 9—Alcoholic Beverages. Washington,
DC: US Government Printing Office; 2005, p. 43–46. Available
at http://www.health.gov/DIETARYGUIDELINES/dga2005/
document/html/chapter9.htm. Accessed March 28, 2008.
2. National Highway Traffic Safety Administration. Available at
http://www.nhtsa.dot.gov/. Accessed March 28, 2008.
3. National Institute of Alcohol Abuse and Alcoholism. NIAAA
council approves definition of binge drinking (PDF–1.6Mb)
NIAAA Newsletter 2004;3:3.
4. Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV), 4th edition, Text Revision. Washington, DC: American
Psychiatric Association; 2000.
5. Centers for Disease Control and Prevention. Fetal alcohol
spectrum disorders. Available at http://www.cdc.gov/ncbddd/
fas/default.htm. Accessed March 31, 2008.
6. Substance Abuse and Mental Health Services Administration.
Available at http://www.samhsa.gov/treatment/treatment_public
_i.aspx. Accessed March 28, 2008.
7. National Research Council and Institute of Medicine. Reducing
Underage Drinking: A Collective Responsibility.* Committee
105
on Developing a Strategy to Reduce and Prevent Underage
Drinking. Division of Behavioral and Social Sciences and Edu-
cation. Washington, DC: The National Academies Press; 2004.
8. U.S. Department of Health and Human Services. The Surgeon
General’s Call to Action to Prevent and Reduce Underage Drink-
ing. Rockville, MD: U.S. Department of Health and Human Ser-
vices; 2007. Available at http://www.surgeongeneral.gov/topics/
underagedrinking/. Accessed March 28, 2008.
9. Hingson RW, Heeren T, Jamanka A, Howland J. Age of onset
and unintentional injury involvement after drinking. JAMA
2000; 284(12):1527–33.
10. Hingson RW, Heeren T, Winter M, Wechsler H. Magnitude of
alcohol-related mortality and morbidity among U.S. college stu-
dents ages 18–24: Changes from 1998 to 2001. Annu Rev Pub-
lic Health 2005; 26:259–79.
11. Levy DT, Mallonee S, Miller TR, Smith GS, Spicer RS, Romano
EO, Fisher DA. Alcohol involvement in burn, submersion, spinal
cord, and brain injuries. Medical Science Monitor 2004;10(1):
CR17–24.
12. Office of Applied Studies. The NSDUH Report: Alcohol depen-
dence or abuse and age at first use. Rockville, MD: Substance
Abuse and Mental Health Services Administration, October 2004.
Available at http://www.oas.samhsa.gov/2k4/ageDependence/
ageDependence.htm. Accessed March 31, 2008.
13. Substance Abuse and Mental Health Services Administra-
tion. A Comprehensive Plan for Preventing and Reducing Un-
derage Drinking. Washington, DC: 2006. Available at http://
www.stopalcoholabuse.gov/media/underagedrinking/pdf/
underagerpttocongress.pdf (PDF). Accessed March 28, 2008.
14. Centers for Disease Control and Prevention (CDC). Alcohol-
Related Disease Impact (ARDI). Atlanta, GA: CDC. Available at
http://www.cdc.gov/alcohol/ardi.htm. Accessed March 28, 2008.
15. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking
and associated health risk behaviors among high school stu-
dents. Pediatrics 2007;119:76–85.
16. Department of Health and Human Services. U.S. Surgeon
General Releases Advisory on Alcohol Use in Pregnancy; urges
106
women who are pregnant or who may become pregnant to ab-
stain from alcohol. Released Monday, February 21, 2005. Avail-
able at http://www.hhs.gov/surgeongeneral/pressreleases/
sg02222005.html. Accessed March 31, 2008.
Excessive Alcohol Use and Risks to Men’s Health

Men are more likely than women to drink excessively. Excessive
drinking is associated with significant increases in short-term risks
to health and safety, and the risk increases as the amount of drink-
ing increases. Men are also more likely than women to take other risks
(e.g., drive fast or without a safety belt), when combined with exces-
sive drinking, further increasing their risk of injury or death.1,2,3,4
Drinking Levels for Men

• Approximately 62 percent of adult men reported drinking
alcohol in the last thirty days and were two times more likely
to binge drink than women during the same time period.5
• Men average about 12.5 binge drinking episodes per person per
year, while women average about 2.7 binge drinking episodes per
year.3
• Most people who binge drink are not alcoholics or alcohol de-
pendent.6,7
• It is estimated that about 17 percent of men and about 8 per-
cent of women will meet criteria for alcohol dependence at some
point in their lives.
Injuries and Deaths as a Result of Excessive Alcohol Use

• Men consistently have higher rates of alcohol-related deaths
and hospitalizations than women.1,9,10
• Among drivers in fatal motor-vehicle traffic crashes, men are
almost twice as likely as women to have been intoxicated (i.e.,
a blood alcohol concentration of 0.08 percent or greater).11
• Excessive alcohol consumption increases aggression and, as a
result, can increase the risk of physically assaulting another per-
son.12
• Men are more likely than women to commit suicide, and more
likely to have been drinking prior to committing suicide.13,14,15
107
Reproductive Health and Sexual Function

Excessive alcohol use can interfere with testicular function and
male hormone production, resulting in impotence, infertility, and re-
duction of male secondary sex characteristics such as facial and chest
hair.16, 17
Excessive alcohol use is commonly involved in sexual assault. Im-
paired judgment caused by alcohol may worsen the tendency of some
men to mistake a women’s friendly behavior for sexual interest and
misjudge their use of force. Also, alcohol use by men increases the
chances of engaging in risky sexual activity, including unprotected sex,
sex with multiple partners, or sex with a partner at risk for sexually
transmitted diseases.4
Cancer
Alcohol consumption increases the risk of cancer of the mouth,
throat, esophagus, liver, and colon in men.18,19,20
References
1. Centers for Disease Control and Prevention (CDC). Alcohol-
Related Disease Impact (ARDI). Atlanta, GA: CDC. Available
at http://www.cdc.gov/alcohol/ardi.htm. Accessed March 28,
2008.
2. Levy DT, Mallonee S, Miller TR, Smith GS, Spicer RS, Romano
EO, Fisher DA. Alcohol involvement in burn, submersion, spinal
cord, and brain injuries. Med Sci Monit 2004; 10(1):CR17–24.
3. Naimi TS, Brewer RD, Mokdad A, Clark D, Serdula MK,
Marks JS. Binge drinking among US adults. JAMA 2003;
289(1):70–75.
4. Nolen-Hoeksema S. Gender differences in risk factors and
consequences for alcohol use and problems. Clinical Psychol-
ogy Review 2004;24:981.
5. Centers for Disease Control and Prevention. Behavioral Risk
Factor Surveillance System prevalence data. Atlanta, GA: Cen-
ters for Disease Control and Prevention. Available at www.cdc.
gov/brfss. Accessed March 28, 2008.
6. Dawson DA, Grant BF, LI T-K. Quantifying the risks associ-
ated with exceeding recommended drinking limits. Alcohol
Clin Exp Res 2005;29:902–8.
108
7. Woerle S, Roeber J, Landen MG. Prevalence of alcohol depen-
dence among excessive drinkers in New Mexico. Alcohol Clin
Exp Res 2007;31:293–98.
8. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, corre-
lates, disability, and comorbidity of DSM-IV alcohol abuse and
dependence in the United States. Arch Gen Psychiatry 2007;
64:830–42.
9. Minino AM, Heron MP, Murphy SL, Kochanek KD. Deaths: fi-
nal data for 2004. National Vital Statistics Report, Volume 55,
No. 19, August 21, 2007. Hyattsville, MD: Centers for Disease
Control and Prevention, National Center for Health Statistics.
Available at http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55
_19.pdf (PDF). Accessed March 28, 2008.
10. Chen CM, Yi H. Trends in alcohol-related morbidity among
short-stay community hospital discharges, United States,
1979–2005. Bethesda, MD: National Institutes of Health, Na-
tional Institute on Alcohol Abuse and Alcoholism. NIAAA Sur-
veillance Report #80; 2007. Available at http://pubs.niaaa.nih
.gov/publications/surveillance80/HDS05.pdf (PDF). Accessed
March 28, 2008.
11. National Highway Traffic Safety Administration. Traffic
Safety Facts 2006. Washington, DC: U.S. Department of Trans-
portation, National Highway Traffic Safety Administration,
National Center for Statistics & Analysis. DOT HS 810 818;
2008. Available at http://www-nrd.nhtsa.dot.gov/CMSWeb/
index.aspx. Accessed March 28, 2008.
12. Scott KD, Schafer J, Greenfield TK. The roles of alcohol in
physical assault perpetration and victimization. J Stud Alco-
hol 1999;60:528–36.
13. Hayward l, Zubrick SR, Silburn S. Blood alcohol levels in sui-
cide cases. J Epidemiol Community Health 1992; 46(3):256–60.
14. May PA, Van Winkle NW, Williams MB, McFeeley PJ,
DeBruyn LM, Serna P. Alcohol and suicide death among
American Indians of New Mexico: 1980–1998. Suicide Life
Threat Behav 2002; 32(3):240–55.
15. Suokas J, Suominen K, Lonnqvist J. Chronic alcohol problems
among suicide attempters—post-mortem findings of a 14-year
follow-up. Nord J Psychiatry 2005;59(1):45–50.
109
16. Adler RA. Clinically important effects of alcohol on endocrine
function. Journal Clinical Endocr Metabol 1992; 74(5):957–60.
17. Emanuele MA, Emanuele NV. Alcohol’s effects on male repro-
duction. Alcohol Research and Health 1998; 22(3):195–201.
18. American Cancer Society. Alcohol and Cancer. Atlanta, GA:
American Cancer Society; 2006. Available at http://www.cancer
.org/downloads/PRO/alcohol.pdf*(PDF). Accessed March 28,
2008.
19. Donato F, Tagger A, Chiesa R, Ribero ML, Tomasoni V,
Fasola M, et al. Hepatitis B and C virus infection, alcohol
drinking and hepatocellular carcinoma: a case-control study
in Italy. Hepatology 1997; 26(3):579–84.
20. Baan R, Straif K, Grosse Y, Secretan B, et al. on behalf of the
WHO International Agency for Research on Cancer Monograph
Working Group. Carcinogenicity of alcoholic beverages. Lancet
Oncol 2007; 8:292–93.
Section 10.2
Health Risks of Smoking and How to Quit

“Health Effects of Cigarette Smoking” is excerpted from the Centers for
the Disease Control and Prevention, January 23, 2008. “What Happens
When You Quit Smoking?” is excerpted from “Smoking and How to Quit:
What Happens When You Quit Smoking?” National Women’s Health In-
formation Center, March 19, 2008. “How to Quit” is reprinted from “Smok-
ing and How to Quit: How to Quit,” National Women’s Health Information
Center, March 19, 2008.
Health Effects of Cigarette Smoking

Smoking harms nearly every organ of the body, causing many dis-
eases and reducing the health of smokers in general.1 The adverse
health effects from cigarette smoking account for an estimated 438,000
deaths, or nearly one of every five deaths, each year in the United
110
States.2,3 More deaths are caused each year by tobacco use than by all
deaths from human immunodeficiency virus (HIV), illegal drug use,
alcohol use, motor vehicle injuries, suicides, and murders combined.2,4
Cancer
Cancer is the second leading cause of death and was among the
first diseases causally linked to smoking.1
Smoking causes about 90 percent of lung cancer deaths in men and
almost 80 percent of lung cancer deaths in women. The risk of dying
from lung cancer is more than twenty-three times higher among men
who smoke cigarettes, and about thirteen times higher among women
who smoke cigarettes, compared with never smokers.1
Smoking causes cancers of the bladder, oral cavity, pharynx, lar-
ynx (voice box), esophagus, cervix, kidney, lung, pancreas, and stom-
ach, and causes acute myeloid leukemia.1
Rates of cancers related to cigarette smoking vary widely among
members of racial/ethnic groups, but are generally highest in African-
American men.5
Cardiovascular Disease (Heart and Circulatory System)

Smoking causes coronary heart disease, the leading cause of death
in the United States.1 Cigarette smokers are two to four times more
likely to develop coronary heart disease than nonsmokers.6
Cigarette smoking approximately doubles a person’s risk for stroke.7,8
Cigarette smoking causes reduced circulation by narrowing the
blood vessels (arteries). Smokers are more than ten times as likely as
nonsmokers to develop peripheral vascular disease.9
Smoking causes abdominal aortic aneurysm.1
Respiratory Disease and Other Effects

Cigarette smoking is associated with a tenfold increase in the risk
of dying from chronic obstructive lung disease.7 About 90 percent of all
deaths from chronic obstructive lung diseases are attributable to ciga-
rette smoking.1
Cigarette smoking has many adverse reproductive and early child-
hood effects, including an increased risk for infertility, preterm delivery,
stillbirth, low birth weight, and sudden infant death syndrome (SIDS).1
Postmenopausal women who smoke have lower bone density than
women who never smoked. Women who smoke have an increased risk
for hip fracture than never smokers.10
111
References
1. U.S. Department of Health and Human Services. The Health
Consequences of Smoking: A Report of the Surgeon General.
U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on Smoking
and Health, 2004 [cited 2006 Dec 5]. Available from: http://
www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm.
2. Centers for Disease Control and Prevention. Annual Smoking-
Attributable Mortality, Years of Potential Life Lost, and Pro-
ductivity Losses—United States, 1997–2001. Morbidity and
Mortality Weekly Report [serial online]. 2002;51(14):300–303
[cited 2006 Dec 5]. Available from: http://www.cdc.gov/mmwr/
preview/mmwrhtml/mm5114a2.htm.
3. Centers for Disease Control and Prevention. Health United
States, 2003, With Chartbook on Trends in the Health of
Americans. (PDF–225KB) Hyattsville, MD: CDC, National
Center for Health Statistics; 2003 [cited 2006 Dec 5]. Avail-
able from: http://www.cdc.gov/nchs/data/hus/tables/2003/
03hus031.pdf.
4. McGinnis J, Foege WH. Actual Causes of Death in the United
States. Journal of the American Medical Association 1993;270:
2207–12.
5. Novotny TE, Giovino GA. Tobacco Use. In: Brownson RC,
Remington PL, Davis JR (eds). Chronic Disease Epidemiology
and Control. Washington, DC: American Public Health Asso-
ciation; 1998;117–148 [cited 2006 Dec 5].
6. U.S. Department of Health and Human Services. Reducing the
Health Consequences of Smoking—25 Years of Progress: A Re-
port of the Surgeon General. Atlanta, GA: U.S. Department of
Health and Human Services, CDC; 1989. DHHS Pub. No. (CDC)
89–8411 [cited 2006 Dec 5]. Available from: http://profiles.nlm
.nih.gov/NN/B/B/X/S/.
7. U.S. Department of Health and Human Services. Tobacco Use
Among U.S. Racial/Ethnic Minority Groups—African Ameri-
cans, American Indians and Alaska Natives, Asian Americans
and Pacific Islanders, and Hispanics: A Report of the Surgeon
General. Atlanta, GA: U.S. Department of Health and Human
112
Services, CDC; 1998 [cited 2006 Dec 5]. Available from: http://
www.cdc.gov/tobacco/data_statistics/sgr/sgr_1998/index.htm.
8. Ockene IS, Miller NH. Cigarette Smoking, Cardiovascular
Disease, and Stroke: A Statement for Healthcare Profession-
als From the American Heart Association. Journal of Ameri-
can Health Association. 1997; 96(9):3243–47 [cited 2006 Dec 5].
9. Fielding JE, Husten CG, Eriksen MP. Tobacco: Health Effects
and Control. In: Maxcy KF, Rosenau MJ, Last JM, Wallace RB,
Doebbling BN (eds.). Public Health and Preventive Medicine.
New York: McGraw-Hill;1998;817–45 [cited 2006 Dec 5].
10. U.S. Department of Health and Human Services. Women and
Smoking: A Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, CDC; 2001 [cited
2006 Dec 5]. Available from: http://www.cdc.gov/tobacco/data
_statistics/sgr/sgr_2001/index.htm.
What Happens When You Quit Smoking?

If you quit smoking right now, your body will begin to heal imme-
diately:
• In twenty minutes your heart rate will drop.
• In twelve hours the carbon monoxide (a gas that can be toxic) in
your blood will drop to normal.
• In two weeks to three months your heart attack risk will begin
to drop and your lungs will be working better.
• In one to nine months your coughing and shortness of breath
will decrease and your lungs will start to function better, lower-
ing your risk of lung infection.
• In one year your risk for heart disease will be half that of a
smoker.
• In five years your risk of having a stroke will be the same as
that of someone who doesn’t smoke.
• In ten years your risk of dying from lung cancer will be half
that of a smoker. Your risk of cancer of the mouth, throat,
esophagus, bladder, kidney, and pancreas will also decrease.
• In fifteen years your risk of heart disease will be the same as
that of someone who doesn’t smoke.
113
How to Quit
Make the Decision to Quit and Feel Great!
If you have made the decision to quit smoking, congratulations! Not
only will you improve your own health, you will also protect the health
of your loved ones by no longer exposing them to secondhand smoke.
We know how hard it can be to quit smoking. Did you know that
many people try to quit two or three times before they give up smok-
ing for good? Nicotine is a very addictive drug—as addictive as heroin
and cocaine. The good news is that millions of people have given up
smoking for good. It’s hard work to quit, but you can do it! Freeing
yourself of an expensive habit that is dangerous to your health and
the health of others will make you feel great!
Many people who smoke worry that they will gain weight if they
quit. In fact, nearly 80 percent of people who quit smoking do gain
weight, but the average weight gain is just five pounds. Keep in mind,
however, that 56 percent of people who continue to smoke will gain
weight too. The bottom line: The health benefits of quitting far exceed
any risks from the weight gain that may follow quitting.
Tips to Help You Quit

Research has shown that these five steps will help you to quit for
good:
• Pick a date to stop smoking: Before that day, get rid of all
cigarettes, ashtrays, and lighters everywhere you smoke. Do not
allow anyone to smoke in your home. Write down why you want
to quit and keep this list as a reminder.
• Get support from your family, friends, and coworkers:
Studies have shown you will be more likely to quit if you have
help. Let the people important to you know the date you will be
quitting and ask them for their support. Ask them not to smoke
around you or leave cigarettes out.
• Find substitutes for smoking and vary your routine:
When you get the urge to smoke, do something to take your
mind off smoking. Talk to a friend, go for a walk, or go to the
movies. Reduce stress with exercise, meditation, hot baths, or
reading. Try sugar-free gum or candy to help handle your cravings.
Drink lots of water and juices. You might want to try changing
your daily routine as well. Try drinking tea instead of coffee,
114
eating your breakfast in a different place, or taking a different
route to work.
• Talk to your doctor or nurse about medicines to help you
quit: Some people have withdrawal symptoms when they quit
smoking. These symptoms can include depression, trouble sleep-
ing, feeling irritable or restless, and trouble thinking clearly. There
are medicines to help relieve these symptoms. Most medicines help
you quit smoking by giving you small, steady doses of nicotine,
the drug in cigarettes that causes addiction. Talk to your doctor
or nurse to see if one of these medicines may be right for you:
• Nicotine patch: Worn on the skin and supplies a steady
amount of nicotine to the body through the skin
• Nicotine gum or lozenge: Releases nicotine into the blood-
stream through the lining in your mouth
• Nicotine nasal spray: Inhaled through your nose and passes
into your bloodstream
• Nicotine inhaler: Inhaled through the mouth and absorbed
in the mouth and throat
• Bupropion: An antidepressant medicine that reduces nico-
tine withdrawal symptoms and the urge to smoke
• Varenicline (Chantix®): A medicine that reduces nicotine
withdrawal symptoms and the pleasurable effects of smok-
ing
• Be prepared for relapse: Most people relapse, or start smok-
ing again, within the first three months after quitting. Don’t get
discouraged if you relapse. Remember, many people try to quit
several times before quitting for good. Think of what helped and
didn’t help the last time you tried to quit. Figuring these out be-
fore you try to quit again will increase your chances for success.
Certain situations can increase your chances of smoking. These
include drinking alcohol, being around other smokers, gaining
weight, stress, or becoming depressed. Talk to your doctor or
nurse for ways to cope with these situations.
Where to Get Help

Get more help if you need it. Join a quit-smoking program or support
group to help you quit. These programs can help you handle withdrawal
and stress and teach you skills to resist the urge to smoke. Contact your
115
local hospital, health center, or health department for information about
quit-smoking programs and support groups in your area.
Section 10.3
Controlling Blood Cholesterol

“About High Blood Cholesterol” and “High Blood Cholesterol
Prevention” are reprinted from the Centers for Disease Control and
Prevention, November 8, 2007.
About High Blood Cholesterol

Cholesterol is a waxy, fat-like substance found in your body. It is
needed for the body to function normally and is found in all cells of
the body. Your body makes enough cholesterol for its needs.
Cholesterol is carried in the blood in particles called lipoproteins.
These particles are made up of cholesterol on the inside and protein
on the outside. There are two kinds of lipoproteins:
• Low-density lipoproteins (LDL): These are the major type
of lipoprotein that carries cholesterol in the bloodstream to the
body. These are the type that can lead to a buildup of cholesterol
in the arteries and lead to heart disease.
• High-density lipoproteins (HDL): These particles carry cho-
lesterol back to the liver to remove it from the body. Higher lev-
els of HDL are considered good.
An excess of either total or LDL cholesterol in the blood is a risk

for heart disease and atherosclerosis. People can have an excess of
cholesterol because of diet and because of the rate at which choles-
terol is processed in the body. Most of the excess cholesterol comes
from diet. Cholesterol can build up on the artery walls of your body.
This buildup is called plaque. Over time, plaque can cause the arter-
ies to become narrow, which is called atherosclerosis. As a result, less
oxygen–rich blood can pass through. When the arteries that carry
blood to the heart are affected, coronary artery disease can result. A
116
heart attack occurs when a coronary artery becomes completely
blocked. A coronary artery can become blocked either by plaque
buildup or by a plaque that ruptures or bursts, which causes a clot.
Angina can also develop because of plaque buildup. Angina happens
when the heart does not receive enough oxygen-rich blood.
High blood cholesterol itself does not cause symptoms, so many
people may not know that their cholesterol level is too high. Simple
blood tests can be done to check your total, LDL, and HDL cholesterol
levels and other types of fats in the blood (such as triglycerides). If it
is found that your cholesterol is high, your doctor may prescribe vari-
ous treatments depending on your risk for developing heart disease.
These include lifestyle changes such as diet, weight control, and physi-
cal activity. Certain drugs can also be prescribed to manage your cho-
lesterol. Lifestyle changes are usually still recommended with
medications. All people can do things to help keep cholesterol within
the normal range.
High Blood Cholesterol Prevention

High blood cholesterol is a major risk factor for heart disease. There
are a number of things that can be done to maintain normal choles-
terol levels and reduce the risk of developing heart disease. All people
at any age can take steps to keep normal cholesterol levels. People
with high total cholesterol, high LDL cholesterol, or low HDL choles-
terol should talk with their doctor about the best way to control or
improve their cholesterol.
What Affects Cholesterol Levels?

A number of things can affect the cholesterol levels in your blood.
These include the following:
• Diet: Certain foods have types of fat that raise your cholesterol
level. These types of fats include saturated fat, trans fatty acids
or trans fats, and dietary cholesterol. Saturated fats come largely
from animal fat in the diet, but also some vegetable oils such as
palm oil. Trans fats are made when vegetable oil is hydrogenated
to harden it. Research suggests that trans fatty acids can raise
cholesterol levels. Dietary cholesterol is found in foods that come
from animal sources such as egg yolks, meat, and dairy products.
• Weight: Being overweight tends to increase LDL levels, lowers
HDL levels, and increases total cholesterol level.
117
• Physical inactivity: Lack of regular physical activity can lead
to weight gain, which could raise your LDL cholesterol level.
• Heredity: High blood cholesterol can run in families. An inher-
ited genetic condition results in very high LDL cholesterol levels.
This condition is called familial hypercholesterolemia.
• Age and sex: As people get older, their LDL cholesterol levels
tend to rise. Men tend to have lower HDL levels than women.
Younger women tend to have lower LDL levels than men, but
higher levels at older ages (after age fifty-five).
What Can You Do?

Have your cholesterol checked. There are usually no signs or symp-
toms of high blood cholesterol, so it is important to have your blood
cholesterol checked. A simple blood test can be done by your doctor
to check your blood cholesterol level. A lipoprotein profile can be done
to measure several different kinds of cholesterol as well as triglycer-
ides (another kind of fat found in the blood).
Desirable or optimal levels for adults with or without existing heart
disease are as follows:
• Total cholesterol: Less than 200 mg/dL

• Low-density lipoprotein (LDL) cholesterol (“bad” cholesterol):
Less than 100 mg/dL
• High-density lipoprotein (HDL) cholesterol (“good” cholesterol):
40 mg/dL or higher
• Triglycerides: Less than 150 mg/dL
If a full lipoprotein panel is not done, you doctor may check your
total and HDL cholesterol with a simpler blood test. The National
Cholesterol Education Program recommends that healthy adults have
their cholesterol levels checked once every five years.
Maintain a healthy diet: An overall healthy diet can help to

maintain normal blood cholesterol levels. Saturated fat, trans fats, and
dietary cholesterol tend to raise blood cholesterol levels. Other types
of fats, such as monounsaturated and polyunsaturated fats can help
to lower blood cholesterol levels. Getting enough soluble fiber in the
diet can also help to lower cholesterol. For some people, a diet that
has too many carbohydrates can lower HDL (the good cholesterol) and
118
raise triglycerides. Alcohol can also raise triglycerides, and excessive
alcohol use can lead to high blood pressure, another risk factor for
heart disease and stroke.
Maintain a healthy weight: Being overweight or obese can raise

your bad cholesterol levels. Losing weight can help you lower your blood
cholesterol levels. Healthy weight status in adults is usually assessed
by using weight and height to compute a number called the “body mass
index” (BMI). BMI is used because it relates to the amount of body fat
for most people. An adult who has a BMI of 30 or higher is considered
to be obese. Overweight is a BMI between 25 and 29.9. Normal weight
is a BMI of 18.5 to 24.9. Proper diet and regular physical activity can
help to maintain a healthy weight. Other measures of excess body fat
may include waist measurements or waist and hip measurements.
Be active: Physical activity can help to maintain a healthy weight

and lower blood cholesterol levels. The Surgeon General recommends
that adults should engage in moderate-level physical activities for at
least thirty minutes on most days of the week.
No tobacco: Smoking injures blood vessels and speeds up the pro-

cess of hardening of the arteries. Further, smoking is a major risk for
heart disease and stroke. If you don’t smoke, don’t start. Quitting smok-
ing lowers one’s risk of heart attack and stroke. Your doctor can sug-
gest programs to help you quit smoking.
Medications: If you are found to have high blood cholesterol, your

doctor may prescribe medications, in addition to lifestyle changes, to
help bring it under control. The primary focus of treatment is to get
LDL cholesterol under control. Your treatment plan and goal will de-
pend on your LDL level and your level of risk for heart disease and
stroke. Your risk for heart disease and stroke will be based on whether
you also have other risk factors and may include your blood pressure
level or high blood pressure treatment, smoking status, age, HDL
level, family history of early heart disease, and existing cardiovascu-
lar disease or diabetes. People with existing cardiovascular disease
or diabetes are considered high risk.
Several types of medicines help to lower cholesterol:
• Statin drugs lower LDL cholesterol by slowing down the produc-
tion of cholesterol and by increasing the liver’s ability to remove
the LDL cholesterol already in the blood.
119
• Bile acid sequestrants help to lower LDL cholesterol by binding
with cholesterol-containing bile acids in the intestines, and are
then eliminated in the stool.
• Niacin, or nicotinic acid, is a B vitamin that can improve all li-
poproteins. Nicotinic acid lowers total cholesterol, LDL choles-
terol, and triglyceride levels, while raising HDL cholesterol levels.
Because the levels needed are well above recommended dietary
intake levels, niacin treatment for cholesterol should be done only
under medical supervision because of possible adverse side ef-
fects.
• Fibrates are used mainly to lower triglycerides and, to a lesser
extent, to increase HDL levels.
All drugs may have adverse side effects, so their use needs to be
checked by your doctor on a regular basis. Once your blood cholesterol
level is controlled, your doctor will want to monitor it. The lifestyle
changes that your doctor recommends are just as important as tak-
ing your medicines as prescribed.
Genetic factors: Genes can play a role in high blood cholesterol.

Very high blood cholesterol levels can be related to a condition known
as familial hypercholesterolemia. It is also possible that high blood
cholesterol levels within a family are due to factors such as common
diet.
120
Section 10.4
Preventing High Blood Pressure

Excerpted from “High Blood Pressure,” “About High Blood Pressure,”
and “Preventing and Controlling High Blood Pressure,” Centers for Dis-
ease Control and Prevention, August 22, 2007.
It is estimated that one of three American adults has high blood

pressure or hypertension. Having high blood pressure increases one’s
chance for developing heart disease, a stroke, and other serious con-
ditions.
High blood pressure is sometimes called the “silent killer” because
it usually has no noticeable warning signs or symptoms until other
serious problems arise; therefore, many people do not know that they
have it. All persons, including children, can develop high blood pres-
sure. However, high blood pressure is easily detectable and usually
can be controlled. Maintaining a healthy blood pressure is an impor-
tant public health strategy. Therefore, it is important for you to know
your blood pressure level and to check it regularly.
About High Blood Pressure

What Is High Blood Pressure?
Blood pressure is the force of blood against the artery walls. It is
often written or stated as two numbers. The first or top number rep-
resents the pressure when the heart contracts. This is called systolic
pressure. The second or bottom number represents the pressure when
the heart rests between beats. This is called diastolic pressure.
Blood pressure is traditionally measured with a device called a
sphygmomanometer. It measures blood pressure in millimeters of
mercury (mmHg). An inflatable cuff is wrapped around the arm and
is inflated to squeeze the blood vessels in the arm. The health care
provider uses a stethoscope to listen to the pulse as the pressure is
released in order to determine the systolic and diastolic pressure.
Some blood pressure testing devices are now electronic and provide
digital readouts of the blood pressure measurement and pulse rate.
121
Blood pressure normally rises and falls throughout the day. When
it consistently stays too high for too long, it is called hypertension.
The Seventh Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure notes these lev-
els for defining normal and high blood pressure in adults:
• High blood pressure or hypertension for adults is defined as
a systolic blood pressure of 140 mmHg or higher or a diastolic
blood pressure of 90 mmHg or higher.
• Normal blood pressure is a systolic blood pressure of less
than 120 mmHg and a diastolic blood pressure of less than
80 mmHg.
• Prehypertension is defined as a systolic blood pressure of 120–
139 mmHg or a diastolic blood pressure of 80–89 mmHg. Persons
with prehypertension are at increased risk to progress to hyper-
tension.
If the systolic and diastolic blood pressure levels are in different

categories, blood pressure status is defined according to the higher
category. For example, a person with a high systolic pressure but a
normal diastolic pressure will be considered to have high blood pres-
sure (sometimes referred to as systolic hypertension). A person with
a high diastolic pressure but a normal systolic pressure will be con-
sidered to have high blood pressure also (sometimes referred to as
diastolic hypertension).
High blood pressure for adults will usually be measured on at least
two different doctor visits before a diagnosis of high blood pressure is
made.
More importantly, high blood pressure can be prevented or con-
trolled through lifestyle changes and with medications when needed.
Types of High Blood Pressure

Essential hypertension: In most cases, high blood pressure does
not have a specific treatable cause. This form is called essential hy-
pertension.
Secondary hypertension: In a few cases, the cause of hyperten-

sion is some other underlying condition. This is called secondary hyper-
tension. This may be due to kidney disorders, congenital abnormalities,
or other conditions. Blood pressure usually returns to normal when the
problem is corrected.
122
Pregnancy-related hypertension: Existing high blood pressure
can predispose some women to develop problems when they become
pregnant. This is called preexisting chronic hypertension. Also, some
women first develop hypertension when they are pregnant. There are
several types of this pregnancy-induced hypertension, sometimes
called gestational hypertension. Either type of high blood pressure can
harm the mother’s kidneys and other organs, and it can cause low
birth weight and early delivery.
Treatment of High Blood Pressure

High blood pressure can be treated with both lifestyle modifica-
tions, usually as the first step, and, if needed, medications. Lifestyle
factors to treat high blood pressure include weight control, exercise,
healthy diet, limiting alcohol use, and other lifestyle modifications.
There are several types of medications that are used to treat high
blood pressure. Frequently, more than one type will be used. It is im-
portant to take these as prescribed. High blood pressure medicines
fall into one of these types:
• Diuretics work in the kidney and flush excess water and sodium
from the body. They are sometimes called “water pills.”
• Beta blockers reduce nerve impulses to the heart and blood ves-
sels that make the heart beat slower and with less force.
• Angiotensin-converting enzyme (ACE) inhibitors cause the
blood vessels to relax. ACE inhibitors prevent the formation
of a hormone called angiotensin II, which normally causes the
blood vessels to narrow.
• Angiotensin antagonists shield the blood vessels from angio-
tensin II. As a result, the vessels become wider.
• Calcium channel blockers prevent calcium from entering the
muscle cells of the heart and blood vessels. This causes the blood
vessels to relax.
• Alpha-blockers reduce nerve impulses to the blood vessels,
which allows the blood to pass more easily.
• Alpha-beta-blockers work the same way as alpha-blockers
but also slow the heartbeat, as beta-blockers do. As a result,
less blood is pumped through the vessels.
• Nervous system inhibitors relax blood vessels by controlling
nerve impulses. This causes the blood vessels to become wider.
123
• Vasodilators directly open the blood vessels by relaxing the
muscle in the vessel walls.
Outcomes of High Blood Pressure

High blood pressure is often called the “silent killer” because it
usually has no noticeable warning signs or symptoms until other se-
rious problems arise. Therefore, many people with high blood pres-
sure do not know that they have it. High blood pressure is a major
risk factor for heart disease, the leading cause of death in the United
States. It can lead to hardened or stiffened arteries, which causes a
decrease of blood flow to the heart muscle and other parts of the body.
Reduced blood to the heart muscle can lead to angina (chest pain or
damage to the heart muscle due to a lack of blood carrying oxygen to
the heart muscle) or to a heart attack (caused by a chronic spasm or
blockage of blood and oxygen to the heart).
High blood pressure is a major risk factor for heart failure, a seri-
ous condition where the heart cannot pump enough blood for the
body’s needs. It is also the major risk factor for stroke, which is the
third leading cause of death in the United States. A stroke may be
caused by a rupture or blockage of an artery that supplies blood and
oxygen to the brain.
In addition, high blood pressure can result in damage to the eyes,
including blindness. The blood vessels in the eyes can rupture or burst
from high blood pressure, leading to impairment of sight.
High blood pressure can also result in kidney disease and kidney
failure. The kidneys filter wastes from fluids in the body. High blood
pressure can thicken and narrow the blood vessels of the kidneys,
resulting in less fluid being filtered and wastes building up in the body.
Also, diseases of the kidney can be a cause of high blood pressure.
Preventing and Controlling High Blood Pressure

There are several things that you can do to keep your blood pres-
sure healthy. These actions should become part of your regular
lifestyle. You should discuss with your health care provider the best
ways for you to address these issues.
Maintain a healthy weight: Being overweight or obese can raise

your blood pressure, and losing weight can help you lower your blood
pressure. Healthy weight status in adults is usually assessed by us-
ing weight and height to compute a number called the “body mass
124
index” (BMI). BMI is used because it relates to the amount of body
fat for most people. An adult who has a BMI of 30 or higher is consid-
ered to be obese. Overweight is a BMI between 25 and 29.9. Normal
weight is a BMI of 18 to 24.9. Proper diet and regular physical activ-
ity can help to maintain a healthy weight. Other measures of excess
body fat may include waist measurements or waist and hip measure-
ments.
Be active: Being physically inactive is related to high blood pres-

sure, and physical activity can help to lower blood pressure. The Sur-
geon General recommends that adults should engage in moderate-level
physical activities for at least thirty minutes on most days of the week.
Maintain a healthy diet: Along with healthy weight and regu-

lar physical activity, an overall healthy diet can help to maintain
healthy blood pressure levels. This includes eating lots of fresh fruits
and vegetables and lowering or cutting out salt or sodium and increas-
ing potassium. High salt and sodium intake and a low potassium in-
take (due to not eating enough fruits and vegetables) can increase
blood pressure. You need to watch the sodium that is already included
in processed foods and to avoid adding sodium or salt in cooking or
at the table. Low saturated fat and cholesterol are also part of an over-
all healthy diet. Recent studies such as the Dietary Approaches to Stop
Hypertension (DASH) trial show that blood pressure can be signifi-
cantly lowered through diet.
Moderate alcohol use: Excessive alcohol consumption is related

to increased blood pressure. People who drink alcohol should do so in
moderation. Based on current dietary guidelines, moderate drinking
for women is defined as an average of one drink or less per day. Moder-
ate drinking for men is defined as an average of two drinks or less
per day.
Prevent and control diabetes: People with diabetes have a

higher risk of high blood pressure, but they can also work to reduce
their risk. Recent studies suggest that all people can take steps to
reduce their risk of diabetes. These include a healthy diet, weight loss,
and regular physical activity.
No tobacco: Smoking injures blood vessels and speeds up the pro-

cess of hardening of the arteries. Further, smoking is a major risk for
heart disease and stroke. If you don’t smoke, don’t start. Quitting
125
smoking lowers one’s risk of heart attack and stroke. Your doctor can
suggest programs to help you quit smoking.
Medications: If you develop high blood pressure, your doctor may

prescribe medications, in addition to lifestyle changes, to help bring
it under control. Once your blood pressure is controlled, continuing
your medication and doctor visits is critical to keep your blood pres-
sure in check. The lifestyle changes noted above are just as impor-
tant as taking your medicines as prescribed.
Genetic factors: Genes can play a role in high blood pressure. It

is also possible that an increased risk of high blood pressure within a
family is due to factors such as a common sedentary lifestyle or poor
eating habits. Therefore, lifestyle factors should be considered for pre-
venting and controlling high blood pressure.
Section 10.5
Managing Stress
“Tips for Better Managing Your Stress,” by Steve Bressert, Ph.D.,
© 2006 PsychCentral (psychcentral.com). Reprinted with permission.
Completely banishing stress from your life may never be an attain-

able goal. Nor, some would argue, should it be. If you consistently try
your hardest and seek new endeavors, you will naturally feel chal-
lenged and sometimes even stressed. This is all part of personal
growth. But sometimes stress threatens to overwhelm you.
Fortunately, there are steps you can take to minimize its negative
toll, and to prevent it from getting a grip on you in the first place.
These strategies provide you with a sense of control over your life and/
or the situation. They also boost your mood and your confidence in
handling a stressful situation.
Usually there is no one right or wrong way to cope with a stress-
ful situation. The idea is to have as much information—as many “tools
in your toolbox”—as possible.
126
For stressors that are uncontrollable, the key is to adapt your re-
sponse to the needs of the situation and/or manage your cognitive or
emotional responses in order to minimize stress. For example:
• Remind yourself that you successfully have handled similar
situations in the past.
• Reassure yourself that you will be fine regardless of what hap-
pens.
• Find some humor in the situation.
• Reward yourself afterward with something enjoyable.
• Find a trusted friend to talk with about the experience.
• Use relaxation exercises to control your physical response to the
situation.
• Make a list of similar situations and how you successfully man-
aged them in the past.
• Ask others what they have done in similar situations to prepare
yourself.
• Expect surprises in your life and in these situations, and don’t
let being stressed add to your stress.
For stressors you have some control over, you can do things to ac-
tively respond to the situation. For example:
• Make a list of stressors, so that you can prioritize them and

tackle them one at a time, in order to minimize feelings of being
overwhelmed.
• Change aspects of a stressful situation that give you problems.
Rearrange your schedule, have a problem-solving discussion with
the bothersome person, organize your workspace, schedule some
time for a break, take a brief walk, or ask someone for help.
• Expect surprises in your life and in these situations, and don’t
let being stressed add to your stress.
Develop systematic problem-solving skills:
• Identify the stressful situation.

• Define it as an objective, solvable problem.
• Brainstorm solutions—don’t evaluate them yet!
127
• Anticipate the possible outcomes of each solution.
• Choose a solution and act on it.
• Evaluate the results, and start over if necessary.
• Don’t expect to be perfect. Give it your best shot and learn from
the experiences.
Improve your coping skills. Practice assertive communication and

problem solving. Find someone who successfully handles stress and
imitate him or her. Surround yourself with confident and competent
people. Take care of yourself physically; learn yoga, relaxation exer-
cises, and deep muscle relaxation skills.
Plan and prepare in advance for problematic situations. For ex-
ample, anticipate problems and develop a game plan for how to re-
spond, including reminding yourself that the situation has occurred
before and that you have survived it before.
Make lifestyle changes that are conducive to healthy and less
stressful living. Exercise regularly, drink plenty of water, maintain a
well-balanced diet and eat regular meals, try to balance work and
personal life, schedule time for personal recreation, stay involved with
family and friends, and limit social contact with people who are chroni-
cally negative.
There also are some medications that can calm the physiological
response to stressful events. They do not teach you new coping skills
to help you get through them. In the long term, learning relaxation
skills, coping strategies, and how to think through problems are what
will help you with the next unexpected situation.
If you find yourself unable to function at the level you used to or
at the level you wish to, stress may be interfering with your life. If
you find yourself worrying, feeling physical (muscle) tension, having
rapid heart rate or doing a lot of “what-if-ing,” or postponing work
because you feel overwhelmed, talk to your family doctor or see a psy-
chologist or psychiatrist to discuss your stress level and coping skills.
128
Chapter 11
Other Behaviors that

Can Affect Your Health
Chapter Contents
Section 11.1—Aggressive Driving .............................................. 130
Section 11.2—Drug Abuse .......................................................... 132
Section 11.3—Anabolic Steroid Use ........................................... 134
Section 11.4—Dangers of Tanning and Ultraviolet Rays ........ 137
Section 11.5—Unsafe Sex ............................................................ 140
129
Section 11.1
Aggressive Driving
Reprinted from “Stop Aggressive Driving Planner,” National Highway
Traffic Safety Administration, October 2000. Despite the older date of
this document, the information presented here remains relevant.
Are You an Aggressive Driver?

Do you do the following:
• Express frustration: Taking out your frustrations on your fel-

low motorists can lead to violence or a crash.
• Fail to pay attention when driving: Reading, eating, drink-
ing, or talking on the phone can be a major cause of roadway
crashes.
• Tailgate: This is a major cause of crashes that can result in se-
rious deaths or injuries.
• Make frequent lane changes: If you whip in and out of lanes
to advance ahead, you can be a danger to other motorists.
• Run red lights: Do not enter an intersection on a yellow light.
Remember flashing red lights should be treated as a stop sign.
• Speed: Going faster than the posted speed limit, being a “road
racer,” and going too fast for conditions are some examples of
speeding.
Life in the Fast Lane

Plan ahead. Allow yourself extra time:
• Concentrate: Don’t allow yourself to become distracted by
talking on your cellular phone, eating, drinking, or putting on
makeup.
• Relax: Tune the radio to your favorite relaxing music. Music
can calm your nerves and help you to enjoy your time in the car.
130
Other Behaviors that Can Affect Your Health
• Drive the posted speed limit: Fewer crashes occur when ve-
hicles are traveling at or about the same speed.
• Identify alternate routes: Try mapping out an alternate
route. Even if it looks longer on paper, you may find it is less
congested.
• Use public transportation: Public transportation can give
you some much-needed relief from life behind the wheel.
• Just be late: If all else fails, just be late.
When Confronted with Aggressive Drivers

• Get out of the way: First and foremost make every attempt to
get out of their way.
• Put your pride aside: Do not challenge them by speeding up
or attempting to hold your own in your travel lane.
• Avoid eye contact: Eye contact can sometimes enrage an ag-
gressive driver.
• Gestures: Ignore gestures and refuse to return them.
• Report serious aggressive driving: You or a passenger may
call the police. But, if you use a cell phone, pull over to a safe lo-
cation.
131
Section 11.2
Drug Abuse
“Commonly Abused Drugs” is adapted from “Drugs of Abuse/Uses and
Effects,” U.S. Department of Justice, June 2004. “Frequently Asked Ques-
tions about Drug Abuse” is excerpted from “Frequently Asked Questions,”
National Institute on Drug Abuse, August 13, 2008.
Commonly Abused Drugs

Commonly abused drugs include narcotics, such as heroin, mor-
phine, oxycodone, and codeine; depressants, such as gamma hydroxy-
butyric acid (liquid ecstasy), benzodiazepines, barbiturates, and
Quaaludes; stimulants, like cocaine and methamphetamines; hallu-
cinogens, such as ecstasy, acid, phencyclidine hydrochloride (PCP),
Psilocybe mushrooms, and peyote cactus; and cannabis, including mari-
juana and hashish.
Frequently Asked Questions about Drug Abuse

What Is Drug Addiction?
Drug addiction is a complex brain disease. It is characterized by
drug craving, seeking, and use that can persist even in the face of
extremely negative consequences. Drug seeking may become compul-
sive in large part as a result of the effects of prolonged drug use on
brain functioning and, thus, on behavior. For many people, relapses
are possible even after long periods of abstinence.
How Quickly Can I Become Addicted to a Drug?

There is no easy answer to this. If and how quickly you might be-
come addicted to a drug depends on many factors, including the biol-
ogy of your body. All drugs are potentially harmful and may have
life-threatening consequences associated with their abuse. There are
also vast differences among individuals in sensitivity to various drugs.
While one person may use a drug one or many times and suffer no ill
effects, another person may be particularly vulnerable and overdose
132
with first use. There is no way of knowing in advance how someone
may react.
How Do I Know If Someone Is Addicted to Drugs?

If a person is compulsively seeking and using a drug despite nega-
tive consequences, such as loss of job, debt, physical problems brought
on by drug abuse, or family problems, then he or she probably is ad-
dicted. Seek professional help to determine if this is the case and, if
so, the appropriate treatment.
What Are the Physical Signs of Abuse or Addiction?

The physical signs of abuse or addiction can vary depending on
the person and the drug being abused. For example, someone who
abuses marijuana may have a chronic cough or worsening of asth-
matic symptoms. Each drug has short-term and long-term physical
effects. Stimulants like cocaine increase heart rate and blood pres-
sure, whereas opioids like heroin may slow the heart rate and re-
duce respiration.
Are There Effective Treatments for Drug Addiction?

Drug addiction can be effectively treated with behavioral-based
therapies and, for addiction to some drugs such as heroin or nicotine,
medications. Treatment will vary for each person depending on the
type of drug(s) being used, and multiple courses of treatment may be
needed to achieve success.
What Is Detoxification, or “Detox”?

Detoxification is the process of allowing the body to rid itself of a
drug while managing the symptoms of withdrawal. It is often the first
step in a drug treatment program and should be followed by treat-
ment with a behavioral-based therapy and/or a medication, if avail-
able. Detox alone with no follow-up is not treatment.
What Is Withdrawal? How Long Does It Last?

Withdrawal is the variety of symptoms that occur after use of some
addictive drugs is reduced or stopped. Length of withdrawal and symp-
toms vary with the type of drug. For example, physical symptoms of
heroin withdrawal may include: restlessness, muscle and bone pain,
133
insomnia, diarrhea, vomiting, and cold flashes. These physical symp-
toms may last for several days, but the general depression, or dys-
phoria (opposite of euphoria), that often accompanies heroin
withdrawal may last for weeks. In many cases withdrawal can be
easily treated with medications to ease the symptoms, but treating
withdrawal is not the same as treating addiction.
Section 11.3
Anabolic Steroid Use

“Hormone Abuse Overview,” © 2009 The Hormone Foundation
(www.hormone.org). All rights reserved. Reprinted with permission.
Hormones are substances produced by glands (or organs) that

travel to various sites in the body to affect bodily functions. Different
types of steroid hormones, a class of hormones chemically similar to
each other, have different functions. For example, the adrenal glands
produce an anti-inflammatory steroid similar to cortisone. Cortisone
may be prescribed to treat asthma, rashes, and various kinds of swell-
ing or inflammation.
Another kind of steroid is called an anabolic steroid. The term “ana-
bolic” means building up of a bodily substance. Anabolic steroids are
related to the major male hormone testosterone, which is produced
in the testes in men and in the adrenal glands in both men and
women. These chemicals are recognized for their effects on building
up muscle.
Synthetic (laboratory-made) anabolic steroids have some accepted
uses as prescribed medications, but they are best used in specific situ-
ations calling for that type of hormone therapy and for a limited
period of time. For example, anabolic steroids can help in rebuilding
tissues that have become weakened because of serious injury or ill-
ness. They also can be used to treat certain types of anemia and breast
cancer.
Anabolic steroids also are helpful in treating men who have a low
level of testosterone and those with a rare genetic problem that causes
episodes of swelling, called angioedema.
134
While anabolic steroids serve a clearly defined role in healing, these
powerful drugs are creating serious health risks, especially for our
nation’s youth. The abuse of steroids, in fact, is evolving into a major
health problem in the United States.
Steroids attract many young people and adults, who take these
drugs to enhance athletic performance and improve their body im-
age. Even though they may take steroids with good intentions, they
may not understand that the drugs are potentially harmful and can
cause a hormone imbalance leading to considerable health problems,
including permanent undesirable sexual changes for both men and
women. Anabolic steroids should never be taken except by prescrip-
tion when under a doctor’s care.
Steroid use among professional and Olympic athletes is believed
to be widespread. Some athletes use steroids to build muscle mass
and to speed recovery time from training and injuries. Others use
them to improve their physical appearance. Athletes may continue
using anabolic steroids because of a feeling of confidence and even
euphoria (extreme feeling of well-being) that may result.
However, a number of unhealthy and damaging effects may result
from the use of anabolic steroids that can lead to both emotional and
physical problems. Studies have shown that abuse of steroids can in-
crease aggressive behavior, cause mood swings, and impair judgment.
More recently, studies have reported an association between steroid
use and later abuse of other harmful drugs. Other reported effects
include male-pattern baldness, acne, and blood-filled liver cysts that
can rupture, causing death. Using steroids can increase the risk of
heart disease, stimulate the growth of certain cancers, and worsen
other medical problems.
Steroids taken orally (by mouth) have been linked to liver disease.
Steroids taken by injection (by needle) can increase the risk of infec-
tious diseases such as hepatitis or acquired immunodeficiency syn-
drome (AIDS). In one study, 25 percent of steroid users shared needles.
Equally troubling, anabolic steroids can retard growth. Young, de-
veloping bodies are particularly sensitive to steroids and some of the
side effects may be permanent. In addition to stunting growth in ado-
lescents whose bones should still be growing, steroids can trigger the
growth of breasts in males. This can happen because the chemical
structure of certain anabolic steroids is converted to the female hor-
mone estrogen by a chemical reaction in the body.
On the other hand, females may develop a deeper voice, an enlarged
clitoris, and facial hair growth. Women and girls also may experience
the loss of scalp hair. These are potentially permanent side effects.
135
Although long-term studies are scarce, experts believe that some
harmful effects may not appear until many years after the abuse of
these drugs.
High-profile athletes who use steroids often become role models
to children and teens because of the athletes’ physical appearance and
success in sports. The use of performance-enhancing substances
among adult sports figures then influences the behavior of some teens,
who begin to use steroids themselves. Although sports can build skills
in cooperation and competition, and sports performance can enhance
self-esteem, use of anabolic steroids harms young athletes’ bodies as
well as their minds.
In 2007, the Centers for Disease Control and Prevention (CDC)
found that 3.9 percent of high school students in the United State
reported using anabolic steroids without a prescription. Among high
school males, 5.1 percent admitted using illegal anabolic steroids;
among females, the rate was 2.7 percent.
Although males are more likely to have used illegal steroids with-
out a prescription than females, girls are also at risk. For young
women, body image is a powerful persuader, often based on inappro-
priate entertainment and media models. These drugs can help to de-
crease body fat, which is their appeal. But their side effects are serious
and unattractive: facial hair, acne, male-pattern baldness, masculine
appearance, and deeper voice, among others.
Easy access to performance-enhancing drugs, combined with the
pressures of popular culture, presents a complex and serious problem.
Because not enough research is done in this area, we still do not know
how great the problem is throughout society and what the effects of
steroid abuse ultimately will be.
136
Section 11.4
Dangers of Tanning and Ultraviolet Rays

This chapter begins with “Protect Yourself from the Sun,” excerpted from
the Centers for Disease Control and Prevention, May 17, 2007. Text un-
der the heading “The Truth about Indoor Tanning” is reprinted from www
.osteopathic.org, with the consent of the American Osteopathic Associa-
tion. © 2008 American Osteopathic Association.
Protect Yourself from the Sun

Summer is a great time to have fun outdoors. It’s also a time to
take precautions to avoid sunburns, which can increase your risk of
skin cancer.
Skin cancer is the most common form of cancer in the United
States. Exposure to the sun’s ultraviolet (UV) rays appears to be the
most important environmental factor involved with developing skin
cancer. During the summer months, UV radiation tends to be greater.
To help prevent skin cancer while still having fun outdoors, regu-
larly use sun protective practices such as the following:
• Seek shade, especially during midday hours (10:00 a.m. to 4:00
p.m.), when UV rays are strongest and do the most damage.
• Cover up with clothing to protect exposed skin.
• Get a hat with a wide brim to shade the face, head, ears, and neck.
• Grab shades that wrap around and block as close to 100 percent
of both ultraviolet A (UVA) and ultraviolet B (UVB) rays as pos-
sible.
• Rub on sunscreen with sun protective factor (SPF) 15 or higher,
and both UVA and UVB protection.
It’s always wise to choose more than one way to cover up when
you’re in the sun. Use sunscreen, and put on a T-shirt. Seek shade,
and grab your sunglasses. Wear a hat, but rub on sunscreen too. Com-
bining these sun protective actions helps protect your skin from the
sun’s damaging UV rays.
137
UV rays reach you on cloudy and hazy days, as well as bright and
sunny days. UV rays will also reflect off any surface like water, ce-
ment, sand, and snow. Additionally, UV rays from artificial sources of
light, like tanning beds, cause skin cancer and should be avoided.
Most forms of skin cancer can be cured. However, the best way to
avoid skin cancer is to protect your skin from the sun.
Remember, when in the sun, seek shade, cover up, get a hat, wear
sunglasses, and use sunscreen!
The Truth about Indoor Tanning

As the temperatures rise and shorts replace pants, pale winter skin
may sway some to consider the speedy effects of indoor tanning to
achieve a bronze summer glow. However, indoor tanning is even more
dangerous than outdoor sun exposure.
“The myth of health associated with a suntan is simply that—a
myth,” explains Craig Wax, D.O., an osteopathic family physician prac-
ticing in Mullica Hill, New Jersey. “Some people expose themselves
to the sun for the vitamin D. The amount of vitamin D made avail-
able is minimal compared with the risk of skin cancer with prolonged
exposure.”
He further explains that tanning is the body’s way of protecting
itself against ultraviolet (UV) ray exposure. The brown pigment mela-
nin produced by skin is spread throughout the exposed areas. This
pigment only minimally protects the skin against further damage
from UV radiation.
Despite this information, the use of indoor tanning devices which
emit ultraviolet light, both in tanning salons and at home, has never
been more popular. The industry serves twenty-eight million people;
generates $5 billion a year; and is represented by 30,000 tanning fa-
cilities across the country, according to the Skin Cancer Foundation.
“Many patients consider indoor tanning to be a safer alternative
to sun tanning,” he explains. “But it is just the opposite; tanning beds
emit up to twice as much skin damaging radiation.”
Dr. Wax explains that overexposure to UV rays can cause eye in-
jury, premature wrinkling and aging of the skin, light-induced skin
rashes, and increased chances of developing skin cancer.
“Young women are prone to use tanning salons,” explains Dr. Wax,
“because while the aging effects and skin cancer might take years to
surface, the perceived social value of a tan is immediate.” He warns
that the dangers of tanning are serious and increase the potential for
skin cancer, including:
138
• Malignant melanoma: The deadliest form of skin cancer, often
surfacing as a flat or slightly raised discolored patch that has ir-
regular borders. This is the result of intense exposure in child-
hood, resulting in multiple sunburns.
• Basal cell carcinoma (BCC): The most common form of skin
cancer, BCC can be identified by an open sore, a red patch of skin,
a shiny bump, a pink growth, or scar-like area. This type of skin
cancer follows a similar pattern to melanoma and is best identi-
fied by a physician.
Dr. Wax further explains that the health risks associated with UV
radiation are even more likely with smoking, the use of birth control
pills, anti-depressants, acne medication, ingredients found in anti-
dandruff shampoos, lime oil, and some cosmetics.
“If you or someone you know is using an indoor tanning device, it
is important to educate them on the hazards of tanning,” explains Dr.
Wax.
Further, he explains that if skin shows signs of possible cancer, it
is important to consult a physician immediately.
139
Section 11.5
Unsafe Sex
Excerpted from “Safe Sex,” © 2009 A.D.A.M., Inc.
Safe sex means taking precautions during sex that can keep you
from getting a sexually transmitted disease (STD), or from giving an
STD to your partner. These diseases include genital herpes, genital
warts, human immunodeficiency virus (HIV), chlamydia, gonorrhea,
syphilis, hepatitis B and C, and others.
An STD is a contagious disease that can be transferred to another
person through sexual intercourse or other sexual contact. Many of
the organisms that cause sexually transmitted diseases live on the
penis, vagina, anus, mouth, and the skin of surrounding areas.
Most of the diseases are transferred by direct contact with a sore
on the genitals or mouth. However, some organisms can be transferred
in body fluids without causing a visible sore. They can be transferred
to another person during oral, vaginal, or anal intercourse.
Some STDs can also be transferred by nonsexual contact with in-
fected tissues or fluids, such as infected blood. For example, sharing
needles when using IV (in the vein) drugs is a major cause of HIV
and hepatitis B transmission. An STD can also be transmitted through
contaminated blood transfusions and blood products, through the pla-
centa from the mother to the fetus, and sometimes through breast-
feeding.
The following factors increase your risk of getting a sexually trans-
mitted disease (STD):
• Not knowing whether a partner has an STD or not
• Having a partner with a past history of any STD
• Having sex without a male or female condom
• Using drugs or alcohol in a situation where sex might occur
• If your partner is an IV drug user
• Having anal intercourse
140
Drinking alcohol or using drugs increases the likelihood that you
will participate in high-risk sex. In addition, some diseases can be
transferred through the sharing of used needles or other drug para-
phernalia.
Abstinence is an absolute answer to preventing STDs. However,
abstinence is not always a practical or desirable option.
Next to abstinence, the least risky approach is to have a mutually
monogamous sexual relationship with someone you know is free of
any STD. Ideally, before having sex with a new partner, each of you
should get screened for STDs, especially HIV and hepatitis B, and
share the test results with each another.
Use condoms to avoid contact with semen, vaginal fluids, or blood.
Both male and female condoms dramatically reduce the chance you
will get or spread an STD. However, condoms must be used properly:
• Keep in mind that STDs can still be spread, even if you use a
condom, because a condom does not cover surrounding skin ar-
eas. But a condom definitely reduces your risk.
• Lubricants may help reduce the chance a condom will break.
Use only water-based lubricants, because oil-based or petroleum-
type lubricants can cause latex to weaken and tear. Using con-
doms with nonoxynol-9 (a spermicide) can help prevent pregnancy,
but may increase the chance of HIV transmission because the
spermicide can irritate the vaginal walls.
• The condom should be in place from the beginning to end of
sexual activity and should be used every time you have sex.
• Use latex condoms for vaginal, anal, and oral intercourse.
Here are additional safe-sex steps:
• Be responsible: If you have an STD, like HIV or herpes, advise

any prospective sexual partner. Allow him or her to decide what
to do. If you mutually agree on engaging in sexual activity, use
latex condoms and other measures to protect the partner.
• If pregnant, take precautions: If you have an STD, learn
about the risk to the infant before becoming pregnant. Ask your
provider how to prevent the fetus from becoming infected. HIV-
positive women should not breastfeed their infant.
• Know your partner: Before having sex, first establish a com-
mitted relationship that allows trust and open communication.
141
You should be able to discuss past sexual histories, any previ-
ous STDs or IV drug use. You should not feel coerced or forced
into having sex.
• Stay sober: Alcohol and drugs impair your judgment, commu-
nication abilities, and ability to properly use condoms or lubri-
cants.
In summary, safe sex requires prior planning and good communi-

cation between partners. Given that, couples can enjoy the pleasures
of a sexual relationship while reducing the potential risks involved.
References
Cohn SE. Sexually transmitted diseases, HIV, and AIDS in women.
Med Clin North Am. 2003; 87(5): 971–95.
Greydanus DE. Contraception for college students. Pediatr Clin North
Am. 2005; 52(1): 135–61, ix.
Polizzotto MJ. Prevention of sexually transmitted diseases. Clin Fam
Pract. 2005; 7(1): 1–12.
Workowski KA, Berman SM. Centers for Disease Control and Preven-
tion (CDC). Clinical prevention guidance. Sexually transmitted dis-
eases treatment guidelines. MMWR Morb Mortal Wkly Rep. 2006;4;
55(RR-11):2–6.
142
Part Two
Leading Causes
of Death in Men
Chapter 12
Causes of Death:
A Statistical Overview
Chapter Contents
Section 12.1—Leading Causes of Death for Men of
All Ages ................................................................. 146
Section 12.2—A Statistical Look at Cancer in Men ................. 149
Section 12.3—Homicide Statistics ............................................. 150
145
Section 12.1
Leading Causes of Death for Men of All Ages

Reprinted from “Leading Causes of Death in Males, United States,
2004,” Centers for Disease Control and Prevention, September 10, 2007.
Below are the leading causes of death in males for 2004.
Table 12.1. All Males, All Ages

Rank Cause of Death Percentage
1 Heart disease 27.2
2 Cancer 24.3
3 Unintentional injuries 6.1
4 Stroke 5.0
5 Chronic lower respiratory diseases 5.0
6 Diabetes 3.0
7 Influenza and pneumonia 2.3
8 Suicide 2.2
9 Kidney disease 1.7
10 Alzheimer disease 1.6
Note regarding Tables 12.2 through 12.6: Percentage is the percent-

age of total deaths in the race category due to the disease indicated.
The white, black, American Indian/Alaska native, and Asian/Pacific
Islander race groups include persons of Hispanic and non-Hispanic
origin. Persons of Hispanic origin may be of any race.
146
Causes of Death: A Statistical Overview
Table 12.2. White Males, All Ages

2 Cancer 24.6
5 Stroke 4.9
6 Diabetes 2.8
8 Suicide 2.3
9 Alzheimer disease 1.7
Table 12.3. Black Males, All Ages

2 Cancer 22.2
4 Stroke 5.2
5 Homicide 4.7
6 Diabetes 3.8
7 Human immunodeficiency virus 3.3
(HIV) disease
Table 12.4. American Indian or Alaska Native Males, All Ages (con-
tinued on next page)
2 Cancer 17.4
4 Diabetes 5.1
5 Chronic liver disease 4.5
147
Table 12.4. American Indian or Alaska Native Males, All Ages (con-
tinued)
6 Suicide 4.3
7 Stroke 3.4
9 Homicide 2.5
Table 12.5. Asian or Pacific Islander Males, All Ages

1 Cancer 26.7
3 Stroke 7.6
6 Diabetes 3.3
8 Suicide 2.5
10 Homicide 1.2
Table 12.6. Hispanic Males, All Ages

2 Cancer 19.0
4 Stroke 4.7
5 Diabetes 4.2
6 Homicide 4.1
7 Chronic liver disease 3.5
8 Suicide 2.7
10 Perinatal conditions 2.2
148
Section 12.2
A Statistical Look at Cancer in Men

Reprinted from “Cancer among Men,”
Centers for Disease Control and Prevention, October 4, 2007.
Three most common cancers among men (the numbers in paren-

theses are the rates per 100,000 persons):
• Prostate cancer (145.3): First among men of all races and His-
panic origin
• Lung cancer (85.3): Second among white (84.4), black (104.5),
Asian/Pacific Islander (49.7), and American Indian/Alaska Na-
tive (51.1) men; third among Hispanic men (48.5)
• Colorectal cancer (58.2): Second among Hispanic men (50.3);
third among white (57.0), black (67.6), Asian/Pacific Islander
(42.0), and American Indian/Alaska Native (32.6) men
Leading causes of cancer death among men:
• Lung cancer (70.3): First among men of all racial and Hispanic
origin
• Prostate cancer (25.4): Second among white (23.4), black (56.1),
American Indian/Alaska Native (16.5), and Hispanic (19.3) men
• Colorectal cancer (21.6): Third among men of all races and His-
panic origin
• Liver cancer: Second among Asian/Pacific Islander men (15.1).
Note: The combined rate for all races is presented when the rank-
ing of cancer sites did not differ across race and ethnicity; race- or
ethnicity-specific rates are presented when ranking differed by race
or ethnicity.
149
Section 12.3
Homicide Statistics
Reprinted from “Homicide Trends in the U.S.: Trends by Gender,”
U.S. Department of Justice, July 11, 2007.
Most victims and perpetrators in homicides are male:

• Male offender/Male victim: 65.3 percent
• Male offender/Female victim: 22.7 percent
• Female offender/Male victim: 9.6 percent
• Female offender/Female victim: 2.4 percent
Both male and female offenders are more likely to target male vic-
tims than female victims.
Victimization rates for both males and females have declined in
recent years:
• Males were almost four times more likely than females to be
murdered in 2005.
• In 2005 rates for females reached their lowest point recorded;
rates for males increased slightly from the low point recorded in
2000.
Offending rates for both males and females followed the same pat-
tern as victimization rates:
• Males were almost ten times more likely than females to com-
mit murder in 2005.
• The offending rates for females declined since the early 1980s
but stabilized after 1999. Offending rates for males peaked in
the early 1990s, fell to record lows, and stabilized in recent
years.
The gender distribution of homicide victims and offenders differs

by type of homicide:
150
• For the years 1976 to 2005 combined, among all homicide vic-
tims, females are particularly at risk for intimate killings and
sex-related homicides.
Figure 12.1. Homicide victimization by gender, 1976–2005
Figure 12.2. Homicide offending by gender, 1976–2005
151
The relationship between the victim and the offender differs for
female and male victims:
• Female victims are more likely than male victims to be killed by

an intimate or family member.
• Male victims are more likely than female victims to be killed by
acquaintances or strangers.
Table 12.7. Homicide Type by Gender, 1976–2005

Victims Offenders
Male Female Male Female
All homicides 76.5% 23.5% 88.8% 11.2%
Victim/offender relationship
Intimate 35.2% 64.8% 65.5% 34.5%
Family 51.5% 48.5% 70.8% 29.2%
Infanticide 54.6% 45.4% 61.8% 38.2%
Eldercide 58.1% 41.9% 85.2% 14.8%
Circumstances
Felony murder 78.4% 21.6% 93.2% 6.8%
Sex related 18.8% 81.2% 93.6% 6.4%
Drug related 90.2% 9.8% 95.5% 4.5%
Gang related 94.7% 5.3% 98.3% 1.7%
Argument 77.8% 22.2% 85.6% 14.4%
Workplace 79.1% 20.9% 91.3% 8.7%
Weapon
Gun homicide 82.7% 17.3% 91.3% 8.7%
Arson 56.4% 43.6% 79.1% 20.9%
Poison 55.3% 44.7% 63.5% 36.5%
Multiple victims or offenders

Multiple victims 63.3% 36.7% 93.5% 6.5%
Multiple offenders 85.6% 14.4% 91.6% 8.4%
152
Table 12.8. Victim Offender Relationship by Victim Gender, 1976–

2005
Percentage of homicide victims by gender
Victim/Offender relationship Male Female
Total 100.0 % 100.0 %
Intimate 5.0% 30.0%

Spouse 3.0 18.3
Ex-spouse 0.2 1.4
Boyfriend/Girlfriend 1.8 10.4
Other family 6.8% 11.8%

Parent 1.3 2.8
Child 2.1 5.4
Sibling 1.2 0.9
Other family 2.2 2.8
Acquaintance/Known 35.3% 21.8%

Neighbor 1.1 1.3
Employee/er 0.1 0.1
Friend/Acquaintance 29.4 17.0
Other Known 4.6 3.4
Stranger 15.5% 8.7%
Undetermined 37.4% 27.6%
Source: FBI, Supplementary Homicide Reports, 1976–2005.
Note: The victims of the September 11, 2001, terrorist attacks are
not included in this analysis.
153
Chapter 13
Heart Disease
Chapter Contents
Section 13.1—Men and Heart Disease ...................................... 156
Section 13.2—Coronary Artery Disease .................................... 158
Section 13.3—Heart Attack ........................................................ 167
Section 13.4—Heart Failure ....................................................... 169
Section 13.5—Cardiac Arrest ..................................................... 172
155
Section 13.1
Men and Heart Disease

Excerpted from “Men and Heart Disease Fact Sheet,”
Centers for Disease Control and Prevention, June 6, 2008.
Facts on Heart Disease in Men

In 2005, 322,841 men died from heart disease, the leading cause
of death for men in the United States.1
The age-adjusted death rate for heart disease in men was 260 per
100,000 population in 2005.1
About 9.4 percent of all white men, 7.1 percent of black men, and
5.6 percent of Mexican American men live with coronary heart dis-
ease.2
The average age of a first heart attack for men is sixty-six years.7
Almost half of men who have a heart attack under age sixty-five
die within eight years.4
Results from the Framingham Heart Study suggest that men have
a 49 percent lifetime risk of developing coronary heart disease after
the age of forty.4
Between 70 and 89 percent of sudden cardiac events occur in men.4
Major risk factors for heart disease include high blood pressure,
high blood cholesterol, tobacco use, diabetes, physical inactivity, and
poor nutrition.5
In a large study of blood pressure treatment and control, an aver-
age reduction of 12 to 13 mm Hg in systolic blood pressure over four
years of follow-up was associated with a 21 percent reduction in coro-
nary heart disease, 37 percent reduction in stroke, and 13 percent
reduction in all-cause mortality rates.6
Studies suggest that a 10 percent decrease in total cholesterol lev-
els may reduce the development of coronary heart disease by as much
as 30 percent.3
In this section, the term “heart disease” refers to the broadest cat-
egory of “disease of the heart” as defined by the International Classifi-
cation of Diseases and used by the Center for Disease Control’s (CDC’s)
National Center for Health Statistics. This category includes acute
156
Heart Disease
rheumatic fever, chronic rheumatic heart disease, hypertensive heart
disease, coronary heart disease, pulmonary heart disease, congestive
heart failure, and any other heart condition or disease.
References
1. National Center for Health Statistics. Health, United States,
2007 with Chartbook on Trends in the Health of Americans.
Hyatsville, MD: 2007.
2. American Heart Association. Heart Disease and Stroke Statis-
tics—2008 Update. Dallas, Texas: American Heart Association,
2008.
3. Cohen, JD. A population-based approach to cholesterol control.
American Journal of Medicine 1997:102:23–25.
4. Hurst W. The Heart, Arteries, and Veins. 10th ed. New York:
McGraw Hill; 2002.
5. Preventing chronic diseases: Investing wisely in health pre-
venting heart disease and stroke. July 2005. Centers for Dis-
ease Control and Prevention. February 6, 2006. http://www
.cdc.gov/nccdphp/publications/factsheets/Prevention/cvh.htm
6. He J, Whelton PK. Elevated systolic blood pressure and risk
of cardiovascular and renal disease: overview of evidence from
observational epidemiologic studies and randomized controlled
trials. Am Heart J. 1999; 138(3 Pt 2):211–19.
7. American Heart Association. Heart Disease and Stroke Statis-
tics—2005 Update. Dallas, Texas: American Heart Association,
2005.
157
Section 13.2
Coronary Artery Disease

Excerpted from “Coronary Artery Disease,” National Heart
Lung and Blood Institute, National Institutes of Health, June 2008.
What Is Coronary Artery Disease?

Coronary artery disease (CAD) is a condition in which plaque
builds up inside the coronary arteries. These arteries supply your
heart muscle with oxygen-rich blood.
Plaque is made up of fat, cholesterol, calcium, and other substances
found in the blood. When plaque builds up in the arteries, the condi-
tion is called atherosclerosis.
Plaque narrows the arteries and reduces blood flow to your heart
muscle. It also makes it more likely that blood clots will form in
your arteries. Blood clots can partially or completely block blood
flow.
Overview
When your coronary arteries are narrowed or blocked, oxygen-rich
blood can’t reach your heart muscle. This can cause angina or a heart
attack.
Angina is chest pain or discomfort that occurs when not enough
oxygen-rich blood is flowing to an area of your heart muscle. Angina
may feel like pressure or squeezing in your chest. The pain also may
occur in your shoulders, arms, neck, jaw, or back.
A heart attack occurs when blood flow to an area of your heart
muscle is completely blocked. This prevents oxygen-rich blood from
reaching that area of heart muscle and causes it to die. Without quick
treatment, a heart attack can lead to serious problems and even
death.
Over time, CAD can weaken the heart muscle and lead to heart
failure and arrhythmias. Heart failure is a condition in which your
heart can’t pump enough blood throughout your body. Arrhythmias
are problems with the speed or rhythm of your heartbeat.
158
Heart Disease
Outlook
CAD is the most common type of heart disease. It’s the leading
cause of death in the United States for both men and women. Lifestyle
changes, medicines, and/or medical procedures can effectively prevent
or treat CAD in most people.
What Causes Coronary Artery Disease?

Research suggests that coronary artery disease (CAD) starts when
certain factors damage the inner layers of the coronary arteries. These
factors include the following:
• Smoking
• High amounts of certain fats and cholesterol in the blood
• High blood pressure
• High amounts of sugar in the blood due to insulin resistance or
diabetes
When damage occurs, your body starts a healing process. Excess

fatty tissues release compounds that promote this process. This heal-
ing causes plaque to build up where the arteries are damaged.
The buildup of plaque in the coronary arteries may start in child-
hood. Over time, plaque can narrow or completely block some of your
coronary arteries. This reduces the flow of oxygen-rich blood to your
heart muscle.
Plaque also can crack, which causes blood cells called platelets to
clump together and form blood clots at the site of the cracks. This
narrows the arteries more and worsens angina or causes a heart at-
tack.
Who Is at Risk for Coronary Artery Disease?

Certain traits, conditions, or habits may raise your chance of de-
veloping CAD. These conditions are known as risk factors.
You can control most risk factors and help prevent or delay CAD.
Other risk factors can’t be controlled.
Major Risk Factors

Many factors raise the risk of developing CAD. The more risk fac-
tors you have, the greater chance you have of developing CAD:
159
• Unhealthy blood cholesterol levels: This includes high low-
density lipoprotein (LDL) cholesterol (sometimes called bad cho-
lesterol) and low high-density lipoprotein (HDL) cholesterol
(sometimes called good cholesterol).
• High blood pressure: Blood pressure is considered high if it
stays at or above 140/90 mmHg over a period of time.
• Smoking: This can damage and tighten blood vessels, raise cho-
lesterol levels, and raise blood pressure. Smoking also doesn’t al-
low enough oxygen to reach the body’s tissues.
• Insulin resistance: This condition occurs when the body can’t
use its own insulin properly. Insulin is a hormone that helps move
blood sugar into cells where it’s used.
• Diabetes: This is a disease in which the body’s blood sugar
level is high because the body doesn’t make enough insulin or
doesn’t use its insulin properly.
• Overweight or obesity: Overweight is having extra body
weight from muscle, bone, fat, and/or water. Obesity is having
a high amount of extra body fat.
• Metabolic syndrome: Metabolic syndrome is the name for a
group of risk factors linked to overweight and obesity that raise
your chance for heart disease and other health problems, such
as diabetes and stroke.
• Lack of physical activity: Lack of activity can worsen other
risk factors for CAD.
• Age: As you get older, your risk for CAD increases. Genetic or
lifestyle factors cause plaque to build in your arteries as you age.
By the time you’re middle-aged or older, enough plaque has built
up to cause signs or symptoms. In men, the risk for CAD increases
after age forty-five. In women, the risk for CAD risk increases af-
ter age fifty-five.
• Family history of early heart disease: Your risk increases if
your father or a brother was diagnosed with CAD before fifty-five
years of age, or if your mother or a sister was diagnosed with
CAD before sixty-five years of age.
Although age and a family history of early heart disease are risk
factors, it doesn’t mean that you will develop CAD if you have one or
both.
160
Heart Disease
Making lifestyle changes and/or taking medicines to treat other
risk factors can often lessen genetic influences and prevent CAD from
developing, even in older adults.
Emerging Risk Factors

Scientists continue to study other possible risk factors for CAD.
High levels of a protein called C-reactive protein (CRP) in the blood
may raise the risk for CAD and heart attack. High levels of CRP are
proof of inflammation in the body. Inflammation is the body’s response
to injury or infection. Damage to the arteries’ inner walls seems to
trigger inflammation and help plaque grow.
Research is under way to find out whether reducing inflammation
and lowering CRP levels also can reduce the risk of developing CAD
and having a heart attack.
High levels of fats called triglycerides in the blood also may raise
the risk of CAD, particularly in women.
Other Factors that Affect Coronary Artery Disease

Other factors also may contribute to CAD. These include the fol-
lowing:
• Sleep apnea: Sleep apnea is a disorder in which your breath-
ing stops or gets very shallow while you’re sleeping. Untreated
sleep apnea can raise your chances of having high blood pres-
sure, diabetes, and even a heart attack or stroke.
• Stress: Research shows that the most commonly reported “trig-
ger” for a heart attack is an emotionally upsetting event—par-
ticularly one involving anger.
• Alcohol: Heavy drinking can damage the heart muscle and
worsen other risk factors for heart disease. Men should have no
more than two drinks containing alcohol a day. Women should
have no more than one drink containing alcohol a day.
What Are the Signs and Symptoms of Coronary Artery

Disease?
A common symptom of coronary artery disease (CAD) is angina.
Angina is chest pain or discomfort that occurs when your heart muscle
doesn’t get enough oxygen-rich blood.
Angina may feel like pressure or a squeezing pain in your chest.
You also may feel it in your shoulders, arms, neck, jaw, or back. This
161
pain tends to get worse with activity and go away when you rest.
Emotional stress also can trigger the pain.
Another common symptom of CAD is shortness of breath. This
symptom happens if CAD causes heart failure. When you have heart
failure, your heart can’t pump enough blood throughout your body.
Fluid builds up in your lungs, making it hard to breathe.
The severity of these symptoms varies. The symptoms may get
more severe as the buildup of plaque continues to narrow the coro-
nary arteries.
Some people who have CAD have no signs or symptoms. This is
called silent CAD. It may not be diagnosed until a person show signs
and symptoms of a heart attack, heart failure, or an arrhythmia (an
irregular heartbeat).
Heart Attack
A heart attack happens when an area of plaque in a coronary ar-
tery breaks apart, causing a blood clot to form.
The blood clot cuts off most or all blood to the part of the heart
muscle that’s fed by that artery. Cells in the heart muscle die because
they don’t receive enough oxygen-rich blood. This can cause lasting
damage to your heart.
The most common symptom of heart attack is chest pain or dis-
comfort. Most heart attacks involve discomfort in the center of the
chest that lasts for more than a few minutes or goes away and comes
back. The discomfort can feel like pressure, squeezing, fullness, or pain.
It can be mild or severe. Heart attack pain can sometimes feel like
indigestion or heartburn.
Heart attacks also can cause upper body discomfort in one or both
arms, the back, neck, jaw, or stomach. Shortness of breath or fatigue
(tiredness) often may occur with or before chest discomfort. Other
symptoms of heart attack are nausea (feeling sick to your stomach),
vomiting, lightheadedness or fainting, and breaking out in a cold sweat.
Heart Failure
Heart failure is a condition in which your heart can’t pump enough
blood to your body. Heart failure doesn’t mean that your heart has
stopped or is about to stop working. It means that your heart can’t
fill with enough blood or pump with enough force, or both.
This causes you to have shortness of breath and fatigue that tends
to increase with activity. Heart failure also can cause swelling in your
feet, ankles, legs, and abdomen.
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Heart Disease
Arrhythmia
An arrhythmia is a problem with the speed or rhythm of the heart-
beat. When you have an arrhythmia, you may notice that your heart
is skipping beats or beating too fast. Some people describe arrhyth-
mias as a fluttering feeling in their chests. These feelings are called
palpitations.
Some arrhythmias can cause your heart to suddenly stop beating.
This condition is called sudden cardiac arrest (SCA). SCA can make
you faint and it can cause death if it’s not treated right away.
How Is Coronary Artery Disease Diagnosed?

Your doctor will diagnose coronary artery disease (CAD) based on
the following things:
• Your medical and family histories

• Your risk factors
• The results of a physical exam and diagnostic tests and proce-
dures
Diagnostic Tests and Procedures

No single test can diagnose CAD. If your doctor thinks you have
CAD, he or she will probably do one or more of the following tests.
Electrocardiogram (EKG): An EKG is a simple test that detects

and records the electrical activity of your heart. An EKG shows how
fast your heart is beating and whether it has a regular rhythm. It also
shows the strength and timing of electrical signals as they pass
through each part of your heart. Certain electrical patterns that the
EKG detects can suggest whether CAD is likely. An EKG also can show
signs of a previous or current heart attack.
Stress testing: During stress testing, you exercise to make your

heart work hard and beat fast while heart tests are performed. If you
can’t exercise, you’re given medicine to speed up your heart rate.
When your heart is beating fast and working hard, it needs more
blood and oxygen. Arteries narrowed by plaque can’t supply enough
oxygen-rich blood to meet your heart’s needs. A stress test can show
possible signs of CAD, such as the following:
• Abnormal changes in your heart rate or blood pressure
163
• Symptoms such as shortness of breath or chest pain
• Abnormal changes in your heart rhythm or your heart’s electri-
cal activity
During the stress test, if you can’t exercise for as long as what’s
considered normal for someone your age, it may be a sign that not
enough blood is flowing to your heart. But other factors besides CAD
can prevent you from exercising long enough (for example, lung dis-
eases, anemia, or poor general fitness).
Some stress tests use a radioactive dye, sound waves, positron
emission tomography (PET), or cardiac magnetic resonance imaging
(MRI) to take pictures of your heart when it’s working hard and when
it’s at rest.
These imaging stress tests can show how well blood is flowing in
the different parts of your heart. They also can show how well your
heart pumps blood when it beats.
Echocardiography: This test uses sound waves to create a mov-

ing picture of your heart. Echocardiography provides information
about the size and shape of your heart and how well your heart cham-
bers and valves are working.
The test also can identify areas of poor blood flow to the heart, areas
of heart muscle that aren’t contracting normally, and previous injury
to the heart muscle caused by poor blood flow.
Chest x-ray: A chest x ray takes a picture of the organs and struc-
tures inside the chest, including your heart, lungs, and blood vessels.
A chest x ray can reveal signs of heart failure, as well as lung disor-
ders and other causes of symptoms that aren’t due to CAD.
Blood tests: Blood tests check the levels of certain fats, choles-
terol, sugar, and proteins in your blood. Abnormal levels may show
that you have risk factors for CAD.
Electron-beam computed tomography (EBCT): This test finds

and measures calcium deposits (called calcifications) in and around
the coronary arteries. The more calcium detected, the more likely you
are to have CAD. EBCT isn’t used routinely to diagnose CAD, because
its accuracy isn’t yet known.
Coronary angiography and cardiac catheterization: Your

doctor may ask you to have coronary angiography if other tests or
164
Heart Disease
factors show that you’re likely to have CAD. This test uses dye and
special x-rays to show the insides of your coronary arteries.
To get the dye into your coronary arteries, your doctor will use a
procedure called cardiac catheterization. A long, thin, flexible tube
called a catheter is put into a blood vessel in your arm, groin (upper
thigh), or neck. The tube is then threaded into your coronary arter-
ies, and the dye is released into your bloodstream. Special x-rays are
taken while the dye is flowing through your coronary arteries.
Cardiac catheterization is usually done in a hospital. You’re awake
during the procedure. It usually causes little to no pain, although you
may feel some soreness in the blood vessel where your doctor put the
catheter.
How Is Coronary Artery Disease Treated?

Treatment for coronary artery disease (CAD) may include lifestyle
changes, medicines, and medical procedures. The goals of treatments
are as follows:
• To relieve symptoms
• To reduce risk factors in an effort to slow, stop, or reverse the
buildup of plaque
• To lower the risk of blood clots forming, which can cause a heart
attack
• To widen or bypass clogged arteries
• To prevent complications of CAD
Lifestyle Changes
Making lifestyle changes can often help prevent or treat CAD. For
some people, these changes may be the only treatment needed:
• Follow a heart healthy eating plan to prevent or reduce high
blood pressure and high blood cholesterol and to maintain a
healthy weight.
• Increase your physical activity. Check with your doctor first to
find out how much and what kinds of activity are safe for you.
• Lose weight, if you’re overweight or obese.
• Quit smoking, if you smoke. Avoid exposure to secondhand smoke.
• Learn to cope with and reduce stress.
165
Medicines
You may need medicines to treat CAD if lifestyle changes aren’t
enough. Medicines used to treat CAD include anticoagulants, aspirin
and other antiplatelet medicines, angiotensin-converting enzyme
(ACE) inhibitors, beta blockers, calcium channel blockers, nitroglyc-
erin, glycoprotein IIb-IIIa, statins, and fish oil and other supplements
high in omega-3 fatty acids.
Medical Procedures
You may need a medical procedure to treat CAD. Both angioplasty
and coronary artery bypass grafting (CABG) are used as treatments.
Angioplasty opens blocked or narrowed coronary arteries. During
angioplasty, a thin tube with a balloon or other device on the end is
threaded through a blood vessel to the narrowed or blocked coronary
artery. Once in place, the balloon is inflated to push the plaque out-
ward against the wall of the artery. This widens the artery and re-
stores the flow of blood.
Angioplasty can improve blood flow to your heart, relieve chest pain,
and possibly prevent a heart attack. Sometimes a small mesh tube called
a stent is placed in the artery to keep it open after the procedure.
In CABG, arteries or veins from other areas in your body are used
to bypass (that is, go around) your narrowed coronary arteries. CABG
can improve blood flow to your heart, relieve chest pain, and possibly
prevent a heart attack.
You and your doctor can discuss which treatment is right for you.
Cardiac Rehabilitation
Your doctor may prescribe cardiac rehabilitation (rehab) for angina
or after CABG, angioplasty, or a heart attack. Cardiac rehab, when
combined with medicine and surgical treatments, can help you recover
faster, feel better, and develop a healthier lifestyle. Almost everyone
with CAD can benefit from cardiac rehab.
Living With Coronary Artery Disease

Doing physical activity regularly, taking prescribed medicines, fol-
lowing a heart healthy eating plan, and watching your weight can help
control CAD.
See your doctor regularly to keep track of your blood pressure and
blood cholesterol and blood sugar levels. Talk to your doctor about how
166
Heart Disease
often you should schedule office visits or blood tests. Between those
visits, call your doctor if you develop any new symptoms or if your
symptoms worsen.
Let the people you see regularly know you’re at risk for a heart
attack. They can seek emergency care if you suddenly faint, collapse,
or develop other severe symptoms.
You may feel depressed or anxious if you’ve been diagnosed with
CAD and/or had a heart attack. You may worry about heart problems
or making lifestyle changes that are necessary for your health. Your
doctor may recommend medicine, professional counseling, or relax-
ation therapy if you have depression or anxiety.
Section 13.3
Heart Attack
Excerpted from “What Is a Heart Attack,” National Heart
Lung and Blood Institute, National Institutes of Health, March 2008.
What Is a Heart Attack?

A heart attack occurs when blood flow to a section of heart muscle
becomes blocked. If the flow of blood isn’t restored quickly, the sec-
tion of heart muscle becomes damaged from lack of oxygen and be-
gins to die.
Heart attack is a leading killer of both men and women in the
United States. But fortunately, today there are excellent treatments
for heart attack that can save lives and prevent disabilities. Treat-
ment is most effective when started within one hour of the beginning
of symptoms. If you think you or someone you’re with is having a heart
attack, call 9–1–1 right away.
Overview
Heart attacks occur most often as a result of a condition called coro-
nary artery disease (CAD). In CAD, a fatty material called plaque builds
up over many years on the inside walls of the coronary arteries (the
167
arteries that supply blood and oxygen to your heart). Eventually, an
area of plaque can rupture, causing a blood clot to form on the surface
of the plaque. If the clot becomes large enough, it can mostly or com-
pletely block the flow of oxygen-rich blood to the part of the heart muscle
fed by the artery.
During a heart attack, if the blockage in the coronary artery isn’t
treated quickly, the heart muscle will begin to die and be replaced by
scar tissue. This heart damage may not be obvious, or it may cause
severe or long-lasting problems.
Severe problems linked to heart attack can include heart failure
and life-threatening arrhythmias (irregular heartbeats). Heart fail-
ure is a condition in which the heart can’t pump enough blood through-
out the body. Ventricular fibrillation is a serious arrhythmia that can
cause death if not treated quickly.
Get Help Quickly

Acting fast at the first sign of heart attack symptoms can save your
life and limit damage to your heart. Treatment is most effective when
started within one hour of the beginning of symptoms.
The most common heart attack signs and symptoms are as follows:
• Chest discomfort or pain—uncomfortable pressure, squeezing,
fullness, or pain in the center of the chest that can be mild or
strong. This discomfort or pain lasts more than a few minutes
or goes away and comes back.
• Upper body discomfort in one or both arms, the back, neck, jaw,
or stomach.
• Shortness of breath may occur with or before chest discomfort.
• Other signs include nausea (feeling sick to your stomach), vomit-
ing, lightheadedness or fainting, or breaking out in a cold sweat.
If you think you or someone you know may be having a heart at-
tack:
• Call 9–1–1 within a few minutes—five at the most—of the start
of symptoms.
• If your symptoms stop completely in less than five minutes, still
call your doctor.
• Only take an ambulance to the hospital. Going in a private car
can delay treatment.
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Heart Disease
• Take a nitroglycerin pill if your doctor has prescribed this type
of medicine.
Outlook
Each year, about 1.1 million people in the United States have heart
attacks, and almost half of them die. CAD, which often results in a
heart attack, is the leading killer of both men and women in the
United States.
Many more people could recover from heart attacks if they got help
faster. Of the people who die from heart attacks, about half die within
an hour of the first symptoms and before they reach the hospital.
Section 13.4
Heart Failure
Reprinted from “Heart Failure: Frequently Asked Questions,”
NIH Senior Health, December 28, 2007.
What is heart failure?

In heart failure, the heart cannot pump enough blood through the
body. Heart failure develops over time as the pumping action of the
heart gets weaker. Heart failure does not mean that the heart has
stopped working or is about to stop working.
When the heart is weakened by heart failure, blood and fluid can
back up into the lungs and fluid builds up in the feet, ankles, and legs.
People with heart failure often experience tiredness and shortness of
breath.
What causes heart failure?

Heart failure is caused by other diseases and conditions that dam-
age the heart muscle. It is most commonly caused by coronary artery
disease, including heart attack. Diabetes and high blood pressure also
contribute to heart failure risk. People who have had a heart attack
are at high risk of developing heart failure.
169
What are the symptoms of heart failure?

The most common symptoms of heart failure include shortness of
breath or difficulty breathing, feeling tired, and swelling. Swelling is
caused by fluid buildup in the body and can lead to weight gain and
frequent urination, as well as coughing.
How common is heart failure?

Approximately five million people in the United States have heart
failure. It contributes to three hundred thousand deaths each year.
It is the number one cause of hospitalizations for people over the age
of sixty-five.
Who is at greatest risk?

Heart failure is most common in people over sixty-five. African
Americans are more likely to have heart failure and to suffer more
severely from it. African Americans are more likely to develop symp-
toms at an earlier age, have their heart failure get worse faster, have
more hospital visits, and die from heart failure. High blood cholesterol,
high blood pressure, and diabetes are risk factors for coronary artery
disease and heart failure.
Do men or women have a higher risk of heart failure?

Men have a higher rate of heart failure than women, but because
women usually live longer, the condition affects more women in their
seventies and eighties.
How can heart failure be prevented?

Keeping your cholesterol and blood pressure levels healthy and
keeping diabetes in check can help prevent coronary artery disease
and heart failure. You can prevent heart disease by losing weight if
you are overweight, quitting smoking, and limiting the amount of al-
cohol you drink. Doctors also recommend that you eat a diet low in
salt because salt can cause extra fluid to build up in your body.
What are the tests for heart failure?

There is not one specific test to diagnose heart failure. Because
the symptoms are common for other conditions, your doctor will de-
termine if you have heart failure by doing a detailed medical history,
170
Heart Disease
an examination, and several tests. During a physical exam, a doctor
will listen for abnormal heart sounds and lung sounds that indicate
fluid buildup, as well as look for signs of swelling.
If there are signs of heart failure, the doctor may order several
tests, including the following:
• An electrocardiogram (EKG) to measure the rate and regularity
of the heartbeat
• A chest x-ray to evaluate the heart and lungs
• A B-type natriuretic peptide (BNP) blood test to measure the
level of a hormone called BNP that increases when heart failure
is present
How is heart failure treated?

Treatment for heart failure includes lifestyle changes, medications,
and specialized care for those in advanced stages of the disease.
Lifestyle changes may mean reducing salt and fluid intake, and adopt-
ing a plan to lose weight.
Medications for the management of heart failure include diuret-
ics to reduce fluid buildup, angiotensin-converting enzyme (ACE) in-
hibitors to lower blood pressure, beta blockers to slow the heart rate,
and digoxin to help the heart beat stronger and pump more blood. For
severe heart failure, patients may require additional oxygen, a me-
chanical heart pump, or transplantation.
What research is being conducted on heart failure?

Scientists are trying to determine the best way to prevent and treat
heart failure. For example, a recent study by the National Heart, Lung,
and Blood Institute found that implantable defibrillators can prolong
the lives of some heart failure patients.
Researchers are also looking at genetics in relation to heart fail-
ure treatments. One study is investigating whether patients who have
certain genetic markers may respond better to beta blockers than
those who do not.
171
Section 13.5
Cardiac Arrest
“Sudden Cardiac Arrest Facts,” © 2008 Sudden Cardiac Arrest
Association (www.suddencardiacarrest.org). Reprinted with permission.
What Is Sudden Cardiac Arrest?

Sudden cardiac arrest (SCA) is a leading cause of death in the
United States, killing more than 325,000 people each year. That’s
more than the total death rate for breast cancer, lung cancer, and
human immunodeficiency virus (HIV)/acquired immunodeficiency
syndrome (AIDS) combined. During SCA, heart function ceases
abruptly and without warning. When this occurs, the heart is no
longer able to pump blood to the rest of the body, and in over 90 per-
cent of victims, death occurs. This is usually caused when the elec-
trical impulses in the affected heart become rapid (ventricular
tachycardia, or “VT”) or chaotic (ventricular fibrillation, or “VF”), or
both. These irregular heart rhythms are arrhythmias. The general
public and media often mistakenly refer to SCA as a “massive heart
attack.”
SCA is an electrical problem, whereby the arrhythmia prevents
the heart from pumping blood to the brain and vital organs. There
is an immediate cessation of the heart. In most cases, there are no
warning signs or symptoms. A heart attack is a “plumbing” problem
caused by one or more blockages in the heart’s blood vessels, prevent-
ing proper flow, and the heart muscle dies. Symptoms include chest
pain, radiating pain in left arm, between shoulder blades, and/or jaw,
difficulty breathing, dizziness, nausea and vomiting, and sweating.
In some cases, a heart attack may lead to a sudden cardiac arrest
event.
Resuscitation from SCA

When someone collapses from SCA, immediate cardiopulmonary
resuscitation (CPR) and use of an automated external defibrillator
(AED) are essential for any chance of recovery. The AED analyzes the
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Heart Disease
heart rhythm of the victim, and if necessary, a computerized command
will instruct the user to press a button to deliver an appropriate shock
to restore the normal operation of the heart. These devices are fail-
safe and will not cause injury to the user, nor will they deliver a shock
if none is needed. For patients in “VF,” studies show that if early
defibrillation is provided within the first minute, the odds are 90 per-
cent that the victim’s life can be saved. After that, the rate of survival
drops 10 percent with every minute. As many as 30 to 50 percent
would likely survive if CPR and AEDs were used within five minutes
of collapse.
Many heart failure patients who have either suffered an SCA or
are at risk have surgery to implant a small device called an implant-
able cardioverter defibrillator, or ICD. ICDs are designed to recognize
certain types of arrhythmias and correct them with a shock. Ninety-
five percent of lethal ventricular arrhythmias were shown to be ef-
fectively terminated by ICDs.
Who Is at Risk for SCA?

SCA can strike persons of any age, gender, race, and even those
who seem in good health, as evidenced by world-class professional ath-
letes at the peak of fitness. Many patients who may be at risk are not
being identified, screened, and given options for medical treatment.
If someone has any of the following risk factors or symptoms, he or
she should discuss with a doctor whether further heart testing and/
or evaluation by an electrophysiologist (EP) or cardiologist is neces-
sary:
• History of early heart disease, heart attack, or cardiac death in

the family
• Unexplained fainting or near fainting or palpitations
• Chest pain, shortness of breath, or fainting with exertion (such
as during sports)
• Heart failure or heart attack
• Weak heart muscle or a cardiac ejection fraction (EF) of less
than 40 percent (EF refers to the percentage of blood that is
pumped out of the heart’s main pumping chamber during each
heartbeat)
• Cardiac risk factors such as high blood pressure, diabetes, obe-
sity, smoking, or high cholesterol
173
Prevention
About 80 percent of SCA victims have signs of coronary heart dis-
ease. Leading a heart healthy lifestyle is important in preventing coro-
nary artery disease and other heart conditions:
• Learn CPR and the use of an AED.

• Activate 911 immediately in an emergency.
• Help your community by advocating placement of AEDs in pub-
lic places.
• Know your personal and family health history that may identify
risk factors.
174
Chapter 14
Prostate Cancer
What is cancer?
The body is made up of many types of cells. Normally, cells grow,
divide, and produce more cells as needed to keep the body healthy.
Sometimes, however, the process goes wrong—cells become abnormal
and form more cells in an uncontrolled way. These extra cells form a
mass of tissue, called a growth or tumor. Tumors can be benign, which
means not cancerous, or malignant, which means cancerous.
What is prostate cancer?

The prostate is a male sex gland, about the size of a large walnut.
It is located below the bladder and in front of the rectum. The
prostate’s main function is to make fluid for semen, a white substance
that carries sperm.
Prostate cancer occurs when a malignant tumor forms in the tis-
sue of the prostate. In its early stage, prostate cancer needs the male
hormone testosterone to grow and survive.
How common is prostate cancer among men in the United

States?
Prostate cancer is one of the most common types of cancer among
American men. It is a slow-growing disease that mostly affects older
Reprinted from “Prostate Cancer: Frequently Asked Questions,” NIH Senior
Health, March 28, 2007.
175
men. In fact, more than 65 percent of all prostate cancers are found
in men over the age of sixty-five. The disease rarely occurs in men
younger than forty years of age.
What is metastatic prostate cancer?

Sometimes, cancer cells break away from the malignant tumor in
the prostate and enter the bloodstream or the lymphatic system and
travel to other organs in the body.
When cancer spreads from its original location in the prostate to
another part of the body such as the bone, it is called metastatic pros-
tate cancer, not bone cancer. Doctors sometimes call this “distant” dis-
ease.
Can a man survive prostate cancer?

Yes. Today, more men are surviving prostate cancer than ever be-
fore. In fact, the number of deaths from prostate cancer has been de-
clining since the early 1990s. If found early, the disease can very likely
be cured.
What causes prostate cancer?

Scientists don’t know exactly what causes prostate cancer. They
cannot explain why one man gets prostate cancer and another does
not. However, they have been able to identify some risk factors that
are associated with the disease. A risk factor is anything that increases
your chances of getting a disease.
What is the most important risk factor for prostate cancer?

Age is the most important risk factor for prostate cancer. The dis-
ease is extremely rare in men under age forty, but the risk increases
greatly with age. More than 65 percent of cases are diagnosed in men
over age sixty-five. The average age at the time of diagnosis is sev-
enty.
Are there other major risk factors for prostate cancer be-
sides age?
Yes. Race is another major risk factor. In the United States, this
disease is much more common in African American men than in any
other group of men. It is least common in Asian and American Indian
176
Prostate Cancer
men. A man’s risk for developing prostate cancer is higher if his fa-
ther or brother has had the disease.
Diet also may play a role. There is some evidence that a diet high
in animal fat may increase the risk of prostate cancer and a diet high
in fruits and vegetables may decrease the risk. Studies to find out
whether men can reduce their risk of prostate cancer by taking cer-
tain dietary supplements are ongoing.
Are conditions like an enlarged prostate or obesity risk

factors for prostate cancer?
Scientists have wondered whether an enlarged prostate, a condi-
tion also known as benign prostatic hyperplasia or BPH, might in-
crease the risk for prostate cancer.
They have also studied obesity, lack of exercise, smoking, radiation
exposure, and a sexually transmitted virus to see if they might in-
crease risk. But at this time, there is little evidence that any of these
factors contribute to an increased risk.
What are the symptoms of prostate cancer?

• A need to urinate frequently, especially at night
• Difficulty starting urination or holding back urine
• Inability to urinate
• Weak or interrupted flow of urine
If prostate cancer develops and is not treated, it can cause these

symptoms:
• Painful or burning urination
• Difficulty in having an erection
• Painful ejaculation
• Blood in urine or semen
• Pain or stiffness in the lower back, hips, or upper thighs
Are there other conditions that have symptoms like pros-

tate cancer?
Yes. Any of the symptoms caused by prostate cancer may also be
due to enlargement of the prostate, which is not cancer. If you have
177
any of the symptoms mentioned above, see your doctor or a urologist
right away to find out if you need treatment. A urologist is a doctor
who specializes in treating diseases of the genitourinary system.
What tests are available for men who have prostate prob-
lems?
Doctors use the following tests to detect prostate abnormalities, but
these tests cannot show whether abnormalities are cancer or another,
less serious condition. The results from these tests will help the doc-
tor decide whether to check the patient further for signs of cancer:
• Digital rectal exam: The doctor inserts a lubricated, gloved

finger into the rectum and feels the prostate through the rectal
wall to check for hard or lumpy areas. A recent study revealed
that men with low prostate specific antigen levels, or PSA, may
still have prostate cancer.
• Blood test for prostate specific antigen or PSA: A lab mea-
sures the levels of PSA in a blood sample. The level of PSA may
rise in men who have prostate cancer, an enlarged prostate, or
infection in the prostate.
If initial tests show that prostate cancer might be present,

what happens next?
The doctor may order other exams, including ultrasound and x-
rays, to learn more about the cause of the symptoms. But to confirm
the presence of cancer, doctors must perform a biopsy. During a bi-
opsy, the doctor uses needles to remove small tissue samples from the
prostate and then looks at the samples under a microscope.
If a biopsy shows that cancer is present, the doctor will report on
the grade of the tumor. Doctors describe a tumor as low-, medium-, or
high-grade cancer, based on the way it appears under the microscope.
If prostate cancer is found, how do doctors describe how

far the cancer has spread?
If cancer is found in the prostate, the doctor needs to stage the dis-
ease. Staging is a careful attempt to find out whether the cancer has
spread and, if so, what parts of the body are affected. The doctor also
needs to find out the grade of the cancer. The grade tells how closely
the tumor resembles normal tissue.
178
Prostate Cancer
There are four stages used to describe prostate cancer. Doctors may
refer to the stages using Roman numerals I–IV or capital letters A–
D. The higher the stage, the more advanced the cancer. Following are
the main features of each stage:
• Stage I or stage A: The cancer is too small to be felt during a

rectal exam and causes no symptoms. The doctor may find it by
accident when performing surgery for another reason, usually
an enlarged prostate. There is no evidence that the cancer has
spread outside the prostate. A sub-stage, T1c, is a tumor identi-
fied by needle biopsy because of elevated PSA.
• Stage II or stage B: The tumor is still confined to the prostate
but involves more tissue within the prostate. The cancer is large
enough to be felt during a rectal exam, or it may be found through
a biopsy that is done because of a high PSA level. There is no evi-
dence that the cancer has spread outside the prostate.
• Stage III or stage C: The cancer has spread outside the pros-
tate to nearby tissues. The person may be experiencing symptoms,
such as problems with urination.
• Stage IV or stage D: The cancer has spread to lymph nodes or
to other parts of the body. There may be problems with urination,
fatigue, and weight loss.
If I do need to seek treatment for prostate cancer, what are

some of my options?
There are a number of ways to treat prostate cancer, and the doc-
tor will develop a treatment to fit each man’s needs. The choice of
treatment mostly depends on the stage of the disease and the grade
of the tumor. But doctors also consider a man’s age, general health,
and his feelings about the treatments and their possible side effects.
Treatment for prostate cancer may involve watchful waiting, sur-
gery, radiation therapy, or hormonal therapy. Some men receive a com-
bination of therapies. A cure is probable for men whose prostate cancer
is diagnosed early.
What are some of the side effects of these treatments?

Surgery, radiation therapy, and hormonal therapy all have the
potential to disrupt sexual desire or performance for a short while or
permanently. Discuss your concerns with your health care provider.
179
Several options are available to help you manage sexual problems
related to prostate cancer treatment.
What is “watchful waiting” and why would I choose it as a

treatment?
With watchful waiting, a man’s condition is closely monitored, but
treatment does not begin until symptoms appear or change. The doc-
tor may suggest watchful waiting for some men who have prostate can-
cer that is found at an early stage and appears to be growing slowly.
Also, watchful waiting may be advised for older men or men with
other serious medical problems. For these men, the risks and possible
side effects of surgery, radiation therapy, or hormonal therapy may
outweigh the possible benefits. Doctors monitor these patients with
regular check-ups. If symptoms appear or get worse, the doctor may
recommend active treatment.
What types of surgery are available for men with prostate

cancer?
Surgery is a common treatment for early stage prostate cancer. It
is used to remove the cancer. The surgeon may remove the entire pros-
tate—a type of surgery called radical prostatectomy—or, in a few
cases, remove only part of it.
Sometimes the surgeon will also remove nearby lymph nodes. Side
effects may include lack of sexual function, which is called impotence,
or problems holding urine, which is called incontinence.
How is radiation used to treat prostate cancer?

Radiation therapy uses high-energy x-rays to kill cancer cells and
shrink tumors. Doctors may recommend it instead of surgery or after
surgery to destroy any cancer cells that may remain in the area. In ad-
vanced stages, the doctor may recommend it to relieve pain or other symp-
toms. Radiation can cause problems with impotence and bowel function.
The radiation may come from a machine, which is external radia-
tion, or from tiny radioactive seeds placed inside or near the tumor,
which is internal radiation. Men who receive only the radioactive seeds
usually have small tumors. Some men receive both kinds of radiation
therapy.
For external radiation therapy, patients go to the hospital or clinic—
usually five days a week for several weeks. Internal radiation may re-
quire patients to stay in the hospital for a short time.
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Prostate Cancer
How is hormonal therapy used to treat prostate cancer?

Hormonal therapy deprives cancer cells of the male hormones they
need to grow and survive. This treatment is often used for prostate
cancer that has spread to other parts of the body. Sometimes doctors
use hormonal therapy to try to keep the cancer from coming back af-
ter surgery or radiation treatment. Side effects can include impotence,
hot flashes, loss of sexual desire, and thinning of bones.
What kinds of follow-up treatment could I have?

Regardless of the type of treatment you receive, you will be closely
monitored to see how well the treatment is working. Monitoring may
include the following:
• A PSA blood test, usually every three months to one year
• A bone scan and/or computed tomography (CT) scan to see if the
cancer has spread
• A complete blood count to monitor for signs and symptoms of
anemia
• Looking for signs or symptoms that the disease might be pro-
gressing, such as fatigue, increased pain, or decreased bowel
and bladder function
What kinds of treatments for prostate cancer are being de-

veloped?
Through research, doctors are trying to find new, more effective
ways to treat prostate cancer. Cryosurgery—destroying cancer by
freezing it—is under study as an alternative to surgery and radia-
tion therapy. To avoid damaging healthy tissue, the doctor places an
instrument known as a cryoprobe in direct contact with the tumor to
freeze it.
Doctors are studying new ways of using radiation therapy and
hormonal therapy, too. Studies have shown that hormonal therapy
given after radiation therapy can help certain men whose cancer has
spread to nearby tissues.
Scientists are also testing the effectiveness of chemotherapy and
biological therapy for men whose cancer does not respond or stops
responding to hormonal therapy.
They are also exploring new ways to schedule and combine vari-
ous treatments. For example, they are studying hormonal therapy to
181
find out if using it to shrink the tumor before a man has surgery or
radiation might be a useful approach. They are also testing combina-
tions of hormone therapy and vaccines to prevent recurrence of pros-
tate cancer.
Are there genes that put me at greater risk of getting pros-

tate cancer?
Researchers are studying changes in genes that may increase the
risk for developing prostate cancer. Some studies are looking at the
genes of men who were diagnosed with prostate cancer at a relatively
young age, less than fifty-five years old, and the genes of families who
have several members with the disease. Other studies are trying to
identify which genes, or arrangements of genes, are most likely to lead
to prostate cancer.
Much more work is needed, however, before scientists can say ex-
actly how genetic changes relate to prostate cancer. At the moment,
no genetic risk has been firmly established.
Are there other options for someone with prostate cancer?

Some prostate cancer patients take part in studies of new treat-
ments. These studies—called clinical trials—are designed to find out
whether a new treatment is safe and effective. Often, clinical trials
compare a new treatment with a standard one so that doctors can learn
which is more effective. People with prostate cancer who are interested
in taking part in a clinical trial should talk with their doctor.
What role do diet and dietary supplements play in pros-

tate cancer?
Diet may play a role. There is some evidence that a diet high in
animal fat may increase the risk of prostate cancer and a diet high
in fruits and vegetables may decrease the risk.
Researchers are also looking at diets that are low in fat and high
in soy, fruits, vegetables, and other food products to see if they might
prevent a recurrence of prostate cancer. In addition, recent studies
suggest that a diet that regularly includes tomato-based foods may
help protect men from prostate cancer.
Studies to find out whether men can reduce their risk of prostate
cancer by taking certain dietary supplements are ongoing.
These studies include the use of dietary supplements such as vi-
tamin E and selenium. At the moment, no dietary factor has been
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Prostate Cancer
proven to change your risk of developing prostate cancer or to alter
the course of the disease after diagnosis.
Who can provide emotional support for someone dealing

with prostate cancer?
Living with a serious disease such as cancer is not easy. Some
people find they need help coping with the emotional as well as the
practical aspects of their disease. Patients often get together in sup-
port groups where they can share what they have learned about cop-
ing with their disease and the effects of treatment. Patients may want
to talk with a member of their health care team about finding a sup-
port group.
People living with cancer may worry about caring for their fami-
lies, keeping their jobs, or continuing daily activities. Concerns about
treatments and managing side effects, hospital stays, and medical bills
are also common. Doctors, nurses, dietitians, and other members of
the health care team can answer questions about treatment, work-
ing, or other activities.
Meeting with a social worker, counselor, or member of the clergy
can be helpful to those who want to talk about their feelings or dis-
cuss their concerns. Often, a social worker can suggest resources for
help with rehabilitation, emotional support, financial aid, transpor-
tation, or home care.
It is natural for a man and his partner to be concerned about the
effects of prostate cancer and its treatment on their sexual relation-
ship. They may want to talk with the doctor about possible side ef-
fects and whether these are likely to be temporary or permanent.
Whatever the outlook, it is usually helpful for patients and their part-
ners to talk about their concerns and help one another find ways to
be intimate during and after treatment.
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Chapter 15
Lung Cancer
What is cancer?
The body is made up of many types of cells. Normally, cells grow,
divide, and produce more cells as needed to keep the body healthy and
functioning properly.
Sometimes, however, the process goes wrong—cells become abnor-
mal and form more cells in an uncontrolled way. These extra cells form
a mass of tissue, called a growth or tumor. Tumors can be benign,
meaning not cancerous, or malignant, meaning cancerous.
What is lung cancer?

Lung cancer occurs when malignant tumors form in the tissue of
the lung. The lungs are a pair of sponge-like organs. The right lung
has three sections, called lobes, and is larger than the left lung, which
has two lobes.
Are there different types of lung cancer?

There are two major types of lung cancer—non–small cell lung
cancer and small cell lung cancer. Each type of lung cancer grows and
spreads in different ways, and each is treated differently.
Excerpted from “Lung Cancer: Frequently Asked Questions,” NIH Senior

Health, March 23, 2007.
185
Non–small cell lung cancer is more common than small cell lung
cancer. It generally grows and spreads slowly. Small cell lung cancer,
sometimes called oat cell cancer, grows more quickly and is more likely
to spread to other organs in the body.
How does smoking affect lung cancer rates?

In 1965, about 42 percent of all adults smoked, but by 2005 only
21 percent did. During that time, there has been a sharp drop in
lung cancer deaths among men, mainly because fewer men are smok-
ing.
Smoking rates, which were dropping, have stopped declining in
recent years. Smoking by young people actually increased by 73 per-
cent in the 1990s.
Also, more women are getting lung cancer than ever before and
more are dying from it, mainly because more young women are smok-
ing. Many smoking education programs now focus on reversing the
increase in the number of women and young people who smoke.
What is the main cause of lung cancer?

Cigarette smoking is the number one cause of lung cancer. Scien-
tists have reported widely on the link between cancer and smoking
since the 1960s. Since then, study after study has provided more proof
that cigarette smoking is the primary cause of lung cancer.
Before cigarette smoking became popular in the early part of the
twentieth century, doctors rarely, if ever, saw patients with lung can-
cer. But today, lung cancer is the leading cause of death by cancer.
Nearly 90 percent of people with lung cancer developed it because they
smoked cigarettes.
Using tobacco products has been shown to cause cancer. In fact,
smoking tobacco, using smokeless tobacco, and being exposed regu-
larly to secondhand tobacco smoke are responsible for a large num-
ber of cancer deaths in the U.S. each year.
What are the risks of getting lung cancer if you are a

smoker?
If you smoke cigarettes, you are at much higher risk for lung can-
cer than a person who has never smoked. The risk of dying from lung
cancer is twenty-three times higher for men who smoke and thirteen
times higher for women who smoke than for people who have never
smoked.
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Lung Cancer
Stopping smoking greatly reduces your risk for developing lung
cancer. But after you stop, the risk goes down slowly. Ten years after
the last cigarette, the risk of dying from lung cancer drops by 50 per-
cent.
Can smoking cigars and pipes lead to lung cancer?

Smoking cigars and pipes also puts you at risk for lung cancer.
Cigar and pipe smokers have a higher risk of lung cancer than non-
smokers. Even cigar and pipe smokers who do not inhale are at in-
creased risk for lung, mouth, and other types of cancer.
Can secondhand smoke cause a nonsmoker to get lung

cancer?
Some studies suggest that nonsmokers who are exposed to envi-
ronmental tobacco smoke, also called secondhand smoke, are at in-
creased risk of lung cancer. Secondhand smoke is the smoke that
nonsmokers are exposed to when they share air space with someone
who is smoking. Each year, about three thousand nonsmoking adults
die of lung cancer as a result of breathing secondhand smoke.
Can exposure to radon lead to lung cancer?

Exposure to radon can put a person at risk for lung cancer, too.
People who work in mines may be exposed to this invisible, odorless,
and radioactive gas that occurs naturally in soil and rocks. It is also
found in houses in some parts of the country. A kit available at most
hardware stores allows homeowners to measure radon levels in their
homes.
Is there a risk of lung cancer from exposure to asbestos?

Another substance that can contribute to lung cancer is asbestos.
Asbestos is used in shipbuilding, asbestos mining and manufactur-
ing, insulation work, and brake repair. If inhaled, asbestos particles
can lodge in the lungs, damaging cells and increasing the risk for lung
cancer.
What are the possible signs of lung cancer?

The possible signs of lung cancer are as follows:
• A cough that doesn’t go away and gets worse over time
187
• Constant chest pain
• Coughing up blood
• Shortness of breath, wheezing, or hoarseness
• Repeated problems with pneumonia or bronchitis
• Swelling of the neck and face
• Loss of appetite or weight loss
• Fatigue
What are the chances of developing a second lung cancer?

A person who has had lung cancer once is more likely to develop a
second lung cancer compared to a person who has never had lung
cancer. Quitting smoking after lung cancer is diagnosed may prevent
the development of a second lung cancer.
How does a doctor usually detect lung cancer?

Seeing a spot on a chest x-ray is usually how a doctor first sus-
pects that lung cancer may be present. Doctors may also use imaging
methods such as a computed tomography (CT) scan or a positron
emission tomography (PET) scan to look for signs of cancer.
A CT scan, is a series of detailed pictures of areas inside the body.
A PET scan is a computerized image of the metabolic activity of body
tissues.
Are there new ways to detect lung cancer before it starts to

spread?
One screening method that shows promise detecting lung cancer
before it has spread is spiral computerized tomography, or spiral CT.
Spiral CT can scan the lungs from the neck to the diaphragm in less
than twenty seconds, or a single breath-hold. Preliminary studies show
that it may help doctors find small tumors, but questions remain about
the technology’s risk and benefits as a screening tool.
In the summer of 2002, the National Cancer Institute launched a
$200 million trial called the National Lung Screening Trial to determine
if spiral CT is better than conventional x-ray at finding dangerous lung
cancers and distinguishing between cancers and noncancerous changes
in the lungs.
The NLST isn’t the only study looking at the benefits of spiral CT
and chest x-ray. Recent reports in two medical journals have reported
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Lung Cancer
conflicting information about whether spiral CT is better than chest
x-ray at improving survival rates or reducing mortality. The only way
to get a sure answer is to conduct a randomized clinical trial to ex-
amine the two methods. The results of the NLST, which is the only
randomized clinical trial in the United States looking at this issue,
will be available by 2009.
How does a doctor confirm that someone has lung cancer?

To confirm that a person has lung cancer, the doctor must exam-
ine fluid or tissue from the lung. This is done through a biopsy—the
removal of a small sample of fluid or tissue for examination under a
microscope by a pathologist. A biopsy can show whether a person has
cancer. A number of procedures may be used to obtain this tissue:
• Bronchoscopy: The doctor puts a bronchoscope—a thin, lighted
tube—into the mouth or nose and down through the windpipe to
look into the breathing passages. Through this tube, the doctor
can collect cells or small samples of tissue.
• Needle aspiration: The doctor numbs the chest area and in-
serts a thin needle into the tumor to remove a sample of tissue.
• Thoracentesis: Using a needle, the doctor removes a sample
of the fluid that surrounds the lungs to check for cancer cells.
• Thoracotomy: Surgery to open the chest is sometimes needed
to diagnose lung cancer. This procedure is a major operation per-
formed in a hospital.
How does a doctor determine how far a lung cancer has

progressed?
Once lung cancer has been found, it is usually staged. Staging
means determining how far the cancer has progressed. Through stag-
ing, the doctor can tell if the cancer has spread and, if so, to what parts
of the body. Lung cancer often spreads to the brain or bones. Know-
ing the stage of the disease helps the doctor plan treatment.
Small cell lung cancer is divided into two stages. Limited stage is
generally cancer confined to the chest and extensive stage is cancer
that has spread outside the chest.
Non–small cell lung cancer is divided into four stages, I–IV. Most
patients with stage I and II non–small cell tumors and some patients
with stage III tumors can undergo surgery with the goal of cure. Stage
IV denotes cancer that has spread to other sites in the body, most often
189
bone, brain, or liver. Most stage IV cancers cannot be cured, although
treatment may be available to help prolong life.
What tests do doctors use to stage lung cancer?

Doctors can perform several tests to stage lung cancer. Staging
means finding out how far the cancer has progressed. The following
tests are used to stage lung cancer:
• Computed axial tomography or CAT scan is a computer linked
to an x-ray machine that creates a series of detailed pictures of
areas inside the body.
• Magnetic resonance imaging, or MRI, is a powerful magnet
linked to a computer that makes detailed pictures of areas in-
side the body.
• Radionuclide scanning uses a mildly radioactive substance to
show whether cancer has spread to other organs, such as the
liver.
• A bone scan uses a small amount of a radioactive substance to
show whether cancer has spread to the bones.
• A mediastinoscopy or mediastinotomy can help show whether
the cancer has spread to the lymph nodes in the chest by remov-
ing a tissue sample. The patient receives a general anesthetic for
this procedure.
What are the standard treatments for lung cancer?

Surgery is an operation to remove the cancer. Depending on the
location of the tumor, the surgeon may remove a small part of the lung,
a lobe of the lung, or the entire lung.
Chemotherapy uses anti-cancer drugs to kill cancer cells throughout
the body. Doctors use chemotherapy to control cancer growth and relieve
symptoms. Anti-cancer drugs are given by injection; through a catheter,
a long thin tube temporarily placed in a large vein; or in pill form.
Radiation therapy uses high-energy beams to kill cancer cells and
shrink tumors. An external machine delivers radiation to a limited
area, affecting cancer cells only in that area. Doctors may use radia-
tion therapy before surgery to shrink a tumor or after surgery to de-
stroy any cancer cells remaining in the treated area.
Photodynamic therapy, a newer technique, is laser therapy that is
used in combination with a chemical to kill cancer cells. Doctors may
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Lung Cancer
use it to reduce symptoms of lung cancer, such as bleeding, or to treat
very small tumors.
What are some common ways to treat non–small cell lung

cancer?
Doctors treat patients with non–small cell lung cancer in several
ways, and surgery is a common treatment. Cryosurgery, a treatment
that freezes and destroys cancer tissue, may be used to control symp-
toms in the later stages of non–small cell lung cancer. Doctors may
also use radiation therapy and chemotherapy to slow the progress of
the disease and to manage symptoms.
What is the best way to treat small cell lung cancer?

Small cell lung cancer spreads quickly. In many cases, cancer cells
have already spread to other parts of the body when the disease is
diagnosed. In order to reach cancer cells throughout the body, doctors
almost always use chemotherapy.
What new procedures have been developed to treat lung

cancer?
Researchers continue to look at new ways to combine, schedule, and
sequence the use of chemotherapy, surgery, and radiation to treat lung
cancer. For instance, in one large study, patients with non–small cell
lung cancer that had spread to nearby tissues or lymph nodes took
radiation and chemotherapy at the same time instead of sequentially.
Their five-year survival rates rose from about 6 percent to 16 percent.
Another study compared treatments given to two groups of people
with small cell lung cancer. One group had chemotherapy plus two
daily radiation treatments. The other had chemotherapy with only one
daily radiation treatment. Researchers found that the group receiv-
ing two daily radiation treatments with their chemotherapy had bet-
ter survival rates.
Are there any new chemotherapy drugs available to treat

lung cancer?
Newer chemotherapy drugs, known by the brand names Navelbine®,
Taxol®, Taxotere®, Gemzar®, Hycamtin®, and Camptosar® have pro-
duced improved response rates in tests of each drug alone. Various com-
binations of the new drugs with traditional agents, such as cisplatin
191
and carboplatin, are now either in clinical trials or have reported early
results of the trials.
Other researchers are working to develop drugs called “molecularly
targeted agents,” which kill cancer cells by targeting key molecules
involved in cancer cell growth. One of these drugs, called Avastin®,
helped patients live a few months longer when it was combined with
traditional chemotherapy.
Are there other options for someone with lung cancer?

Some lung cancer patients take part in studies of new treatments.
These studies, called clinical trials, are designed to find out whether
a new treatment is safe and effective. Often, clinical trials compare a
new treatment with a standard one so that doctors can learn which
is more effective. People with lung cancer who are interested in tak-
ing part in a clinical trial should talk with their doctor.
192
Chapter 16
Colorectal Cancer
What is colorectal cancer?

Cancer of the colon or rectum is called colorectal cancer. The colon
and the rectum are part of the large intestine, which is part of the
digestive system. Colorectal cancer occurs when malignant tumors
form in the lining of the large intestine, also called the large bowel.
How common is colorectal cancer?

Colorectal cancer accounts for almost 10 percent of all cancer
deaths in the United States. The risk of developing colorectal cancer
rises after age fifty. It is common in both men and women.
What are some of the risk factors for colorectal cancer?

Studies show that the following risk factors can increase a person’s
chances of developing colorectal cancer: age, polyps, diet, personal
history, family history, and ulcerative colitis.
If I have a polyp, does that mean I’m going to get

colorectal cancer?
Polyps are benign, or noncancerous, growths on the inner wall of
the colon and rectum. They are fairly common in people over age fifty.
Excerpted from “Colorectal Cancer: Frequently Asked Questions,” NIH Se-

nior Health, April 30, 2007.
193
Some types of polyps increase a person’s risk of developing colorectal
cancer. Not all polyps become cancerous, but nearly all colon cancers
start as polyps.
Does the condition known as ulcerative colitis increase my

risk of getting colorectal cancer?
Yes. Ulcerative colitis is a condition in which there is a chronic break
in the lining of the colon. It has been associated with an increased risk
of colon cancer.
Does diet play a role in colorectal cancer?

Diet may be associated with a risk of developing colorectal cancer.
Colorectal cancer occurs more frequently in populations that consume
a diet high in fat, protein, calories, alcohol, and both red and white
meat, and low in calcium and folate, than in populations that consume
a low-fat, high-fiber diet.
If a family member had colorectal cancer, what are the

chances I will have the disease?
Parents, siblings, or children of a person who has had colorectal
cancer are somewhat more likely to develop this type of cancer them-
selves. This is especially true if the relative had the cancer at a young
age. If many family members have had colorectal cancer, the chances
increase even more.
What are possible signs of colorectal cancer?

Possible signs of colorectal cancer include the following:
• A change in the frequency of bowel movements

• Diarrhea, constipation, or feeling that the bowel does not empty
completely
• Either bright red or very dark blood in the stool
• Stools that are narrower than usual
• General abdominal discomfort such as frequent gas pains, bloat-
ing, fullness, and/or cramps
• Weight loss with no known reason
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Colorectal Cancer
• Constant tiredness
• Vomiting
What are some of the tools used to detect colorectal cancer?

Here are some of the tools used to detect colorectal cancer:
• A fecal occult blood test, or FOBT, is a test used to check for

hidden blood in the stool. Sometimes cancers or polyps can bleed,
and FOBT can detect small amounts of bleeding.
• A sigmoidoscopy is an examination of the rectum and lower co-
lon—or sigmoid colon—using a lighted instrument called a sig-
moidoscope.
• A colonoscopy is an examination of the rectum and entire colon
using a lighted instrument called a colonoscope.
• A double contrast barium enema, or DCBE, is a series of x-rays
of the colon and rectum. The patient is given an enema with a so-
lution that contains barium, a substance that outlines the colon
and rectum on the x-rays.
Does the U.S. government have any specific recommenda-

tions about getting tested for colorectal cancer?
Yes. In July 2002, the U.S. Preventive Services Task Force made
its strongest ever recommendation for colorectal cancer screening: it
urged all adults age fifty and over to get screened, or tested, for the
disease. The task force noted that various screening tests are avail-
able, making it possible for patients and their clinicians to decide
which test is best for each person.
If colorectal cancer is found, how do doctors describe how

far the cancer has spread?
Doctors use the following stages to describe how the cancer
spreads:
• Stage 0: The cancer is very early. It is found only in the inner-

most lining of the colon or rectum.
• Stage I: The cancer involves more of the inner wall of the colon
or rectum.
195
• Stage II: The cancer has spread outside the colon or rectum to
nearby tissue, but not to the lymph nodes. Lymph nodes are small,
bean-shaped structures that are part of the body’s immune sys-
tem.
• Stage III: The cancer has spread to nearby lymph nodes, but
not to other parts of the body.
• Stage IV: The cancer has spread to other parts of the body.
Colorectal cancer tends to spread to the liver and/or lungs.
• Recurrent: Recurrent cancer means the cancer has come back
after treatment. The disease may recur in the colon or rectum or
in another part of the body.
What are the standard methods for treating colorectal

cancer?
The three standard treatments for colon cancer are surgery, che-
motherapy, and radiation. Surgery, however, is the most common
treatment for all stages of colon cancer. Surgery is an operation to
remove the cancer. A doctor may remove the cancer using several
types of surgery. For rectal cancer, radiation treatment also is an
option.
What types of surgery are available for someone with

colorectal cancer?
Several types of surgery are available for someone with colorectal
cancer. If the cancer is found at a very early stage, the doctor may
remove it without cutting through the abdominal wall. Instead, the
doctor may put a tube up the rectum into the colon and cut the can-
cer out. This is called a local excision.
If the cancer is found in a polyp, which is a small bulging piece of
tissue, the operation is called a polypectomy.
If the cancer is larger, the surgeon will remove the cancer and a
small amount of healthy tissue around it. This is called a colectomy.
The surgeon may then sew the healthy parts of the colon together.
Usually, the surgeon will also remove lymph nodes near the colon and
examine them under a microscope to see whether they contain can-
cer.
If the doctor is not able to sew the two ends of the colon back to-
gether, an opening called a stoma is made on the abdomen for waste
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Colorectal Cancer
to pass out of the body before it reaches the rectum. This procedure
is called a colostomy.
Sometimes the colostomy is needed only until the lower colon has
healed, and then it can be reversed. But if the doctor needs to remove
the entire lower colon, the colostomy may be permanent.
Are there any treatments that follow surgery?

Even if the doctor removes all the cancer that can be seen at the time
of the operation, some patients may receive chemotherapy after surgery
to kill any cancer cells that are left. Chemotherapy treatment after sur-
gery—to increase the chances of a cure—is called adjuvant therapy.
Researchers have found that patients who received adjuvant ther-
apy usually survived longer and went for longer periods of time with-
out a recurrence of colon cancer than patients treated with surgery
alone.
Patients age seventy and older benefited from adjuvant treatment
as much as their younger counterparts. In fact, adjuvant therapy is
equally as effective—and no more toxic—for patients seventy and
older as it is for younger patients, provided the older patients have
no other serious diseases.
What are some of the side effects of treatment for

colorectal cancer?
For surgery, the main side effects are short-term pain and tender-
ness around the area of the operation. For chemotherapy, the side ef-
fects depend on which drugs you take and what the dosages are. Most
often the side effects include nausea, vomiting, and hair loss. For ra-
diation therapy, fatigue, loss of appetite, nausea, and diarrhea may
occur.
Are there therapies that use a person’s own immune system

to fight colorectal cancer?
Yes. One treatment, biological therapy, stimulates the immune
system’s ability to fight cancer. In this therapy, substances made by
the body or in a laboratory are used to boost, direct, or restore the
body’s natural defenses against disease.
Another term for biological therapy is immunotherapy. At the mo-
ment, biological therapies are not standard therapy. They are experi-
mental treatments.
197
What are some of the newest drugs doctors use to combat

colorectal cancer?
Various drugs are under study as possible treatments for colorectal
cancer. In May 2002 researchers found that a drug regimen consist-
ing of oxaliplatin, 5-fluorouracil, and leucovorin can improve outcomes
for patients with colorectal cancer.
A 2005 study found that patients who took the drug Avastin® with
their standard chemotherapy treatment had a longer survival than those
who did not take Avastin. The generic name for Avastin is bevacizumab.
Scientists are also working on new vaccines and monoclonal anti-
bodies that may improve how patients’ immune systems respond to
colorectal cancers. Monoclonal antibodies are a single type of antibody
that researchers make in large amounts in a laboratory.
Are there tools that are better at finding colorectal cancer

early?
Scientists are looking at the role that sigmoidoscopy and colonos-
copy may play in reducing deaths from colorectal cancer through early
detection.
Two studies reported in the July 20, 2000, issue of the New En-
gland Journal of Medicine showed that colonoscopy can find many pre-
cancerous polyps that sigmoidoscopy misses. However, more studies
are needed to find out if colonoscopy can actually reduce the number
of deaths from colorectal cancer.
Are there any drugs available that can help prevent

colorectal cancer?
Scientists are doing research on chemoprevention—the use of
drugs to prevent cancer from developing in the first place. For ex-
ample, researchers have found that anti-inflammatory drugs helped
keep intestinal tumors from forming, but serious side effects have been
noted so researchers are proceeding cautiously.
Studies have shown that non-steroidal anti-inflammatory drugs
can keep large bowel polyps from forming. Bowel polyps can start out
benign, or noncancerous, but can become cancerous.
Are there genes that put me at greater risk of getting

colorectal cancer?
Researchers are working hard to understand and identify the genes
involved in colorectal cancer. Hereditary nonpolyposis colorectal cancer,
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Colorectal Cancer
or HNPCC, is one condition that causes people to develop colorectal can-
cer at a young age. The discovery of four genes involved with this dis-
ease has provided crucial clues about the role of DNA repair in colorectal
and other cancers.
Are there other options for someone with colorectal cancer?

Some colorectal cancer patients take part in studies of new treat-
ments. These studies, called clinical trials, are designed to find out
whether a new treatment is safe and effective.
199
Chapter 17
Liver Cancer
The Liver
The liver is the largest organ in the body. It is found behind the
ribs on the right side of the abdomen. The liver has two parts, a right
lobe and a smaller left lobe.
The liver has many important functions that keep a person healthy.
It removes harmful material from the blood. It makes enzymes and
bile that help digest food. It also converts food into substances needed
for life and growth.
The liver gets its supply of blood from two vessels. Most of its blood
comes from the hepatic portal vein. The rest comes from the hepatic
artery.
Understanding Liver Cancer

Most primary liver cancers begin in hepatocytes (liver cells). This
type of cancer is called hepatocellular carcinoma or malignant hepa-
toma.
When liver cancer spreads (metastasizes) outside the liver, the can-
cer cells tend to spread to nearby lymph nodes and to the bones and
lungs. When this happens, the new tumor has the same kind of ab-
normal cells as the primary tumor in the liver. For example, if liver
cancer spreads to the bones, the cancer cells in the bones are actually
Excerpted from “What You Need to Know about Liver Cancer,” National Can-
cer Institute, September 16, 2002. Revised by David A. Cooke, M.D., March 2009.
201
liver cancer cells. The disease is metastatic liver cancer, not bone can-
cer. It is treated as liver cancer, not bone cancer. Doctors sometimes
call the new tumor “distant” disease.
Similarly, cancer that spreads to the liver from another part of the
body is different from primary liver cancer. The cancer cells in the liver
are like the cells in the original tumor. When cancer cells spread to
the liver from another organ (such as the colon, lung, or breast), doc-
tors may call the tumor in the liver a secondary tumor. In the United
States, secondary tumors in the liver are far more common than pri-
mary tumors.
Liver Cancer: Who’s at Risk?

Studies have shown the following risk factors:
• Chronic liver infection (hepatitis): Certain viruses can in-

fect the liver. The infection may be chronic. (It may not go away.)
The most important risk factor for liver cancer is a chronic in-
fection with the hepatitis B virus or the hepatitis C virus. These
viruses can be passed from person to person through blood (such
as by sharing needles) or sexual contact. An infant may catch
these viruses from an infected mother. Liver cancer can develop
after many years of infection with the virus. These infections may
not cause symptoms, but blood tests can show whether either vi-
rus is present. If so, the doctor may suggest treatment. Also, the
doctor may discuss ways of avoiding infecting other people. In
people who are not already infected with hepatitis B virus, hepa-
titis B vaccine can prevent chronic hepatitis B infection and can
protect against liver cancer. Researchers are now working to de-
velop a vaccine to prevent hepatitis C infection.
• Cirrhosis: Cirrhosis is a disease that develops when liver cells
are damaged and replaced with scar tissue. Cirrhosis may be
caused by alcohol abuse, certain drugs and other chemicals, and
certain viruses or parasites. About 5 percent of people with cir-
rhosis develop liver cancer.
• Aflatoxin: Liver cancer can be caused by aflatoxin, a harmful
substance made by certain types of mold. Aflatoxin can form on
peanuts, corn, and other nuts and grains. In Asia and Africa, afla-
toxin contamination is a problem. However, the U.S. Food and
Drug Administration (FDA) does not allow the sale of foods that
have high levels of aflatoxin.
202
Liver Cancer
• Being male: Men are twice as likely as women to get liver can-
cer.
• Family history: People who have family members with liver
cancer may be more likely to get the disease.
• Age: In the United States, liver cancer occurs more often in
people over age sixty than in younger people.
The more risk factors a person has, the greater the chance that
liver cancer will develop. However, many people with known risk fac-
tors for liver cancer do not develop the disease.
People who think they may be at risk for liver cancer should dis-
cuss this concern with their doctor. The doctor may plan a schedule
for checkups.
Symptoms
Liver cancer is sometimes called a “silent disease” because in an
early stage it often does not cause symptoms. But, as the cancer grows,
symptoms may include the following:
• Pain in the upper abdomen on the right side; the pain may ex-
tend to the back and shoulder
• Swollen abdomen (bloating)
• Weight loss
• Loss of appetite and feelings of fullness
• Weakness or feeling very tired
• Nausea and vomiting
• Yellow skin and eyes, and dark urine from jaundice
• Fever
These symptoms are not sure signs of liver cancer. Other liver dis-
eases and other health problems can also cause these symptoms. Any-
one with these symptoms should see a doctor as soon as possible. Only
a doctor can diagnose and treat the problem.
Diagnosis
If a patient has symptoms that suggest liver cancer, the doctor
performs one or more of the following procedures:
203
• Physical exam: The doctor feels the abdomen to check the
liver, spleen, and nearby organs for any lumps or changes in
their shape or size. The doctor also checks for ascites, an abnor-
mal buildup of fluid in the abdomen. The doctor may examine
the skin and eyes for signs of jaundice.
• Blood tests: Many blood tests may be used to check for liver
problems. One blood test detects alpha-fetoprotein (AFP). High
AFP levels could be a sign of liver cancer. Other blood tests can
show how well the liver is working.
• Computed tomography (CT) scan: An x-ray machine linked
to a computer takes a series of detailed pictures of the liver and
other organs and blood vessels in the abdomen. The patient may
receive an injection of a special dye so the liver shows up clearly
in the pictures. From the CT scan, the doctor may see tumors in
the liver or elsewhere in the abdomen.
• Ultrasound test: The ultrasound device uses sound waves that
cannot be heard by humans. The sound waves produce a pattern
of echoes as they bounce off internal organs. The echoes create a
picture (sonogram) of the liver and other organs in the abdomen.
Tumors may produce echoes that are different from the echoes
made by healthy tissues.
• Magnetic resonance imaging (MRI): A powerful magnet
linked to a computer is used to make detailed pictures of areas
inside the body. These pictures are viewed on a monitor and can
also be printed.
• Angiogram: For an angiogram, the patient may be in the hos-
pital and may have anesthesia. The doctor injects dye into an
artery so that the blood vessels in the liver show up on an x-ray.
The angiogram can reveal a tumor in the liver.
• Biopsy: In some cases, the doctor may remove a sample of tis-
sue. A pathologist uses a microscope to look for cancer cells in
the tissue. The doctor may obtain tissue in several ways. One
way is by inserting a thin needle into the liver to remove a small
amount of tissue. This is called fine-needle aspiration. The doc-
tor may use CT or ultrasound to guide the needle. Sometimes
the doctor obtains a sample of tissue with a thick needle (core
biopsy) or by inserting a thin, lighted tube (laparoscope) into a
small incision in the abdomen. Another way is to remove tissue
during an operation.
204
Liver Cancer
Staging
If liver cancer is diagnosed, the doctor needs to know the stage, or
extent, of the disease to plan the best treatment. Staging is an attempt
to find out the size of the tumor, whether the disease has spread, and
if so, to what parts of the body. Careful staging shows whether the
tumor can be removed with surgery. This is very important because
most liver cancers cannot be removed with surgery.
The doctor may determine the stage of liver cancer at the time of
diagnosis, or the patient may need more tests. These tests may include
imaging tests, such as a CT scan, MRI, angiogram, or ultrasound.
Imaging tests can help the doctor find out whether the liver cancer
has spread. The doctor also may use a laparoscope to look directly at
the liver and nearby organs.
Treatment
At this time, liver cancer can be cured only when it is found at an
early stage (before it has spread) and only if the patient is healthy
enough to have an operation. However, treatments other than surgery
may be able to control the disease and help patients live longer and
feel better. When a cure or control of the disease is not possible, some
patients and their doctors choose palliative therapy. Palliative therapy
aims to improve the quality of a person’s life by controlling pain and
other problems caused by the disease.
Treatment Choices
The doctor can describe treatment choices and discuss the results
expected with each treatment option. The doctor and patient can work
together to develop a treatment plan that fits the patient’s needs.
Cancer of the liver is very hard to control with current treatments.
For that reason, many doctors encourage patients with liver cancer
to consider taking part in a clinical trial. Clinical trials are research
studies testing new treatments. They are an important option for
people with all stages of liver cancer.
The choice of treatment depends on the condition of the liver; the
number, size, and location of tumors; and whether the cancer has
spread outside the liver. Other factors to consider include the patient’s
age, general health, concerns about the treatments and their possible
side effects, and personal values.
Usually, the most important factor is the stage of the disease. The
stage is based on the size of the tumor, the condition of the liver, and
205
whether the cancer has spread. The following are brief descriptions
of the stages of liver cancer and the treatments most often used for
each stage. For some patients, other treatments may be appropriate.
Localized Resectable Cancer

Localized resectable liver cancer is cancer that can be removed
during surgery. There is no evidence that the cancer has spread to the
nearby lymph nodes or to other parts of the body. Lab tests show that
the liver is working well.
Surgery to remove part of the liver is called partial hepatectomy.
The extent of the surgery depends on the size, number, and location
of the tumors. It also depends on how well the liver is working. The
doctor may remove a wedge of tissue that contains the liver tumor,
an entire lobe, or an even larger portion of the liver.
In a partial hepatectomy, the surgeon leaves a margin of normal
liver tissue. This remaining healthy tissue takes over the functions
of the liver.
For a few patients, liver transplantation may be an option. For this
procedure, the transplant surgeon removes the patient’s entire liver
(total hepatectomy) and replaces it with a healthy liver from a donor.
A liver transplant is an option only if the disease has not spread out-
side the liver and only if a suitable donated liver can be found. While
the patient waits for a donated liver to become available, the health
care team monitors the patient’s health and provides other treat-
ments, as necessary.
Localized Unresectable Cancer

Localized unresectable liver cancer cannot be removed by surgery
even though it has not spread to the nearby lymph nodes or to dis-
tant parts of the body. Surgery to remove the tumor is not possible
because of cirrhosis (or other conditions that cause poor liver func-
tion), the location of the tumor within the liver, or other health prob-
lems.
Patients with localized unresectable cancer may receive other
treatments to control the disease and extend life:
• Radiofrequency ablation: The doctor uses a special probe to
kill the cancer cells with heat. The probe contains tiny electrodes
that destroy the cancer cells. Sometimes the doctor can insert the
probe directly through the skin. Only local anesthesia is needed.
In other cases, the doctor may insert the probe through a small
206
Liver Cancer
incision in the abdomen or may make a wider incision to open
the abdomen. These procedures are done in the hospital with
general anesthesia. Other therapies that use heat to destroy
liver tumors include laser or microwave therapy.
• Percutaneous ethanol injection: The doctor injects alcohol
(ethanol) directly into the liver tumor to kill cancer cells. The doc-
tor uses ultrasound to guide a small needle. The procedure may
be performed once or twice a week. Usually local anesthesia is
used, but if the patient has many tumors in the liver, general an-
esthesia may be needed.
• Cryosurgery: The doctor makes an incision into the abdomen
and inserts a metal probe to freeze and kill cancer cells. The doc-
tor may use ultrasound to help guide the probe.
• Hepatic arterial infusion: The doctor inserts a tube (catheter)
into the hepatic artery, the major artery that supplies blood to
the liver. The doctor then injects an anticancer drug into the cath-
eter. The drug flows into the blood vessels that go to the tumor.
Because only a small amount of the drug reaches other parts of
the body, the drug mainly affects the cells in the liver. Hepatic
arterial infusion also can be done with a small pump. The doctor
implants the pump into the body during surgery. The pump con-
tinuously sends the drug to the liver.
• Chemoembolization: The doctor inserts a tiny catheter into
an artery in the leg. Using x-rays as a guide, the doctor moves
the catheter into the hepatic artery. The doctor injects an anti-
cancer drug into the artery and then uses tiny particles to block
the flow of blood through the artery. Without blood flow, the drug
stays in the liver longer. Depending on the type of particles used,
the blockage may be temporary or permanent. Although the he-
patic artery is blocked, healthy liver tissue continues to receive
blood from the hepatic portal vein, which carries blood from the
stomach and intestine. Chemoembolization requires a hospital
stay.
• Total hepatectomy with liver transplantation: If localized
liver cancer is unresectable because of poor liver function, some
patients may be able to have a liver transplant. While the patient
waits for a donated liver to become available, the health care team
monitors the patient’s health and provides other treatments, as
necessary.
207
Advanced Cancer
Advanced cancer is cancer that is found in both lobes of the liver
or that has spread to other parts of the body. Although advanced liver
cancer cannot be cured, some patients receive anticancer therapy to
try to slow the progress of the disease. Others discuss the possible
benefits and side effects and decide they do not want to have anti-
cancer therapy. In either case, patients receive palliative care to re-
duce their pain and control other symptoms.
Treatment for advanced liver cancer may involve chemotherapy,
radiation therapy, or both:
• Chemotherapy uses drugs to kill cancer cells. The patient may
receive one drug or a combination of drugs. The doctor may use
chemoembolization or hepatic arterial infusion. Or the doctor
may give systemic therapy, meaning that the drugs are injected
into a vein and flow through the bloodstream to nearly every
part of the body. The doctor may call this intravenous or IV che-
motherapy. Usually chemotherapy is an outpatient treatment
given at the hospital, clinic, or at the doctor’s office. However,
depending on which drugs are given and the patient’s general
health, the patient may need to stay in the hospital.
• Radiation therapy (also called radiotherapy) uses high-energy
rays to kill cancer cells. Radiation therapy is local therapy,
meaning that it affects cancer cells only in the treated area. A
large machine outside the body directs radiation to the tumor
area.
Recurrent Cancer
Recurrent cancer means the disease has come back after the ini-
tial treatment. Even when a tumor in the liver seems to have been
completely removed or destroyed, the disease sometimes returns be-
cause undetected cancer cells remained somewhere in the body after
treatment. Most recurrences occur within the first two years of treat-
ment. The patient may have surgery or a combination of treatments
for recurrent liver cancer.
Side Effects of Treatment

Because cancer treatment may damage healthy cells and tissues,
unwanted side effects often occur. Side effects depend on many fac-
tors, including the type and extent of the treatment. Side effects may
208
Liver Cancer
not be the same for each person, and they may even change from one
treatment session to the next. The health care team will explain the
possible side effects of treatment and how they will help the patient
manage them.
Surgery
It takes time to heal after surgery, and the time needed to recover
is different for each person. Patients are often uncomfortable during
the first few days. However, medicine can usually control their pain.
Patients should feel free to discuss pain relief with the doctor or nurse.
It is common to feel tired or weak for a while. Also, patients may have
diarrhea and a feeling of fullness in the abdomen. The health care
team watches the patient for signs of bleeding, infection, liver failure,
or other problems requiring immediate treatment.
After a liver transplant, the patient may need to stay in the hos-
pital for several weeks. During that time, the health care team checks
for signs of how well the patient’s body is accepting the new liver. The
patient takes drugs to prevent the body from rejecting the new liver.
These drugs may cause puffiness in the face, high blood pressure, or
an increase in body hair.
Cryosurgery
Because a smaller incision is needed for cryosurgery than for tra-
ditional surgery, recovery after cryosurgery is generally faster and less
painful. Also, infection and bleeding are not as likely.
Percutaneous Ethanol Injection

Patients may have fever and pain after percutaneous ethanol in-
jection. The doctor can suggest medicines to relieve these problems.
Chemoembolization and Hepatic Arterial Infusion

Chemoembolization and hepatic arterial infusion cause fewer side
effects than systemic chemotherapy because the drugs do not flow
through the entire body. Chemoembolization sometimes causes nau-
sea, vomiting, fever, and abdominal pain. The doctor can give medi-
cations to help lessen these problems. Some patients may feel very
tired for several weeks after the treatment.
Side effects from hepatic arterial infusion include infection and
problems with the pump device. Sometimes the device may have to
be removed.
209
Systemic Chemotherapy
The side effects of chemotherapy depend mainly on the drugs and
the doses the patient receives. As with other types of treatment, side
effects are different for each patient.
Systemic chemotherapy affects rapidly dividing cells throughout
the body, including blood cells. Blood cells fight infection, help the blood
to clot, and carry oxygen to all parts of the body. When anticancer
drugs damage blood cells, patients are more likely to get infections,
may bruise or bleed easily, and may have less energy. Cells in hair
roots and cells that line the digestive tract also divide rapidly. As a
result, patients may lose their hair and may have other side effects
such as poor appetite, nausea and vomiting, or mouth sores. Usually,
these side effects go away gradually during the recovery periods be-
tween treatments or after treatment is complete. The health care team
can suggest ways to relieve side effects.
Recently, new classes of chemotherapy agents have shown prom-
ise in treatment of liver cancer. These drugs are given systemically,
but are more targeted in their effects. Many of these agents disrupt
systems in cancer cells that allow for growth and spread, and their
side effects may be less severe than those of traditional agents. Their
roles in treatment of this cancer are still being defined, but they ap-
pear promising.
Radiation Therapy
The side effects of radiation therapy depend mainly on the treat-
ment dose and the part of the body that is treated. Patients are likely
to become very tired during radiation therapy, especially in the later
weeks of treatment. Resting is important, but doctors usually advise
patients to try to stay as active as they can.
Radiation therapy to the chest and abdomen may cause nausea,
vomiting, diarrhea, or urinary discomfort. Radiation therapy also may
cause a decrease in the number of healthy white blood cells, cells that
help protect the body against infection. Although the side effects of
radiation therapy can be distressing, the doctor can usually treat or
control them.
The Promise of Cancer Research

Laboratory scientists are studying the liver to learn more about
what may cause liver cancer and how liver cancer cells work. They
are looking for new therapies to kill cancer cells.
210
Liver Cancer
Doctors in hospitals and clinics are conducting many types of clini-
cal trials. These are research studies in which people take part vol-
untarily. In these trials, researchers are studying ways to treat liver
cancer that have shown promise in laboratory studies. Research has
led to advances in treatment methods, but controlling liver cancer
remains a challenge. Scientists continue to search for more effective
ways to treat this disease.
Patients who join clinical trials have the first chance to benefit from
new treatments. They also make an important contribution to medi-
cal science. Although clinical trials may pose some risks, researchers
take very careful steps to protect people.
Currently, clinical trials involve chemotherapy, chemoembolization,
and radiofrequency ablation for the treatment of liver cancer. Another
approach under study is biological therapy, which uses the body’s
natural ability (immune system) to fight cancer. Biological therapy
is being studied in combination with chemotherapy.
211
Chapter 18
Other Cancers of
Special Concern to Men
Chapter Contents
Section 18.1—Penile Cancer ....................................................... 214
Section 18.2—Testicular Cancer ................................................ 220
Section 18.3—Breast Cancer in Men ......................................... 226
213
Section 18.1
Penile Cancer
Excerpted from PDQ® Cancer Information Summary. National Cancer
Institute; Bethesda, MD. Penile Cancer Treatment (PDQ®): Patient Ver-
sion. Updated June 2008. Available at: http://cancergov. Accessed Septem-
ber 1, 2008.
Penile cancer is a disease in which malignant (cancer) cells form

in the tissues of the penis.
The penis is a rod-shaped male reproductive organ that passes
sperm and urine from the body. It contains two types of erectile tis-
sue (spongy tissue with blood vessels that fill with blood to make an
erection):
• Corpora cavernosa: The two columns of erectile tissue that
form most of the penis.
• Corpus spongiosum: The single column of erectile tissue that
forms a small portion of the penis. The corpus spongiosum sur-
rounds the urethra (the tube through which urine and sperm
pass from the body).
The erectile tissue is wrapped in connective tissue and covered with

skin. The glans (head of the penis) is covered with loose skin called
the foreskin.
Human papillomavirus infection may increase the risk of develop-
ing penile cancer. Anything that increases your chance of getting a dis-
ease is called a risk factor. Circumcision may help prevent infection with
the human papillomavirus (HPV). A circumcision is an operation in
which the doctor removes part or all of the foreskin from the penis.
Many boys are circumcised shortly after birth. Men who were not cir-
cumcised at birth may have a higher risk of developing penile cancer.
Other risk factors for penile cancer include the following:
• Being age sixty or older
• Having phimosis (a condition in which the foreskin of the penis
cannot be pulled back over the glans)
214
Other Cancers of Special Concern to Men
• Having poor personal hygiene
• Having many sexual partners
• Using tobacco products
Possible signs of penile cancer include sores, discharge, and bleed-

ing. These and other symptoms may be caused by penile cancer. Other
conditions may cause the same symptoms. A doctor should be con-
sulted if any of the following problems occur:
• Redness, irritation, or a sore on the penis

• A lump on the penis
Tests that examine the penis are used to detect (find) and diag-
nose penile cancer. The following tests and procedures may be used:
• Physical exam and history: An exam of the body to check

general signs of health, including checking the penis for signs
of disease, such as lumps or anything else that seems unusual.
A history of the patient’s health habits and past illnesses and
treatments will also be taken.
• Biopsy: The removal of cells or tissues so they can be viewed
under a microscope by a pathologist to check for signs of cancer.
The prognosis (chance of recovery) and treatment options depend

on the following:
• The stage of the cancer

• The location and size of the tumor
• Whether the cancer has just been diagnosed or has recurred
(come back)
Stages of Penile Cancer

After penile cancer has been diagnosed, tests are done to find out
if cancer cells have spread within the penis or to other parts of the
body.
The process used to find out if cancer has spread within the penis
or to other parts of the body is called staging. The information gath-
ered from the staging process determines the stage of the disease. It
is important to know the stage in order to plan treatment.
215
The following stages are used for penile cancer:
• Stage 0 (carcinoma in situ): In stage 0, abnormal cells are
found on the surface of the skin of the penis. These abnormal
cells may become cancer and spread into nearby normal tissue.
Stage 0 is also called carcinoma in situ.
• Stage I: In stage I, cancer has formed and spread to connective
tissue just under the skin of the penis.
• Stage II: In stage II, cancer has spread to connective tissue just
under the skin of the penis and to one lymph node in the groin or
to erectile tissue (spongy tissue that fills with blood to make an
erection) and possibly to one lymph node in the groin.
• Stage III: In stage III, cancer has spread to connective tissue
or erectile tissue of the penis and to more than one lymph node
on one or both sides of the groin; or to the urethra or prostate
and possibly to one or more lymph nodes on one or both sides
of the groin.
• Stage IV: In stage IV, cancer has spread to tissues near the
penis and may have spread to lymph nodes in the groin or pel-
vis; spread to anywhere in or near the penis and to one or more
lymph nodes deep in the pelvis or groin; or spread to distant
parts of the body.
Recurrent Penile Cancer

Recurrent penile cancer is cancer that has recurred (come back) af-
ter it has been treated. The cancer may come back in the penis or in
other parts of the body.
Treatment Option Overview

Different types of treatments are available for patients with penile
cancer. Some treatments are standard (the currently used treatment),
and some are being tested in clinical trials. A treatment clinical trial
is a research study meant to help improve current treatments or ob-
tain information on new treatments for patients with cancer. When
clinical trials show that a new treatment is better than the standard
treatment, the new treatment may become the standard treatment.
Patients may want to think about taking part in a clinical trial. Some
clinical trials are open only to patients who have not started treatment.
Three types of standard treatment are used.
216
Surgery
Surgery is the most common treatment for all stages of penile can-
cer. A doctor may remove the cancer using one of the following opera-
tions:
• Mohs microsurgery: A procedure in which the tumor is cut
from the skin in thin layers. During the surgery, the edges of
the tumor and each layer of tumor removed are viewed through
a microscope to check for cancer cells. Layers continue to be re-
moved until no more cancer cells are seen. This type of surgery
removes as little normal tissue as possible and is often used to
remove cancer on the skin. It is also called Mohs surgery.
• Laser surgery: A surgical procedure that uses a laser beam (a
narrow beam of intense light) as a knife to make bloodless cuts
in tissue or to remove a surface lesion such as a tumor.
• Cryosurgery: A treatment that uses an instrument to freeze
and destroy abnormal tissue. This type of treatment is also called
cryotherapy.
• Circumcision: Surgery to remove part or all of the foreskin of
the penis.
• Wide local excision: Surgery to remove only the cancer and
some normal tissue around it.
• Amputation of the penis: Surgery to remove part or all of the
penis. If part of the penis is removed, it is a partial penectomy. If
all of the penis is removed, it is a total penectomy.
Lymph nodes in the groin may be taken out during surgery.

Even if the doctor removes all the cancer that can be seen at the
time of the surgery, some patients may be given chemotherapy or ra-
diation therapy after surgery to kill any cancer cells that are left.
Treatment given after the surgery, to increase the chances of a cure,
is called adjuvant therapy.
Radiation Therapy
Radiation therapy is a cancer treatment that uses high-energy x-
rays or other types of radiation to kill cancer cells or keep them from
growing. There are two types of radiation therapy. External radiation
therapy uses a machine outside the body to send radiation toward the
cancer. Internal radiation therapy uses a radioactive substance sealed
217
in needles, seeds, wires, or catheters that are placed directly into or
near the cancer. The way the radiation therapy is given depends on
the type and stage of the cancer being treated.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the
growth of cancer cells, either by killing the cells or by stopping them
from dividing. When chemotherapy is taken by mouth or injected into
a vein or muscle, the drugs enter the bloodstream and can reach can-
cer cells throughout the body (systemic chemotherapy). When chemo-
therapy is placed directly onto the skin (topical chemotherapy) or into
the spinal column, an organ, or a body cavity such as the abdomen,
the drugs mainly affect cancer cells in those areas (regional chemo-
therapy). The way the chemotherapy is given depends on the type and
stage of the cancer being treated.
Topical chemotherapy may be used to treat stage 0 penile cancer.
Experimental Treatments
New types of treatment are being tested in clinical trials.
Biologic therapy: Biologic therapy is a treatment that uses the

patient’s immune system to fight cancer. Substances made by the body
or made in a laboratory are used to boost, direct, or restore the body’s
natural defenses against cancer. This type of cancer treatment is also
called biotherapy or immunotherapy. Topical biologic therapy may be
used to treat stage 0 penile cancer.
Radiosensitizers: Radiosensitizers are drugs that make tumor

cells more sensitive to radiation therapy. Combining radiation therapy
with radiosensitizers helps kill more tumor cells.
Sentinel lymph node biopsy followed by surgery: Sentinel

lymph node biopsy is the removal of the sentinel lymph node during
surgery. The sentinel lymph node is the first lymph node to receive
lymphatic drainage from a tumor. It is the first lymph node the can-
cer is likely to spread to from the tumor. A radioactive substance and/
or blue dye is injected near the tumor. The substance or dye flows
through the lymph ducts to the lymph nodes. The first lymph node to
receive the substance or dye is removed. A pathologist views the tis-
sue under a microscope to look for cancer cells. If cancer cells are not
218
found, it may not be necessary to remove more lymph nodes. After the
sentinel lymph node biopsy, the surgeon removes the cancer.
Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best
treatment choice. Clinical trials are part of the cancer research pro-
cess. Clinical trials are done to find out if new cancer treatments are
safe and effective or better than the standard treatment.
Many of today’s standard treatments for cancer are based on ear-
lier clinical trials. Patients who take part in a clinical trial may re-
ceive the standard treatment or be among the first to receive a new
treatment.
Patients who take part in clinical trials also help improve the way
cancer will be treated in the future. Even when clinical trials do not
lead to effective new treatments, they often answer important ques-
tions and help move research forward.
Patients can enter clinical trials before, during, or after starting
their cancer treatment. Some clinical trials only include patients who
have not yet received treatment. Other trials test treatments for pa-
tients whose cancer has not gotten better. There are also clinical tri-
als that test new ways to stop cancer from recurring (coming back)
or reduce the side effects of cancer treatment.
Follow-up
Follow-up tests may be needed. Some of the tests that were done
to diagnose the cancer or to find out the stage of the cancer may be
repeated. Some tests will be repeated in order to see how well the
treatment is working. Decisions about whether to continue, change,
or stop treatment may be based on the results of these tests. This is
sometimes called re-staging.
Some of the tests will continue to be done from time to time after
treatment has ended. The results of these tests can show if your con-
dition has changed or if the cancer has recurred (come back). These
tests are sometimes called follow-up tests or check-ups.
219
Section 18.2
Testicular Cancer
Excerpted from “Testicular Cancer: Questions and Answers,”
National Cancer Institute, May 24, 2005.
What is testicular cancer?

Testicular cancer is a disease in which cells become malignant (can-
cerous) in one or both testicles.
The testicles (also called testes or gonads) are a pair of male sex glands.
They produce and store sperm and are the main source of testosterone
(male hormones) in men. These hormones control the development of the
reproductive organs and other male physical characteristics. The testicles
are located under the penis in a sac-like pouch called the scrotum.
Based on the characteristics of the cells in the tumor, testicular can-
cers are classified as seminomas or nonseminomas. Other types of can-
cer that arise in the testicles are rare and are not described here.
Seminomas may be one of three types: classic, anaplastic, or sperma-
tocytic. Types of nonseminomas include choriocarcinoma, embryonal
carcinoma, teratoma, and yolk sac tumors. Testicular tumors may con-
tain both seminoma and nonseminoma cells.
Testicular cancer accounts for only 1 percent of all cancers in men in
the United States. About 8,000 men are diagnosed with testicular can-
cer and about 390 men die of this disease each year.1 Testicular cancer
occurs most often in men between the ages of twenty and thirty-nine, and
is the most common form of cancer in men between the ages of fifteen
and thirty-four. It is most common in white men, especially those of Scan-
dinavian descent. The testicular cancer rate has more than doubled
among white men in the past forty years, but has only recently begun to
increase among black men. The reason for the racial differences in inci-
dence is not known.
What are the risk factors for testicular cancer?

The exact causes of testicular cancer are not known. However, stud-
ies have shown that several factors increase a man’s chance of devel-
oping this disease:
220
• Undescended testicle (cryptorchidism): Normally, the tes-
ticles descend from inside the abdomen into the scrotum before
birth. The risk of testicular cancer is increased in males with a
testicle that does not move down into the scrotum. This risk does
not change even after surgery to move the testicle into the scro-
tum. The increased risk applies to both testicles.
• Congenital abnormalities: Men born with abnormalities of
the testicles, penis, or kidneys, as well as those with inguinal her-
nia (hernia in the groin area, where the thigh meets the abdo-
men), may be at increased risk.
• History of testicular cancer: Men who have had testicular can-
cer are at increased risk of developing cancer in the other testicle.
• Family history of testicular cancer: The risk for testicular
cancer is greater in men whose brother or father has had the dis-
ease.
How is testicular cancer detected? What are symptoms of

testicular cancer?
Most testicular cancers are found by men themselves. Also, doc-
tors generally examine the testicles during routine physical exams.
Between regular checkups, if a man notices anything unusual about
his testicles, he should talk with his doctor. Men should see a doctor
if they notice any of the following symptoms:
• A painless lump or swelling in a testicle
• Pain or discomfort in a testicle or in the scrotum
• Any enlargement of a testicle or change in the way it feels
• A feeling of heaviness in the scrotum
• A dull ache in the lower abdomen, back, or groin
• A sudden collection of fluid in the scrotum
These symptoms can be caused by cancer or by other conditions.

It is important to see a doctor to determine the cause of any of these
symptoms.
How is testicular cancer diagnosed?

To help find the cause of symptoms, the doctor evaluates a man’s
general health. The doctor also performs a physical exam and may or-
der laboratory and diagnostic tests. These tests include the following:
221
• Blood tests that measure the levels of tumor markers. Tumor
markers are substances often found in higher-than-normal
amounts when cancer is present. Tumor markers such as alpha-
fetoprotein (AFP), beta-human chorionic gonadotropin (ßHCG),
and lactate dehydrogenase (LDH) may suggest the presence of a
testicular tumor, even if it is too small to be detected by physical
exams or imaging tests.
• Ultrasound, a test in which high-frequency sound waves are
bounced off internal organs and tissues. Their echoes produce a
picture called a sonogram. Ultrasound of the scrotum can show
the presence and size of a mass in the testicle. It is also helpful
in ruling out other conditions, such as swelling due to infection
or a collection of fluid unrelated to cancer.
• Biopsy (microscopic examination of testicular tissue by a pa-
thologist) to determine whether cancer is present. In nearly all
cases of suspected cancer, the entire affected testicle is removed
through an incision in the groin. This procedure is called radical
inguinal orchiectomy. In rare cases (for example, when a man has
only one testicle), the surgeon performs an inguinal biopsy, re-
moving a sample of tissue from the testicle through an incision
in the groin and proceeding with orchiectomy only if the patholo-
gist finds cancer cells. (The surgeon does not cut through the scro-
tum to remove tissue. If the problem is cancer, this procedure
could cause the disease to spread.)
If testicular cancer is found, more tests are needed to find out if

the cancer has spread from the testicle to other parts of the body. De-
termining the stage (extent) of the disease helps the doctor to plan ap-
propriate treatment.
How is testicular cancer treated? What are the side effects

of treatment?
Although the incidence of testicular cancer has risen in recent
years, more than 95 percent of cases can be cured. Treatment is more
likely to be successful when testicular cancer is found early. In addi-
tion, treatment can often be less aggressive and may cause fewer side
effects.
Most men with testicular cancer can be cured with surgery, radia-
tion therapy, and/or chemotherapy. The side effects depend on the type
of treatment and may be different for each person.
222
Seminomas and nonseminomas grow and spread differently and
are treated differently. Nonseminomas tend to grow and spread more
quickly; seminomas are more sensitive to radiation. If the tumor con-
tains both seminoma and nonseminoma cells, it is treated as a
nonseminoma. Treatment also depends on the stage of the cancer, the
patient’s age and general health, and other factors. Treatment is of-
ten provided by a team of specialists, which may include a surgeon, a
medical oncologist, and a radiation oncologist.
The three types of standard treatment are described below.
Surgery: Surgery to remove the testicle through an incision in the

groin is called a radical inguinal orchiectomy. Men may be concerned
that losing a testicle will affect their ability to have sexual intercourse
or make them sterile (unable to produce children). However, a man
with one healthy testicle can still have a normal erection and produce
sperm. Therefore, an operation to remove one testicle does not make
a man impotent (unable to have an erection) and seldom interferes
with fertility (the ability to produce children). For cosmetic purposes,
men can have a prosthesis (an artificial testicle) placed in the scro-
tum at the time of their orchiectomy or at any time afterward.
Some of the lymph nodes located deep in the abdomen may also
be removed (lymph node dissection). This type of surgery does not
usually change a man’s ability to have an erection or an orgasm, but
it can cause problems with fertility if it interferes with ejaculation.
Patients may wish to talk with their doctor about the possibility of
removing the lymph nodes using a special nerve-sparing surgical tech-
nique that may preserve the ability to ejaculate normally.
Radiation therapy: Radiation therapy (also called radiotherapy)

uses high-energy rays to kill cancer cells and shrink tumors. It is a
local therapy, meaning that it affects cancer cells only in the treated
areas. External radiation (from a machine outside the body), aimed
at the lymph nodes in the abdomen, is used to treat seminomas. It is
usually given after surgery. Because nonseminomas are less sensitive
to radiation, men with this type of cancer usually do not undergo ra-
diation therapy.
Radiation therapy affects normal as well as cancerous cells. The
side effects of radiation therapy depend mainly on the treatment dose.
Common side effects include fatigue, skin changes at the site where
the treatment is given, loss of appetite, nausea, and diarrhea. Radia-
tion therapy interferes with sperm production, but many patients
regain their fertility over a period of one to two years.
223
Chemotherapy: Chemotherapy is the use of anticancer drugs to
kill cancer cells. When chemotherapy is given to testicular cancer
patients, it is usually given as adjuvant therapy (after surgery) to
destroy cancerous cells that may remain in the body. Chemotherapy
may also be the initial treatment if the cancer is advanced; that is, if
it has spread outside the testicle at the time of the diagnosis. Most
anticancer drugs are given by injection into a vein.
Chemotherapy is a systemic therapy, meaning drugs travel through
the bloodstream and affect normal as well as cancerous cells through-
out the body. The side effects depend largely on the specific drugs and
the doses. Common side effects include nausea, hair loss, fatigue, di-
arrhea, vomiting, fever, chills, coughing/shortness of breath, mouth
sores, or skin rash. Other side effects include dizziness, numbness, loss
of reflexes, or difficulty hearing. Some anticancer drugs also interfere
with sperm production. Although the reduction in sperm count is per-
manent for some patients, many others recover their fertility.
Some men with advanced or recurrent testicular cancer may un-
dergo treatment with very high doses of chemotherapy. These high
doses of chemotherapy kill cancer cells, but they also destroy the bone
marrow, which makes and stores blood cells. Such treatment can be
given only if patients undergo a bone marrow transplant. In a trans-
plant, bone marrow stem cells are removed from the patient before
chemotherapy is administered. These cells are frozen temporarily and
then thawed and returned to the patient through a needle (like a blood
transfusion) after the high-dose chemotherapy has been administered.
Men with testicular cancer should discuss their concerns about
sexual function and fertility with their doctor. It is important to know
that men with testicular cancer often have fertility problems even
before their cancer is treated. If a man has preexisting fertility prob-
lems, or if he is to have treatment that might lead to infertility, he
may want to ask the doctor about sperm banking (freezing sperm
before treatment for use in the future). This procedure allows some
men to have children even if the treatment causes loss of fertility.
Is follow-up treatment necessary? What does it involve?

Regular follow-up exams are extremely important for men who
have been treated for testicular cancer. Like all cancers, testicular
cancer can recur (come back). Men who have had testicular cancer
should see their doctor regularly and should report any unusual symp-
toms right away. Follow-up varies for different types and stages of
testicular cancer. Generally, patients are checked frequently by their
224
doctor and have regular blood tests to measure tumor marker levels.
They also have regular x-rays and computed tomography, also called
CT scans or CAT scans (detailed pictures of areas inside the body cre-
ated by a computer linked to an x-ray machine). Men who have had
testicular cancer have an increased likelihood of developing cancer
in the remaining testicle. Patients treated with chemotherapy may
have an increased risk of certain types of leukemia, as well as other
types of cancer. Regular follow-up care ensures that changes in health
are discussed and that problems are treated as soon as possible.
Are clinical trials (research studies) available for men

with testicular cancer?
Yes. Participation in clinical trials is an important treatment op-
tion for many men with testicular cancer. To develop new treatments,
and better ways to use current treatments, the National Cancer In-
stitute (NCI) is sponsoring clinical trials (research studies with people)
in many hospitals and cancer centers around the country. Clinical
trials are a critical step in the development of new methods of treat-
ment. Before any new treatment can be recommended for general use,
doctors conduct clinical trials to find out whether the treatment is safe
for patients and effective against the disease.
People interested in taking part in a clinical trial should talk with
their doctor.
Reference
1. American Cancer Society, Inc. Cancer Facts and Figures 2005.
Atlanta: American Cancer Society, Inc., 2005. Also available at
http://www.cancer.org/downloads/STT/CAFF2005f4PWSecured
.pdf on the Internet.
225
Section 18.3
Breast Cancer in Men

PDQ® Cancer Information Summary. National Cancer Institute; Bethesda,
MD. Male Breast Cancer Treatment (PDQ®): Patient Version. Updated July
2008. Available at: http://cancergov. Accessed September 1, 2008.
General Information about Male Breast Cancer

Male breast cancer is a disease in which malignant (cancer) cells
form in the tissues of the breast.
Breast cancer may occur in men. Men at any age may develop
breast cancer, but it is usually detected (found) in men between sixty
and seventy years of age. Male breast cancer makes up less than 1
percent of all cases of breast cancer.
The following types of breast cancer are found in men:
• Infiltrating ductal carcinoma: Cancer that has spread be-

yond the cells lining ducts in the breast. Most men with breast
cancer have this type of cancer.
• Ductal carcinoma in situ: Abnormal cells that are found in
the lining of a duct; also called intraductal carcinoma.
• Inflammatory breast cancer: A type of cancer in which the
breast looks red and swollen and feels warm.
• Paget disease of the nipple: A tumor that has grown from
ducts beneath the nipple onto the surface of the nipple.
Lobular carcinoma in situ (abnormal cells found in one of the lobes

or sections of the breast), which sometimes occurs in women, has not
been seen in men.
Risk Factors
Anything that increases your risk of getting a disease is called a
risk factor. Having a risk factor does not mean that you will get can-
cer; not having risk factors doesn’t mean that you will not get cancer.
226
People who think they may be at risk should discuss this with their
doctor. Risk factors for breast cancer in men may include the follow-
ing:
• Being exposed to radiation

• Having a disease related to high levels of estrogen in the body,
such as cirrhosis (liver disease) or Klinefelter syndrome (a ge-
netic disorder)
• Having several female relatives who have had breast cancer, es-
pecially relatives who have an alteration of the BRCA2 gene
Male breast cancer is sometimes caused by inherited gene muta-

tions (changes).
The genes in cells carry the hereditary information that is received
from a person’s parents. Hereditary breast cancer makes up approxi-
mately 5 to 10 percent of all breast cancer. Some altered genes related
to breast cancer are more common in certain ethnic groups. Men who
have an altered gene related to breast cancer have an increased risk
of developing this disease.
Tests have been developed that can detect altered genes. These
genetic tests are sometimes done for members of families with a high
risk of cancer.
Symptoms and Diagnosis

Men with breast cancer usually have lumps that can be felt.
Lumps and other symptoms may be caused by male breast cancer.
Other conditions may cause the same symptoms. A doctor should be
seen if changes in the breasts are noticed.
Tests that examine the breasts are used to detect (find) and diag-
nose breast cancer in men. The following tests and procedures may
be used:
• Biopsy: The removal of cells or tissues so they can be viewed

under a microscope by a pathologist to check for signs of cancer.
The following are different types of biopsies:
• Fine-needle aspiration (FNA) biopsy: The removal of tis-
sue or fluid using a thin needle.
• Core biopsy: The removal of tissue using a wide needle.
• Excisional biopsy: The removal of an entire lump of tissue.
227
• Estrogen and progesterone receptor test: A test to measure
the amount of estrogen and progesterone (hormones) receptors
in cancer tissue. If cancer is found in the breast, tissue from the
tumor is checked in the laboratory to find out whether estrogen
and progesterone could affect the way cancer grows. The test re-
sults show whether hormone therapy may stop the cancer from
growing.
• HER2 test: A test to measure the amount of HER2 in cancer
tissue. HER2 is a growth factor protein that sends growth signals
to cells. When cancer forms, the cells may make too much of the
protein, causing more cancer cells to grow. If cancer is found in
the breast, tissue from the tumor is checked in the laboratory to
find out if there is too much HER2 in the cells. The test results
show whether monoclonal antibody therapy may stop the cancer
from growing.
Prognosis
Survival for men with breast cancer is similar to that for women
with breast cancer when their stage at diagnosis is the same. Breast
cancer in men, however, is often diagnosed at a later stage. Cancer
found at a later stage may be less likely to be cured.
The prognosis (chance of recovery) and treatment options depend
on the following:
• The stage of the cancer (whether it is in the breast only or has
spread to other places in the body)
• The type of breast cancer
• Estrogen-receptor and progesterone-receptor levels in the tumor
tissue
• Whether the cancer is also found in the other breast
• The patient’s age and general health
Stages of Male Breast Cancer

After breast cancer has been diagnosed, tests are done to find out
if cancer cells have spread within the breast or to other parts of the
body. This process is called staging. The information gathered from
the staging process determines the stage of the disease. It is impor-
tant to know the stage in order to plan treatment. Breast cancer in
men is staged the same as it is in women. The spread of cancer from
228
the breast to lymph nodes and other parts of the body appears to be
similar in men and women.
Recurrent Male Breast Cancer

Recurrent breast cancer is cancer that has recurred (come back)
after it has been treated. The cancer may come back in the breast, in
the chest wall, or in other parts of the body.
Treatment Option Overview

Different types of treatment are available for men with breast can-
cer. Some treatments are standard (the currently used treatment), and
some are being tested in clinical trials. A treatment clinical trial is a
research study meant to help improve current treatments or obtain
information on new treatments for patients with cancer. When clini-
cal trials show that a new treatment is better than the standard treat-
ment, the new treatment may become the standard treatment.
For some patients, taking part in a clinical trial may be the best
treatment choice. Many of today’s standard treatments for cancer are
based on earlier clinical trials. Patients who take part in a clinical
trial may receive the standard treatment or be among the first to re-
ceive a new treatment.
Patients who take part in clinical trials also help improve the way
cancer will be treated in the future. Even when clinical trials do not
lead to effective new treatments, they often answer important ques-
tions and help move research forward.
Some clinical trials only include patients who have not yet received
treatment. Other trials test treatments for patients whose cancer has
not gotten better. There are also clinical trials that test new ways to
stop cancer from recurring (coming back) or reduce the side effects of
cancer treatment.
Choosing the most appropriate cancer treatment is a decision that
ideally involves the patient, family, and health care team.
Four types of standard treatment are used to treat men with breast
cancer.
Surgery: Surgery for men with breast cancer is usually a modi-
fied radical mastectomy (removal of the breast, many of the lymph
nodes under the arm, the lining over the chest muscles, and some-
times part of the chest wall muscles).
Breast-conserving surgery, an operation to remove the cancer but
not the breast itself, is also used for some men with breast cancer. A
229
lumpectomy is done to remove the tumor (lump) and a small amount
of normal tissue around it. Radiation therapy is given after surgery
to kill any cancer cells that are left.
Chemotherapy: Chemotherapy is a cancer treatment that uses

drugs to stop the growth of cancer cells, either by killing the cells or
by stopping them from dividing. When chemotherapy is taken by
mouth or injected into a vein or muscle, the drugs enter the blood-
stream and can reach cancer cells throughout the body (systemic che-
motherapy). When chemotherapy is placed directly into the spinal
column, an organ, or a body cavity such as the abdomen, the drugs
mainly affect cancer cells in those areas (regional chemotherapy). The
way the chemotherapy is given depends on the type and stage of the
cancer being treated.
Hormone therapy: Hormone therapy is a cancer treatment that

removes hormones or blocks their action and stops cancer cells from
growing. Hormones are substances made by glands in the body and
circulated in the bloodstream. Some hormones can cause certain can-
cers to grow. If tests show that the cancer cells have places where
hormones can attach (receptors), drugs, surgery, or radiation therapy
are used to reduce the production of hormones or block them from
working.
Radiation therapy: Radiation therapy is a cancer treatment that

uses high-energy x-rays or other types of radiation to kill cancer cells
or keep them from growing. There are two types of radiation therapy.
External radiation therapy uses a machine outside the body to send
radiation toward the cancer. Internal radiation therapy uses a radio-
active substance sealed in needles, seeds, wires, or catheters that are
placed directly into or near the cancer. The way the radiation therapy
is given depends on the type and stage of the cancer being treated.
New types of treatment are being tested in clinical trials.
Monoclonal antibodies as adjuvant therapy: Monoclonal an-

tibody therapy is a cancer treatment that uses antibodies made in the
laboratory from a single type of immune system cell. These antibod-
ies can identify substances on cancer cells or normal substances that
may help cancer cells grow. The antibodies attach to the substances
and kill the cancer cells, block their growth, or keep them from spread-
ing. Monoclonal antibodies are given by infusion. They may be used
230
alone or to carry drugs, toxins, or radioactive material directly to can-
cer cells. Monoclonal antibodies are also used in combination with
chemotherapy as adjuvant therapy (treatment given after surgery to
increase the chances of a cure).
Trastuzumab (Herceptin®) is a monoclonal antibody that blocks
the effects of the growth factor protein HER2.
Treatment Options for Male Breast Cancer

Breast cancer in men is treated the same as breast cancer in
women.
Initial Surgery
Treatment for men diagnosed with breast cancer is usually modi-
fied radical mastectomy. Breast-conserving surgery with lumpectomy
may be used for some men.
Adjuvant Therapy
Therapy given after an operation when cancer cells can no longer
be seen is called adjuvant therapy. Even if the doctor removes all the
cancer that can be seen at the time of the operation, the patient may
be given radiation therapy, chemotherapy, hormone therapy, and/or
monoclonal antibody therapy after surgery to try to kill any cancer
cells that may be left:
• Node-negative: For men whose cancer is node-negative (cancer
has not spread to the lymph nodes), adjuvant therapy should be
considered on the same basis as for a woman with breast cancer
because there is no evidence that response to therapy is differ-
ent for men and women.
• Node-positive: For men whose cancer is node-positive (cancer
has spread to the lymph nodes), adjuvant therapy may include
chemotherapy plus tamoxifen (to block the effect of estrogen),
other hormone therapy, or a clinical trial of trastuzumab (Her-
ceptin).
These treatments appear to increase survival in men, as they do

in women. The patient’s response to hormone therapy depends on
whether there are hormone receptors (proteins) in the tumor. Most
breast cancers in men have these receptors. Hormone therapy is usu-
ally recommended for male breast cancer patients, but it can have
231
many side effects, including hot flashes and impotence (the inability
to have an erection adequate for sexual intercourse).
Distant Metastases
Treatment for men with distant metastases (cancer that has spread
to other parts of the body) may be hormone therapy, chemotherapy,
or both. Hormone therapy may include the following:
• Orchiectomy (the removal of the testicles to decrease hormone

production).
• Luteinizing hormone-releasing hormone agonist with or with-
out total androgen blockade (to decrease the production of sex
hormones).
• Tamoxifen for cancer that is estrogen-receptor positive.
• Progesterone (a female hormone).
• Aromatase inhibitors (to lessen the amount of estrogen pro-
duced).
Hormone therapies may be used in sequence (one after the other).

Standard chemotherapy regimens may be used if hormone therapy
does not work. Men usually respond to therapy in the same way as
women who have breast cancer.
Treatment Options for Locally Recurrent Male Breast

Cancer
For men with locally recurrent disease (cancer that has come back
in a limited area after treatment), treatment is usually either surgery
combined with chemotherapy or radiation therapy combined with
chemotherapy.
232
Chapter 19
Accidents and Injuries
Chapter Contents
Section 19.1—Safe Steps to Reduce Falls .................................. 234
Section 19.2—Preventing Fire-Related Injuries ....................... 236
Section 19.3—Preventing Motor Vehicle Accidents ................. 241
Section 19.4—Occupational Injuries .......................................... 250
Section 19.5—Water-Related Injuries and Water Safety ........ 256
233
Section 19.1
Safe Steps to Reduce Falls

“Safe Steps to Reduce Falls,” © 2008 Home Safety Council
(www.homesafetycouncil.org). Reprinted with permission.
Millions of Americans are only a step away from becoming victims

of the leading cause of unintentional home injuries—falls.
According to The State of Home Safety in America™ (2004) con-
ducted by the Home Safety Council, falls are by far the leading cause
of unintentional home injury death. Falls account for an average of
5.1 million injuries and nearly 6,000 deaths each year. The vast ma-
jority of fall deaths occur among people age sixty-five and older and
fall death rates are higher for males.
In an effort to reduce injuries among people of all ages, the Home
Safety Council encourages families to identify and correct potential
falling hazards in and around the home.
Home Safety “Walk-Through”

Walk through your home to identify and remedy potential falling
hazards. What to look for:
• Prevent falls:
• Have handrails on both sides of stairs and steps. Make sure
handrails go from the top to the bottom of stairs.
• Have lots of lights at the top and bottom of the stairs.
• It is easy to trip on small rugs. Tape them to the floor or do
not use them at all.
• Keep the stairs clear.
• Have nightlights in the bedroom, hall, and bathroom.
• Have a mat or non-slip strips in the tub and shower.
• Have a bath mat with a nonskid bottom on the bathroom
floor.
234
• Have grab bars in the tub and shower.
• Wipe up spills when they happen.
• Protect young children:
• Always watch young children.
• Use safety gates at the top and bottom of stairs.
• Window guards can keep a child from falling out the win-
dow. Have window guards on upstairs windows.
• Cover the ground under playground equipment with a thick
layer (nine to twelve inches) of mulch, wood chips, or other
safety material.
• Outdoors:
• Put bright lights over all porches and walkways.
• Have handrails on both sides of the stairs.
• Put ladders away after using them. Store ladders on their
sides, in a shed or garage.
• Keep sidewalks and paths clear, so you don’t trip.
• Fix broken or chipped steps and walkways as soon as pos-
sible.
235
Section 19.2
Preventing Fire-Related Injuries

“Fire Deaths and Injuries: An Overview” is reprinted from “Fire Deaths
and Injuries Fact Sheet,” Centers for Disease Control and Prevention,
August 8, 2008. “Fire Prevention Tips” is reprinted from “Think Safe
Be Safe: Fire Prevention Tips,” © 2008 Home Safety Council (www
.homesafetycouncil.org). Reprinted with permission.
Fire Deaths and Injuries: An Overview

Deaths from fires and burns are the fifth most common cause of
unintentional injury deaths in the United States (CDC 2005) and the
third leading cause of fatal home injury (Runyan 2004). The United
States mortality rate from fires ranks sixth among the twenty-five
developed countries for which statistics are available (International
Association for the Study of Insurance Economics 2003).
Although the number of fatalities and injuries caused by residen-
tial fires has declined gradually over the past several decades, many
residential fire-related deaths remain preventable and continue to
pose a significant public health problem.
Occurrence and Consequences

On average in the United States in 2006, someone died in a fire
about every 162 minutes, and someone was injured every 32 minutes
(Karter 2007).
Four out of five U.S. fire deaths in 2005 occurred in homes (Karter
2007).
In 2006, fire departments responded to 412,500 home fires in the
United States, which claimed the lives of 2,580 people (not including
firefighters) and injured another 12,925, not including firefighters
(Karter 2007).
Most victims of fires die from smoke or toxic gases and not from
burns (Hall 2001).
Smoking is the leading cause of fire-related deaths (Ahrens 2003).
Cooking is the primary cause of residential fires (Ahrens 2003).
236
Costs
In 2005, residential fires caused nearly $7 billion in property dam-
age (Karter 2007).
Fire and burn injuries represent 1 percent of the incidence of in-
juries and 2 percent of the total costs of injuries, or $7.5 billion each
year (Finkelstein et al. 2006):
• Males account for $4.8 billion (64 percent) of the total costs of
fire/burn injuries.
• Females account for $2.7 billion (36 percent) of the total costs of
fire/burn injuries.
• Fatal fire and burn injuries cost $3 billion, representing 2 per-
cent of the total costs of all fatal injuries.
• Hospitalized fire and burn injuries total $1 billion, or 1 percent
of the total cost of all hospitalized injuries.
• Nonhospitalized fire and burn injuries cost $3 billion, or 2 per-
cent of the total cost of all nonhospitalized injuries.
Groups at Risk
Groups at increased risk of fire-related injuries and deaths include
the following:
• Children age four and under (CDC 1998)

• Older Adults ages sixty-five and older (CDC 1998)
• African Americans and Native Americans (CDC 1998)
• The poorest Americans (Istre 2001)
• Persons living in rural areas (Ahrens 2003)
• Persons living in manufactured homes or substandard housing
(Runyan 1992; Parker 1993)
Risk Factors
Approximately half of home fire deaths occur in homes without
smoke alarms (Ahrens 2004).
Most residential fires occur during the winter months (CDC 1998).
Alcohol use contributes to an estimated 40 percent of residential
fire deaths (Smith 1999).
237
References
Ahrens M. The U.S. fire problem overview report: leading causes and
other patterns and trends. Quincy (MA): National Fire Protection As-
sociation; 2003.
Ahrens M. U.S. experience with smoke alarms and other fire alarms.
Quincy (MA): National Fire Protection Association; 2004.
Centers for Disease Control and Prevention. Deaths resulting from resi-
dential fires and the prevalence of smoke alarms—United States 1991–
1995. Morbidity and Mortality Weekly Report 1998; 47(38): 803–6.
Centers for Disease Control and Prevention, National Center for
Health Statistics (NCHS). National vital statistics system. Hyattsville
(MD): U.S. Department of Health and Human Services, CDC, National
Center for Health Statistics; 1998.
Centers for Disease Control and Prevention. Web-based Injury Sta-
tistics Query and Reporting System (WISQARS) [Online]. (2005).
National Center for Injury Prevention and Control, Centers for Dis-
ease Control and Prevention (producer). Available from: URL:
www.cdc.gov/ncipc/wisqars. [Cited 2006 Aug 21].
Finkelstein EA, Corso PS, Miller TR, Associates. Incidence and Eco-
nomic Burden of Injuries in the United States. New York: Oxford Uni-
versity Press; 2006.
Hall JR. Burns, toxic gases, and other hazards associated with fires:
Deaths and injuries in fire and non-fire situations. Quincy (MA): National
Fire Protection Association, Fire Analysis and Research Division; 2001.
International Association for the Study of Insurance Economics. World
fire statistics: information bulletin of the world fire statistics. Geneva
(Switzerland): The Geneva Association; 2003.
Istre GR, McCoy MA, Osborn L, Barnard JJ, Bolton A. Deaths and
injuries from house fires. New England Journal of Medicine 2001;
344:1911–16.
Karter MJ. Fire loss in the United States during 2006. Quincy (MA):
National Fire Protection Association, Fire Analysis and Research Di-
vision; 2007.
Parker DJ, Sklar DP, Tandberg D, Hauswald M, Zumwalt RE. Fire
fatalities among New Mexico children. Annals of Emergency Medicine
1993;22(3):517–22.
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tors for fatal residential fires. New England Journal of Medicine
1992;327(12):859–63.
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Facts about unintentional injuries in the home, 2nd edition. Washing-
ton, D.C.: Home Safety Council, 2004.
Smith GS, Branas C, Miller TR. Fatal nontraffic injuries involving
alcohol: a meta-analysis. Annals of Emergency Medicine 1999;33(6):
659–68.
Fire Prevention Tips

According to the Home Safety Council’s State of Home Safety in
America™ Report, fires and burns are the third leading cause of un-
intentional home injury and related deaths. Fire safety and survival
begin with everyone in your household being prepared. Follow these
safety measures from the Home Safety Council to reduce the chance
of fire in your home:
• Prevent fires caused by cooking:
• Always stay in the kitchen while cooking.
• Keep things that can burn, such as dishtowels, paper or
plastic bags, and curtains at least three feet away from the
range top.
• Before cooking, roll up sleeves and use oven mitts. Loose-
fitting clothes can touch a hot burner and catch on fire.
• Never leave barbecue grills unattended while in use.
• Keep grills at least ten feet away from other objects, includ-
ing the house and any shrubs or bushes.
• Always stay by the grill when cooking.
• Prevent fires caused by heating:
• Store matches and lighters in a locked cabinet.
• Keep space heaters at least three feet away from things
that can burn, such as curtains or stacks of newspaper. Al-
ways turn off heaters when leaving the room or going to bed.
• Have a service person inspect chimneys, fireplaces, wood
and coal stoves, and central furnaces once a year. Have them
cleaned when necessary.
239
• Keep things that can burn away from your fireplace and
keep a glass or metal screen in front of your fireplace.
• Prevent fires caused by smoking:
• Use “fire-safe” cigarettes and smoke outside.
• Use large, deep ashtrays on sturdy surfaces like a table.
• Douse cigarette and cigar butts with water before dumping
them in the trash.
• Prevent fires caused by candles:
• Never leave burning candles unattended. Do not allow chil-
dren to keep candles or incense in their rooms.
• Always use stable candle holders made of material that
won’t catch fire, such as metal, glass, etc.
• Blow out candles when adults leave the room.
• Prevent fires caused by gasoline and other products:
• Store gasoline in a garage or shed in a container approved
for gasoline storage.
• Never bring or use gasoline indoors; and use it as a motor
fuel only.
• Close the lid on all dangerous products and put them away
after using them.
• Store them away from the home and in a safe place with a
lock.
• Don’t plug in too many appliances at once.
• Keep your family safe at home:
• Make a fire escape plan for your family. Find two exits out
of every room. Pick a meeting place outside. Practice makes
perfect—hold a family fire drill at least twice each year.
• Install smoke alarms on every level of your home. For the best
detection and notification protection, install both ionization-
and photoelectric-type smoke alarms. Some models provide
dual coverage. The type will be printed on the box or package.
Put them inside or near every bedroom. Test them monthly
to make sure they work. Put in new batteries once a year.
• Know how to put out a small pan fire by sliding a lid over
the flames.
240
• Teach every family member to “Stop, Drop, and Roll” if
clothes catch fire.
• Consider having a home fire sprinkler system installed in
your new home, or when you remodel.
• Learn how and when to use a fire extinguisher.
• If you have a fire in your home, once you get out, stay out.
• Do not go back inside for any reason.
Section 19.3
Preventing Motor Vehicle Accidents

“Older Drivers” is reprinted from the National Institute on Aging, Febru-
ary 16, 2008. “Impaired Driving” is reprinted from the Centers for Dis-
ease Control and Prevention, June 2, 2008. Permission to reprint “Driving
Defensively” is granted by the National Safety Council, a membership
organization dedicated to protecting life and promoting health.
Older Drivers
How Does Age Affect Driving?
More and more older drivers are on the roads these days. It’s im-
portant to know that getting older doesn’t automatically turn people
into bad drivers. Many of us continue to be good, safe drivers as we
age. But there are changes that can affect driving skills as we age.
Changes to our bodies: Over time your joints may get stiff and
your muscles weaken. It can be harder to move your head to look back,
quickly turn the steering wheel, or safely hit the brakes.
Your eyesight and hearing may change, too. As you get older, you
need more light to see things. Also, glare from the sun, oncoming head-
lights, or other street lights may trouble you more than before. The
area you can see around you (called peripheral vision) may become nar-
rower. The vision problems from eye diseases such as cataracts, macu-
lar degeneration, or glaucoma can also affect your driving ability.
241
You may also find that your reflexes are getting slower. Or, your at-
tention span may shorten. Maybe it’s harder for you to do two things at
once. These are all normal changes, but they can affect your driving skills.
Some older people have conditions like Alzheimer disease (AD) that
change their thinking and behavior. People with AD may forget fa-
miliar routes or even how to drive safely. They become more likely to
make driving mistakes, and they have more “close calls” than other
drivers. However, people in the early stages of AD may be able to keep
driving for a while. Caregivers should watch their driving over time.
As the disease worsens, it will affect driving ability. Doctors can help
you decide whether it’s safe for the person with AD to keep driving.
Other health changes: While health problems can affect driving

at any age, some occur more often as we get older. For example, arthri-
tis, Parkinson disease, and diabetes may make it harder to drive. People
who are depressed may become distracted while driving. The effects of
a stroke or even lack of sleep can also cause driving problems. Devices
such as an automatic defibrillator or pacemaker might cause an irregu-
lar heartbeat or dizziness, which can make driving dangerous.
Medicine side effects: Some medicines can make it harder for you
to drive safely. These medicines include sleep aids, anti-depression
drugs, antihistamines for allergies and colds, strong painkillers, and
diabetes medications. If you take one or more of these or other medi-
cines, talk to your doctor about how they might affect your driving.
Smart Driving Tips

Planning before you leave:
• Plan to drive on streets you know.

• Limit your trips to places that are easy to get to and close to
home.
• Take routes that let you avoid risky spots like ramps and left
turns.
• Add extra time for travel if driving conditions are bad.
• Don’t drive when you are stressed or tired.
While you are driving:
• Always wear your seatbelt.
242
• Stay off the cell phone.
• Avoid distractions such as listening to the radio or having con-
versations.
• Leave a big space, at least two car lengths, between your car
and the one in front of you. If you are driving at higher speeds
or if the weather is bad, leave even more space between you and
the next car.
• Make sure there is enough space behind you. (Hint: if someone
follows you too closely, slow down so that the person will pass
you.)
• Use your rear window defroster to keep the back window clear
at all times.
• Keep your headlights on at all times.
Car safety:
• Drive a car with features that make driving easier, such as

power steering, power brakes, automatic transmission, and
large mirrors.
• Drive a car with airbags.
• Check your windshield wiper blades often and replace them
when needed.
• Keep your headlights clean and aligned.
• Think about getting hand controls for the accelerator and
brakes if you have leg problems.
Driving skills:
• Take a driving refresher class every few years. (Hint: Some car
insurance companies lower your bill when you pass this type of
class. Check with the American Association of Retired Persons
[AARP], the American Automobile Association [AAA], or local
private driving schools to find a class near you.)
Am I a Safe Driver?
Maybe you already know of some driving situations that are hard
for you––nights, highways, rush hours, or bad weather. If so, try to
change your driving habits to avoid them. Other hints? Older drivers
243
are most at risk when yielding the right of way, turning (especially
making left turns), changing lanes, passing, and using expressway
ramps. Pay special attention at those times.
Is It Time to Give Up Driving?

We all age differently. For this reason, there is no way to say what
age should be the upper limit for driving. So, how do you know if you
should stop driving? To help you decide, ask yourself the following
questions:
• Do other drivers often honk at me?
• Have I had some accidents, even “fender benders”?
• Do I get lost, even on roads I know?
• Do cars or people walking seem to appear out of nowhere?
• Have family, friends, or my doctor said they are worried about
my driving?
• Am I driving less these days because I am not as sure about my
driving as I used to be?
If you answered yes to any of these questions, you should think

seriously about whether or not you are still a safe driver. If you an-
swered no to all these questions, don’t forget to have your eyes and
ears checked regularly. Talk to your doctor about any changes to your
health that could affect your ability to drive safely.
How Will I Get Around?

You can stay active and do the things you like to do, even if you
decide to give up driving. There may be more options for getting around
than you think. Some areas offer low-cost bus or taxi service for older
people. Some also have carpools or other transportation on request.
Religious and civic groups sometimes have volunteers who take se-
niors where they want to go. Your local Agency on Aging has infor-
mation about transportation services in your area.
If you do not have these services where you live, look into taking
taxis. Too expensive, you think? Well, think about this: the AAA now
estimates that the average cost of owning and running a car is about
$6,420 a year. So, by giving up your car, you might have as much as
$123 a week to use for taxis, buses, or to buy gas for friends and rela-
tives who can drive you!
244
Impaired Driving
Alcohol-related motor vehicle crashes kill someone every thirty-one
minutes and nonfatally injure someone every two minutes (NHTSA
2006). But there are effective measures that can be taken to prevent
injuries and deaths from impaired driving.
Occurrence and Consequences

• During 2005, 16,885 people in the U.S. died in alcohol-related
motor vehicle crashes, representing 39 percent of all traffic-
related deaths (NHTSA 2006).
• In 2005, nearly 1.4 million drivers were arrested for driving un-
der the influence of alcohol or narcotics (Department of Justice
2005). That’s less than 1 percent of the 159 million self-reported
episodes of alcohol–impaired driving among U.S. adults each year
(Quinlan et al. 2005).
• Drugs other than alcohol (e.g., marijuana and cocaine) are in-
volved in about 18 percent of motor vehicle driver deaths. These
other drugs are generally used in combination with alcohol (Jones
et al. 2003).
• More than half of the 414 child passengers ages fourteen and
younger who died in alcohol-related crashes during 2005 were
riding with the drinking driver (NHTSA 2006).
• In 2005, 48 children age fourteen years and younger who were
killed as pedestrians or pedal cyclists were struck by impaired
drivers (NHTSA 2006).
Cost
Each year, alcohol-related crashes in the United States cost about
$51 billion (Blincoe et al. 2002).
Groups at Risk
• Male drivers involved in fatal motor vehicle crashes are al-
most twice as likely as female drivers to be intoxicated with a
blood alcohol concentration (BAC) of 0.08 percent or greater
(NHTSA 2006). It is illegal to drive with a BAC of 0.08 percent
or higher in all fifty states, the District of Columbia, and Puerto
Rico.
245
• At all levels of blood alcohol concentration, the risk of being in-
volved in a crash is greater for young people than for older people
(Zador et al. 2000). In 2005, 16 percent of drivers ages sixteen to
twenty who died in motor vehicle crashes had been drinking al-
cohol (NHTSA 2006).
• Young men ages eighteen to twenty (under the legal drinking
age) reported driving while impaired more frequently than any
other age group (Shults et al. 2002, Quinlan et al. 2005).
• Among motorcycle drivers killed in fatal crashes, 30 percent
have BACs of 0.08 percent or greater (Paulozzi et al. 2004).
• Nearly half of the alcohol-impaired motorcyclists killed each
year are age forty or older, and motorcyclists ages forty to forty-
four years have the highest percentage of fatalities with BACs
of 0.08 percent or greater (Paulozzi et al. 2004).
• Of the 1,946 traffic fatalities among children ages zero to four-
teen years in 2005, 21 percent involved alcohol (NHTSA 2006b).
• Among drivers involved in fatal crashes, those with BAC levels
of 0.08 percent or higher were nine times more likely to have a
prior conviction for driving while impaired (DWI) than were driv-
ers who had not consumed alcohol (NHTSA 2006).
Prevention Strategies
Effective measures to prevent injuries and deaths from impaired
driving include the following:
• Aggressively enforcing existing 0.08 percent BAC laws, mini-

mum legal drinking age laws, and zero tolerance laws for driv-
ers younger than twenty-one years old in all states (Shults et al.
2002, Quinlan et al. 2005).
• Promptly suspending the driver’s licenses of people who drive
while intoxicated (DeJong et al. 1998).
• Sobriety checkpoints (Elder et al. 2002).
• Health promotion efforts that use an ecological framework to in-
fluence economic, organizational, policy, and school/community
action (Howat et al. 2004; Hingson et al. 2006).
• Multifaceted community-based approaches to alcohol control
and DWI prevention (Holder et al. 2000, DeJong et al. 1998).
246
• Mandatory substance abuse assessment and treatment for
driving-under-the-influence offenders (Wells-Parker et al. 1995).
Other suggested measures include the following:

• Reducing the legal limit for blood alcohol concentration (BAC)
to 0.05 percent (Howat et al. 1991; National Committee on In-
jury Prevention and Control 1989).
• Raising state and federal alcohol excise taxes (National Com-
mittee on Injury Prevention and Control 1989).
• Implementing compulsory blood alcohol testing when traffic
crashes result in injury (National Committee on Injury Preven-
tion and Control 1989).
References
Blincoe L, Seay A, Zaloshnja E, Miller T, Romano E, Luchter S, et al.
The Economic Impact of Motor Vehicle Crashes, 2000. Washington
(DC): Dept of Transportation (US), National Highway Traffic Safety
Administration (NHTSA); 2002. Available from URL: http://www.nhtsa
.dot.gov/people/economic/econimpact2000/index.htm.
DeJong W. Hingson R. Strategies to reduce driving under the influ-
ence of alcohol. Annual Review of Public Health 1998;19:359–78.
Department of Justice (US), Federal Bureau of Investigation (FBI).
Crime in the United States 2005: Uniform Crime Reports. Washing-
ton (DC): FBI; 2005 [cited 2006 Nov 3]. Available from URL: http://
www.fbi.gov/ucr/05cius/index.html.
Dept of Transportation (US), National Highway Traffic Safety Admin-
istration (NHTSA). Traffic safety facts 2005: alcohol. Washington (DC):
NHTSA; 2006 [cited 2006 Oct 3]. Available from URL: http://www-
nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2005/AlcoholTSF05.pdf.
Dept of Transportation (US), National Highway Traffic Safety Admin-
istration (NHTSA). Traffic safety facts 2005: children. Washington
(DC): NHTSA; 2006b [cited 2006 Oct 3]. Available from URL: http://
www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2005/ChildrenTSF05
.pdf.
Elder RW, Shults RA, Sleet DA, et al. Effectiveness of sobriety check-
points for reducing alcohol-involved crashes. Traffic Injury Prevention
2002;3:266-74.
247
Hingson, R, Sleet, DA. Modifying alcohol use to reduce motor vehicle
injury. In Gielen, Ac, Sleet, DA, DiClemente, R (Eds). Injury and Vio-
lence Prevention: Behavior change Theories, Methods, and Applications.
San Francisco, CA: Jossey-Bass, 2006.
Holder HD, Gruenewald PJ, Ponicki WR, Treno AJ, Grube JW, Saltz
RF, et al. Effect of community-based interventions on high-risk drink-
ing and alcohol-related injuries. Journal of the American Medical
Association 2000;284:2341–47.
Howat P, Sleet D, Smith I. Alcohol and driving: is the .05% blood al-
cohol concentration limit justified? Drug and Alcohol Review 1991;
10(1):151–66.
Howat, P, Sleet, D, Elder, R, Maycock, B. Preventing Alcohol-related
traffic injury: a health promotion approach. Traffic Injury Prevention
2004;5:208–19.
Jones RK, Shinar D, Walsh JM. State of knowledge of drug-impaired
driving. Dept of Transportation (US), National Highway Traffic Safety
Administration (NHTSA); 2003. Report DOT HS 809 642.
National Committee on Injury Prevention and Control. Injury preven-
tion: meeting the challenge. American Journal of Preventive Medicine
1989;5(3 Suppl):123–27.
Paulozzi LJ, Patel R. Changes in motorcycle crash mortality rates by
blood alcohol concentration and age—United States, 1983–2003.
MMWR 2004;53(47):1103–6.
Quinlan KP, Brewer RD, Siegel P, Sleet DA, Mokdad AH, Shults RA,
Flowers N. Alcohol-impaired driving among U.S. adults, 1993–2002.
American Journal of Preventive Medicine 2005;28(4):345–50.
Shults RA, Sleet DA, Elder RW, Ryan GW, Sehgal M. Association be-
tween state-level drinking and driving countermeasures and self-
reported alcohol-impaired driving. Inj Prev 2002;8:106–10.
Wells-Parker E, Bangert-Drowns R, McMillen R, Williams M. Final
results from a meta-analysis of remedial interventions with drink/
drive offenders. Addiction 1995;90:907–26.
Zador PL, Krawchuk SA, Voas RB. Alcohol-related relative risk of
driver fatalities and driver involvement in fatal crashes in relation
to driver age and gender: an update using 1996 data. Journal of Stud-
ies on Alcohol 2000;61:387–95.
248
Driving Defensively
More than forty-one thousand people lose their lives in motor ve-
hicle crashes each year and over two million more suffer disabling
injuries, according to the National Safety Council. The triple threat
of high speeds, impaired or careless driving, and not using occupant
restraints threatens every driver—regardless of how careful or how
skilled.
Driving defensively means not only taking responsibility for your-
self and your actions but also keeping an eye on “the other guy.” The
National Safety Council suggests the following guidelines to help re-
duce your risks on the road:
• Don’t start the engine without securing each passenger in the

car, including children and pets. Safety belts save thousands of
lives each year! Lock all doors.
• Remember that driving too fast or too slow can increase the
likelihood of collisions.
• Don’t kid yourself. If you plan to drink, designate a driver who
won’t drink. Alcohol is a factor in almost half of all fatal motor
vehicle crashes.
• Be alert! If you notice that a car is straddling the center line,
weaving, making wide turns, stopping abruptly or responding
slowly to traffic signals, the driver may be impaired.
• Avoid an impaired driver by turning right at the nearest corner
or exiting at the nearest exit. If it appears that an oncoming car
is crossing into your lane, pull over to the roadside, sound the
horn, and flash your lights.
• Notify the police immediately after seeing a motorist who is
driving suspiciously.
• Follow the rules of the road. Don’t contest the “right of way” or
try to race another car during a merge. Be respectful of other
motorists.
• Don’t follow too closely. Always use a “three-second following
distance” or a “three-second plus following distance.”
• While driving, be cautious, aware, and responsible.
249
Section 19.4
Occupational Injuries
Excerpted from “National Census of Fatal Occupational
Injuries in 2007,” Bureau of Labor Statistics, August 20, 2008.
A total of 5,488 fatal work injuries were recorded in the United

States in 2007, a decrease of 6 percent from the revised total of 5,840
fatal work injuries reported for 2006. While these results are consid-
ered preliminary, this figure represents the smallest annual prelimi-
nary total since the Census of Fatal Occupational Injuries (CFOI)
program was first conducted in 1992. Final results for 2007 will be
released in April 2009.
Based on these preliminary counts, the rate of fatal injury for U.S.
workers in 2007 was 3.7 fatal work injuries per 100,000 workers, down
from the final rate of 4.0 per 100,000 workers in 2006, and the low-
est annual fatality rate ever reported by the fatality census.
Key Findings of the 2007 Census of Fatal Occupational

Injuries
• The number of fatal falls in 2007 rose to a series high of 835—a
39 percent increase since 1992 when the CFOI program was first
conducted.
• Transportation incidents, which typically account for two-fifths of
all workplace fatalities, fell to a series low of 2,234 cases in 2007.
• Workplace homicides rose 13 percent to 610 in 2007 after reach-
ing a series low of 540 in 2006.
• The number of fatal workplace injuries among protective ser-
vice occupations rose 19 percent in 2007 to 337, led by an in-
crease in the number of police officers fatally injured on the job.
• Fatal occupational injuries incurred by non-Hispanic black or
African American workers were at the highest level since 1999,
but fatal work injuries among Hispanic workers were lower by 8
percent in 2007.
250
Profile of 2007 Fatal Work Injuries by Type of Incident

Nearly all types of transportation fatalities saw sizable decreases
in 2007 relative to 2006, including non-highway incidents (down 15
percent); workers struck by vehicle, mobile equipment (down 10 per-
cent); water vehicle incidents (down 28 percent); railway incidents
(down 26 percent); and aircraft incidents (down 23 percent). Highway
incidents also decreased, but only by 3 percent.
The 835 fatal falls in 2007 represented a series high for the fatal-
ity census. The increase for falls overall was driven primarily by in-
creases in falls on same level (up 21 percent from 2006) and falls from
nonmoving vehicles (up 17 percent). Falls from roofs, however, were
down 13 percent from the number in 2006.
Table 19.1. Number of Work-Related Fatal Events in Four Most

Common Categories, 1992–2007
Highway Struck
Incidents Homicides Falls by Object
1992 1,158 1,044 600 557
1993 1,242 1,074 618 565
1994 1,343 1,080 665 591
1995 1,346 1,036 651 547
1996 1,346 927 691 582
1997 1,393 860 716 579
1998 1,442 714 706 520
1999 1,496 651 721 585
2000 1,365 677 734 571
2001 1,409 643 810 553
2002 1,373 609 719 505
2003 1,353 632 696 531
2004 1,398 599 822 602
2005 1,437 567 770 607
2006 1,356 540 827 589
2007 1,311 610 835 504
Note: Data from 2001 exclude fatalities resulting from the September 11 terrorist
attacks.
Source: U.S. Bureau of Labor Statistics, U.S. Department of Labor, 2008.
251
Workplace homicides increased by 13 percent in 2007. Even with
the increase, workplace homicides have declined 44 percent from the
high of 1,080 reported in 1994. Workplace homicides involving police
officers and supervisors of retail sales workers both saw substantial
increases in 2007.
Profile of Fatal Work Injuries by Industry

Overall, 90 percent of the fatal work injuries involved workers in
private industry. Service-providing industries in the private sector
recorded 48 percent of all fatal work injuries in 2007, while goods-
producing industries recorded 42 percent. Another 10 percent of the
fatal work injury cases in 2007 involved government workers. The
number of fatal work injuries in the private sector decreased 7 per-
cent in 2007, while fatalities among government workers, including
resident military personnel, increased 2 percent.
Fatalities declined in the construction industry, but construction
continued to incur the most fatalities of any industry in the private
sector, as it has for the five years since the CFOI program began us-
ing the North American Industry Classification System (NAICS) to
categorize industry. The percentage decrease in fatalities from 2006
(1,239 to 1,178, a 5 percent drop) was about the same as the decrease
for all fatal work injuries in 2007. Of the three major subsectors within
construction, fatalities among workers in construction of buildings
actually rose 11 percent from 2006, with most of the increase in non-
residential construction industries. The largest construction subsector,
specialty trade contractors, had 6 percent fewer fatalities in 2007 as
compared to 2006.
Fatalities among private sector workers in transportation and
warehousing sector, which had the second largest number of fatali-
ties, decreased 3 percent from the number reported in 2006. Truck
transportation, the largest subsector in transportation and warehous-
ing, also had a 3 percent decrease in 2007. The number of fatal inju-
ries in air, rail, and water transportation were also lower.
Fatalities were down 13 percent among private sector workers in
the agriculture, forestry, fishing, and hunting industry sector in 2007.
Non-highway incidents in agriculture, forestry, fishing, and hunting
decreased 17 percent, and incidents of being struck by an object de-
creased 12 percent, each of which accounts for about one-fifth of fatali-
ties in the agriculture, forestry, fishing, and hunting industry. Fatalities
to workers in crop production fell 19 percent while fatalities to work-
ers in animal production rose 7 percent. Fishing and logging, two of
252
the industries with the highest fatality rates, had lower numbers of
fatalities in 2007.
In the trade industry (wholesale and retail), fatal work injuries
were down 8 percent from their 2006 level. While most wholesale trade
subsectors declined, fatal work injuries in retail grocery stores were
up 26 percent (from 57 in 2006 to 72 in 2007), due largely to an in-
crease in workplace homicides in that industry.
The preliminary total of 392 fatal work injuries in manufacturing
represents the lowest total recorded in the five years since the CFOI
program began using the North American Industry Classification
System (NAICS). The 2007 total for manufacturing represents a 14
percent decrease from the 2006 count.
Fatalities among government workers were up 2 percent from 2006,
primarily due to a 14 percent increase in workplace fatalities among
local government workers. The increase among local government
workers was primarily attributable to higher numbers of fatalities in
police protection and fire protection (up 32 and 43 percent, respec-
tively). Fatal work injury rates were lower for federal and state work-
ers.
Figure 19.1. Number and Rate of Fatal Occupational Injuries, by Indus-

try Sector, 2007 (Source: U.S. Bureau of Labor Statistics, U.S. Department
of Labor, 2008).
253
Profile of Fatal Work Injuries by Occupation

About one-fourth of all occupational fatalities in 2007 involved
workers in transportation and material moving occupations, though
fatalities among these workers declined by 5 percent in 2007. This
decline was largely the result of a 6 percent decline in highway inci-
dents, which account for about 50 percent of the fatalities in this oc-
cupation. Construction and extraction occupations, which accounted
for 21 percent of all fatalities, decreased by 10 percent from 2006 to
2007 after increasing the previous three years. Operating engineers
and other construction equipment operators; painters, construction and
maintenance; and electricians all saw decreases of 20 percent or more.
Fatalities among workers employed in protective service occupa-
tions rose 19 percent from 2006 to 2007, including police officers (up
30 percent), firefighters (up 17 percent), and security guards (up 11
percent). Among other occupation groups, fatalities incurred by work-
ers in sales and related occupations decreased 2 percent although
fatalities incurred by supervisors of sales workers increased by 10
percent. Office and administrative support occupations had 50 per-
cent more workplace fatalities in 2007 (from 88 in 2006 to 132 in 2007),
due in part to an increase in fatal transportation incidents.
Figure 19.2. Selected Occupations with High Fatality Rates, 2007 (Source:
U.S. Bureau of Labor Statistics, U.S. Department of Labor, 2008).
254
The four occupations with the highest fatality rates were fishers
and related fishing workers with a fatality rate of 111.8 per 100,000
workers, logging workers (86.4), aircraft pilots and flight engineers
(66.7), and structural iron and steel workers (45.5).
Profile of Fatal Work Injuries by Demographic

Characteristics
While fatal work injuries in general fell 6 percent, those incurred
by non-Hispanic black or African American workers increased by 5
percent to 591 in 2007. This is the highest number reported for black
or African American workers since 1999. A tripling in the number of
fatalities involving black or African American police officers in local
government (from 6 to 18) was one of the reasons for the higher num-
ber of fatalities. Fatalities among Hispanic or Latino workers de-
creased 8 percent from 2006 and among white, non-Hispanic workers
by 6 percent.
While fatalities incurred by workers age sixty-five and older de-
creased 7 percent, these workers were about three times more likely
than all workers to be killed on the job. Self-employed workers had a
2 percent drop in fatalities, while their wage and salary counterparts
fell by 7 percent. Workplace fatalities incurred by both male and fe-
male workers decreased 6 percent.
Of the 5,488 fatal occupational injuries in 2007, 959 were incurred
by workers who were born outside of the United States. Of the foreign-
born workers who were fatally injured in the United States in 2007,
the largest share were born in Mexico (44 percent).
255
Section 19.5
Water-Related Injuries and Water Safety

Reprinted from “Water-Related Injuries Fact Sheet,”
Centers for Disease Control and Prevention, June 12, 2008.
How big is the problem?

In 2005, there were 3,582 fatal unintentional drownings in the
United States, averaging ten deaths per day. An additional 710 peo-
ple died, from drowning and other causes, in boating-related inci-
dents.1, 2
More than one in four fatal drowning victims are children fourteen
and younger.1 For every child who dies from drowning, another four
received emergency department care for nonfatal submersion injuries.1
Nonfatal drownings can cause brain damage that may result in
long-term disabilities including memory problems, learning disabili-
ties, and permanent loss of basic functioning (i.e., permanent vegeta-
tive state).
Who is most at risk?

Males: In 2005, males were four times more likely than females
to die from unintentional drownings in the United States.1
Children: In 2005, of all children one to four years old who died,
almost 30 percent died from drowning.1 Although drowning rates have
slowly declined,1, 3 fatal drowning remains the second-leading cause
of unintentional injury-related death for children ages one to fourteen
years.4
Minorities: Between 2000 and 2005, the fatal unintentional drown-

ing rate for African Americans across all ages was 1.3 times that of
whites. For American Indians and Alaskan Natives, this rate was 1.8
times that of whites.1
Rates of fatal drowning are notably higher among these populations
in certain age groups. The fatal drowning rate of African American
256
children ages five to fourteen is 3.2 times that of white children in
the same age range. For American Indian and Alaskan Native chil-
dren, the fatal drowning rate is 2.4 times higher than for white chil-
dren.1
Factors such as the physical environment (e.g., access to swimming
pools) and a combination of social and cultural issues (e.g., valuing
swimming skills and choosing recreational water-related activities)
may contribute to the racial differences in drowning rates. If minori-
ties participate less in water-related activities than whites, their
drowning rates (per exposure) may be higher than currently reported.5
What are the major risk factors?

Lack of barriers and supervision: Children under one year
most often drown in bathtubs, buckets, or toilets.6 Among children ages
one to four years, most drownings occur in residential swimming
pools.6 Most young children who drowned in pools were last seen in
the home, had been out of sight less than five minutes, and were in
the care of one or both parents at the time.7 Barriers, such as pool
fencing, can help prevent children from gaining access to the pool area
without caregivers’ awareness.8
Age and recreation in natural water settings (such as lakes,

rivers, or the ocean): The percent of drownings in natural water
settings increases with age. Most drownings in those over fifteen years
of age occur in natural water settings.9
Lack of appropriate choices in recreational boating: In 2006,

the U.S. Coast Guard received reports for 4,967 boating incidents;
3,474 boaters were reported injured, and 710 died. Among those who
drowned, nine out of ten were not wearing life jackets. Most boating
fatalities from 2006 (70 percent) were caused by drowning; the remain-
der were due to trauma, hypothermia, carbon monoxide poisoning, or
other causes. Open motor boats were involved in 45 percent of all re-
ported incidents, and personal watercraft were involved in another
24 percent.2
Alcohol use: Alcohol use is involved in up to half of adolescent and

adult deaths associated with water recreation and about one in five
reported boating fatalities.10, 11 Alcohol influences balance, coordina-
tion, and judgment, and its effects are heightened by sun exposure
and heat.12
257
Seizure disorders: For persons with seizure disorders, drowning
is the most common cause of unintentional injury death, with the
bathtub as the site of highest drowning risk.13
What has Centers for Disease Control and Prevention

(CDC) research found?
A CDC study about self-reported swimming ability14 found that:
• younger respondents reported greater swimming ability than
older respondents;
• self-reported ability increased with level of education (i.e., high
school graduate, college graduate, etc.);
• among racial groups, African Americans reported the most lim-
ited swimming ability; and
• men of all ages, races, and educational levels consistently re-
ported greater swimming ability than women.
How can water-related injuries be prevented?

To help prevent water-related injuries:1, 8, 9, 12, 13
• Designate a responsible adult to watch young children while in
the bath and all children swimming or playing in or around wa-
ter. Adults should not be involved in any other distracting activity
(such as reading, playing cards, talking on the phone, or mowing
the lawn) while supervising children.
• Always swim with a buddy. Select swimming sites that have
lifeguards whenever possible.
• Avoid drinking alcohol before or during swimming, boating, or
water skiing. Do not drink alcohol while supervising children.
• Learn to swim. Be aware that the American Academy of Pediat-
rics does not recommend swimming classes as the primary means
of drowning prevention for children younger than four. Constant,
careful supervision and barriers such as pool fencing are neces-
sary even when children have completed swimming classes.
• Learn cardiopulmonary resuscitation (CPR). In the time it
might take for paramedics to arrive, your CPR skills could
make a difference in someone’s life. CPR performed by bystand-
ers has been shown to improve outcomes in drowning victims.
258
• Do not use air-filled or foam toys, such as “water wings,” “noodles,”
or inner-tubes, in place of life jackets (personal flotation devices).
These toys are not designed to keep swimmers safe.
If you have a swimming pool at home:

• Install a four-sided, isolation pool fence that completely sepa-
rates the house and play area of the yard from the pool area.
The fence should be at least four feet high. Use self-closing and
self-latching gates that open outward with latches that are out
of reach of children. Also, consider additional barriers such as
automatic door locks or alarms to prevent access or notify you
if someone enters the pool area.
• Remove floats, balls, and other toys from the pool and surround-
ing area immediately after use. The presence of these toys may
encourage children to enter the pool area or lean over the pool
and potentially fall in.
If you are in or around natural bodies of water:

• Know the local weather conditions and forecast before swim-
ming or boating. Strong winds and thunderstorms with light-
ning strikes are dangerous.
• Use U.S. Coast Guard approved life jackets when boating, re-
gardless of distance to be traveled, size of boat, or swimming
ability of boaters.
• Know the meaning of and obey warnings represented by colored
beach flags.
• Watch for dangerous waves and signs of rip currents (e.g., water
that is discolored and choppy, foamy, or filled with debris and
moving in a channel away from shore). If you are caught in a rip
current, swim parallel to shore; once free of the current, swim
toward shore.
References
1. Centers for Disease Control and Prevention, National Center
for Injury Prevention and Control. Web-based Injury Statis-
tics Query and Reporting System (WISQARS) [online]. (2008)
[cited 2008 March 23]. Available from: URL: www.cdc.gov/
ncipc/wisqars.
259
2. U.S. Coast Guard, Department of Homeland Security (US).
Boating Statistics—2006 [online]. 2008. [cited 2008 March 26].
Available from URL: www.uscgboating.org/statistics/Boating
_Statistics_2006.pdf.
3. Branche CM. What is happening with drowning rates in the
United States? In: Fletemeyer JR and Freas SJ, editors. Drown-
ing: New perspectives on intervention and prevention. Boca
Raton (FL): CRC Press LLC; 1999.
4. Centers for Disease Control and Prevention. Swimming and
Recreational Water Safety. In: Health Information for Interna-
tional Travel 2005–2006. Atlanta: US Department of Health
and Human Services, Public Health Service, 2005.
5. Branche CM, Dellinger AM, Sleet DA, Gilchrist J, Olson SJ.
Unintentional injuries: the burden, risks and preventive strat-
egies to address diversity. In: Livingston IL, editor. Praeger
handbook of Black American health (2nd edition): Policies and
issues behind disparities in health. Westport (CT): Praeger
Publishers; 2004. p. 317–27.
6. Brenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck
MD. Where children drown, United States, 1995. Pediatrics
2001;108(1):85–89.
7. Present P. Child drowning study. A report on the epidemiology
of drowning in residential pools to children under age five. Wash-
ington (DC): Consumer Product Safety Commission (US); 1987.
8. U. S. Consumer Product Safety Commission. Safety barrier
guidelines for home pools [online]. [cited 2007 Mar 21]. Avail-
able from URL: www.cpsc.gov/cpscpub/pubs/pool.pdf.
9. Gilchrist J, Gotsch K, Ryan GW. Nonfatal and Fatal
Drownings in Recreational Water Settings—United States,
2001 and 2002. MMWR 2004;53(21):447–52.
10. Howland J, Mangione T, Hingson R, Smith G, Bell N. Alcohol
as a risk factor for drowning and other aquatic injuries. In:
Watson RR, editor. Alcohol and accidents. Drug and alcohol
abuse reviews. Vol 7. Totowa (NJ): Humana Press, Inc.; 1995.
11. Howland J, Hingson R. Alcohol as a risk factor for drownings:
A review of the literature (1950–1985). Accident Analysis and
Prevention 1988;20(1):19–25.
260
12. Smith GS, Kraus JF. Alcohol and residential, recreational, and
occupational injuries: A review of the epidemiologic evidence.
Annual Rev of Public Health 1988;9:99–121.
13. Quan L, Bennett E, Branche C. Interventions to prevent
drowning. In Doll L, Bonzo S, Mercy J, Sleet D (Eds). Hand-
book of injury and violence prevention. New York: Springer,
2007.
14. Gilchrist J, Sacks JJ, Branche CM. Self-reported swimming
ability in U.S. adults, 1994. Public Health Reports 2000;115(2–
3):110–11.
261
Chapter 20
Stroke
Stroke Facts and Statistics

Stroke is the third leading cause of death in the United States. Over
160,000 people die each year from stroke in the United States.
Stroke is a leading cause of serious long–term disability.
About 700,000 strokes occur in the United States each year. About
500,000 of these are first or new strokes. About 200,000 occur in people
who have already had a stroke before.
Nearly three-quarters of all strokes occur in people over the age
of sixty-five. The risk of having a stroke more than doubles each de-
cade after the age of fifty-five.
Strokes can—and do—occur at any age. Nearly one quarter of
strokes occur in people under the age of sixty-five.
Stroke death rates are higher for African Americans than for
whites, even at younger ages.
According to the American Heart Association, stroke cost almost
$57 billion in both direct and indirect costs in 2005.
It has been noted for several decades that the southeastern United
States has the highest stroke mortality rates in the country. It is not
Reprinted from the following documents from the Centers for Disease Con-
trol and Prevention: “Stroke Facts,” October 10, 2007; “Stroke,” October 10, 2007;
“Types of Stroke,” October 10, 2007; “Outcomes from Stroke,” October 10, 2007;
“Treatment,” October 10, 2007; “Risk Factors,” October 10, 2007; and “Signs and
Symptoms of Stroke,” May 12, 2008.
263
completely clear what factors might contribute to the higher incidence
of and mortality from stroke in this region.
About Stroke
A stroke occurs either when the blood supply to part of the brain is
blocked or when a blood vessel in the brain bursts, causing damage to
a part of the brain. A stroke is also sometimes called a brain attack.
Stroke is the third leading cause of death in the United States.
Among survivors, stroke can cause significant disability including
paralysis as well as speech and emotional problems. New treatments
are available that can reduce the damage caused by a stroke for some
victims. But these treatments need to be given soon after the symp-
toms start.
Knowing the symptoms of stroke, calling 911 right away, and get-
ting to a hospital are crucial to the most beneficial outcomes after
having a stroke. The best treatment is to try to prevent a stroke by
taking steps to lower your risk for stroke.
Types of Stroke
Ischemic stroke: An ischemic stroke occurs when an artery that
supplies blood and oxygen to the brain becomes blocked. Most strokes
are of this type. Blood clots are the most common cause of artery block-
age. Ischemic strokes can also be caused by a narrowing of the arter-
ies (called stenosis). The most common condition that causes stenosis
is atherosclerosis. In atherosclerosis, plaque (a mixture of fatty sub-
stances including cholesterol and other lipids) and blood clots build
up inside the artery walls, causing thickening, hardening, and loss of
elasticity. These lead to decreased blood flow.
Hemorrhagic stroke: A hemorrhagic stroke occurs when an ar-

tery in the brain bursts. Hemorrhage can occur in several ways. One
cause is an aneurysm, a weak or thin spot on an artery wall that can
expand like a balloon. The thin walls of the stretched artery can rup-
ture or break. Hemorrhage also occurs when arterial walls lose their
elasticity and become brittle and thin. They can then crack and bleed.
This can happen with atherosclerosis. High blood pressure increases
the risk of a hemorrhagic stroke.
There are two main types of hemorrhagic stroke. An intracerebral
hemorrhage occurs when a blood vessel in the brain leaks blood into
the brain itself. A subarachnoid hemorrhage is bleeding under the
264
Stroke
outer membranes of the brain and into the thin, fluid-filled space that
surrounds the brain.
Transient ischemic attacks: A transient ischemic attack (TIA)

is sometimes called a mini-stroke. It starts just like a stroke but then
clears up within twenty-four hours, leaving no apparent symptoms
or deficits. A TIA is a warning that the person is at risk for a more
serious stroke. Having other risk factors increases a person’s chances
of a recurrent stroke if they have had a TIA. For most TIAs the symp-
toms go away within an hour. However, there is no way to tell whether
symptoms will be a TIA or a more serious stroke that can lead to death
or disability. The sudden onset of the symptoms of a stroke should
signal an emergency. Patients and witnesses should not wait to see if
the symptoms go away.
Outcomes from Stroke

Stroke is the third leading cause of death in the United States. It is
also a leading cause of serious long-term disability. While most strokes
occur in people over the age of sixty-five, strokes can occur at any age.
Among people who survive, strokes can affect the entire body.
Stroke can leave victims with physical, mental, and emotional defi-
cits. The amount of disability is related to the severity of the stroke.
People who survive a stroke are also at risk for having another stroke.
Physical: Persons who have had a stroke can have weakness or

even complete paralysis on one side of the body. The paralysis or weak-
ness may affect only the face, an arm, or a leg or may affect one en-
tire side of the body and face. Some stroke patients may have trouble
with swallowing. Slurred speech due to weakness of the muscles used
in speaking may also occur.
Activity and balance: A stroke victim may have problems per-

forming daily activities, such as walking, dressing, eating, and using
the bathroom. Balance and coordination may also be a problem.
Cognitive deficits: Stroke may cause problems with thinking,

awareness, attention, learning, judgment, and memory.
Language: Stroke victims may find it hard to understand or form

speech. This is called aphasia. Aphasia usually occurs along with prob-
lems in reading or writing.
265
Emotional: Stroke patients may find it difficult to control their
emotions or may express inappropriate emotions in certain situations.
One common emotional problem with many stroke patients is depres-
sion. Post-stroke depression may be more than a general sadness re-
sulting from the stroke. Medications and therapy might be needed to
treat the depression.
Pain: Stroke patients may experience pain, uncomfortable numb-

ness, or strange sensations after a stroke. These sensations may be
due to many factors including damage to the sensory regions of the
brain, stiff joints, or a disabled limb.
Recurrent stroke: Recurrent stroke is a major contributor to

stroke disability and death, with the risk of severe disability or death
from stroke increasing with each stroke. The risk of a recurrent stroke
is greatest right after a stroke.
Treatment
Medical treatments can help to control the risk factors that put
people at higher risk for stroke. These include treating high blood
pressure, heart disease, and diabetes. Lifestyle changes such as quit-
ting smoking can also lower the risk of stroke.
Acute stroke therapies try to stop a stroke while it is happening.
These treatments try to dissolve the blood clot causing an ischemic
stroke or to stop the bleeding of a hemorrhagic stroke. These thera-
pies are most effective when given very soon after the onset of a
stroke.
Post-stroke treatment and rehabilitation are used to lower the risk
of another stroke and to help patients overcome disabilities that re-
sult from stroke. People who have had a stroke can do things to lower
their risk of having another stroke. These include controlling their
underlying risk factors.
Rehabilitation helps stroke victims relearn skills that may be lost
when the brain is damaged. Rehabilitation may include the follow-
ing:
• Physical therapy to help restore movement, balance, and coordi-
nation.
• Occupational therapy to help the patient relearn everyday ac-
tivities such as eating, drinking, dressing, bathing, cooking, read-
ing, and writing.
266
Stroke
• Speech therapy to help stroke patients relearn language and
speaking skills, including swallowing, or learn other forms of
communication.
• Psychological or psychiatric help after a stroke. Psychological
problems, such as depression, anxiety, frustration, and anger,
can be common after a stroke.
The best treatment for stroke is the take steps to lower the risk
for stroke.
Risk Factors
Some conditions as well as some lifestyle factors can put people at
a higher risk for stroke. The most important risk factors for stroke
are high blood pressure, heart disease, diabetes, and cigarette smok-
ing. Persons who have already had a stroke need to control the risk
factors in order to lower their risk of having another stroke. All per-
sons can take steps to lower their risk for stroke.
High blood pressure: High blood pressure, or hypertension, is a
major risk factor for stroke. It is a condition where the pressure of
the blood in the arteries is too high. There are often no symptoms to
signal high blood pressure. About sixty million people in the United
States have high blood pressure. Lowering blood pressure can lower
the risk of stroke. Medicines to lower blood pressure can decrease the
risk of stroke among those with high blood pressure.
Heart disease: Common heart disorders such as coronary artery

disease can also increase a person’s risk for stroke. Coronary artery
disease (CAD) occurs when the arteries that supply blood to the heart
muscle become hardened and narrowed due to the buildup of plaque.
Plaque (a mixture of fatty substances, including cholesterol and other
lipids) and blood clots can build up inside the artery walls, causing
thickening, hardening, and loss of elasticity. They can result in de-
creased or blocked blood flow and lead to a heart attack. Also, heart
problems such as valve defects, irregular heartbeat, and enlargement
of one of the heart’s chambers can result in blood clots that may break
loose and cause a stroke. Persons with heart disease may be given
medicines such as aspirin to help prevent clots from forming.
Atrial fibrillation: A heart condition known as atrial fibrillation

is a major concern. Atrial fibrillation is irregular beating of the upper
267
chambers, or atria, of the heart. When the atria quivers instead of beat-
ing in a regular pattern, blood is not fully pumped out of them and
may pool and clot. The clots can then leave the heart and travel to the
brain, causing a stroke. Atrial fibrillation affects as many as 2.2 mil-
lion Americans. About 15 percent of stroke patients have had atrial
fibrillation before they experience a stroke.
Diabetes: Diabetes is another disease that increases a person’s

risk for stroke. With diabetes, the body does not make enough insu-
lin, cannot use its own insulin as well as it should, or both. This causes
sugars to be unavailable to the body tissues and to build up in the
blood. People with diabetes have two to four times the risk of stroke
compared to people without diabetes. Further, having diabetes can
worsen the outcome of stroke.
Tobacco use: Smoking almost doubles a person’s risk for ischemic

stroke, independently of other risk factors. Cigarette smoking in-
creases the risk of stroke by promoting atherosclerosis and increas-
ing the levels of blood clotting factors, such as fibrinogen. Also, nicotine
raises blood pressure, and carbon monoxide reduces the amount of
oxygen that blood can carry to the brain.
Other Factors
Blood cholesterol levels: Some strokes can be caused by a nar-
rowing of the arteries through the buildup of plaque, a mixture of fatty
substances, including cholesterol and other lipids. This is called ath-
erosclerosis. Plaque and blood clots build up inside the artery walls,
causing thickening, hardening, and loss of elasticity. These can lead
to decreased blood flow and to stroke if they occur in the arteries to
the brain.
Cholesterol is a waxy substance produced by the liver. It is needed
by the body, and the liver makes enough cholesterol for the body’s needs.
Excess cholesterol—usually from eating foods that contain high levels
of cholesterol and saturated fats—contributes to atherosclerosis.
There are two major kinds of cholesterol, one that is good, and one
that is bad when there is too much of it. A higher level of high-density
lipoprotein cholesterol, or HDL, is considered good. However, higher
levels of low-density lipoprotein, or LDL, can lead to atherosclerosis
and stroke. A lipoprotein profile can be done to measure several dif-
ferent kinds of cholesterol as well as triglycerides (another kind of fat
found in the blood).
268
Stroke
Alcohol: Generally, excessive alcohol use can lead to an increase
in blood pressure, which increases the risk for stroke.
Genetic risk factors: Stroke can run in families. Genes play a

role in stroke risk factors such as high blood pressure, heart disease,
diabetes, and vascular conditions. It is also possible that an increased
risk for stroke within a family is due to factors such as a common sed-
entary lifestyle or poor eating habits, rather than hereditary factors.
Signs and Symptoms of Stroke

A stroke, or cerebrovascular accident, occurs when the blood sup-
ply to the brain is cut off (an ischemic stroke) or when a blood vessel
bursts (a hemorrhagic stroke). Without oxygen, brain cells begin to
die. Death or permanent disability can result. High blood pressure,
smoking, and having had a previous stroke or heart attack increase
a person’s chances of having a stroke. With timely treatment, the risk
of death and disability from stroke can be lowered. It is very impor-
tant to know the symptoms of a stroke and act right away.
The National Institute of Neurological Disorders and Stroke notes
these five major signs of stroke:
• Sudden numbness or weakness of the face, arms, or legs

• Sudden confusion or trouble speaking or understanding others
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, or loss of balance or coordi-
nation
• Sudden severe headache with no known cause
All of the major symptoms of stroke appear suddenly, and often

there is more than one symptom at the same time.
If you think someone is having a stroke, you should call 9–1–1 or
emergency medical services immediately. Receiving immediate treat-
ment is critical in lowering the risk of disability and even death.
269
Chapter 21
Chronic Obstructive
Pulmonary Disease (COPD)
What Is COPD?
Chronic obstructive pulmonary disease (COPD) is a serious lung
disease that, over time, makes it hard to breathe. You may also have
heard COPD called other names, like emphysema or chronic bronchi-
tis. In people who have COPD, the airways—tubes that carry air in
and out of your lungs—are partially blocked, which makes it hard to
get air in and out.
When COPD is severe, shortness of breath and other symptoms of
COPD can get in the way of even the most basic tasks, such as doing
light housework, taking a walk, even washing and dressing.
Did You Know?

• COPD is the 4th leading cause of death in the United States
and causes serious, long-term disability.
• COPD kills more than 120,000 Americans each year. That’s one
death every four minutes.
• More than twelve million people have been diagnosed with COPD.
• An additional twelve million likely have COPD and don’t even
know it.
Reprinted from “What Is COPD?” “How Does COPD Affect Breathing?” “Symp-
toms,” “Getting Tested,” “Taking Action,” “Am I at Risk?” and “Treatment Options,”
National Heart, Lung, and Blood Institute, National Institutes of Health, 2007.
271
How Does COPD Affect Breathing?

The “airways” are the tubes that carry air in and out of the lungs
through the nose and mouth. Healthy airways and air sacs in the
lungs are elastic—they try to bounce back to their original shape af-
ter being stretched or filled with air, just the way a new rubber band
or balloon does. This elastic quality helps retain the normal structure
of the lung and helps to move the air quickly in and out.
In people with COPD, the air sacs no longer bounce back to their
original shape. The airways can also become swollen or thicker than
normal, and mucus production might increase. The floppy airways are
blocked, or obstructed, making it even harder to get air out of the
lungs.
Symptoms
Many people with COPD avoid activities that they used to enjoy
because they become short of breath more easily.
Symptoms of COPD include the following:
• Constant coughing, sometimes called “smoker’s cough”
• Shortness of breath while doing activities you used to be able to do
• Excess sputum production
• Feeling like you can’t breathe
• Not being able to take a deep breath
• Wheezing
When COPD is severe, shortness of breath and other symptoms

can get in the way of doing even the most basic tasks, such as doing
light housework, taking a walk, even bathing and getting dressed.
COPD develops slowly, and can worsen over time, so be sure to
report any symptoms you might have to your doctor as soon as pos-
sible, no matter how mild they may seem.
Getting Tested
Everyone at risk for COPD who has cough, sputum production, or
shortness of breath should be tested for the disease. The test for COPD
is called spirometry.
Spirometry can detect COPD before symptoms become severe. It
is a simple, non-invasive breathing test that measures the amount of
272
Chronic Obstructive Pulmonary Disease (COPD)
air a person can blow out of the lungs (volume) and how fast he or
she can blow it out (flow). Based on this test, your doctor can tell if
you have COPD, and if so, how severe it is. The spirometry reading
can help your doctor determine the best course of treatment.
How Spirometry Works

Spirometry is one of the best and most common lung function tests.
The test is done with a spirometer, a machine that measures how well
your lungs function, records the results, and displays them on a graph
for your doctor. You will be asked to take a deep breath, then blow
out as hard and as fast as you can using a mouthpiece connected to
the machine with tubing. The spirometer then measures the total
amount exhaled, called the forced vital capacity or FVC, and how
much you exhaled in the first second, called the forced expiratory
volume in one second or FEV1. Your doctor will read the results to
assess how well your lungs are working and whether or not you have
COPD.
Taking Action
There are many things people at risk for COPD can do.
Quit smoking: If you smoke, the best thing you can to do pre-
vent more damage to your lungs is to quit. To help you quit, there
are many online resources and several new aids available from your
doctor.
Avoid exposure to pollutants: Try to stay away from other

things that could irritate your lungs, like dust and strong fumes. Stay
indoors when the outside air quality is poor. You should also stay away
from places where there might be cigarette smoke.
Visit your doctor on a regular basis: See your doctor regularly

even if you are feeling fine. Make a list of your breathing symptoms
and think about any activities that you can no longer do because of
shortness of breath. Be sure to bring a list of all the medicines you
are taking to each doctor’s visit.
Take precautions against the flu: Do your best to avoid crowds

during flu season. It is also a good idea to get a flu shot every year,
since the flu can cause serious problems for people with COPD. You
should also ask your doctor about the pneumonia vaccine.
273
Am I At Risk?
Most people who are at risk for getting COPD have never even
heard of it and, in many cases, don’t even realize that the condition
has a name. Some of the things that put you at risk for COPD include
smoking, environmental exposure, and genetic factors.
Smoking: COPD most often occurs in people age forty and over
with a history of smoking (either current or former smokers), although
as many as one out of six people with COPD never smoked. Smoking
is the most common cause of COPD—it accounts for as many as nine
out of ten COPD-related deaths.
Environmental exposure: COPD can also occur in people who

have had long-term exposure to things that can irritate your lungs,
like certain chemicals, dust, or fumes in the workplace. Heavy or long-
term exposure to secondhand smoke or other air pollutants may also
contribute to COPD.
Genetic factors: In some people, COPD is caused by a genetic

condition known as alpha-1 antitrypsin, or AAT, deficiency. While very
few people know they have AAT deficiency, it is estimated that close
to one hundred thousand Americans have it. People with AAT defi-
ciency can get COPD even if they have never smoked or had long-term
exposure to harmful pollutants.
Treatment Options
Once you have been diagnosed with COPD, there are many ways
that you and your doctor can work together to manage the symptoms
of the disease and improve your quality of life. Your doctor may sug-
gest one or more of the following options.
Medications (such as bronchodilators and inhaled steroids):
Bronchodilators are medicines that usually come in the form of an
inhaler. They work to relax the muscles around your airways, to help
open them and make it easier to breathe. Inhaled steroids help pre-
vent the airways from getting inflamed. Each patient is different—
your doctor may suggest other types of medications that might work
better for you.
Pulmonary rehabilitation: Your doctor may recommend that you

participate in pulmonary rehabilitation, or “rehab.” This is a program
274
Chronic Obstructive Pulmonary Disease (COPD)
that helps you learn to exercise and manage your disease with physi-
cal activity and counseling. It can help you stay active and carry out
your day-to-day tasks.
Physical activity training: Your doctor or a pulmonary thera-

pist recommended by your doctor might teach you some activities to
help your arms and legs get stronger and/or breathing exercises that
strengthen the muscles needed for breathing.
Lifestyle changes: Lifestyle changes such as quitting smoking

can help you manage the effects of COPD.
Oxygen treatment: If your COPD is severe, your doctor might

suggest oxygen therapy to help with shortness of breath. You might
need oxygen all of the time or just some of the time—your doctor will
work with you to learn which treatment will be most helpful.
Surgery: COPD patients with very severe symptoms may have a

hard time breathing all the time. In some of these cases, doctors may
suggest lung surgery to improve breathing and help lessen some of
the most severe symptoms.
Managing complications: Symptoms of COPD can get worse all

of a sudden. When this happens, it is much harder to catch your breath.
You might also have chest tightness, more coughing or a change in your
cough (becomes more productive, more mucus is expelled), and a fe-
ver.
When symptoms get worse quickly, it could be a sign of a lung in-
fection. There could be other causes for symptoms getting worse, such
as heart disease related to severe lung damage. The best thing to do
is call your doctor right away so he or she can find out what the cause
of the problem is and take steps to treat it.
When to Get Emergency Help

Seek emergency help if your usual medications aren’t working and
one or more of the following is true:
• You find that it is unusually hard to walk or talk (such as diffi-
culty completing a sentence).
• Your heart is beating very fast or irregularly.
• Your lips or fingernails are gray or blue.
275
• Your breathing is fast and hard, even when you are using your
medication.
Be prepared and have information on hand that you or others

would need in a medical emergency, such as a list of medicines you
are taking, the name of your doctor and his or her contact informa-
tion, directions to the hospital or your doctor’s office, and people to
contact if you are unable to speak or drive yourself to the doctor or
hospital.
276
Chapter 22
Diabetes
Basics about Diabetes

What is diabetes?
Diabetes is a disease in which blood glucose levels are above nor-
mal. Most of the food we eat is turned into glucose, or sugar, for our
bodies to use for energy. The pancreas, an organ that lies near the
stomach, makes a hormone called insulin to help glucose get into the
cells of our bodies. When you have diabetes, your body either doesn’t
make enough insulin or can’t use its own insulin as well as it should.
This causes sugar to build up in your blood.
Diabetes can cause serious health complications including heart
disease, blindness, kidney failure, and lower-extremity amputations.
Diabetes is the sixth leading cause of death in the United States.
What are the symptoms of diabetes?

People who think they might have diabetes must visit a physician
for diagnosis. They might have some or none of the following symp-
toms:
• Frequent urination
“Basics about Diabetes” is excerpted from “Frequently Asked Questions: Ba-

sics about Diabetes” and “Preventing Diabetes” is reprinted from “Frequently
Asked Questions: Preventing Diabetes,” Centers for Disease Control and Preven-
tion, July 12, 2007.
277
• Excessive thirst
• Unexplained weight loss
• Extreme hunger
• Sudden vision changes
• Tingling or numbness in hands or feet
• Feeling very tired much of the time
• Very dry skin
• Sores that are slow to heal
• More infections than usual.
Nausea, vomiting, or stomach pains may accompany some of these

symptoms in the abrupt onset of insulin-dependent diabetes, now
called type 1 diabetes.
What are the types of diabetes?

Type 1 diabetes, which was previously called insulin-dependent dia-
betes mellitus (IDDM) or juvenile-onset diabetes, may account for 5 to
10 percent of all diagnosed cases of diabetes. Type 2 diabetes, which
was previously called non-insulin-dependent diabetes mellitus
(NIDDM) or adult-onset diabetes, may account for about 90 to 95 per-
cent of all diagnosed cases of diabetes. Gestational diabetes is a type
of diabetes that only pregnant women get. If not treated, it can cause
problems for mothers and babies. Gestational diabetes develops in 2
to 5 percent of all pregnancies but usually disappears when a pregnancy
is over. Other specific types of diabetes resulting from specific genetic
syndromes, surgery, drugs, malnutrition, infections, and other illnesses
may account for 1 to 2 percent of all diagnosed cases of diabetes.
What are the risk factors for diabetes?

Risk factors for type 2 diabetes include older age, obesity, family
history of diabetes, prior history of gestational diabetes, impaired glu-
cose tolerance, physical inactivity, and race/ethnicity. African Ameri-
cans, Hispanic/Latino Americans, American Indians, and some Asian
Americans and Pacific Islanders are at particularly high risk for type
2 diabetes.
Risk factors are less well defined for type 1 diabetes than for type
2 diabetes, but autoimmune, genetic, and environmental factors are
involved in developing this type of diabetes.
278
Diabetes
Gestational diabetes occurs more frequently in African Americans,
Hispanic/Latino Americans, American Indians, and people with a fam-
ily history of diabetes than in other groups. Obesity is also associated
with higher risk. Women who have had gestational diabetes are at
increased risk for later developing type 2 diabetes. In some studies,
nearly 40 percent of women with a history of gestational diabetes
developed diabetes in the future.
Other specific types of diabetes, which may account for 1 to 2 per-
cent of all diagnosed cases, result from specific genetic syndromes,
surgery, drugs, malnutrition, infections, and other illnesses.
What is the treatment for diabetes?

Healthy eating, physical activity, and insulin injections are the
basic therapies for type 1 diabetes. The amount of insulin taken must
be balanced with food intake and daily activities. Blood glucose lev-
els must be closely monitored through frequent blood glucose testing.
Healthy eating, physical activity, and blood glucose testing are the
basic therapies for type 2 diabetes. In addition, many people with type
2 diabetes require oral medication, insulin, or both to control their
blood glucose levels.
People with diabetes must take responsibility for their day-to-day
care, and keep blood glucose levels from going too low or too high.
People with diabetes should see a health care provider who will
monitor their diabetes control and help them learn to manage their
diabetes. In addition, people with diabetes may see endocrinologists,
who may specialize in diabetes care; ophthalmologists for eye exami-
nations; podiatrists for routine foot care; and dietitians and diabetes
educators who teach the skills needed for daily diabetes management.
What causes type 1 diabetes?

The causes of type 1 diabetes appear to be much different than those
for type 2 diabetes, though the exact mechanisms for developing both
diseases are unknown. The appearance of type 1 diabetes is suspected
to follow exposure to an “environmental trigger,” such as an unidenti-
fied virus, stimulating an immune attack against the beta cells of the
pancreas (that produce insulin) in some genetically predisposed people.
Is there a cure for diabetes?

In response to the growing health burden of diabetes, the diabe-
tes community has three choices: prevent diabetes; cure diabetes; and
279
improve the quality of care of people with diabetes to prevent devas-
tating complications. All three approaches are actively being pursued
by the U.S. Department of Health and Human Services.
Both the National Institutes of Health (NIH) and the Centers for
Disease Control and Prevention (CDC) are involved in prevention ac-
tivities. The NIH is involved in research to cure both type 1 and type
2 diabetes, especially type 1. CDC focuses most of its programs on be-
ing sure that the proven science is put into daily practice for people
with diabetes. The basic idea is that if all the important research and
science are not applied meaningfully in the daily lives of people with
diabetes, then the research is, in essence, wasted.
Several approaches to “cure” diabetes are being pursued:
• Pancreas transplantation
• Islet cell transplantation (islet cells produce insulin)
• Artificial pancreas development
• Genetic manipulation (fat or muscle cells that don’t normally
make insulin have a human insulin gene inserted—then these
“pseudo” islet cells are transplanted into people with type 1 dia-
betes)
Each of these approaches still has a lot of challenges, such as pre-

venting immune rejection; finding an adequate number of insulin cells;
keeping cells alive; and others. But progress is being made in all areas.
Preventing Diabetes
What are the most important things to do to prevent dia-
betes?
The Diabetes Prevention Program (DPP), a major federally funded
study of 3,234 people at high risk for diabetes, showed that people can
delay and possibly prevent the disease by losing a small amount of
weight (5 to 7 percent of total body weight) through thirty minutes of
physical activity five days a week and healthier eating.
When should I be tested for diabetes?

Anyone aged forty-five years or older should consider getting tested
for diabetes, especially if you are overweight. If you are younger than
forty-five, but are overweight and have one or more additional risk
factors (see below), you should consider testing.
280
Diabetes
What are the risk factors that increase the likelihood of

developing diabetes?
• Being overweight or obese
• A parent, brother, or sister with diabetes
• African American, American Indian, Asian American, Pacific Is-
lander, or Hispanic American/Latino heritage
• Prior history of gestational diabetes or birth of at least one baby
weighing more than nine pounds
• High blood pressure measuring 140/90 or higher
• Abnormal cholesterol with HDL (“good”) cholesterol is 35 or
lower, or triglyceride level is 250 or higher
• Physical inactivity—exercising fewer than three times a week
How does body weight affect the likelihood of developing

diabetes?
Being overweight or obese is a leading risk factor for type 2 diabe-
tes. Being overweight can keep your body from making and using in-
sulin properly, and can also cause high blood pressure. The Diabetes
Prevention Program (DPP), a major federally funded study of 3,234
people at high risk for diabetes, showed that moderate diet and exer-
cise of about thirty minutes or more, five or more days per week, or
of 150 or more minutes per week, resulting in a 5 to 7 percent weight
loss can delay and possibly prevent type 2 diabetes.
What is pre-diabetes?
People with blood glucose levels that are higher than normal but
not yet in the diabetic range have “pre-diabetes.” Doctors sometimes
call this condition impaired fasting glucose (IFG) or impaired glu-
cose tolerance (IGT), depending on the test used to diagnose it. In-
sulin resistance and pre-diabetes usually have no symptoms. You may
have one or both conditions for several years without noticing any-
thing.
If you have pre-diabetes, you have a higher risk of developing type
2 diabetes. Studies have shown that most people with pre-diabetes
go on to develop type 2 diabetes within ten years, unless they lose
weight through modest changes in diet and physical activity. People
with pre-diabetes also have a higher risk of heart disease.
281
Can vaccines cause diabetes?

No. Carefully performed scientific studies show that vaccines do
not cause diabetes or increase a person’s risk of developing diabetes.
In 2002, the Institute of Medicine reviewed the existing studies and
released a report concluding that the scientific evidence favors rejec-
tion of the theory that immunizations cause diabetes. The only evi-
dence suggesting a relationship between vaccination and diabetes
comes from Dr. John B. Classen, who has suggested that certain vac-
cines if given at birth may decrease the occurrence of diabetes,
whereas if initial vaccination is performed after two months of age
the occurrence of diabetes increases. Dr. Classen’s studies have a num-
ber of limitations and have not been verified by other researchers.
282
Chapter 23
Influenza and Pneumonia
Chapter Contents
Section 23.1—Influenza .............................................................. 284
Section 23.2—Pneumonia ........................................................... 287
283
Section 23.1
Influenza
Reprinted from “Key Facts about Seasonal Influenza (Flu),”
Centers for Disease Control and Prevention, July 16, 2008.
What Is Influenza (Also Called Flu)?

The flu is a contagious respiratory illness caused by influenza vi-
ruses. It can cause mild to severe illness, and at times can lead to
death. The best way to prevent the flu is by getting a flu vaccination
each year.
Every year in the United States, on average, 5 to 20 percent of the
population gets the flu, more than 200,000 people are hospitalized
from flu complications, and about 36,000 people die from flu. Some
people, such as older people, young children, and people with certain
health conditions (such as asthma, diabetes, or heart disease), are at
high risk for serious flu complications.
Symptoms of Flu
Symptoms of flu include the following:
• Fever (usually high) • Sore throat

• Headache • Runny or stuffy nose
• Extreme tiredness • Muscle aches
• Dry cough
Stomach symptoms, such as nausea, vomiting, and diarrhea, also

can occur but are more common in children than adults
Complications of Flu
Complications of flu can include bacterial pneumonia, ear infec-
tions, sinus infections, dehydration, and worsening of chronic medi-
cal conditions, such as congestive heart failure, asthma, or diabetes.
284
How Flu Spreads

Flu viruses spread mainly from person to person through coughing
or sneezing of people with influenza. Sometimes people may become in-
fected by touching something with flu viruses on it and then touching
their mouth or nose. Most healthy adults may be able to infect others
beginning one day before symptoms develop and up to five days after
becoming sick. That means that you may be able to pass on the flu to
someone else before you know you are sick, as well as while you are sick.
Preventing Seasonal Flu: Get Vaccinated

The single best way to prevent the flu is to get a flu vaccination
each year. There are two types of vaccines:
• The “flu shot”: An inactivated vaccine (containing killed virus)
that is given with a needle. The flu shot is approved for use in
people six months of age and older, including healthy people and
people with chronic medical conditions.
• The nasal-spray flu vaccine: A vaccine made with live, weak-
ened flu viruses that do not cause the flu (sometimes called LAIV
for “live attenuated influenza vaccine”). LAIV is approved for use
in healthy people two to forty-nine years of age who are not preg-
nant.
About two weeks after vaccination, antibodies develop that protect

against influenza virus infection. Flu vaccines will not protect against
flu-like illnesses caused by non-influenza viruses.
When to Get Vaccinated

Yearly flu vaccination should begin in September or as soon as
vaccine is available and continue throughout the influenza season,
into December, January, and beyond. This is because the timing and
duration of influenza seasons vary. While influenza outbreaks can
happen as early as October, most of the time influenza activity peaks
in January or later.
Who Should Get Vaccinated?

In general, anyone who wants to reduce their chances of getting the
flu can get vaccinated. However, certain people should get vaccinated
285
each year either because they are at high risk of having serious flu-related
complications or because they live with or care for high-risk persons.
During flu seasons when vaccine supplies are limited or delayed, the
Advisory Committee on Immunization Practices (ACIP) makes recom-
mendations regarding priority groups for vaccination.
People who should get vaccinated each year are as follows:
• Children aged six months up to their nineteenth birthday.

• Pregnant women.
• People fifty years of age and older.
• People of any age with certain chronic medical conditions.
• People who live in nursing homes and other long-term care fa-
cilities.
• People who live with or care for those at high risk for compli-
cations from flu, including health care workers, household con-
tacts of persons at high risk for complications from the flu, and
household contacts and out of home caregivers of children less
than six months of age (these children are too young to be vac-
cinated).
Use of the Nasal Spray Flu Vaccine

Vaccination with the nasal-spray flu vaccine is an option for healthy
people two to forty-nine years of age who are not pregnant, even
healthy persons who live with or care for those in a high-risk group.
The one exception is healthy persons who care for persons with se-
verely weakened immune systems who require a protected environ-
ment; these healthy persons should get the inactivated vaccine.
Who Should Not Be Vaccinated?

Some people should not be vaccinated without first consulting a
physician. They include the following:
• People who have a severe allergy to chicken eggs

• People who have had a severe reaction to an influenza vaccina-
tion in the past
• People who developed Guillain-Barré syndrome (GBS) within
six weeks of getting an influenza vaccine previously
286
• Children less than six months of age (influenza vaccine is not
approved for use in this age group)
People who have a moderate or severe illness with a fever should

wait to get vaccinated until their symptoms lessen.
If you have questions about whether you should get a flu vaccine,
consult your health-care provider.
Section 23.2
Pneumonia
“What Is Pneumonia?” © 2008 American Lung Association. Reprinted with
permission. For more information about the American Lung Association
or to support the work it does, call 800-LUNG-USA (586-4872) or log on
to http://www.lungusa.org.
What Is Pneumonia?
Pneumonia is a serious infection and/or inflammation of your lungs.
The air sacs in the lungs fill with pus and other liquid. Oxygen has
trouble reaching your blood. If there is too little oxygen in your blood,
your body cells can’t work properly. Because of this and spreading
infection through the body pneumonia can cause death.
Until 1936, pneumonia was the number one cause of death in the
United States. Since then, the use of antibiotics brought it under con-
trol. In 2004, pneumonia and influenza combined ranked as the eighth
leading cause of death.1
Pneumonia affects your lungs in two ways. Lobar pneumonia af-
fects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneu-
monia) affects patches throughout both lungs.
Causes of Pneumonia
Pneumonia is not a single disease. It can have over thirty differ-
ent causes. There are five main causes of pneumonia:
287
• Bacteria
• Viruses
• Mycoplasmas
• Other infectious agents, such as fungi—including Pneumocystis
• Various chemicals
Bacterial Pneumonia
Bacterial pneumonia can attack anyone from infants through the
elderly. Alcoholics, the debilitated, postoperative patients, people with
respiratory diseases or viral infections, and people who have weak-
ened immune systems are at greater risk.
Pneumonia bacteria are present in some healthy throats. When body
defenses are weakened in some way, by illness, old age, malnutrition,
general debility, or impaired immunity, the bacteria can multiply and
cause serious damage. Usually, when a person’s resistance is lowered,
bacteria work their way into the lungs and inflame the air sacs.
The tissue of part of a lobe of the lung, an entire lobe, or even most
of the lung’s five lobes becomes completely filled with liquid (this is
called “consolidation”). The infection quickly spreads through the
bloodstream and the whole body is invaded.
The organism Streptococcus pneumoniae is the most common cause
of bacterial pneumonia. It is one form of pneumonia for which a vac-
cine is available.
Symptoms: The onset of bacterial pneumonia can vary from

gradual to sudden. In the most severe cases, the patient may experi-
ence shaking chills, chattering teeth, severe chest pain, and a cough
that produces rust-colored or greenish mucus.
A person’s temperature may rise as high as 105 degrees F. The
patient sweats profusely, and breathing and pulse rate increase rap-
idly. Lips and nail beds may have a bluish color due to lack of oxygen
in the blood. A patient’s mental state may be confused or delirious.
Viral Pneumonia
Half of all pneumonias are believed to be caused by viruses. More
and more viruses are being identified as the cause of respiratory in-
fection, and though most attack the upper respiratory tract, some
produce pneumonia, especially in children. Most of these pneumonias
are not serious and last a short time but some may be.
288
Infection with the influenza virus may be severe and occasionally
fatal. The virus invades the lungs and multiplies, but there are al-
most no physical signs of lung tissue becoming filled with fluid. It finds
many of its victims among those who have preexisting heart or lung
disease or are pregnant.
Symptoms: The initial symptoms of viral pneumonia are the same
as influenza symptoms: fever, a dry cough, headache, muscle pain, and
weakness. Within twelve to thirty-six hours, there is increasing breath-
lessness; the cough becomes worse and produces a small amount of
mucus. There is a high fever and there may be blueness of the lips.
In extreme cases, the patient has a desperate need for air and
extreme breathlessness. Viral pneumonias may be complicated by an
invasion of bacteria, with all the typical symptoms of bacterial pneu-
monia.
Mycoplasma Pneumonia
Because of its somewhat different symptoms and physical signs,
and because the course of the illness differed from classical pneumo-
coccal pneumonia, mycoplasma pneumonia was once believed to be
caused by one or more undiscovered viruses and was called “primary
atypical pneumonia.”
Identified during World War II, mycoplasmas are the smallest free-
living agents of disease in humankind, unclassified as to whether
bacteria or viruses, but having characteristics of both. They generally
cause a mild and widespread pneumonia. They affect all age groups,
occurring most frequently in older children and young adults. The
death rate is low, even in untreated cases.
Symptoms: The most prominent symptom of mycoplasma pneu-
monia is a cough that tends to come in violent attacks, but produces
only sparse whitish mucus. Chills and fever are early symptoms, and
some patients experience nausea or vomiting. Patients may experi-
ence profound weakness that lasts for a long time.
Other Kinds of Pneumonia

Pneumocystis carinii pneumonia (PCP) is caused by an organism
believed to be a fungus. PCP may be the first sign of illness in many
persons with acquired immunodeficiency syndrome (AIDS).
PCP can be successfully treated in many cases. It may recur a few
months later, but treatment can help to prevent or delay its recurrence.
289
Other less common pneumonias may be quite serious and are oc-
curring more often. Various special pneumonias are caused by the
inhalation of food, liquid, gases, or dust, and by fungi. Foreign bodies
or a bronchial obstruction such as a tumor may promote the occur-
rence of pneumonia, although they are not causes of pneumonia.
Rickettsia (also considered an organism somewhere between vi-
ruses and bacteria) cause Rocky Mountain spotted fever, Q fever, ty-
phus, and psittacosis, diseases that may have mild or severe effects
on the lungs. Tuberculosis pneumonia is a very serious lung infection
and extremely dangerous unless treated early.
Treating Pneumonia
If you develop pneumonia, your chances of a fast recovery are great-
est under certain conditions: if you’re young, if your pneumonia is
caught early, if your defenses against disease are working well, if the
infection hasn’t spread, and if you’re not suffering from other illnesses.
In the young and healthy, early treatment with antibiotics can cure
bacterial pneumonia and speed recovery from mycoplasma pneumo-
nia and a certain percentage of rickettsia cases. There is not yet a
general treatment for viral pneumonia, although antiviral drugs are
used for certain kinds. Most people can be treated at home.
The drugs used to fight pneumonia are determined by the germ
causing the pneumonia and the judgment of the doctor. After a
patient’s temperature returns to normal, medication must be contin-
ued according to the doctor’s instructions, otherwise the pneumonia
may recur. Relapses can be far more serious than the first attack.
Besides antibiotics, patients are given supportive treatment: proper
diet, and oxygen to increase oxygen in the blood when needed. In some
patients, medication to ease chest pain and to provide relief from vio-
lent cough may be necessary.
The vigorous young person may lead a normal life within a week
of recovery from pneumonia. For the middle-aged, however, weeks may
elapse before they regain their accustomed strength, vigor, and feel-
ing of well-being. A person recovering from mycoplasma pneumonia
may be weak for an extended period of time.
Adequate rest is important to maintain progress toward full re-
covery and to avoid relapse. Remember, don’t rush recovery!
Preventing Pneumonia Is Possible

Because pneumonia is a common complication of influenza (flu),
getting a flu shot every fall is good pneumonia prevention.
290
A vaccine is also available to help fight pneumococcal pneumonia,
one type of bacterial pneumonia. Your doctor can help you decide if
you, or a member of your family, need the vaccine against pneumo-
coccal pneumonia. It is usually given only to people at high risk of
getting the disease and its life-threatening complications.
The greatest risk of pneumococcal pneumonia is usually among
people who:
• have chronic illnesses such as lung disease, heart disease, kid-
ney disorders, sickle cell anemia, or diabetes;
• are recovering from severe illness;
• are in nursing homes or other chronic care facilities;
• are age sixty-five or older.
If you are at risk, ask your doctor for the vaccine.

Ask your doctor about any revaccination recommendations. The
vaccine is not recommended for pregnant women or children under
age two.
Since pneumonia often follows ordinary respiratory infections, the
most important preventive measure is to be alert to any symptoms
of respiratory trouble that linger more than a few days. Good health
habits, proper diet and hygiene, rest, regular exercise, etc., increase
resistance to all respiratory illnesses. They also help promote fast
recovery when illness does occur.
If You Have Symptoms of Pneumonia

Call your doctor immediately. Even with the many effective anti-
biotics, early diagnosis and treatment are important.
Follow your doctor’s advice. In serious cases, your doctor may ad-
vise a hospital stay. Or recovery at home may be possible.
Continue to take the medicine your doctor prescribes until told you
may stop. This will help prevent recurrence of pneumonia and relapse.
Remember, even though pneumonia can be treated, it is an ex-
tremely serious illness. Don’t wait, get treatment early.
Sources
1. National Center for Health Statistics. National Vital Statistics
Report. Deaths: Preliminary Data for 2004. Vol. 54, 19 June 2006.
291
Chapter 24
Suicide
Suicide is a major, preventable public health problem. In 2004, it

was the eleventh leading cause of death in the United States, account-
ing for 32,439 deaths.1 The overall rate was 10.9 suicide deaths per
100,000 people.1 An estimated eight to twenty-five attempted suicides
occur per every suicide death.2
Suicidal behavior is complex. Some risk factors vary with age, gen-
der, or ethnic group and may occur in combination or change over time.
If you are in a crisis and need help right away, call this toll-free
number, available twenty-four hours a day, every day: 800-273-TALK
(8255). You will reach the National Suicide Prevention Lifeline, a ser-
vice available to anyone. You may call for yourself or for someone you
care about. All calls are confidential.
What Are the Risk Factors for Suicide?

Research shows that risk factors for suicide include the following:
• Depression and other mental disorders, or a substance-abuse
disorder (often in combination with other mental disorders). More
than 90 percent of people who die by suicide have these risk fac-
tors.2
The first part of this chapter is reprinted from “Suicide in the U.S.: Statis-
tics and Prevention,” National Institute of Mental Health, National Institutes
of Health, June 26, 2008. “Suicide Warning Signs” is reprinted from the U.S.
Department of Health and Human Services Substance Abuse and Mental Health
Services Administration, September 2005.
293
• Stressful life events, in combination with other risk factors,
such as depression. However, suicide and suicidal behavior are
not normal responses to stress; many people have these risk fac-
tors but are not suicidal.
• Prior suicide attempt.
• Family history of mental disorder or substance abuse.
• Family history of suicide.
• Family violence, including physical or sexual abuse.
• Firearms in the home,3 the method used in more than half of
suicides.
• Incarceration.
• Exposure to the suicidal behavior of others, such as family
members, peers, or media figures.2
Research also shows that the risk for suicide is associated with
changes in brain chemicals called neurotransmitters, including sero-
tonin. Decreased levels of serotonin have been found in people with
depression, impulsive disorders, and a history of suicide attempts, and
in the brains of suicide victims.4
Are Women or Men at Higher Risk?

Suicide was the eighth leading cause of death for males and the
sixteenth leading cause of death for females in 2004.1
Almost four times as many males as females die by suicide.1
Firearms, suffocation, and poison are by far the most common
methods of suicide, overall. However, men and women differ in the
method used, as shown in Table 24.1.1
Is Suicide Common among Children and Young People?

In 2004, suicide was the third leading cause of death in each of the
following age groups.1 Of every 100,000 young people in each age
group, the following number died by suicide:1
• Children ages 10 to 14—1.3 per 100,000

• Adolescents ages 15 to 19—8.2 per 100,000
• Young adults ages 20 to 24—12.5 per 100,000
294
Suicide
Table 24.1. Methods of Suicide

Suicide by: Males (%) Females (%)
Firearms 57 32
Suffocation 23 20
Poisoning 13 38
As in the general population, young people were much more likely

to use firearms, suffocation, and poisoning than other methods of sui-
cide, overall. However, while adolescents and young adults were more
likely to use firearms than suffocation, children were dramatically
more likely to use suffocation.1
There were also gender differences in suicide among young people,
as follows:
• Almost four times as many males as females ages fifteen to

nineteen died by suicide.1
• More than six times as many males as females ages twenty to
twenty-four died by suicide.1
Are Older Adults at Risk?

Older Americans are disproportionately likely to die by suicide:
• Of every 100,000 people ages sixty-five and older, 14.3 died by

suicide in 2004. This figure is higher than the national average
of 10.9 suicides per 100,000 people in the general population.1
• Non-Hispanic white men age eighty-five or older had an even
higher rate, with 17.8 suicide deaths per 100,000.1
Are Some Ethnic Groups or Races at Higher Risk?

Of every 100,000 people in each of the following ethnic/racial
groups below, the following number died by suicide in 2004.1
• Highest rates:
• Non-Hispanic Whites—12.9 per 100,000
• American Indian and Alaska Natives—12.4 per 100,000
• Lowest rates:
• Non-Hispanic Blacks—5.3 per 100,000
295
• Asian and Pacific Islanders—5.8 per 100,000
• Hispanics—5.9 per 100,000
What Are Some Risk Factors for Nonfatal Suicide At-

tempts?
As noted, an estimated eight to twenty-five nonfatal suicide at-

tempts occur per every suicide death. Men and the elderly are more
likely to have fatal attempts than are women and youth.2
Risk factors for nonfatal suicide attempts by adults include depres-
sion and other mental disorders, alcohol abuse, cocaine use, and sepa-
ration or divorce.5,6
Risk factors for attempted suicide by youth include depression,
alcohol or other drug-use disorder, physical or sexual abuse, and dis-
ruptive behavior.6,7
Most suicide attempts are expressions of extreme distress, not
harmless bids for attention. A person who appears suicidal should not
be left alone and needs immediate mental health treatment.
What Can Be Done to Prevent Suicide?
Research helps determine which factors can be modified to help

prevent suicide and which interventions are appropriate for specific
groups of people. Before being put into practice, prevention programs
should be tested through research to determine their safety and ef-
fectiveness.8 For example, because research has shown that mental
and substance-abuse disorders are major risk factors for suicide, many
programs also focus on treating these disorders.
Studies showed that a type of psychotherapy called cognitive
therapy reduced the rate of repeated suicide attempts by 50 percent
during a year of follow-up. A previous suicide attempt is among the
strongest predictors of subsequent suicide, and cognitive therapy helps
suicide attempters consider alternative actions when thoughts of self-
harm arise.9
Specific kinds of psychotherapy may be helpful for specific groups
of people. For example, a recent study showed that a treatment called
dialectical behavior therapy reduced suicide attempts by half, com-
pared with other kinds of therapy, in people with borderline person-
ality disorder (a serious disorder of emotion regulation).10
The medication clozapine is approved by the Food and Drug Ad-
ministration for suicide prevention in people with schizophrenia.11
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Suicide
Other promising medications and psychosocial treatments for suicidal
people are being tested.
Since research shows that older adults and women who die by sui-
cide are likely to have seen a primary care provider in the year be-
fore death, improving primary-care providers’ ability to recognize and
treat risk factors may help prevent suicide among these groups.12
Improving outreach to men at risk is a major challenge in need of
investigation.
What Should I Do If I Think Someone Is Suicidal?
If you think someone is suicidal, do not leave him or her alone. Try
to get the person to seek immediate help from his or her doctor or the
nearest hospital emergency room, or call 911. Eliminate access to fire-
arms or other potential tools for suicide, including unsupervised ac-
cess to medications.
References
for Injury Prevention and Control. Web-based Injury Statistics
Query and Reporting System (WISQARS): www.cdc.gov/ncipc/
wisqars
2. Moscicki EK. Epidemiology of completed and attempted sui-

cide: toward a framework for prevention. Clinical Neuro-
science Research, 2001; 1: 310–23.
3. Miller M, Azrael D, Hepburn L, Hemenway D, Lippmann SJ.

The association between changes in household firearm owner-
ship and rates of suicide in the United States, 1981–2002. In-
jury Prevention 2006;12:178–82; doi:10.1136/ip.2005.010850
4. Arango V, Huang YY, Underwood MD, Mann JJ. Genetics of

the serotonergic system in suicidal behavior. Journal of Psy-
chiatric Research. Vol. 37: 375–86. 2003.
5. Kessler RC, Borges G, Walters EE. Prevalence of and risk fac-

tors for lifetime suicide attempts in the National Comorbidity
Survey. Archives of General Psychiatry, 1999; 56(7): 617–26.
6. Petronis KR, Samuels JF, Moscicki EK, Anthony JC. An epi-

demiologic investigation of potential risk factors for suicide
297
attempts. Social Psychiatry and Psychiatric Epidemiology,
1990; 25(4): 193–99.
7. U.S. Public Health Service. National strategy for suicide

prevention: goals and objectives for action. Rockville, MD:
USDHHS, 2001.
8. Gould MS, Greenberg T, Velting DM, Shaffer D. Youth suicide

risk and preventive interventions: a review of the past 10 years.
Journal of the American Academy of Child and Adolescent
Psychiatry, 2003; 42(4): 386–405.
9. Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE,
Beck AT. Cognitive therapy for the prevention of suicide at-
tempts: a randomized controlled trial. Journal of the American
Medical Association. 2005 Aug 3;294(5):563–70.
10. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ,
Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim
N. Two-Year Randomized Controlled Trial and Follow-up of
Dialectical Behavior Therapy vs Therapy by Experts for Sui-
cidal Behaviors and Borderline Personality Disorder. Archives
of General Psychiatry, 2006 Jul;63(7):757–66.
11. Meltzer HY, Alphs L, Green AI, Altamura AC, Anand R,

Bertoldi A, Bourgeois M, Chouinard G, Islam MZ, Kane J,
Krishnan R, Lindenmayer JP, Potkin S; International Suicide
Prevention Trial Study Group. Clozapine treatment for sui-
cidality in schizophrenia: International Suicide Prevention Trial
(InterSePT). Archives of General Psychiatry, 2003; 60(1): 82–91.
12. Luoma JB, Pearson JL, Martin CE. Contact with mental
health and primary care prior to suicide: a review of the evi-
dence. American Journal of Psychiatry, 2002; 159: 909–16.
Suicide Warning Signs

Seek help as soon as possible by contacting a mental health pro-
fessional or by calling the National Suicide Prevention Lifeline at 800-
273-TALK if you or someone you know exhibits any of the following
signs:
• Threatening to hurt or kill oneself or talking about wanting to

hurt or kill oneself
298
Suicide
• Looking for ways to kill oneself by seeking access to firearms,
pills, or other means
• Talking or writing about death, dying, or suicide when these ac-
tions are out of the ordinary for the person
• Feeling hopeless
• Feeling rage or uncontrolled anger or seeking revenge
• Acting reckless or engaging in risky activities—seemingly with-
out thinking
• Feeling trapped—like there’s no way out
• Increasing alcohol or drug use
• Withdrawing from friends, family, and society
• Feeling anxious, agitated, or unable to sleep or sleeping all the
time
• Experiencing dramatic mood changes
• Seeing no reason for living or having no sense of purpose in life
299
Chapter 25
Alzheimer Disease
Introduction
Dementia is a brain disorder that seriously affects a person’s abil-
ity to carry out daily activities. The most common form of dementia
among older people is Alzheimer disease (AD), which initially involves
the parts of the brain that control thought, memory, and language.
Although scientists are learning more every day, right now they still
do not know what causes AD, and there is no cure.
Scientists think that as many as 4.5 million Americans suffer from
AD. The disease usually begins after age sixty, and risk goes up with
age. While younger people also may get AD, it is much less common.
About 5 percent of men and women ages sixty-five to seventy-four
have AD, and nearly half of those age eighty-five and older may have
the disease. It is important to note, however, that AD is not a normal
part of aging.
AD is named after Dr. Alois Alzheimer, a German doctor. In 1906,
Dr. Alzheimer noticed changes in the brain tissue of a woman who had
died of an unusual mental illness. He found abnormal clumps (now
called amyloid plaques) and tangled bundles of fibers (now called
neurofibrillary tangles). Today, these plaques and tangles in the brain
are considered signs of AD.
Excerpted from “Alzheimer’s Disease Fact Sheet,” National Institute on Ag-

ing, July 24, 2008.
301
Scientists also have found other brain changes in people with AD.
Nerve cells die in areas of the brain that are vital to memory and other
mental abilities, and connections between nerve cells are disrupted.
There also are lower levels of some of the chemicals in the brain that
carry messages back and forth between nerve cells. AD may impair
thinking and memory by disrupting these messages.
What Causes AD?

Scientists do not yet fully understand what causes AD. There prob-
ably is not one single cause, but several factors that affect each per-
son differently. Age is the most important known risk factor for AD.
The number of people with the disease doubles every five years be-
yond age sixty-five.
Family history is another risk factor. Scientists believe that genet-
ics may play a role in many AD cases. For example, early-onset fa-
milial AD, a rare form of AD that usually occurs between the ages of
thirty and sixty, is inherited. The more common form of AD is known
as late-onset. It occurs later in life, and no obvious inheritance pat-
tern is seen in most families. However, several risk factor genes may
interact with each other and with nongenetic factors to cause the dis-
ease. The only risk factor gene identified so far for late-onset AD is a
gene that makes one form of a protein called apolipoprotein E (ApoE).
Everyone has ApoE, which helps carry cholesterol in the blood. Only
about 15 percent of people have the form that increases the risk of
AD. It is likely that other genes also may increase the risk of AD or
protect against AD, but they remain to be discovered.
Scientists still need to learn a lot more about what causes AD. In
addition to genetics and ApoE, they are studying education, diet, and
environment to learn what role they might play in the development
of this disease. Scientists are finding increasing evidence that some
of the risk factors for heart disease and stroke, such as high blood
pressure, high cholesterol, and low levels of the vitamin folate, may
also increase the risk of AD. Evidence for physical, mental, and so-
cial activities as protective factors against AD is also increasing.
What Are the Symptoms of AD?

AD begins slowly. At first, the only symptom may be mild forget-
fulness, which can be confused with age-related memory change. Most
people with mild forgetfulness do not have AD. In the early stage of
AD, people may have trouble remembering recent events, activities,
302
Alzheimer Disease
or the names of familiar people or things. They may not be able to
solve simple math problems. Such difficulties may be a bother, but
usually they are not serious enough to cause alarm.
However, as the disease goes on, symptoms are more easily noticed
and become serious enough to cause people with AD or their family
members to seek medical help. Forgetfulness begins to interfere with
daily activities. People in the middle stages of AD may forget how to do
simple tasks like brushing their teeth or combing their hair. They can
no longer think clearly. They can fail to recognize familiar people and
places. They begin to have problems speaking, understanding, reading,
or writing. Later on, people with AD may become anxious or aggres-
sive, or wander away from home. Eventually, patients need total care.
How Is AD Diagnosed?
An early, accurate diagnosis of AD helps patients and their fami-
lies plan for the future. It gives them time to discuss care while the
patient can still take part in making decisions. Early diagnosis will
also offer the best chance to treat the symptoms of the disease.
Today, the only definite way to diagnose AD is to find out whether
there are plaques and tangles in brain tissue. To look at brain tissue,
however, doctors usually must wait until they do an autopsy, which
is an examination of the body done after a person dies. Therefore,
doctors can only make a diagnosis of “possible” or “probable” AD while
the person is still alive.
At specialized centers, doctors can diagnose AD correctly up to 90
percent of the time. Doctors use several tools to diagnose “probable”
AD, including the following:
• Questions about the person’s general health, past medical prob-

lems, and ability to carry out daily activities
• Tests of memory, problem solving, attention, counting, and lan-
guage
• Medical tests—such as tests of blood, urine, or spinal fluid, and
brain scans
Sometimes these test results help the doctor find other possible
causes of the person’s symptoms. For example, thyroid problems, drug
reactions, depression, brain tumors, and blood vessel disease in the
brain can cause AD-like symptoms. Some of these other conditions can
be treated successfully.
303
How Is AD Treated?
AD is a slow disease, starting with mild memory problems and
ending with severe brain damage. The course the disease takes and
how fast changes occur vary from person to person. On average, AD
patients live from eight to ten years after they are diagnosed, though
some people may live with AD for as many as twenty years.
No treatment can stop AD. However, for some people in the early
and middle stages of the disease, the drugs tacrine (Cognex®, which
is still available but no longer actively marketed by the manufacturer),
donepezil (Aricept®), rivastigmine (Exelon®), or galantamine (Ra-
zadyne®, previously known as Reminyl®) may help prevent some
symptoms from becoming worse for a limited time. Another drug,
memantine (Namenda®), has been approved to treat moderate to se-
vere AD, although it also is limited in its effects. Also, some medicines
may help control behavioral symptoms of AD such as sleeplessness,
agitation, wandering, anxiety, and depression. Treating these symp-
toms often makes patients more comfortable and makes their care
easier for caregivers.
New Areas of Research

Neuroimaging: Scientists are finding that damage to parts of the
brain involved in memory, such as the hippocampus, can sometimes
be seen on brain scans before symptoms of the disease occur. An NIA
public-private partnership—the AD Neuroimaging Initiative (ADNI)—
is a large study that will determine whether magnetic resonance im-
aging (MRI) and positron emission tomography (PET) scans, or other
imaging or biological markers, can see early AD changes or measure
disease progression. The project is designed to help speed clinical tri-
als and find new ways to determine the effectiveness of treatments.
AD genetics: The NIA is sponsoring the AD Genetics Study to

learn more about risk factor genes for late-onset AD.
Mild cognitive impairment: During the past several years, sci-

entists have focused on a type of memory change called mild cogni-
tive impairment (MCI), which is different from both AD and normal
age-related memory change. People with MCI have ongoing memory
problems, but they do not have other losses such as confusion, atten-
tion problems, and difficulty with language. The NIA-funded Memory
Impairment Study compared donepezil, vitamin E, or placebo in par-
304
Alzheimer Disease
ticipants with MCI to see whether the drugs might delay or prevent
progression to AD. The study found that the group with MCI taking
donepezil were at reduced risk of progressing to AD for the first eigh-
teen months of a three-year study, when compared with their coun-
terparts on placebo. The reduced risk of progressing from MCI to a
diagnosis of AD among participants on donepezil disappeared after
eighteen months, and by the end of the study, the probability of pro-
gressing to AD was the same in the two groups. Vitamin E had no ef-
fect at any time point in the study when compared with placebo.
Inflammation: There is evidence that inflammation in the brain

may contribute to AD damage. Some studies have suggested that drugs
such as nonsteroidal anti-inflammatory drugs (NSAIDs) might help
slow the progression of AD, but clinical trials thus far have not demon-
strated a benefit from these drugs. A clinical trial studying two of these
drugs, rofecoxib (Vioxx®) and naproxen (Aleve®) showed that they did
not delay the progression of AD in people who already have the dis-
ease. Another trial, testing whether the NSAIDs celecoxib (Celebrex®)
and naproxen could prevent AD in healthy older people at risk of the
disease, was suspended due to concerns over possible cardiovascular
risk. Researchers are continuing to look for ways to test how other anti-
inflammatory drugs might affect the development or progression of AD.
Antioxidants: Several years ago, a clinical trial showed that vita-

min E slowed the progress of some consequences of AD by about seven
months. Additional studies are investigating whether antioxidants—
vitamins E and C—can slow AD. Another clinical trial is examining
whether vitamin E and/or selenium supplements can prevent AD or
cognitive decline, and additional studies on other antioxidants are on-
going or being planned, including a study of the antioxidant treat-
ments—vitamins E, C, alpha-lipoic acid, and coenzyme Q—in patients
with mild to moderate AD.
Ginkgo biloba: Early studies suggested that extracts from the

leaves of the ginkgo biloba tree may be of some help in treating AD
symptoms. There is no evidence yet that ginkgo biloba will cure or
prevent AD, but scientists now are trying to find out in a clinical trial
whether ginkgo biloba can delay cognitive decline or prevent demen-
tia in older people.
Estrogen: Some studies have suggested that estrogen used by

women to treat the symptoms of menopause also protects the brain.
305
Experts also wondered whether using estrogen could reduce the risk
of AD or slow the disease. Clinical trials to test estrogen, however, have
not shown that estrogen can slow the progression of already diagnosed
AD. And one study found that women over the age of sixty-five who
used estrogen with a progestin were at greater risk of dementia, in-
cluding AD, and that older women using only estrogen could also in-
crease their chance of developing dementia.
Scientists believe that more research is needed to find out if es-
trogen may play some role in AD. They would like to know whether
starting estrogen therapy around the time of menopause, rather than
at age sixty-five or older, will protect memory or prevent AD.
306
Chapter 26
Kidney Disease
What do my kidneys do?

Your kidneys are bean-shaped organs, each about the size of your
fist. They are located near the middle of your back, just below the
ribcage.
Your kidneys filter blood. The filtering occurs in tiny units inside
your kidneys called nephrons. One kidney has about a million neph-
rons. They remove waste products and extra water, which become
urine. The urine flows through tubes called ureters to your bladder,
which stores the urine until you go to the bathroom.
The wastes in your blood come from the normal breakdown of ac-
tive tissues and from food you eat. After your body has taken what it
needs from the food, waste is sent to the blood. If your kidneys did
not remove these wastes, the wastes would build up in the blood and
damage your body.
What is kidney disease?

Kidney disease results from damage to the nephrons, the tiny struc-
tures inside your kidneys that filter blood.
Usually the damage occurs very gradually over years. It happens
in both kidneys. There aren’t any obvious symptoms, so you don’t know
it’s happening.
Reprinted from “Kidney Disease Information,” National Kidney Disease Edu-

cation Program, National Institutes of Health, March 2005.
307
Common causes of kidney disease are as follows:
• Diabetes: In diabetes, the body doesn’t use glucose (sugar) very

well. The glucose stays in your blood and acts like a poison. If you
have diabetes, you can prevent kidney disease by controlling your
blood sugar levels.
• High blood pressure: High blood pressure can damage the
small blood vessels in your kidneys. When this happens your
kidneys cannot filter wastes from your blood very well. If you
have high blood pressure (hypertension) be sure to take any
medicines your doctor prescribes.
• Heredity: Some kidney diseases result from hereditary factors,
and can run in families. If your family has a history of any kind
of kidney problems, you may be at risk for kidney disease and
should talk to your doctor.
Am I at risk for kidney disease?

• Do you have diabetes (problems with your blood sugar)?
• Do you have high blood pressure?
• Did your mother, father, sister, or brother ever have kidney fail-
ure? Kidney disease runs in families.
If you answered “yes” to any of these questions, you are at risk for
kidney disease. Now is the time to talk to your doctor or health care
professional about getting tested. It could save your life.
How can my doctor tell if I have kidney disease?

Early kidney disease is a silent problem, like high blood pressure,
and does not have any symptoms. You may have it, but not know it,
because you don’t feel sick.
To detect the disease doctors can do very simple tests that include
the following:
• Measure the level of serum creatinine in your blood to estimate
your glomerular filtration rate (GFR)
• Measure the level of protein in your urine (increased levels of
protein show your kidneys are not working right)
• Check your blood pressure
308
Kidney Disease
If I have kidney disease, how can it be treated?

Unfortunately, kidney disease often cannot be cured. But if you are
in the early stages of a kidney disease, you may be able to make your
kidneys last longer by taking certain steps. You will also want to be
sure that risks for heart attack and stroke are minimized, since kid-
ney patients are susceptible to these problems.
If you have diabetes, watch your blood glucose closely to keep it
under control. Consult your doctor for the latest in treatment.
People with reduced kidney function should have their blood pres-
sure controlled, and an angiotensin-converting enzyme (ACE) inhibi-
tor or an angiotensin II receptor blocker (ARB) should be one of their
medications. Many people will require two or more types of medica-
tion to keep the blood pressure below 130/80 mm Hg. A diuretic is an
important addition to the ACE inhibitor or ARB.
What happens if my kidneys fail completely?

Complete and irreversible kidney failure is sometimes called end-
stage renal disease, or ESRD. If your kidneys stop working completely,
your body fills with extra water and waste products. This condition
is called uremia. Your hands or feet may swell. You will feel tired and
weak because your body needs clean blood to function properly.
Untreated uremia may lead to seizures or coma and will ultimately
result in death. If your kidneys stop working completely, you will need
to undergo dialysis or kidney transplantation.
Dialysis: There are two major forms of dialysis. In hemodialysis,
your blood is sent through a machine that filters away waste prod-
ucts. The clean blood is returned to your body. Hemodialysis is usu-
ally performed at a dialysis center three times per week for three to
four hours. In peritoneal dialysis, a fluid is put into your abdomen.
This fluid, called dialysate, captures the waste products from your
blood. After a few hours, the dialysate containing your body’s wastes
is drained away. Then, a fresh bag of dialysate is dripped into the
abdomen. Patients can perform peritoneal dialysis themselves. Pa-
tients using continuous ambulatory peritoneal dialysis (CAPD), the
most common form of peritoneal dialysis, change dialysate four times
a day.
Transplantation: A donated kidney may come from an anony-

mous donor who has recently died or from a living person, usually a
relative. The kidney that you receive must be a good match for your
309
body. The more the new kidney is like you, the less likely your im-
mune system is to reject it. You will take special drugs to help trick
your immune system so it does not reject the transplanted kidney.
310
Chapter 27
Chronic Liver Disease

and Cirrhosis
Viral Hepatitis
What Is Viral Hepatitis?
Viral hepatitis is inflammation of the liver caused by a virus. Sev-
eral different viruses, named the hepatitis A, B, C, D, and E viruses,
cause viral hepatitis.
All of these viruses cause acute, or short-term, viral hepatitis. The
hepatitis B, C, and D viruses can also cause chronic hepatitis, in which
the infection is prolonged, sometimes lifelong. Chronic hepatitis can
lead to cirrhosis, liver failure, and liver cancer.
Researchers are looking for other viruses that may cause hepati-
tis, but none have been identified with certainty. Other viruses that
less often affect the liver include cytomegalovirus; Epstein-Barr vi-
rus, also called infectious mononucleosis; herpesvirus; parvovirus; and
adenovirus.
“Viral Hepatitis” is excerpted from “Viral Hepatitis: A through E and Be-

yond,” National Institute of Diabetes and Digestive and Kidney Diseases, Na-
tional Institutes of Health, NIH Publication No. 08-4762, February 2008.
“Cirrhosis of the Liver” is excerpted from “What I Need to Know about Cirrho-
sis of the Liver,” National Institute of Diabetes and Digestive and Kidney Dis-
eases, National Institutes of Health, NIH Publication No. 06-5166, October
2005.
311
What Are the Symptoms of Viral Hepatitis?

Symptoms include the following:
• Jaundice, which causes a yellowing of the skin and eyes

• Fatigue
• Abdominal pain
• Loss of appetite
• Nausea
• Vomiting
• Diarrhea
• Low-grade fever
• Headache
However, some people do not have symptoms.
Hepatitis A
Disease spread: Hepatitis A is spread primarily through food or
water contaminated by feces from an infected person. Rarely, it spreads
through contact with infected blood.
People at risk: People most likely to get hepatitis A are: inter-

national travelers, particularly those traveling to developing coun-
tries; people who live with or have sex with an infected person ; people
living in areas where children are not routinely vaccinated against
hepatitis A, where outbreaks are more likely; day care children and
employees, during outbreaks; men who have sex with men; and us-
ers of illicit drugs.
Prevention: The hepatitis A vaccine offers immunity to adults and

children older than age one. The Centers for Disease Control and Pre-
vention recommends routine hepatitis A vaccination for children aged
twelve to twenty-three months and for adults who are at high risk
for infection. Treatment with immune globulin can provide short-term
immunity to hepatitis A when given before exposure or within two
weeks of exposure to the virus. Avoiding tap water when traveling in-
ternationally and practicing good hygiene and sanitation also help pre-
vent hepatitis A.
312
Chronic Liver Disease and Cirrhosis
Treatment: Hepatitis A usually resolves on its own over several
weeks.
Hepatitis B
Disease spread: Hepatitis B is spread through contact with in-
fected blood, through sex with an infected person, and from mother
to child during childbirth, whether the delivery is vaginal or via ce-
sarean section.
People at risk: People most likely to get hepatitis B are: people

who live with or have sexual contact with an infected person; men who
have sex with men; people who have multiple sex partners; injection
drug users; immigrants and children of immigrants from areas with
high rates of hepatitis B; infants born to infected mothers; health care
workers; hemodialysis patients; people who received a transfusion of
blood or blood products before 1987, when better tests to screen blood
donors were developed; and international travelers.
Prevention: The hepatitis B vaccine offers the best protection. All

infants and unvaccinated children, adolescents, and at-risk adults
should be vaccinated. For people who have not been vaccinated, re-
ducing exposure to the virus can help prevent hepatitis B. Reducing
exposure means using latex condoms, which may lower the risk of
transmission; not sharing drug needles; and not sharing personal
items such as toothbrushes, razors, and nail clippers with an infected
person.
Treatment: Drugs approved for the treatment of chronic hepati-

tis B include alpha interferon and peginterferon, which slow the rep-
lication of the virus in the body and also boost the immune system,
and the antiviral drugs lamivudine, adefovir dipivoxil, entecavir, and
telbivudine. Other drugs are also being evaluated. Infants born to in-
fected mothers should receive hepatitis B immune globulin and the
hepatitis B vaccine within twelve hours of birth to help prevent in-
fection.
People who develop acute hepatitis B are generally not treated with
antiviral drugs because, depending on their age at infection, the dis-
ease often resolves on its own. Infected newborns are most likely to
progress to chronic hepatitis B, but by young adulthood, most people
with acute infection recover spontaneously. Severe acute hepatitis B
can be treated with an antiviral drug such as lamivudine.
313
Hepatitis C
Disease spread: Hepatitis C is spread primarily through contact
with infected blood. Less commonly, it can spread through sexual con-
tact and childbirth.
People at risk: People most likely to be exposed to the hepatitis

C virus are: injection drug users; people who have sex with an infected
person; people who have multiple sex partners; health care workers;
infants born to infected women; hemodialysis patients; people who
received a transfusion of blood or blood products before July 1992,
when sensitive tests to screen blood donors for hepatitis C were in-
troduced; and people who received clotting factors made before 1987,
when methods to manufacture these products were improved.
Prevention: There is no vaccine for hepatitis C. The only way to

prevent the disease is to reduce the risk of exposure to the virus. Re-
ducing exposure means avoiding behaviors like sharing drug needles
or personal items such as toothbrushes, razors, and nail clippers with
an infected person.
Treatment: Chronic hepatitis C is treated with peginterferon to-

gether with the antiviral drug ribavirin.
If acute hepatitis C does not resolve on its own within two to three
months, drug treatment is recommended.
Hepatitis D
Disease spread: Hepatitis D is spread through contact with in-
fected blood. This disease occurs only at the same time as infection with
hepatitis B or in people who are already infected with hepatitis B.
People at risk: Anyone infected with hepatitis B is at risk for

hepatitis D. Injection drug users have the highest risk. Others at risk
include people who live with or have sex with a person infected with
hepatitis D and people who received a transfusion of blood or blood
products before 1987.
Prevention: People not already infected with hepatitis B should

receive the hepatitis B vaccine. Other preventive measures include
avoiding exposure to infected blood, contaminated needles, and an in-
fected person’s personal items such as toothbrushes, razors, and nail
clippers.
314
Treatment: Chronic hepatitis D is usually treated with pegylated
interferon, although other potential treatments are under study.
Hepatitis E
Disease spread: Hepatitis E is spread through food or water con-
taminated by feces from an infected person. This disease is uncom-
mon in the United States.
People at risk: People most likely to be exposed to the hepatitis

E virus are: international travelers, particularly those traveling to
developing countries; people living in areas where hepatitis E out-
breaks are common; and people who live with or have sex with an
infected person.
Prevention: There is no U.S. Food and Drug Administration (FDA)-

approved vaccine for hepatitis E. The only way to prevent the disease
is to reduce the risk of exposure to the virus. Reducing risk of expo-
sure means avoiding tap water when traveling internationally and
practicing good hygiene and sanitation.
Treatment: Hepatitis E usually resolves on its own over several

weeks to months.
Other Causes of Viral Hepatitis

Some cases of viral hepatitis cannot be attributed to the hepatitis
A, B, C, D, or E viruses, or even the less common viruses that can infect
the liver, such as cytomegalovirus, Epstein-Barr virus, herpesvirus,
parvovirus, and adenovirus. These cases are called non-A–E hepatitis.
Scientists continue to study the causes of non-A–E hepatitis.
Cirrhosis of the Liver

What is cirrhosis of the liver?
Cirrhosis refers to scarring of the liver. Scar tissue forms because
of injury or long-term disease. It replaces healthy tissue.
Scar tissue cannot do what healthy liver tissue does—make pro-
tein, help fight infections, clean the blood, help digest food, and store
energy for when you need it. Scar tissue also blocks the normal flow
of blood through the liver. Too much scar tissue means that your liver
cannot work properly. To live, you need a liver that works.
315
Cirrhosis can be life threatening, but it can also be controlled if
treated early.
What are the symptoms of cirrhosis?

You may have no symptoms at all in the early stages. As cirrhosis
progresses you may:
• feel tired or weak;

• lose your appetite;
• feel sick to your stomach;
• lose weight.
Cirrhosis can also lead to other problems:

• You may bruise or bleed easily, or have nosebleeds.
• Bloating or swelling may occur as fluid builds up in the abdo-
men or legs. Fluid buildup in the abdomen is called ascites and
in the legs is called edema.
• Medications may have a stronger effect on you because your
liver does not break them down as quickly.
• Waste materials from food may build up in the blood or brain
and may cause confusion or difficulty thinking. For example, pro-
tein that you eat breaks down into chemicals like ammonia. When
red blood cells get old, they break down and leave a substance
called bilirubin. A healthy liver removes these byproducts, but
a diseased liver leaves them in the body.
• Blood pressure may increase in the vein entering the liver, a
condition called portal hypertension.
• Enlarged veins, called varices, may develop in the esophagus
and stomach. Varices can bleed suddenly, causing vomiting of
blood or passing of blood in a bowel movement.
• The kidneys may not work properly or may fail.
As cirrhosis progresses, your skin and the whites of your eyes may
turn yellow, a condition called jaundice. You may also develop severe
itching or gallstones.
In the early stages, cirrhosis causes your liver to swell. Then, as
more scar tissue replaces normal tissue, the liver shrinks.
316
About 5 percent of patients with cirrhosis also get cancer of the
liver.
What causes cirrhosis?

Cirrhosis has many causes, including the following:
• Alcohol abuse (alcoholic liver disease)
• Chronic viral hepatitis (hepatitis B, C, or D)
• Autoimmune hepatitis, which is destruction of liver cells by the
body’s immune system
• Nonalcoholic fatty liver disease or nonalcoholic steatohepatitis
(NASH), which is fat deposits and inflammation in the liver
• Some drugs, toxins, and infections
• Blocked bile ducts, the tubes that carry bile from the liver
• Some inherited diseases such as hemochromatosis, a disease
that occurs when the body absorbs too much iron and stores the
excess iron in the liver, pancreas, and other organs; Wilson dis-
ease, which is caused by the buildup of too much copper in the
liver; or protoporphyria, a disorder that affects the skin, bone
marrow, and liver
Sometimes the cause of cirrhosis remains unknown even after a

thorough medical examination.
How is cirrhosis diagnosed?

Your symptoms, a physical examination, and certain tests can help
your doctor diagnose cirrhosis. Some tests are as follows:
• Blood tests to see whether your liver is working properly. Routine

blood tests may be normal in cirrhosis. However, with advanced
cirrhosis, blood tests may reveal abnormal levels of bilirubin and
other substances.
• X-rays, magnetic resonance imaging, or ultrasound images
(pictures developed from sound waves), which may show an
enlarged or shrunken liver.
• Liver biopsy, an examination of a piece of your liver under a mi-
croscope, to look for scar tissue. This is the most accurate way to
diagnose cirrhosis.
317
How is cirrhosis treated?

Once you have cirrhosis, nothing can make the scar tissue go away
completely. However, treating the cause will keep cirrhosis from get-
ting worse. For example, if cirrhosis is due to alcoholic liver disease,
the treatment is to completely stop drinking alcohol. If cirrhosis is
caused by hepatitis C, then that disease may be treated with medica-
tion.
Your doctor will suggest treatment based on the cause of your cir-
rhosis and your symptoms. Early diagnosis and carefully following an
appropriate treatment plan can help many people with cirrhosis. In
very advanced cirrhosis, however, certain treatments may not be pos-
sible. In that situation, your doctors will work with you to prevent or
manage the complications that cirrhosis can cause.
How can I prevent cirrhosis if I already have liver disease?

• See your doctor for treatment of your liver disease. Many of the
causes of cirrhosis are treatable, and early treatment may pre-
vent cirrhosis.
• Follow a healthy lifestyle, eat a healthy diet, and stay active.
• Try to keep your weight in the normal range. Being overweight
can make several liver diseases worse.
• Do not drink alcohol. Alcohol can harm liver cells, and chronic
alcohol use is one of the major causes of cirrhosis.
• Stay away from illegal (street) drugs, which can increase your
chances of getting hepatitis B or hepatitis C.
• See your doctor if you have chronic viral hepatitis. Effective
treatments for both hepatitis B and hepatitis C are available. If
you are on treatment, follow your treatment directions exactly.
• If you have autoimmune hepatitis, take medications and have
regular check-ups as recommended by your doctor or a liver
specialist (hepatologist).
What can I do to keep cirrhosis from getting worse?

• Stop drinking alcohol completely.
• Do not take any medications, including those you can buy with-
out a prescription such as vitamins and herbal supplements,
318
without discussing them with your doctor. Cirrhosis makes your
liver sensitive to certain medications.
• Get vaccinated against hepatitis A and hepatitis B. These forms
of liver disease are preventable. Also, ask your doctor about get-
ting a flu shot and being vaccinated against pneumonia.
• Avoid eating raw oysters or other raw shellfish. Raw shellfish
can harbor bacteria (Vibrio vulnificus) that cause severe infec-
tions in people with cirrhosis.
319
Part Three
Reproductive and Sexual

Concerns
Chapter 28
Male Reproductive System
All living things reproduce. Reproduction—the process by which

organisms make more organisms like themselves—is one of the things
that sets living things apart from nonliving matter. But even though
the reproductive system is essential to keeping a species alive, un-
like other body systems it’s not essential to keeping an individual
alive.
In the human reproductive process, two kinds of sex cells, or ga-
metes (pronounced: gah-meetz), are involved. The male gamete, or
sperm, and the female gamete, the egg or ovum, meet in the female’s
reproductive system to create a new individual. Both the male and
female reproductive systems are essential for reproduction.
Humans, like other organisms, pass certain characteristics of them-
selves to the next generation through their genes, the special carri-
ers of human traits. The genes parents pass along to their children
are what make children similar to others in their family, but they are
also what make each child unique. These genes come from the father’s
sperm and the mother’s egg, which are produced by the male and fe-
male reproductive systems.
“Male Reproductive System,” November 2007, reprinted with permission from

www.kidshealth.org. Copyright © 2007 The Nemours Foundation. This informa-
tion was provided by KidsHealth, one of the largest resources online for medi-
cally reviewed health information written for parents, kids, and teens. For more
articles like this one, visit www.KidsHealth.org, or www.TeensHealth.org.
323
What Is the Male Reproductive System?

Most species have two sexes: male and female. Each sex has its
own unique reproductive system. They are different in shape and
structure, but both are specifically designed to produce, nourish, and
transport either the egg or sperm.
Unlike the female, whose sex organs are located entirely within
the pelvis, the male has reproductive organs, or genitals (pronounced:
jen-ih-tulz), that are both inside and outside the pelvis. The male geni-
tals include:
• the testicles;
• the duct system, which is made up of the epididymis and the
vas deferens;
• the accessory glands, which include the seminal vesicles and
prostate gland;
• the penis.
In a guy who’s reached sexual maturity, the two testicles (pro-

nounced: tes-tih-kulz), or testes (pronounced: tes-teez) produce and
store millions of tiny sperm cells. The testicles are oval-shaped and
grow to be about two inches (five centimeters) in length and one inch
(three centimeters) in diameter. The testicles are also part of the endo-
crine system because they produce hormones, including testosterone
(pronounced: tes-tos-tuh-rone). Testosterone is a major part of puberty
in guys, and as a guy makes his way through puberty, his testicles pro-
duce more and more of it. Testosterone is the hormone that causes guys
to develop deeper voices, bigger muscles, and body and facial hair, and
it also stimulates the production of sperm.
Alongside the testicles are the epididymis (pronounced: ep-ih-did-
uh-mus) and the vas deferens (pronounced: vas def-uh-runz), which
make up the duct system of the male reproductive organs. The vas
deferens is a muscular tube that passes upward alongside the testicles
and transports the sperm-containing fluid called semen (pronounced:
see-mun). The epididymis is a set of coiled tubes (one for each testicle)
that connects to the vas deferens.
The epididymis and the testicles hang in a pouch-like structure
outside the pelvis called the scrotum. This bag of skin helps to regu-
late the temperature of testicles, which need to be kept cooler than
body temperature to produce sperm. The scrotum changes size to
maintain the right temperature. When the body is cold, the scrotum
324
shrinks and becomes tighter to hold in body heat. When it’s warm,
the scrotum becomes larger and more floppy to get rid of extra heat.
This happens without a guy ever having to think about it. The brain
and the nervous system give the scrotum the cue to change size.
The accessory glands, including the seminal vesicles and the pros-
tate gland, provide fluids that lubricate the duct system and nourish
the sperm. The seminal vesicles (pronounced: sem-uh-nul ves-ih-kulz)
are sac-like structures attached to the vas deferens to the side of the
bladder. The prostate gland, which produces some of the parts of se-
men, surrounds the ejaculatory ducts at the base of the urethra (pro-
nounced: yoo-ree-thruh), just below the bladder. The urethra is the
channel that carries the semen to the outside of the body through the
penis. The urethra is also part of the urinary system because it is also
the channel through which urine passes as it leaves the bladder and
exits the body.
The penis is actually made up of two parts: the shaft and the glans
(pronounced: glanz). The shaft is the main part of the penis and the
glans is the tip (sometimes called the head). At the end of the glans
is a small slit or opening, which is where semen and urine exit the
body through the urethra. The inside of the penis is made of a spongy
tissue that can expand and contract.
All boys are born with a foreskin, a fold of skin at the end of the
penis covering the glans. Some boys have a circumcision (pronounced:
sur-kum-sih-zhun), which means that a doctor or clergy member cuts
away the foreskin. Circumcision is usually performed during a baby
boy’s first few days of life. Although circumcision is not medically nec-
essary, parents who choose to have their children circumcised often
do so based on religious beliefs, concerns about hygiene, or cultural
or social reasons. Boys who have circumcised penises and those who
don’t are no different: All penises work and feel the same, regardless
of whether the foreskin has been removed.
What Does the Male Reproductive System Do?

The male sex organs work together to produce and release semen
into the reproductive system of the female during sexual intercourse.
The male reproductive system also produces sex hormones, which help
a boy develop into a sexually mature man during puberty (pronounced:
pyoo-bur-tee).
When a baby boy is born, he has all the parts of his reproductive
system in place, but it isn’t until puberty that he is able to reproduce.
When puberty begins, usually between the ages of ten and fourteen,
325
the pituitary (pronounced: pih-too-uh-ter-ee) gland—which is located
near the brain—secretes hormones that stimulate the testicles to pro-
duce testosterone. The production of testosterone brings about many
physical changes. Although the timing of these changes is different
for every guy, the stages of puberty generally follow a set sequence:
• During the first stage of male puberty, the scrotum and testes
grow larger.
• Next, the penis becomes longer, and the seminal vesicles and
prostate gland grow.
• Hair begins to appear in the pubic area and later it grows on the
face and underarms. During this time, a male’s voice also deepens.
• Boys also undergo a growth spurt during puberty as they reach
their adult height and weight.
Once a guy has reached puberty, he will produce millions of sperm

cells every day. Each sperm is extremely small: only 1/600 of an inch
(0.05 millimeters long). Sperm develop in the testicles within a sys-
tem of tiny tubes called the seminiferous tubules (pronounced: sem-
uh-nih-fuh-rus too-byoolz). At birth, these tubules contain simple round
cells, but during puberty, testosterone and other hormones cause these
cells to transform into sperm cells. The cells divide and change until
they have a head and short tail, like tadpoles. The head contains ge-
netic material (genes). The sperm use their tails to push themselves
into the epididymis, where they complete their development. It takes
sperm about four to six weeks to travel through the epididymis.
The sperm then move to the vas deferens, or sperm duct. The semi-
nal vesicles and prostate gland produce a whitish fluid called semi-
nal fluid, which mixes with sperm to form semen when a male is
sexually stimulated. The penis, which usually hangs limp, becomes
hard when a male is sexually excited. Tissues in the penis fill with
blood and it becomes stiff and erect (an erection). The rigidity of the
erect penis makes it easier to insert into the female’s vagina during
sexual intercourse. When the erect penis is stimulated, muscles
around the reproductive organs contract and force the semen through
the duct system and urethra. Semen is pushed out of the male’s body
through his urethra—this process is called ejaculation (pronounced:
ih-jak-yuh-lay-shun). Each time a guy ejaculates, it can contain up
to five hundred million sperm.
When the male ejaculates during intercourse, semen is deposited
into the female’s vagina. From the vagina the sperm make their way
326
up through the cervix and move through the uterus with help from
uterine contractions. If a mature egg is in one of the female’s fallo-
pian tubes, a single sperm may penetrate it, and fertilization, or con-
ception, occurs.
This fertilized egg is now called a zygote (pronounced: zy-goat) and
contains forty-six chromosomes—half from the egg and half from the
sperm. The genetic material from the male and female has combined
so that a new individual can be created. The zygote divides again and
again as it grows in the female’s uterus, maturing over the course of
the pregnancy into an embryo, a fetus, and finally a newborn baby.
Things That Can Go Wrong with the Male Reproductive

System
Guys may sometimes experience reproductive system problems.
Below are some examples of disorders that affect the male reproduc-
tive system.
Disorders of the Scrotum, Testicles, or Epididymis

Conditions affecting the scrotal contents may involve the testicles,
epididymis, or the scrotum itself.
Testicular injury: Even a mild injury to the testicles can cause

severe pain, bruising, or swelling. Most testicular injuries occur when
the testicles are struck, hit, kicked, or crushed, usually during sports
or due to other trauma. Testicular torsion (pronounced: tor-zhun),
when one of the testicles twists around, cutting off its blood supply,
is also a problem that some teen guys experience—although it’s not
common.
Varicocele (pronounced: var-uh-koh-seal): This is a varicose

vein (an abnormally swollen vein) in the network of veins that run
from the testicles. Varicoceles commonly develop while a guy is going
through puberty. A varicocele is usually not harmful, although in some
people it may damage the testicle or decrease sperm production, so it
helps for a guy to see his doctor if he’s concerned about changes in
his testicles.
Testicular cancer: This is one of the most common cancers in men

younger than forty. It occurs when cells in the testicle divide abnor-
mally and form a tumor. Testicular cancer can spread to other parts
327
of the body, but if it’s detected early, the cure rate is excellent. All guys
should perform testicular self-examinations regularly to help with
early detection.
Epididymitis (pronounced: ep-uh-did-ih-my-tus): This is in-

flammation of the epididymis, the coiled tubes that connect the tes-
tes with the vas deferens. It is usually caused by an infection, such
as the sexually transmitted disease chlamydia, and results in pain
and swelling next to one of the testicles.
Hydrocele: A hydrocele (pronounced: high-druh-seel) occurs when

fluid collects in the membranes surrounding the testes. Hydroceles
may cause swelling in the scrotum around the testicle but are gener-
ally painless. In some cases, surgery may be needed to correct the
condition.
Inguinal hernia: When a portion of the intestines pushes through

an abnormal opening or weakening of the abdominal wall and into
the groin or scrotum, it is known as an inguinal hernia (pronounced:
in-gwuh-nul her-nee-uh). The hernia may look like a bulge or swell-
ing in the groin area. It can be corrected with surgery.
Disorders of the Penis

Disorders affecting the penis include the following.
Inflammation of the penis: Symptoms of penile inflammation

include redness, itching, swelling, and pain. Balanitis occurs when the
glans (the head of the penis) becomes inflamed. Posthitis is foreskin
inflammation, which is usually due to a yeast or bacterial infection.
Hypospadias: This is a disorder in which the urethra opens on

the underside of the penis, not at the tip.
If you think you have symptoms of a problem with your reproduc-

tive system or if you have questions about your growth and develop-
ment, talk to your doctor—many problems with the male reproductive
system can be treated.
328
Chapter 29
Circumcision
Alternative Names
Foreskin removal; removal of foreskin
Definition
Circumcision is the surgical removal of the foreskin of the penis.
Description
The healthcare provider will usually numb the penis with local
anesthesia before the procedure starts. The numbing medicine may
be injected at the base of the penis, in the shaft, or applied as a cream.
There are a variety of ways to perform a circumcision. Most com-
monly, the foreskin is pushed from the head of the penis and clamped
with a metal or plastic ring-like device.
If the ring is metal, the foreskin is cut off and the metal device is
removed. The wound heals in five to seven days.
If the ring is plastic, a piece of suture is tied tightly around the
foreskin. This pushes the tissue into a groove in the plastic over the
head of the penis. Within five to seven days, the plastic covering the
penis falls free, leaving a completely healed circumcision.
Reprinted from “Circumcision,” © 2009 A.D.A.M., Inc. Reprinted with permis-

sion.
329
The baby may be given a sweetened pacifier or lollipop during the
procedure. Tylenol (acetaminophen) may be given afterward.
In older and adolescent boys, circumcision is usually done under
general anesthesia while the child is completely asleep. The foreskin
is removed and stitched onto the remaining skin of the penis. Stitches
that dissolve are used to close the wound. They will be absorbed by
the body within seven to ten days. The wound may take up to three
weeks to heal.
Why the Procedure Is Performed

Circumcision is often performed in healthy boys for cultural or
religious reasons. In the United States, a newborn boy is usually cir-
cumcised before he leaves the hospital. Jewish boys, however, are cir-
cumcised when they are eight days old.
In other parts of the world, including Europe, Asia, and South and
Central America, circumcision is rare in the general population.
The merits of circumcision have been debated. Opinions about the
need for circumcision in healthy boys vary among healthcare provid-
ers. Some believe there is great value to having an intact foreskin,
such as allowing for a more natural sexual response during adult-
hood.
Rather than routinely recommending circumcision for healthy boys,
many healthcare providers allow the parents to make the decision
after presenting them with the pros and cons.
There is no compelling medical rationale for the procedure in
healthy boys, although some boys have a medical condition requiring
circumcision.
In 1999 the American Academy of Pediatrics revised their policy
statement on circumcision, and this policy is supported by the Ameri-
can Medical Association. A summary of the policy is below:
“Existing scientific evidence demonstrates potential medical ben-

efits of newborn male circumcision; however, these data are not
sufficient to recommend routine neonatal circumcision. In circum-
stances in which there are potential benefits and risks, yet the
procedure is not essential to the child’s current well-being, par-
ents should determine what is in the best interest of the child. To
make an informed choice, parents of all male infants should be
given accurate and unbiased information and be provided the op-
portunity to discuss this decision. If a decision for circumcision is
made, procedural analgesia should be provided.”
330
Circumcision
Risks
Risks related to circumcision:
• Bleeding
• Infection
• Redness around the surgery site
• Injury to the penis
Some research has suggested that uncircumcised male infants have

an increased risk of certain conditions, including:
• cancer of the penis;
• certain sexually transmitted diseases including human immu-
nodeficiency virus (HIV);
• infections of the penis;
• phimosis (tightness of the foreskin that prevents it from retract-
ing);
• urinary tract infections.
The overall increased risk for these conditions is thought to be rela-

tively small.
Proper hygiene of the penis and safe sexual practices can help pre-
vent many of these conditions. Proper hygiene is always important,
but is thought to be especially important for uncircumcised males.
Outlook (Prognosis)
Circumcision is considered a very safe procedure for both newborns
and older children.
Recovery
Healing time for newborns after circumcision usually is about one
week. Place petroleum jelly (Vaseline) onto the area after changing
the diaper. This helps protect the healing area. Some swelling and
yellow crust formation around the site is normal.
For older children and adolescents, healing may take up to three
weeks. In most cases, the child will be released from the hospital on
the day of the surgery.
331
At home, older children should avoiding vigorous exercise while the
wound heals. If bleeding occurs during the first twenty-four hours
after surgery, use a clean cloth to apply pressure to the wound for ten
minutes. Place an ice pack on the area (twenty minutes on, twenty
minutes off) for the first twenty-four hours after surgery. This helps
reduce swelling and pain.
Bathing or showering is usually allowed. The surgical cut may be
gently washed with mild, unscented soap.
Change the dressing at least once a day and apply an antibiotic
ointment. If the dressing gets wet, change it promptly.
Use prescribed pain medicine as directed. Pain medicines should
not be needed longer than four to seven days. In infants, use only acet-
aminophen (Tylenol), if needed.
Call your pediatrician or surgeon if:
• new bleeding occurs;

• pus drains from the area of the surgical cut;
• pain becomes severe or lasts for longer than expected;
• the entire penis looks red and swollen.
332
Chapter 30
Preventing Pregnancy
Chapter Contents
Section 30.1—Birth Control Methods: How Well Do
They Work? .......................................................... 334
Section 30.2—Condoms: Basic Facts ......................................... 336
Section 30.3—Vasectomy ............................................................ 339
333
Section 30.1
Birth Control Methods:

How Well Do They Work?
“Birth Control Methods: How Well Do They Work?,” March 2007, reprinted
with permission from www.kidshealth.org. Copyright © 2007 The Nemours
Foundation. This information was provided by KidsHealth, one of the larg-
est resources online for medically reviewed health information written
for parents, kids, and teens. For more articles like this one, visit www
.KidsHealth.org, or www.TeensHealth.org.
Some birth control methods work better than others. Table 30.1
below compares how well different birth control methods work.
The most effective way to prevent pregnancy is abstinence. How-
ever, within the first year of committing to abstinence, many couples
become pregnant because they have sex anyway but don’t use pro-
tection. So it’s a good idea even for people who don’t plan to have sex
to be informed about birth control.
Couples who do have sex need to use birth control properly and
every time to prevent pregnancy. For example, Table 30.1 below shows
that the birth control pill can be effective in preventing pregnancy.
But if a girl forgets to take her birth control pills, then this is not an
effective method for her. Condoms can be an effective way to prevent
pregnancy, too. But if a guy forgets to use a condom or doesn’t use it
correctly, then it’s not an effective way for him to prevent pregnancy.
For every one hundred couples using each type of birth control,
Table 30.1 shows how many of these couples will get pregnant within
a year. The information shown is for all couples, not just teenage
couples. Some birth control methods may be less effective for teen
users. For example, teenage girls who use fertility awareness (also
called the rhythm method) may have an even greater chance of get-
ting pregnant than adult women because their bodies have not yet
settled into a regular menstrual cycle.
We list the effectiveness of different birth control methods based
on their typical use rates. Typical use refers to how the average per-
son uses that method of birth control (compared to “perfect” use, which
means no mistakes are made in using that method).
334
For us to consider a birth control method completely effective, no
couples will become pregnant while using that method. Very effective
means that between 1 and 2 out of 100 couples become pregnant while
using that method. Effective means that 2 to 12 out of 100 couples
become pregnant while using that method. Moderately effective means
that 13 to 20 out of 100 couples become pregnant while using that
method. Less effective means that 21 to 40 out of 100 couples become
Table 30.1. Effectiveness of Birth Control Methods

How Many How Well
Couples Using Does This Can
This Method Will Method Work This Method
Method of Birth Get Pregnant in in Preventing Also Protect
Control a Year? Pregnancy? Against STDs?
Consistent None Completely Yes
Abstinence effective
Birth Control Patch 5 to 8 Effective No
(“The Patch”) out of 100
Birth Control Pill 5 to 8 Effective No
(“The Pill”) out of 100
Birth Control Ring 5 to 8 Effective No
(“The Ring”) out of 100
Female Condom 21 out of 100 Less effective Yes
Male Condom 15 out of 100 Moderately Yes
effective
Birth Control Shot 3 out of 100 Effective No
Diaphragm 16 out of 100 Moderately No
effective
Emergency 1 to 2 Very effective No
Contraception out of 100
Intrauterine Device Fewer than Very effective No
(IUD) 1 out of 100
Fertility Awareness 25 out of 100 Less effective No
Spermicide 29 out of 100 Less effective No
Withdrawal 27 out of 100 Less effective No
(“Pulling Out”)
Not Using Any 85 out of 100 Not effective No
Birth Control
335
pregnant while using that method. And not effective means that more
than 40 out of 100 couples become pregnant while using that method.
In addition to preventing pregnancy, abstinence and condoms pro-
vide some protection against sexually transmitted diseases (STDs).
However, most birth control methods do not provide much protection
against STDs.
Choosing a birth control method based on how well it works is
important, but there are other things to keep in mind when choosing
a form of birth control. These include:
• how easy a particular birth control method is to use;

• how much a particular birth control method costs;
• whether a person has a health condition or is taking medica-
tion that will interfere; with how well a particular birth control
method works.
Section 30.2
Condoms: Basic Facts

“Birth Control: Condom,” February 2007, reprinted with permission from
www.kidshealth.org. Copyright © 2007 The Nemours Foundation. This
information was provided by KidsHealth, one of the largest resources
online for medically reviewed health information written for parents, kids,
and teens. For more articles like this one, visit www.KidsHealth.org, or
www.TeensHealth.org.
What Is It?
Condoms are considered a barrier method of contraception. There
are male condoms and female condoms. A male condom is a thin la-
tex (a type of rubber) sheath that is worn on the penis. A female con-
dom is a polyurethane sheath with a flexible ring at either end. One
end is closed and is inserted into the vagina, the other end is open
and the ring sits outside the opening of the vagina. The male condom
is far more widely used and is sometimes called a “rubber” or “pro-
phylactic.”
336
How Does It Work?

The condom works by keeping semen (the fluid that contains
sperm) from entering the vagina. The male condom is placed on a guy’s
penis when it becomes erect. It is unrolled all the way to the base of
the penis while holding the tip of the condom to leave some extra rub-
ber. This creates a space for semen after ejaculation and makes it less
likely that the condom will break.
After the guy ejaculates, he should hold the condom at the base of
the penis as he pulls out of the vagina. He must do this while the pe-
nis is still erect to prevent the condom from slipping off when he gets
soft. If this happens, sperm could enter the vagina.
The female condom is inserted into the vagina using the closed-
end ring. The other ring creates the open end of the condom. The sheath
then lines the walls of the vagina creating a barrier between the sperm
and the cervix. The male and female condoms should not be used at
the same time because they can get stuck together and cause one or
the other to slip during intercourse, making them ineffective. The fe-
male condom can be inserted up to eight hours prior to intercourse.
It should be removed immediately after sex.
A used condom should be thrown in the garbage, not down the toi-
let. Once a condom is used, it cannot be reused. A new condom should
be used each time you have sex and it must be used from start to fin-
ish every time you have sex to prevent pregnancy and sexually trans-
mitted diseases (STDs). Never use oil-based lubricants such as mineral
oil, petroleum jelly, or baby oil with condoms because these substances
can break down the rubber.
And if a condom ever seems dry, sticky, or stiff when it comes out
of the package, or if it is past its expiration date, throw it away and
use a new one. It’s a good idea to have several condoms on hand in
case there is a problem with one. It’s best to store unused condoms in
a cool, dry place.
How Well Does It Work?

Over the course of one year, fifteen out of one hundred typical
couples who rely on male condoms alone to prevent pregnancy will
have an accidental pregnancy. The use of the female condom is a little
less reliable and twenty-one out of one hundred couples will have an
unintended pregnancy.
Of course, these are average figures and the chance of getting preg-
nant depends on whether you use this method correctly and every time
337
you have sex. In fact studies show that, although it’s possible for
condoms to break or slip during intercourse, the most common rea-
son that condoms “fail” is that the couple fails to use one at all.
Experts used to think that using spermicide with a condom would
decrease the pregnancy rate as well as help fight against STDs. How-
ever, more recent information indicates that this is not necessarily
true and spermicide does not help make condoms more effective.
In general, how well each type of birth control method works de-
pends on a lot of things. One factor is whether the method chosen is
convenient—and whether the person remembers to use it correctly
all the time.
Abstinence (not having sex) is the only method that always pre-
vents pregnancy and STDs.
Protection Against STDs

Most male condoms are made of latex. Those made of lambskin may
offer less protection against some STDs, including human immuno-
deficiency virus (HIV), so use of latex condoms is recommended. For
people who may have an allergic skin reaction to latex, both male and
female condoms made of polyurethane are available.
When properly used, latex and polyurethane condoms are effective
against most STDs. Condoms do not protect against infections spread
from sores on the skin not covered by a condom (such as the base of
the penis or scrotum). For those having sex, condoms must always be
used to protect against STDs even when using another method of birth
control.
Possible Side Effects

Most men and women have no problems using condoms. Side ef-
fects that can occasionally occur include:
• allergy to latex condoms;

• irritation of the penis or the vagina from spermicides or lubri-
cants that some condoms are treated with.
Who Uses It?

Couples who are responsible enough to stop and put a condom on
each time before sex and people who want protection against STDs
use condoms. Because condoms are the only method of birth control
338
currently available for men, they allow the guy to take responsibility
for birth control and STD protection. Condoms are also a good choice
for people who do not have a lot of money to spend on birth control.
How Do You Get It?

Condoms are available without a prescription and are sold in drug-
stores, supermarkets, and even vending machines (in some stores,
they’re in the “Family Planning” aisle). Condoms come in different
sizes, textures, and colors.
How Much Does It Cost?

Condoms are the least expensive and most available method of
birth control—other than abstinence, of course. Male condoms cost
about $0.50 to $1 each and are less expensive when they are bought
in boxes that contain several condoms.
In addition, many health centers and family planning clinics (such
as Planned Parenthood) and some schools distribute them free of
charge. Female condoms are a little more expensive and cost about
$2 to $3 per condom.
Section 30.3
Vasectomy
Excerpted from “Facts about Vasectomy Safety,” National
Institute of Child Health and Human Development, August 17, 2006.
Vasectomy is a simple operation designed to make a man sterile,

or unable to father a child. It is used as a means of contraception in
many parts of the world. A total of about fifty million men have had
a vasectomy—a number that corresponds to roughly 5 percent of all
married couples of reproductive age. In comparison, about 15 percent
of couples rely on female sterilization for birth control.
Approximately half a million vasectomies are performed in the
United States each year. About one out of six men over age thirty-five
339
has been vasectomized, the prevalence increasing along with educa-
tion and income. Among married couples in this country, only female
sterilization and oral contraception are relied upon more often for
family planning.
Vasectomy involves blocking the tubes through which sperm pass
into the semen. Sperm are produced in a man’s testis and stored in
an adjacent structure known as the epididymis. During sexual climax,
the sperm move from the epididymis through a tube called the vas
deferens and mix with other components of semen to form the ejacu-
late. All vasectomy techniques involve cutting or otherwise blocking
both the left and right vas deferens, so the man’s ejaculate will no
longer contain sperm, and he will not be able to make a woman preg-
nant.
Vasectomy Techniques
In the conventional approach, a physician makes one or two small
incisions, or cuts, in the skin of the scrotum, which has been numbed
with a local anesthetic. The vas is cut, and a small piece may be re-
moved. Next, the doctor ties the cut ends and sews up the scrotal in-
cision. The entire procedure is then repeated on the other side.
An improved method, devised by a Chinese surgeon, has been widely
used in China since 1974. This so-called nonsurgical or no-scalpel va-
sectomy was introduced into the United States in 1988, and many
doctors are now using the technique here.
In a no-scalpel vasectomy, the doctor feels for the vas under the
skin of the scrotum and holds it in place with a small clamp. Then a
special instrument is used to make a tiny puncture in the skin and
stretch the opening so the vas can be cut and tied. This approach pro-
duces very little bleeding, and no stitches are needed to close the punc-
tures, which heal quickly by themselves. The newer method also
produces less pain and fewer complications than conventional vasec-
tomy.
Post-Vasectomy
Regardless of how it is performed, vasectomy offers many advan-
tages as a method of birth control. Like female sterilization, it is a
highly effective one-time procedure that provides permanent contra-
ception. But vasectomy is medically much simpler than female ster-
ilization, has a lower incidence of complications, and is much less
expensive.
340
After vasectomy, the patient will probably feel sore for a few days,
and he should rest for at least one day. However, he can expect to re-
cover completely in less than a week. Many men have the procedure
on a Friday and return to work on Monday. Although complications
such as swelling, bruising, inflammation, and infection may occur, they
are relatively uncommon and almost never serious. Nevertheless, men
who develop these symptoms at any time should inform their physi-
cian.
A man can resume sexual activity within a few days after vasec-
tomy, but precautions should be taken against pregnancy until a test
shows that his semen is free of sperm. Generally, this test is performed
after the patient has had ten to twenty post-vasectomy ejaculations.
If sperm are still present in the semen, the patient is told to return
later for a repeat test.
A major study of vasectomy side effects occurring within eight to
ten years after the procedure was published in the British Medical
Journal in 1992. This study—the Health Status of American Men, or
HSAM—was sponsored by the National Institute of Child Health and
Human Development (NICHD). Investigators questioned 10,590 va-
sectomized men, and an equal number of nonvasectomized men, to
see if they had developed any of ninety-nine different disorders. Af-
ter a total of 182,000 person-years of follow-up, only one condition,
epididymitis/orchitis (defined as painful, swollen, and tender epididy-
mis or testis)—was found to be more common after vasectomy. This
local inflammation most often occurs during the first year after sur-
gery. Treated with heat, it usually clears up within a week.
Disadvantages of Vasectomy
The chief advantage of vasectomy—its permanence—is also its
chief disadvantage. The procedure itself is simple, but reversing it is
difficult, expensive, and often unsuccessful. Researchers are study-
ing new methods of blocking the vas that may produce less tissue
damage and scarring and might thus permit more successful rever-
sal. But these methods are all experimental, and their effectiveness
has not yet been confirmed. It is possible to store semen in a sperm
bank to preserve the possibility of producing a pregnancy at some
future date. However, doing this is costly, and the sperm in stored
semen do not always remain viable (able to cause pregnancy). For all
of these reasons, doctors advise that vasectomy be undertaken only
by men who are prepared to accept the fact that they will no longer
be able to father a child. The decision should be considered along with
341
other contraceptive options and discussed with a professional coun-
selor. Men who are married or in a serious relationship should also
discuss the issue with their partners.
Although it is extremely effective for preventing pregnancy, vasec-
tomy does not offer protection against acquired immunodeficiency
syndrome (AIDS) or other sexually transmitted diseases. Conse-
quently, it is important that vasectomized men continue to use
condoms, preferably latex, which offer considerable protection against
the spread of disease, in any sexual encounter that carries the risk of
contracting or transmitting infection.
Masculinity and Sexuality

Vasectomy does not affect production or release of testosterone, the
male hormone responsible for a man’s sex drive, beard, deep voice, and
other masculine traits. The operation also has no effect on sexuality.
Erections, climaxes, and the amount of ejaculate remain the same.
Occasionally, a man may experience sexual difficulties after vasec-
tomy, but these almost always have an emotional basis and can usu-
ally be alleviated with counseling. More often, men who have
undergone the procedure, and their partners, find that sex is more
spontaneous and enjoyable once they are freed from concerns about
contraception and accidental pregnancy.
Immune Reactions to Sperm

After vasectomy, the testes continue to make sperm. When the
sperm cells die, they are absorbed by the body, much like unused
sperm in a nonvasectomized man. Nevertheless, many vasectomized
men develop immune reactions to sperm, although current evidence
indicates that these reactions do not cause any harm.
Ordinarily, sperm do not come in contact with immune cells, so they
do not elicit an immune response. But vasectomy breaches the barri-
ers that separate immune cells from sperm, and many men develop
anti-sperm antibodies after undergoing the procedure. This has given
rise to concern on the part of doctors and researchers, because im-
mune reactions against parts of one’s own body sometimes cause dis-
ease. Rheumatoid arthritis, juvenile diabetes, and multiple sclerosis
are just some of the illnesses suspected or known to be caused by
immune reactions of this type.
Immune reactions can also contribute to the development of ath-
erosclerosis, the clogging of arteries that leads to heart attacks. In the
342
late 1970s, after a study of ten monkeys showed an increased risk of
atherosclerosis in vasectomized animals, doctors became concerned
that vasectomy might increase the risk of heart disease in men.
Other, more persuasive research results, however, indicated that
these concerns were not warranted. In particular, the HSAM study
provided a high level of reassurance. Researchers conducting this
study found no evidence that vasectomized men were more likely than
others to develop heart disease or any other immune illnesses.
Vasectomy has been used for about a century as a means of steril-
ization. It has a long track record as a safe and effective method of
contraception and is relied upon by millions of people throughout the
world. On the basis of much evidence, experts believe that vasectomy
can safely continue to be used as it has been in the past, while fur-
ther research is carried out.
343
Chapter 31
Vasectomy Reversal
Vasectomies can be reversed even after very long periods of time,

sometimes after more than twenty-five years. Sperm are constantly
being produced in men and even after time, there should be viable
sperm. However, the success of the reversal, in terms of achieving a
pregnancy, is dependent upon the experience of the surgeon, the age
and fertility status of the female partner, and the length of time since
the vasectomy.
The surgeon noted that he both cauterized and tied the vas
during surgery. Would that reduce the positive outcome of
an operation?
No. The outcome of the surgery is more dependent upon what is
found at the time of the reversal as well as the experience of the sur-
geon performing the reversal surgery. During the reversal, the sur-
geon will check for sperm within the vas. If sperm is present, then
the two ends of the vas deferens can be put back together, and the
success rate should be fairly high. However, if there is no sperm at
the end of the vas, there is likely a blockage closer to the testicle. Then,
a more complicated surgery may be performed, but this procedure has
a lower success rate.
“Vasectomy Reversals: Frequently Asked Questions,” by Moshe Wald, M.D.

Reprinted with permission of the University of Iowa Department of Urology,
© 2006.
345
Is there ever any nerve damage when a vasectomy is

performed? If reversed, will the nerves restore them-
selves?
It is possible but rare that significant pain from nerve damage can
occur after a vasectomy. There are some cases where a reversal will
help with the pain, but these are rare. A full work-up should be per-
formed before undergoing a vasectomy reversal as the success rate
in getting rid of the pain may not be very high.
How is the surgery performed? Does it require general

anesthetic and how many hours? How about recovery?
Most vasectomy reversals are performed as an outpatient surgery
and can be done under local, regional, or general anesthesia. It typi-
cally takes approximately three to four hours using an operating mi-
croscope to perform the surgery. Recovery is variable and can take
anywhere from five to fourteen days. We recommend avoiding heavy
lifting and sexual intercourse during the first four weeks after this sur-
gery.
Does insurance pay for vasectomy reversal?

The cost of the surgery, as well as whether or not it is covered by
insurance, is variable, and dependent upon where the surgery is per-
formed and the patient’s individual insurance policy.
What is the typical cost?

Cost can range anywhere from approximately $2,000 to $12,000,
depending upon the surgeon, the type of practice where it is per-
formed, and what part of the country the patient lives in.
Is there anyone who is automatically not a candidate for

vasectomy reversal?
There are certainly some patients who are better candidates
than others; time from the vasectomy is not necessarily a reason
not to have a reversal. However, in the case of a couple where the
woman has, for instance, had a tubal ligation, sperm aspiration
combined with in-vitro fertilization is probably a better choice
than performing vasectomy reversal followed by tubal ligation re-
versal.
346
Vasectomy Reversal
Please explain the probability of any side effects . . . impo-

tence, urinary incontinence, etc.
Side effects are typically minimal and usually would include swell-
ing, pain, or bruising; however, the vasectomy itself and the reversal
should not have any effect upon potency or urinary function.
What is the effective rate of reversal?

The success rate varies based on several factors. Time from the va-
sectomy certainly helps to predict how likely it would be to be able to
put the two ends of the vas deferens back together; however, getting
return of sperm into the ejaculate does not guarantee pregnancy, so
pregnancy rates typically vary from 30 to 70 percent, whereas patency
rate, that is the return of sperm, can be as high as 95 percent.
Are there other means of “fertility” that I should consider

as options to reversal?
The only other option to a reversal that would allow use of a man’s
sperm with the woman’s egg would be surgical sperm retrieval
(through either extraction or aspiration) combined with in-vitro fer-
tilization. The sperm removed from the testicle can be injected directly
into the eggs that have been retrieved from the woman after she has
been stimulated with hormone injections.
This is a very effective but expensive treatment with relatively good
success rates. However, it is not possible to remove enough sperm from
the man’s testicle to inseminate the woman.
If antibodies from your immune system are present, why

does this affect pregnancy rates?
There is some debate about the effects of antibodies on pregnancy
rates after vasectomy reversal. Approximately 70 to 80 percent of men
who have had vasectomies will have antibodies to their sperm. How-
ever, these antibodies rarely prevent the sperm from fertilizing the egg.
Therefore, we counsel patients that it is unnecessary to routinely test
for antibodies, as they rarely will have a bad effect upon the success rate.
What are the risks of cancer and do they increase with the
reversal?
There was a report several years ago stating that men with va-
sectomies had a higher rate of prostate cancer. This report has since
347
been challenged and, for the most part, disproven. There is also no
evidence to show that reversal of the vasectomy would have any ef-
fect upon risk of cancer.
How many times can a reversal be done?

There is no maximum number of times that a man can have a
reversal, although the success rate may decrease with increased
number of reversals. However, there is good data to show that
“redo-reversals” can have as high a success rate as first-time rever-
sals. The more surgery is performed, the greater the likelihood of
scarring in the scrotum, making subsequent surgeries more diffi-
cult.
What are my options if you do not find sperm in the vas at

the time of surgery?
If the surgeon is experienced in doing vasectomy reversals, they
should be able to find the blockage, which is likely to be in the epididy-
mis, and perform the bypass above that point. However, if the surgeon
is not able to perform this bypass, then the best thing to do is reat-
tach the two ends of the vas and hope for the best. That is why it is
important that prior to surgery, the patient question the surgeon re-
garding their experience in vasectomy reversals to determine if they
would be able to perform both types of bypasses.
I had a reversal and checked okay at six weeks. Would

scarring be a concern after this amount of time?
Scarring can occur at any time after a vasectomy reversal although
it typically occurs within the first six months. Therefore, even if there
was sperm in the ejaculate after six weeks, it is possible that scar-
ring could occur later on. We typically offer sperm banking in case late
scarring does occur.
How would I find a good surgeon for the procedure?

It is important to choose a surgeon who performs reversals on a
regular basis, preferably someone with fellowship training or other
special training in male infertility. Patients should ask the surgeon
how often they perform the procedure, what their own personal suc-
cess rate is, both in obtaining sperm and pregnancy rates, and if they
have the ability to perform both types of reversals.
348
Vasectomy Reversal
Are there any effects to the sperm quality after several

years of a vasectomy and reattachment?
The sperm quality should return to normal three to six months
following a reversal as it takes that long for the testicles to make new
sperm. However, the count and the motility may be lower after rever-
sal due to partial blockage or scarring.
How often should you check on scarring?

We typically recommend checking every three months, and we of-
fer sperm banking based upon the quality of the sample. The chance
of scarring is approximately 7 to 10 percent in the first one to two
years following a successful reversal.
What are the statistics of men in the United States who are
infertile and can that be reversed?
The incidence of male infertility is not well known, however, ap-
proximately 15 percent of U.S. couples have fertility problems and half
of those are related to the male factor. Therefore, in any couple that
is having fertility problems, there is a 50 percent chance that the male
may be involved and therefore he should be evaluated.
Is it safe to get a boy a vasectomy for his eighteenth birth-

day then be able to switch it back later when he decides to
have children?
No, we do not feel that is a reasonable option. Vasectomy rever-
sals do not always work and in someone who is both young and never
fathered children, it is probably not a good idea. We would counsel
this patient to reconsider having a vasectomy. Prior to a vasectomy,
the patient and his partner should be absolutely sure that they are
done having children.
How does one prepare for the vasectomy or the reversal?

Prior to a vasectomy, the patient and his partner should be abso-
lutely sure that they are done having children. There are no special
preparations in terms of abstaining from ejaculation prior to either
the vasectomy or the reversal. The patient should be aware that a
vasectomy reversal is a more expensive procedure than the original
vasectomy and likely will take longer to recover.
349
What is the recovery for a vasectomy and the reversal?

Most men will recover from a vasectomy in a couple of days. We
typically recommend taking it easy for two days, using ice packs and
scrotal support, and then going back to work two or three days later.
However, vasectomy reversals tend to take longer, depending on the
type of work that the patient does. While some men can return to a
desk job in three or four days, we recommend that heavy construc-
tion and lifting should be avoided for four weeks after a vasectomy
reversal.
What is the oldest age for a male to be considered for re-

versal?
The success of the reversal is related more to the age of the female
rather than the male. Therefore, there is no age limit for a reversal.
Have any studies been done to show what the psychologi-

cal/emotional problems are for a vasectomy or reversal?
A report on psychological factors prior to a vasectomy has sug-
gested that most men are not worried about having a vasectomy, but
they are a little concerned regarding the recovery of a vasectomy. Very
few men have reported serious psychological or emotional problems
following their vasectomy.
350
Chapter 32
Infertility
It is estimated that up to 15 percent of all couples encounter a

problem with fertility; one-third of the cases are related to the male
partner, one-third are related to the female, and one-third are a com-
bination of both. So, in 50 percent of all infertile couples, a male fer-
tility problem plays a role in the couple’s inability to conceive. It is
generally accepted that an evaluation of fertility problems should be-
gin whenever the patients express concern and that the male and fe-
male should be evaluated simultaneously.
Why Male Infertility Occurs

There are many causes of male infertility. It is estimated that be-
tween 30 and 40 percent of men evaluated for infertility will be found
to have a varicocele. It is currently believed that the number one cause
of male infertility is varicocele. A varicocele is a dilation or swelling
of the veins that drain the testicle. Varicocele can occur on one or both
sides, but is most common on the left side. It is felt that varicoceles
cause male infertility by raising the temperature of the testicles.
Abnormalities in hormone production may be a factor. Decreased
testosterone levels can lead to low sperm counts. Other hormones such
as follicle stimulating hormone (FSH) and leuteinizing hormone (LH)
may play a role as well.
Excerpted from “Male Infertility,” by Moshe Wald, M.D. and Jay I. Sandlow, M.D.
Reprinted with permission of the University of Iowa Department of Urology,
© 2006.
351
A wide range of chemical substances can affect sperm quality and/
or quantity, including medications. The medications listed below all
have been associated with male infertility:
• Anabolic steroids • Colchicine
• Antihypertensives • Cyclosporine
• Allopurinol • Dilantin
• Erythromycin • Gentamicin
• Chemotherapy • Nitrofurantoin
• Cimetidine • Tetracycline
Other drugs associated with infertility include: alcohol, tobacco,

excessive caffeine, marijuana, heroin, and methadone.
Previous surgical procedures may play a role. Prior surgeries to
the groin, pelvis, or abdominal area may have damaged nerves or
structures necessary for ejaculation.
Testicular trauma or torsion may affect fertility. Testicular torsion
is a condition in which the testicle twists on the cord that attaches it
to the body. Approximately 30 to 40 percent of men with a history of
testicular torsion have an abnormal semen analysis.
Diseases such as diabetes mellitus or multiple sclerosis can impair
potency as well as ejaculation.
Infections of the reproductive tract also affect male fertility. Bac-
teria can affect semen quality and can produce an obstruction within
the tract, especially at the epididymis. The most common sites of in-
fection are the prostate gland, the epididymis, the seminal vesicles,
and the testicle. The mumps virus, if contracted after puberty, can
affect fertility. Testicular damage occurs in approximately 10 percent
of patients who develop mumps after puberty.
What to Expect at the Initial Visit

A thorough medical history, physical examination, and a semen
analysis are the cornerstones of the male fertility evaluation. The pa-
tient will be asked to abstain from ejaculation for approximately sev-
enty-two hours prior to the doctor visit. On the day of the visit, he will
be asked to provide a semen sample for analysis. The semen sample
provides valuable information, and is more than just the “sperm count.”
Multiple parameters are examined, including the volume (amount) of
the ejaculate, the sperm density (count), percent motility (the percent
of sperm moving), and speed (forward progression).
352
Infertility
Minimal Standards of Adequacy

• Volume: 1.5–5.0 milliliters
• Sperm: 20 million per milliliter
• Motility: Over 60 percent
• Speed: Grade 2 or higher
• Morphology: Greater than 60 percent are normal shape
• Fructose: Present
The sperm count is given, and it is reported in two ways. First, as

the number of sperm per milliliter of ejaculate. A “normal” sperm count
is typically sixty to eighty million, but could be much higher. Another
very important aspect of the semen analysis is sperm motility. That
is, the sperm’s ability to move. Between 50 and 60 percent of the sperm
cells should be motile. They are also “graded” on the quality of their
movement on a scale from zero to four. The semen analysis also re-
ports the sperm’s shape or morphology. To be considered normal, a
sperm must have an oval head, a normal mid-piece, and a tail. An ab-
normal sperm could have a tapered head or two tails. The semen analy-
sis also reports the presence or absence of fructose. A nutrient for
sperm, fructose is normally present in the semen. The volume of the
ejaculate is also measured and reported. A normal amount is one and
a half to five milliliters. Too little semen decreases the odds of the
sperm reaching the ovum. Too much semen can dilute the sperm count
and reduce the chances of impregnation.
At the initial visit, in addition to the semen analysis, a health his-
tory will be obtained. Questions regarding past infections of the urinary
tract, past surgical procedures, alcohol and tobacco use, medication use,
and past testicular trauma will be asked. Questions regarding conditions
of the work environment, such as exposures to chemicals and high tem-
peratures, will also be asked. The health history also includes questions
regarding sexual practices, timing of intercourse, and sexual habits.
A physical examination will be performed, as well. During the physi-
cal, the patient will be evaluated for factors that may contribute to in-
fertility, including, a varicocele.
If the physician suspects a hormone imbalance, hormone levels will
be drawn.
Considerable discussion often occurs at the initial physician visit.
Quite frequently, couples have questions. The physician and the pa-
tient (or couple) discuss the possible causes of the infertility, as well
as decide on a treatment plan.
353
Treatment Options
The treatment plan begins with the physician counseling the pa-
tients regarding sexual practices. They are reminded that the opti-
mal timing for intercourse is every forty-eight hours during the time
when ovulation is most likely. They are cautioned to avoid lubricants,
or use them very sparingly, as lubricants can impair sperm survival.
Even saliva can impair sperm survival.
Lifestyle changes may be a part of the treatment plan. Alcohol,
tobacco, and marijuana are all considered toxic to sperm. Decreasing
the consumption of these drugs, or eliminating them altogether, will
be recommended.
If hormonal abnormalities are found to be the cause of the infertil-
ity, hormonal replacement therapy is prescribed. This may be either
in the form of an injection self-administered periodically throughout
the week, or a tablet taken every day.
Treatment with antibiotics may be prescribed if a patient shows
an infection or inflammation in any of the organs associated with
sperm production or transportation. Such infections can lead to de-
creased fertility.
It is possible to correct a varicocele with a surgical procedure called
varicocelectomy, or varix ligation. During this procedure, a small in-
cision is made in the groin area and the enlarged veins are tied off.
This procedure is performed on an outpatient basis.
Assisted reproductive treatments have revolutionized male infer-
tility care. These procedures manipulate sperm in a controlled man-
ner and have greatly facilitated pregnancy. The procedures include:
• Intrauterine insemination (IUI): Involves depositing a large
number of specially processed sperm into the uterus at the opti-
mal point in the menstrual cycle.
• In vitro fertilization (IVF): Involves harvesting eggs from
the female partner and combining them with sperm in a care-
fully controlled laboratory procedure.
• Gamete intrafallopian transfer (GIFT): Involves hyper-
stimulation of the ovum. The ovum are not removed from the
body, rather, they are mixed with processed sperm in a special-
ized catheter and immediately transferred to the fallopian tubes.
• Intracytoplasmic sperm injection (ICSI): Usually performed
in a major IVF center; involves injecting a single sperm into an
egg; considered a highly specialized technique.
354
Infertility
These new technologies have added an entirely new dimension to
male infertility treatment. One important consideration in the use of
these “high-tech” treatments is the cost. Unfortunately, these forms
of treatment may not be covered by insurance plans.
Special Populations
Men who have sustained spinal cord injuries may be unable to
ejaculate. Yet it may be possible for them to father a child utilizing
one of several outpatient procedures. In the first procedure, which
requires approximately five minutes, a special vibrator is placed on
the underside of the tip of the penis. This stimulates the ejacula-
tory reflex and ejaculation may occur. If it does not stimulate the
reflex, other procedures such as electro-ejaculation or vasal aspira-
tion may be performed. The sperm obtained may then be manipulated
for use in any of the above-mentioned assisted reproductive treat-
ments.
Vasectomy reversal has greatly increased over the past twenty
years, owing in part to the increasing number of men who have had
a vasectomy and subsequently desire more children. During the pro-
cedure, the surgeon uses an operating microscope to assist with the
reconnection of the ends of the vas deferens. One factor that influ-
ences the success rate is the length of time between the vasectomy
and the reversal. The longer the time interval, the lower the success
rate. Another factor is surgical expertise. When researching surgeons,
it is important to ask how many procedures he/she has performed,
how often, and specifics regarding his/her success rate.
The diagnosis of male infertility can invoke many emotions. Frus-
tration, fear, anger, anxiety, and depression are all common emotional
responses. When approaching the diagnostic process, it is important
to remember that male infertility is not uncommon, it is treatable,
and that knowledgeable, expert health care professionals can assist
the patients in achieving their goal.
Frequently Asked Questions

Are there any sexual positions that you recommend to in-
crease chances of pregnancy?
Typically, the only one that has been shown to make any differ-
ence, is after ejaculation, having the woman lie with her legs elevated
or propped up on a pillow for about fifteen or twenty minutes.
355
How can a couple tell whether their lack of ability to con-

ceive is caused by the man or the woman?
Since approximately half of infertility problems involve the man,
we typically recommend obtaining one or two semen analyses prior
to the workup of the woman, unless there are obvious female prob-
lems.
Are there any over-the-counter products that increase fer-

tility?
No. There is a dietary supplement that has been advertised but,
to date, there is insufficient evidence to show that it really changes
fertility.
How do tight jeans cause a low sperm count?

That is actually a myth. There is very good evidence that shows
that tight jeans and tight underwear, as well as all types of clothing
do not have any effect on sperm count. There is really no difference
in boxers versus briefs, tight jeans versus loose pants.
Can a vasectomy be reversed?

Yes. Vasectomy reversal can be successful. It is dependent upon
several factors including the time from vasectomy, the experience of
the surgeon, and type of vasectomy reversal performed.
How much time do you usually let go by before testing for a

fertility problem?
I leave that up to the couple. The definition of infertility is inabil-
ity to get pregnant after one year of unprotected intercourse. Some
couples want to know before a year, and it is not unreasonable to start
with something easy such as a semen analysis.
What is retrograde ejaculation, and how can it be pre-

vented?
Retrograde ejaculation is fairly uncommon and is typically asso-
ciated with a neurologic disorder or previous abdominal surgery. It is
not something that can be prevented, but it can be treated. Treatment
is based on the specific underlying problem.
356
Infertility
Quick question!! I had a tubal pregnancy; after that he

had a vasectomy, what are the chances of that failing?
The chances of a vasectomy failing are dependent upon whether
or not the man has undergone an adequate test to show that he truly
is sterile. Once he has been confirmed to be sterile, the chances of fail-
ure are approximately 1 in 4,500.
What causes varicocele, and how does it affect fertility?

What can be done to correct it?
Varicoceles are very common and tend to develop during adoles-
cence. Fifteen percent of all men have varicoceles, but not all
varicoceles affect fertility. It appears that decreased fertility is based
on increased temperature within the testicles. They can be corrected
by surgery or by radiologic placement of coils in the dilated veins. The
success rate is fairly reasonable with improvement in sperm param-
eters in approximately 65 to 70 percent of patients and natural con-
ception occurring in approximately 30 to 40 percent of patients.
What is Peyronie’s disease, and can it cause infertility?

Peyronie’s disease does not cause infertility, but may be associated
with erectile dysfunction. It is a curvature of the penis when it is erect.
It is typically seen in men between ages thirty and fifty. It tends to
be self-limited, meaning, it will stop progressing by itself. It does not
always need to be treated.
What are the chances of conceiving after a man has a va-

sectomy?
The chances of conception after a man has had a vasectomy and
has been confirmed to be sterile are approximately 1 in 4,500. The
chances of conception after a vasectomy reversal are related to
several issues including the type of reversal, the age of the female
partner, the time from vasectomy, and the sperm count after the re-
versal.
What chances are there if I have a spinal injury? I do

ejaculate.
If you do ejaculate, then the chance of conception would be re-
lated to the ability to get an erection as well as the sperm count and
357
motility. Assisted reproductive techniques such as artificial insemi-
nation may improve those chances.
I have heard that a new food supplement called proXeed®

can help couples improve their chances for conception by
improving the quality of the man’s sperm. Is there any truth
to this one?
This is the dietary supplement that I referred to earlier. There are
very few studies that talk about the effect and none of these studies
examine the chance for conception. For now, I tend to tell couples to
use caution with this product, as there have not been any good stud-
ies performed to date.
What causes some men to have fertility problems?

Fertility problems can be related to many factors including var-
icoceles, blockages, infection, hormonal problems, as well as genetic
causes. Seeking help from a male fertility specialist is a good start to
determining the problem as well as the answer.
It has been a year, and no pregnancy, so should we assume

he is infertile?
Although there has been no pregnancy after a year, I would not
consider him sterile without a semen specimen showing no sperm.
My husband had a disease when he was a child that has

led to him not producing sperm at all. Is there any way to
change that?
That one is best answered by consultation with a male fertility spe-
cialist to determine if there are any reversible causes for his condition.
My boyfriend doesn’t have any trouble getting an erection,

but doesn’t always ejaculate. Is this ok?
Yes. It is not uncommon to occasionally not ejaculate.
Do men go through any type of male menopause?

This is controversial. There are some who believe that as men age,
they go through what is called “andropause.” However, the evidence
is conflicting, and there is no definite agreement on this condition.
358
Infertility
What causes lack of ejaculate?

That can be due to different causes including infection, blockage,
or neurologic problems. It would require evaluation by a urologist or
male fertility specialist.
What are the latest treatments for infertility?

This is a fairly broad question. Much of the treatments now evolve
around assisted reproductive techniques such as artificial insemina-
tion and in vitro fertilization. However, it is very important that prior
to proceeding with these treatments, both partners are evaluated.
There are often problems discovered, some of which are medically
important when evaluating the infertile male. These should be ad-
dressed.
Can you tell us more about varicoceles?

As I mentioned, varicoceles are dilated veins around the testicles.
Although they do not cause fertility problems in all men who have
them, they are the most common cause of male infertility. They typi-
cally lead to increased testicular temperature, even when they are only
on one side. They can cause low sperm counts, low motility, and even
effect sperm function. They are typically diagnosed by physical exam
and treatment is aimed at eradicating the veins. This can be either
through surgery or radiographic methods.
What is the process for in-vitro?

In vitro fertilization is essentially uniting an egg and a sperm in a
dish to promote fertilization. The fertilized egg is then placed back
inside the woman so that implantation can occur. Typically, the woman
is placed on hormonal injections so that she will make multiple eggs
for fertilization.
What is the percentage of infertility being caused by psy-

chological problems?
Male sexual problems are estimated to account for approximately
5 percent of male infertility cases. There is some evidence that psy-
chological problems, including stress, can affect hormonal function.
This, in turn, can have an effect on fertility. Other factors may also
be involved.
359
What drugs are best for hypertension if you are trying to

have a baby?
The only antihypertensives that would have an effect on the male
would be those that would cause difficulties with erection. The phy-
sician monitoring hypertension can select a drug that will have mini-
mal effects.
Does the use of marijuana cause infertility or other tes-

ticular problems?
Yes. Marijuana is a well-known cause of fertility problems. It tends
to cause hormonal problems as well as having a direct effect on the
testicles. This can be with long-term as well as short-term use al-
though short-term use tends to be reversible. However, it is impor-
tant to realize that it takes approximately three months for the
testicles to make sperm. Therefore, even after the marijuana is no
longer used, it may be several months or more before those effects have
been reversed.
What other drugs cause fertility problems?

Many drugs can have an effect on sperm production. Sulfasalazine,
a drug that is used in Crohn disease, is well known to do this. Most
hormonal supplements, including anabolic steroids, as well as other
street drugs, can have an adverse effect on fertility. Antibiotics, alco-
hol, and tobacco all have been shown to have some effects on fertility.
What questions should a patient ask before undergoing a

vasectomy reversal?
The success rate of vasectomy reversal is dependent upon several
factors. Although the time from vasectomy is important, the experi-
ence of the surgeon performing the procedure is also an important
factor. A surgeon should be able to perform both a vasovasostomy as
well as vasoepididymostomy. It is also important that the surgeon uses
an operating microscope and performs reversals on a regular basis.
Furthermore, it is important to find out that individual surgeon’s
success rate, not the success rate quoted in the literature. Finally, the
pregnancy rates are dependent upon female factors as well. There-
fore, women over forty may have a lower pregnancy rate even if the
reversal is technically successful. This information should be readily
shared with the patient prior to undergoing a procedure. However, it
360
Infertility
is also important not to undergo a vasectomy in the first place if you
anticipate wanting to become fertile at some future time.
Do hot baths cause a low sperm count or is that just and

old wives’ tale?
Frequent and regular use of hot tubs can decrease a man’s sperm
count. Having said that, it probably should not be used as a method
of birth control. Couples that are trying to conceive should probably
avoid frequent hot tub use.
What other myths would you like to clear up regarding fer-

tility and possibly men’s sexual health?
One of the oldest myths is that there are no infertile men, only
infertile women. This is obviously not true. Nearly 50 percent of in-
fertility problems involve the male. Furthermore, there is much that
can be done to improve male reproductive health, thus improving the
couple’s chances of conception.
Who should not get a vasectomy?

That is a difficult question—there are some physicians who will
not perform a vasectomy on a young single male or on a man without
children. My feeling is that the patient should be adequately coun-
seled regarding the risks and benefits as well as the possibility of
sperm banking prior to the vasectomy. There are no absolutes in terms
of who should not get a vasectomy. The only other important point is
that the patient’s wife, or partner, is in complete agreement.
I have heard that exposure to toxic chemicals or radiation

can cause infertility. Is this very common?
The number of toxic chemicals in use today that can cause infer-
tility is becoming much smaller. However, we know that exposure to
radiation can certainly have an effect on fertility.
I was here earlier, Please tell what can you do short of in-
vitro? Our salaries will not allow that expense.
Options other than in vitro are dependent upon the cause of infer-
tility, the male and the female factors involved, as well as the sperm
count and motility.
361
Should the man be evaluated prior to in vitro fertilization?

There is good evidence that much of male factor infertility can be
treated. Furthermore, a small but significant percentage of men with
infertility have an underlying medical problem that is discovered
during their evaluation. This can include hormonal problems as well
as testicular cancer, infection, or blockages. Therefore, it is important
that the urologist or male fertility specialist prior to proceeding with
in vitro fertilization evaluate the male partner.
Does smoking or alcohol affect fertility?

Recently several studies have addressed the effects of smoking on
male fertility. There is some very good evidence that smoking can have
an adverse effect on sperm count, motility, and function. It is always
a good idea to quit smoking, particularly when trying to conceive. Al-
cohol is slightly more controversial. Mild to moderate amounts of
alcohol have not been shown to have any effects; however, moderate
to heavy amounts can affect sperm count as well as hormone produc-
tion.
Is infertility often an indicator of cancer?

No. It can be, but this is a rare finding. However, the most com-
mon type of cancer in men of reproductive age is testicular cancer. This
would be discovered during the evaluation of the man.
I’ve read that bike-riders have to be careful what kind of

seat they use as to not damage the testicles. True?
The best evidence regarding bicycle seats pertains to erection, not
fertility. Any seat that causes numbness could potentially damage a
man’s erection. However, there has not been any evidence to show that
fertility is affected.
I still want a baby, and I’m a paralyzed guy who can func-
tion correctly. Any advice?
If natural conception has been unsuccessful, I would seek an evalu-
ation from an urologist including a history, physical exam, and a se-
men analysis. Specific treatment options can then be recommended.
362
Chapter 33
Sexually Transmitted
Diseases (STDs)
Chapter Contents
Section 33.1—Basic Information about STDs ......................... 364
Section 33.2—Chancroid ........................................................... 365
Section 33.3—Chlamydia .......................................................... 368
Section 33.4—Genital Herpes ................................................... 371
Section 33.5—Gonorrhea .......................................................... 375
Section 33.6—Hepatitis B ......................................................... 379
Section 33.7—HIV and AIDS .................................................... 381
Section 33.8—Human Papillomavirus (HPV) ......................... 385
Section 33.9—Pubic Lice (Crabs) ............................................. 390
Section 33.10—Scabies ................................................................ 394
Section 33.11—Syphilis ............................................................... 397
Section 33.12—Trichomoniasis ................................................... 402
363
Section 33.1
Basic Information about STDs

Reprinted from “Sexually Transmitted Diseases (STDs),” National
Institute of Child Health and Human Development, May 25, 2007.
What are sexually transmitted diseases (STDs)?

STDs, also called sexually transmitted infections or STIs, are dis-
eases that you get by having intimate sexual contact, that is, hav-
ing sex (vaginal, oral, or anal intercourse), with someone who already
has the disease. Every year, STDs affect more than thirteen million
people.
What are the different types of STDs?

Researchers have identified more than twenty different kinds of
STDs, which can fall into two main groups:
• STDs caused by bacteria: These diseases can be treated

and often cured with antibiotics. Some bacterial STDs include:
chlamydia, gonorrhea, trichomoniasis, and syphilis.
• STDs caused by viruses: These diseases can be controlled,
but not cured. If you get a viral STD, you will always have it.
Some viral STDs include: human immunodeficiency virus (HIV)/
acquired immunodeficiency syndrome (AIDS), genital herpes,
genital warts, human papillomavirus (HPV), hepatitis B virus,
and cytomegalovirus.
What are the symptoms of STDs?

The symptoms vary among the different types of STDs. Some ex-
amples of common symptoms include the following:
• Unusual discharge from the penis or vagina

• Sores or warts on the genital area
• Burning while urinating
364
Sexually Transmitted Diseases (STDs)
• Itching and redness in the genital area
• Anal itching, soreness, or bleeding
If you are having any of these symptoms or think you might have
an STD, talk to your health care provider.
How can STDs be prevented?

The only way to ensure that you won’t get infected is to not have
sex. This means avoiding all types of intimate sexual contact.
If you are sexually active, you can reduce your risk of getting STDs
by practicing “safe sex.” This means:
• using a condom for vaginal, oral, and anal intercourse—every

time;
• knowing your partner and his/her STD status and health;
• having regular medical check-ups, especially if you have more
than one sexual partner.
Section 33.2
Chancroid
Excerpted from “Chancroid,”
Chancroid is a bacterial disease that is spread only through sexual

contact.
Causes
Chancroid is a sexually transmitted infection caused by a type of
bacteria called Haemophilus ducreyi.
The disease is found mainly in developing and third world coun-
tries. Only a small number of cases are diagnosed in the United States
each year. Most people in the United States diagnosed with chancroid
365
have traveled outside the country to areas where the disease is known
to occur frequently.
Uncircumcised men are at much higher risk than circumcised men
for getting chancroid from an infected partner. Chancroid is a risk
factor for the human immunodeficiency virus (HIV).
Symptoms
Within one day to two weeks after getting chancroid, a person will
get a small bump in the genitals. The bump becomes an ulcer within
a day of its appearance. The ulcer:
• ranges in size from one-eighth inch to two inches across;
• is painful;
• has sharply defined borders;
• has irregular or ragged borders;
• has a base that is covered with a grey or yellowish-grey mate-
rial;
• has a base that bleeds easily if banged or scraped.
About half of infected men have only a single ulcer. Women often
have four or more ulcers. The ulcers appear in specific locations.
Common locations in men are:
• foreskin (prepuce);
• groove behind the head of the penis (coronal sulcus);
• shaft of the penis;
• head of the penis (glans);
• opening of the penis (urethral meatus);
• scrotum.
The ulcer may look like a chancre, the typical sore of primary syphi-
lis.
Approximately half of the people infected with a chancroid will
develop enlarged inguinal lymph nodes, the nodes located in the fold
between the leg and the lower abdomen.
Half of those who have swelling of the inguinal lymph nodes will
progress to a point where the nodes break through the skin, produc-
ing draining abscesses. The swollen lymph nodes and abscesses are
often referred to as buboes.
366
Exams and Tests

Chancroid is diagnosed by looking at the ulcer(s) and checking for
swollen lymph nodes, as well as by getting a culture from the base of
the ulcers. There are no lab tests for chancroid as there are for syphi-
lis.
Treatment
The infection is treated with antibiotics, including azithromycin,
ceftriaxone, ciprofloxacin, and erythromycin. Large lymph node swell-
ings need to be drained, either with a needle or local surgery.
Outlook (Prognosis)
Chancroid can get better on its own. However, some people may
have months of painful ulcers and draining. Antibiotic treatment usu-
ally clears up the lesions quickly with very little scarring.
Possible Complications
Complications include urethral fistulas and scars on the foreskin
of the penis in uncircumcised males. Patients with chancroid should
also be checked for syphilis, HIV, and genital herpes.
Chancroids in persons with HIV may take much longer to heal.
When to Contact a Medical Professional

Call for an appointment with your health care provider if you have
symptoms of chancroid. Also call if you have had sexual contact with
a person known to have any STD, or if you have engaged in high-risk
sexual practices.
Prevention
Chancroid is a bacterial infection that is spread by sexual contact
with an infected person. Although not having sex is the only sure pre-
vention, safe sex practices are helpful for preventing the spread of
chancroid.
Having sexual relations with only one partner who you know to
be disease-free is the safest and most practical “safe sex” method.
Condoms provide very good protection from the spread of most sexu-
ally transmitted diseases when used properly and consistently.
367
Section 33.3
Chlamydia
Excerpted from “Chlamydia,” Centers for
Disease Control and Prevention, December 20, 2007.
What is chlamydia?
Chlamydia is a common sexually transmitted disease (STD) caused
by the bacterium Chlamydia trachomatis, which can damage a wom-
an’s reproductive organs. Even though symptoms of chlamydia are
usually mild or absent, serious complications that cause irreversible
damage, including infertility, can occur “silently” before a woman ever
recognizes a problem. Chlamydia also can cause discharge from the
penis of an infected man.
How common is chlamydia?

Chlamydia is the most frequently reported bacterial sexually trans-
mitted disease in the United States.
How do people get chlamydia?

Chlamydia can be transmitted during vaginal, anal, or oral sex.
Chlamydia can also be passed from an infected mother to her baby
during vaginal childbirth.
Any sexually active person can be infected with chlamydia. The
greater the number of sex partners, the greater the risk of infection.
Because the cervix (opening to the uterus) of teenage girls and young
women is not fully matured and is probably more susceptible to in-
fection, they are at particularly high risk for infection if sexually ac-
tive. Since chlamydia can be transmitted by oral or anal sex, men who
have sex with men are also at risk for chlamydial infection.
What are the symptoms of chlamydia?

Chlamydia is known as a “silent” disease because about three
quarters of infected women and about half of infected men have no
368
symptoms. If symptoms do occur, they usually appear within one to
three weeks after exposure.
Men with signs or symptoms might have a discharge from their
penis or a burning sensation when urinating. Men might also have
burning and itching around the opening of the penis. Pain and swell-
ing in the testicles are uncommon.
Men or women who have receptive anal intercourse may acquire
chlamydial infection in the rectum, which can cause rectal pain, dis-
charge, or bleeding. Chlamydia can also be found in the throats of
women and men having oral sex with an infected partner.
What complications can result from untreated chlamydia?

If untreated, chlamydial infections can progress to serious repro-
ductive and other health problems with both short-term and long-term
consequences. Like the disease itself, the damage that chlamydia
causes is often “silent.”
To help prevent the serious consequences of chlamydia, screening
at least annually for chlamydia is recommended for all sexually ac-
tive women age twenty-five years and younger. An annual screening
test also is recommended for older women with risk factors for chlamy-
dia (a new sex partner or multiple sex partners). All pregnant women
should have a screening test for chlamydia.
Complications among men are rare. Infection sometimes spreads
to the epididymis (the tube that carries sperm from the testis), caus-
ing pain, fever, and, rarely, sterility.
Rarely, genital chlamydial infection can cause arthritis that can
be accompanied by skin lesions and inflammation of the eye and ure-
thra (Reiter syndrome).
How does chlamydia affect a pregnant woman and her baby?

In pregnant women, there is some evidence that untreated chlamy-
dial infections can lead to premature delivery. Babies who are born
to infected mothers can get chlamydial infections in their eyes and
respiratory tracts. Chlamydia is a leading cause of early infant pneu-
monia and conjunctivitis (pink eye) in newborns.
How is chlamydia diagnosed?

There are laboratory tests to diagnose chlamydia. Some can be
performed on urine; other tests require that a specimen be collected
from a site such as the penis or cervix.
369
What is the treatment for chlamydia?

Chlamydia can be easily treated and cured with antibiotics. A single
dose of azithromycin or a week of doxycycline (twice daily) are the most
commonly used treatments. HIV-positive persons with chlamydia
should receive the same treatment as those who are HIV negative.
All sex partners should be evaluated, tested, and treated. Persons
with chlamydia should abstain from sexual intercourse until they and
their sex partners have completed treatment; otherwise re-infection
is possible.
Women whose sex partners have not been appropriately treated
are at high risk for re-infection. Having multiple infections increases
a woman’s risk of serious reproductive health complications, includ-
ing infertility. Retesting should be encouraged for women three to four
months after treatment. This is especially true if a woman does not
know if her sex partner received treatment.
How can chlamydia be prevented?

The surest way to avoid transmission of STDs is to abstain from
sexual contact, or to be in a long-term mutually monogamous relation-
ship with a partner who has been tested and is known to be uninfected.
Latex male condoms, when used consistently and correctly, can
reduce the risk of transmission of chlamydia.
Any genital symptoms such as an unusual sore, discharge with
odor, burning during urination, or bleeding between menstrual cycles
could mean an STD infection. If a woman has any of these symptoms,
she should stop having sex and consult a health care provider imme-
diately. Treating STDs early can prevent PID. Women who are told
they have an STD and are treated for it should notify all of their re-
cent sex partners (sex partners within the preceding sixty days) so
they can see a health care provider and be evaluated for STDs. Sexual
activity should not resume until all sex partners have been examined
and, if necessary, treated.
Sources
Centers for Disease Control and Prevention. Sexually Transmitted
Diseases Treatment Guidelines 2006. MMWR 2006;55(No. RR-11).
Disease Surveillance, 2006. Atlanta, GA: U.S. Department of Health
and Human Services, November 2007.
370
SD Datta et al. Gonorrhea and chlamydia in the United States among
persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med. 2007:
147:89–96.
Stamm W E. Chlamydia trachomatis infections of the adult. In: K.
Holmes, P. Sparling, P. Mardh et al (eds). Sexually Transmitted Dis-
eases, 3rd edition. New York: McGraw-Hill, 1999, 407–22.
Weinstock H, Berman S, Cates W. Sexually transmitted disease among
American youth: Incidence and prevalence estimates, 2000. Perspec-
tives on Sexual and Reproductive Health 2004; 36: 6–10.
Section 33.4
Genital Herpes
Reprinted from “Genital Herpes,” Centers for
Disease Control and Prevention, January 4, 2008.
What is genital herpes?

Genital herpes is a sexually transmitted disease (STD) caused by
the herpes simplex viruses type 1 (HSV-1) or type 2 (HSV-2). Most
genital herpes is caused by HSV-2. Most individuals have no or only
minimal signs or symptoms from HSV-1 or HSV-2 infection. When
signs do occur, they typically appear as one or more blisters on or
around the genitals or rectum. The blisters break, leaving tender ul-
cers (sores) that may take two to four weeks to heal the first time they
occur. Typically, another outbreak can appear weeks or months after
the first, but it almost always is less severe and shorter than the first
outbreak. Although the infection can stay in the body indefinitely, the
number of outbreaks tends to decrease over a period of years.
How common is genital herpes?

Results of a nationally representative study show that genital her-
pes infection is common in the United States. Nationwide, at least forty-
five million people ages twelve and older, or one out of five adolescents
371
and adults, have had genital HSV infection. Over the past decade, the
percentage of Americans with genital herpes infection in the United
States has decreased.
Genital HSV-2 infection is more common in women (approximately
one out of four women) than in men (almost one out of eight). This
may be due to male-to-female transmission being more likely than
female-to-male transmission.
How do people get genital herpes?

HSV-1 and HSV-2 can be found in and released from the sores that
the viruses cause, but they also are released between outbreaks from skin
that does not appear to have a sore. Generally, a person can only get HSV-
2 infection during sexual contact with someone who has a genital HSV-
2 infection. Transmission can occur from an infected partner who does
not have a visible sore and may not know that he or she is infected.
HSV-1 can cause genital herpes, but it more commonly causes in-
fections of the mouth and lips, so-called fever blisters. HSV-1 infec-
tion of the genitals can be caused by oral-genital or genital-genital
contact with a person who has HSV-1 infection. Genital HSV-1 out-
breaks recur less regularly than genital HSV-2 outbreaks.
What are the signs and symptoms of genital herpes?

Most people infected with HSV-2 are not aware of their infection. How-
ever, if signs and symptoms occur during the first outbreak, they can be
quite pronounced. The first outbreak usually occurs within two weeks af-
ter the virus is transmitted, and the sores typically heal within two to four
weeks. Other signs and symptoms during the primary episode may include
a second crop of sores, and flu-like symptoms, including fever and swollen
glands. However, most individuals with HSV-2 infection never have sores,
or they have very mild signs that they do not even notice or that they mis-
take for insect bites or another skin condition.
People diagnosed with a first episode of genital herpes can expect
to have several (typically four or five) outbreaks (symptomatic recur-
rences) within a year. Over time these recurrences usually decrease
in frequency. It is possible that a person becomes aware of the “first
episode” years after the infection is acquired.
What are the complications of genital herpes?

Genital herpes can cause recurrent painful genital sores in many
adults, and herpes infection can be severe in people with suppressed
372
immune systems. Regardless of severity of symptoms, genital herpes
frequently causes psychological distress in people who know they are
infected.
In addition, genital HSV can lead to potentially fatal infections in
babies. It is important that women avoid contracting herpes during preg-
nancy because a newly acquired infection during late pregnancy poses
a greater risk of transmission to the baby. If a woman has active geni-
tal herpes at delivery, a cesarean delivery is usually performed. Fortu-
nately, infection of a baby from a woman with herpes infection is rare.
Herpes may play a role in the spread of human immunodeficiency
virus (HIV), the virus that causes acquired immunodeficiency syn-
drome (AIDS). Herpes can make people more susceptible to HIV in-
fection, and it can make HIV-infected individuals more infectious.
How is genital herpes diagnosed?

The signs and symptoms associated with HSV-2 can vary greatly.
Health care providers can diagnose genital herpes by visual inspec-
tion if the outbreak is typical, and by taking a sample from the sore(s)
and testing it in a laboratory. HSV infections can be diagnosed be-
tween outbreaks by the use of a blood test. Blood tests, which detect
antibodies to HSV-1 or HSV-2 infection, can be helpful, although the
results are not always clear-cut.
Is there a treatment for herpes?

There is no treatment that can cure herpes, but antiviral medica-
tions can shorten and prevent outbreaks during the period of time the
person takes the medication. In addition, daily suppressive therapy
for symptomatic herpes can reduce transmission to partners.
How can herpes be prevented?

The surest way to avoid transmission of sexually transmitted dis-
eases, including genital herpes, is to abstain from sexual contact, or
to be in a long-term mutually monogamous relationship with a part-
ner who has been tested and is known to be uninfected.
Genital ulcer diseases can occur in both male and female genital
areas that are covered or protected by a latex condom, as well as in
areas that are not covered. Correct and consistent use of latex condoms
can reduce the risk of genital herpes.
Persons with herpes should abstain from sexual activity with
uninfected partners when lesions or other symptoms of herpes are
373
present. It is important to know that even if a person does not have
any symptoms he or she can still infect sex partners. Sex partners of
infected persons should be advised that they may become infected and
they should use condoms to reduce the risk. Sex partners can seek
testing to determine if they are infected with HSV. A positive HSV-2
blood test most likely indicates a genital herpes infection.
Sources
Diseases Treatment Guidelines 2006. MMWR 2006; 55(no. RR-11).
Corey L, Wald A. Genital herpes. In: Holmes KK, Sparling PF, Mardh
P et al (eds). Sexually Transmitted Disease, 3rd Edition. New York:
McGraw-Hill, 1999, p. 285–312.
Corey L, Wald A, Patel R et al. Once-daily valacyclovir to reduce the
risk of transmission of genital herpes. New England Journal of Medi-
cine 2004; 350:11–20.
Wald A, Langenberg AGM, Link K, et al. Effect of condoms on reduc-
ing the transmission of herpes simplex virus type 2 from men to
women. JAMA 2001;285: 3100–3106.
Wald A, Link K. Risk of human immunodeficiency virus infection in
herpes simplex virus type 2–seropositive persons: A meta-analysis.
J Infect Dis 2002; 185: 45–52.
Weinstock H, Berman S, Cates W. Sexually transmitted diseases
among American youth: Incidence and prevalence estimates, 2000.
Perspectives on Sexual and Reproductive Health 2004; 36:6–10.
Xu F, Sternberg M, Kottiri B, McQuillan G, Lee F, Nahmias A, Berman
S, Markowitz L. National trends in herpes simplex virus type 1 and
type 2 in the United States: Data from the National Health and Nu-
trition Examination Survey (NHANES). JAMA 2006; Vol 296: 964–
73.
374
Section 33.5
Gonorrhea
Excerpted from “Gonorrhea,” Centers for
Disease Control and Prevention, February 28, 2008.
What is gonorrhea?
Gonorrhea is a sexually transmitted disease (STD). Gonorrhea is
caused by Neisseria gonorrhoeae, a bacterium that can grow and
multiply easily in the warm, moist areas of the reproductive tract,
including the cervix (opening to the womb), uterus (womb), and fallo-
pian tubes (egg canals) in women, and in the urethra (urine canal) in
women and men. The bacterium can also grow in the mouth, throat,
eyes, and anus.
How common is gonorrhea?

Gonorrhea is a very common infectious disease. The Centers for
Disease Control and Prevention (CDC) estimates that more than
700,000 persons in the United States get new gonorrheal infections
each year.
How do people get gonorrhea?

Gonorrhea is spread through contact with the penis, vagina, mouth,
or anus. Ejaculation does not have to occur for gonorrhea to be trans-
mitted or acquired. Gonorrhea can also be spread from mother to baby
during delivery.
People who have had gonorrhea and received treatment may get
infected again if they have sexual contact with a person infected with
gonorrhea.
Who is at risk for gonorrhea?

Any sexually active person can be infected with gonorrhea. In the
United States, the highest reported rates of infection are among sexu-
ally active teenagers, young adults, and African Americans.
375
What are the signs and symptoms of gonorrhea?

Some men with gonorrhea may have no symptoms at all. However,
some men have signs or symptoms that appear two to five days after
infection; symptoms can take as long as thirty days to appear. Symp-
toms and signs include a burning sensation when urinating, or a
white, yellow, or green discharge from the penis. Sometimes men with
gonorrhea get painful or swollen testicles.
In women, the symptoms of gonorrhea are often mild, but most
women who are infected have no symptoms. Even when a woman has
symptoms, they can be so nonspecific as to be mistaken for a bladder
or vaginal infection. The initial symptoms and signs in women include
a painful or burning sensation when urinating, increased vaginal dis-
charge, or vaginal bleeding between periods. Women with gonorrhea
are at risk of developing serious complications from the infection, re-
gardless of the presence or severity of symptoms.
Symptoms of rectal infection in both men and women may include
discharge, anal itching, soreness, bleeding, or painful bowel move-
ments. Rectal infection also may cause no symptoms. Infections in the
throat may cause a sore throat but usually cause no symptoms.
What are the complications of gonorrhea?

Untreated gonorrhea can cause serious and permanent health prob-
lems in both women and men.
In women, gonorrhea is a common cause of pelvic inflammatory
disease (PID). About one million women each year in the United States
develop PID. The symptoms may be quite mild or can be very severe
and can include abdominal pain and fever. PID can lead to internal
abscesses (pus-filled “pockets” that are hard to cure) and long-lasting,
chronic pelvic pain. PID can damage the fallopian tubes enough to
cause infertility or increase the risk of ectopic pregnancy. Ectopic preg-
nancy is a life-threatening condition in which a fertilized egg grows
outside the uterus, usually in a fallopian tube.
In men, gonorrhea can cause epididymitis, a painful condition of
the ducts attached to the testicles that may lead to infertility if left
untreated.
Gonorrhea can spread to the blood or joints. This condition can be
life threatening. In addition, people with gonorrhea can more easily
contract human immunodeficiency virus (HIV), the virus that causes
acquired immunodeficiency syndrome (AIDS). HIV-infected people
with gonorrhea can transmit HIV more easily to someone else than
if they did not have gonorrhea.
376
How does gonorrhea affect a pregnant woman and her baby?

If a pregnant woman has gonorrhea, she may give the infection to
her baby as the baby passes through the birth canal during delivery.
This can cause blindness, joint infection, or a life-threatening blood
infection in the baby. Treatment of gonorrhea as soon as it is detected
in pregnant women will reduce the risk of these complications. Preg-
nant women should consult a health care provider for appropriate
examination, testing, and treatment, as necessary.
How is gonorrhea diagnosed?

Several laboratory tests are available to diagnose gonorrhea. A doc-
tor or nurse can obtain a sample for testing from the parts of the body
likely to be infected (cervix, urethra, rectum, or throat) and send the
sample to a laboratory for analysis. Gonorrhea that is present in the
cervix or urethra can be diagnosed in a laboratory by testing a urine
sample. A quick laboratory test for gonorrhea that can be done in some
clinics or doctor’s offices is a Gram stain. A Gram stain of a sample from
a urethra or a cervix allows the doctor to see the gonorrhea bacterium
under a microscope. This test works better for men than for women.
What is the treatment for gonorrhea?

Several antibiotics can successfully cure gonorrhea in adolescents
and adults. However, drug-resistant strains of gonorrhea are increas-
ing in many areas of the world, including the United States, and suc-
cessful treatment of gonorrhea is becoming more difficult. Because
many people with gonorrhea also have chlamydia, another STD, an-
tibiotics for both infections are usually given together. Persons with
gonorrhea should be tested for other STDs.
It is important to take all of the medication prescribed to cure gon-
orrhea. Although medication will stop the infection, it will not repair
any permanent damage done by the disease. People who have had gon-
orrhea and have been treated can get the disease again if they have
sexual contact with persons infected with gonorrhea. If a person’s
symptoms continue even after receiving treatment, he or she should
return to a doctor to be reevaluated.
How can gonorrhea be prevented?

The surest way to avoid transmission of STDs is to abstain from
sexual intercourse, or to be in a long-term mutually monogamous
377
relationship with a partner who has been tested and is known to be
uninfected.
Latex condoms, when used consistently and correctly, can reduce
the risk of transmission of gonorrhea.
Any genital symptoms such as discharge or burning during uri-
nation or unusual sore or rash should be a signal to stop having sex
and to see a doctor immediately. If a person has been diagnosed and
treated for gonorrhea, he or she should notify all recent sex partners
so they can see a health care provider and be treated. This will re-
duce the risk that the sex partners will develop serious complications
from gonorrhea and will also reduce the person’s risk of becoming re-
infected. The person and all of his or her sex partners must avoid sex
until they have completed their treatment for gonorrhea.
Sources
Diseases Treatment Guidelines, 2006. MMWR 2006; 55 (No. RR-11).
www.cdc.gov/std/treatment
and Human Services, November 2007.
Hook EW III and Handsfield HH. Gonococcal infections in the adult.
In: K. Holmes, P. Sparling, P. Markh et al (eds). Sexually Transmitted
Diseases, 3rd Edition. New York: McGraw-Hill, 1999, 451–66.
378
Section 33.6
Hepatitis B
“Hepatitis B,” April 2007, reprinted with permission from www.kidshealth
.org. Copyright © 2007 The Nemours Foundation. This information was
provided by KidsHealth, one of the largest resources online for medically
reviewed health information written for parents, kids, and teens. For more
articles like this one, visit www.KidsHealth.org, or www.TeensHealth.org.
What is it?
Hepatitis (pronounced: hep-uh-tie-tiss) is a disease of the liver. It
is usually caused by a virus, although it can also be caused by long-
term overuse of alcohol or other toxins (poisons).
Although there are several different types of hepatitis, hepatitis
B is a type that can move from one person to another through blood
and other bodily fluids. It can be transmitted through sexual inter-
course and through needles—such as those shared by intravenous
drug or steroid users who have the virus, or tattoo needles that haven’t
been properly sterilized. A pregnant woman can also pass hepatitis
B to her unborn baby. You cannot catch hepatitis B from an object,
such as a toilet seat.
What are the symptoms?

Someone with hepatitis B may have symptoms similar to those
caused by other viral infections, such as the flu—for example, tired-
ness, nausea, loss of appetite, mild fever, and vomiting—as well as ab-
dominal pain or pain underneath the right ribcage where the liver is.
Hepatitis B can also cause jaundice, which is a yellowing of the skin
and the whites of the eyes, and may cause the urine to appear brown-
ish.
How long until symptoms appear?

Someone who has been exposed to hepatitis B may have symptoms
one to four months later. Some people with hepatitis B don’t notice symp-
toms until they become quite severe. Some have few or no symptoms,
379
but even someone who doesn’t notice any symptoms can still transmit
the disease to others. Some people carry the virus in their bodies and
are contagious for the rest of their lives.
What can happen?

Hepatitis B can be very dangerous to a person’s health, leading to
liver damage and an increased risk of liver cancer. Of babies born to
women who have the hepatitis B virus, 90 percent will have the vi-
rus unless they receive a special immune injection and the first dose
of hepatitis B vaccine at birth.
How is it prevented?
Because hepatitis B can easily be transmitted through blood and
most body fluids, it can be prevented by:
• abstaining from sex (not having oral, vaginal, or anal sex);
• always using latex condoms for all types of sexual intercourse;
• avoiding contact with an infected person’s blood;
• not using intravenous drugs or sharing any drug paraphernalia;
• not sharing things like toothbrushes or razors.
Tattoo parlors sometimes reuse needles without properly steriliz-

ing them, so be sure to research and choose tattoo and piercing pro-
viders carefully.
To help prevent the spread of hepatitis B, health care profession-
als wear gloves at all times when in contact with blood or body flu-
ids, and are usually required to be immunized against the hepatitis
B virus.
There is an immunization (vaccine) against hepatitis B. The im-
munization is given as a series of three shots over a six-month pe-
riod. Newborn babies in the United States now routinely receive this
immunization series. Teens who see their health care provider for
yearly exams are also likely to be given the hepatitis B immuniza-
tion if they haven’t had it before. Immunization programs have been
responsible for a significant drop in the number of cases of hepatitis
B among teens over the past ten years.
Sometimes, if someone has been recently exposed to the hepatitis B
virus, a doctor may recommend a shot of immune globulin containing
antibodies against the virus to try to prevent the person from coming
380
down with the disease. For this reason, it’s especially important to see
a doctor quickly after any possible exposure to the virus.
How is it treated?
If you think you may have hepatitis B or if you have been intimate
with someone who may have hepatitis B, you need to see your doctor
or gynecologist, who will do blood tests. Let the doctor know the best
way to reach you confidentially with any test results.
If your doctor diagnoses hepatitis B, you may get medicines to help
fight it. Sometimes, people need to be hospitalized for a little while if
they are too sick to eat or drink. Most people with hepatitis B feel
better within six months.
Section 33.7
HIV and AIDS

Excerpted from “HIV and AIDS: Are You at Risk?”
Centers for Disease Control and Prevention, August 1, 2007.
What is HIV and how can I get it?

HIV—the human immunodeficiency virus—is a virus that kills
your body’s “CD4 cells.” CD4 cells (also called T-helper cells) help your
body fight off infection and disease. HIV can be passed from person
to person if someone with HIV infection has sex with or shares drug
injection needles with another person. It also can be passed from a
mother to her baby when she is pregnant, when she delivers the baby,
or if she breastfeeds her baby.
What is AIDS?
AIDS—the acquired immunodeficiency syndrome—is a disease you
get when HIV destroys your body’s immune system. Normally, your
immune system helps you fight off illness. When your immune sys-
tem fails you can become very sick and can die.
381
What do I need to know about HIV?

The first cases of AIDS were identified in the United States in 1981,
but AIDS most likely existed here and in other parts of the world for
many years before that time. In 1984 scientists proved that HIV
causes AIDS.
Anyone can get HIV. The most important thing to know is how you
can get the virus.
You can get HIV in the following ways:
• By having unprotected sex—sex without a condom—with some-

one who has HIV. The virus can be in an infected person’s blood,
semen, or vaginal secretions and can enter your body through
tiny cuts or sores in your skin, or in the lining of your vagina,
penis, rectum, or mouth.
• By sharing a needle and syringe to inject drugs or sharing drug
equipment used to prepare drugs for injection with someone who
has HIV.
• From a blood transfusion or blood clotting factor that you got
before 1985. (But today it is unlikely you could get infected that
way because all blood in the United States has been tested for
HIV since 1985.)
Babies born to women with HIV also can become infected during
pregnancy, birth, or breastfeeding.
You cannot get HIV in the following ways:
• By working with or being around someone who has HIV

• From sweat, spit, tears, clothes, drinking fountains, phones,
toilet seats, or through everyday things like sharing a meal
• From insect bites or stings
• From donating blood
• From a closed-mouth kiss (but there is a very small chance of
getting it from open-mouthed or “French” kissing with an infected
person because of possible blood contact)
How can I protect myself?

Don’t share needles and syringes used to inject drugs, steroids,
vitamins, or for tattooing or body piercing. Also, don’t share equipment
382
(“works”) used to prepare drugs to be injected. Many people have been
infected with HIV, hepatitis, and other germs this way. Germs from
an infected person can stay in a needle and then be injected directly
into the next person who uses the needle.
eases is to abstain from sexual intercourse, or to be in a long-term
mutually monogamous relationship with a partner who has been
tested and you know is uninfected.
For persons whose sexual behaviors place them at risk for STDs,
correct and consistent use of the male latex condom can reduce the
risk of STD transmission. However, no protective method is 100 per-
cent effective, and condom use cannot guarantee absolute protection
against any STD. The more sex partners you have, the greater your
chances are of getting HIV or other diseases passed through sex.
Condoms used with a lubricant are less likely to break. However,
condoms with the spermicide nonoxynol-9 are not recommended for
STD/HIV prevention. Condoms must be used correctly and consis-
tently to be effective and protective. Incorrect use can lead to condom
slippage or breakage, thus diminishing the protective effect. Incon-
sistent use, e.g., failure to use condoms with every act of intercourse,
can result in STD transmission because transmission can occur with
a single act of intercourse.
Don’t share razors or toothbrushes because they may have the
blood of another person on them.
If you are pregnant or think you might be soon, talk to a doctor or
your local health department about being tested for HIV. If you have
HIV, drug treatments are available to help you and they can reduce
the chance of passing HIV to your baby.
How do I know if I have HIV or AIDS?

You might have HIV and still feel perfectly healthy. The only way
to know for sure if you are infected is to be tested. Talk with a knowl-
edgeable health care provider or counselor both before and after you
are tested. You can go to your doctor or health department for test-
ing.
Your doctor or health care provider can give you a confidential HIV
test. The information on your HIV test and test results are confiden-
tial, as is your other medical information. This means it can be shared
only with people authorized to see your medical records. You can ask
your doctor, health care provider, or HIV counselor at the place you
are tested to explain who can obtain this information. For example,
383
you may want to ask whether your insurance company could find out
your HIV status if you make a claim for health insurance benefits or
apply for life insurance or disability insurance.
The Centers for Disease Control and Prevention (CDC) recom-
mends that everyone know their HIV status. How often you should
an HIV test depends on your circumstances. If you have never been
tested for HIV, you should be tested. CDC recommends being tested
at least once a year if you do things that can transmit HIV infection,
such as the following:
• Injecting drugs or steroids with used injection equipment
• Having sex for money or drugs
• Having sex with an HIV-infected person
• Having more than one sex partner since your HIV test
• Having a sex partner who has had other sex partners since your
last HIV test
In many states, you can be tested anonymously. These tests are

usually given at special places known as anonymous testing sites.
When you get an anonymous HIV test, the testing site records only a
number or code with the test result, not your name. A counselor gives
you this number at the time your blood, saliva, or urine is taken for
the test, then you return to the testing site (or perhaps call the test-
ing site, for example with home collection kits) and give them your
number or code to learn the results of your test.
If you have been tested for HIV and the result is negative and
you never do things that might transmit HIV infection, then you and
your health care provider can decide whether you need to get tested
again.
What can I do if the test shows I have HIV?

Although HIV is a very serious infection, many people with HIV
and AIDS are living longer, healthier lives today, thanks to new and
effective treatments. It is very important to make sure you have a
doctor who knows how to treat HIV. If you don’t know which doctor
to use, talk with a health care professional or trained HIV counselor.
If you are pregnant or are planning to become pregnant, this is espe-
cially important.
There also are other things you can do for yourself to stay healthy.
Here are a few:
384
• Follow your doctor’s instructions. Keep your appointments. Your
doctor may prescribe medicine for you. Take the medicine just
the way he or she tells you to because taking only some of your
medicine gives your HIV infection more chance to grow.
• Get immunizations (shots) to prevent infections such as pneu-
monia and flu. Your doctor will tell you when to get these shots.
• If you smoke or if you use drugs not prescribed by your doctor,
quit.
• Eat healthy foods. This will help keep you strong, keep your
energy and weight up, and help your body protect itself.
• Exercise regularly to stay strong and fit.
• Get enough sleep and rest.
Section 33.8
Human Papillomavirus (HPV)

Excerpted from “HPV and Men,” Centers for
Disease Control and Prevention, April 3, 2008.
Genital human papillomavirus (HPV) is a common virus. Most

sexually active people in the United States (U.S.) will have HPV at
some time in their lives. There are more than forty types of HPV that
are passed on during sex. These types can infect the genital areas of
men, including the skin on and around the penis or anus.
What are the health problems caused by HPV in men?

Most men who get HPV (of any type) never develop any symptoms
or health problems. But some types of HPV can cause genital warts.
Other types can cause penile cancer or anal cancer. The types of HPV
that can cause genital warts are not the same as the types that can
cause penile or anal cancer. Anal cancer is not the same as colorectal
cancer. Colorectal cancer is more common than anal cancer, but it is
not caused by HPV.
385
How common are HPV-related health problems in men?

About 1 percent of sexually active men in the United States have
genital warts at any one time.
Penile cancer is rare, especially in circumcised men. In the United
States, it affects about 1 in every 100,000 men. The American Can-
cer Society (ACS) estimated that about 1,530 men would be diagnosed
with penile cancer in the United States in 2006.
Anal cancer is also uncommon—especially in men with healthy
immune systems. According to the ACS, about 1,900 men will be di-
agnosed with anal cancer in the United States in 2007.
Some men are more likely to develop HPV-related diseases than
others:
• Gay and bisexual men are seventeen times more likely to de-
velop anal cancer than heterosexual men.
• Men with weak immune systems, including those who have hu-
man immunodeficiency virus (HIV), are more likely than other
men to develop anal cancer. Men with HIV are also more likely
to get severe cases of genital warts that are hard to treat.
What are the signs and symptoms?

Among men who do develop health problems, these are some of the
signs to look for.
Signs of genital warts are as follows:
• One or more growths on the penis, testicles, groin, thighs, or anus.

• Warts may be raised, flat, or cauliflower-shaped. They usually
do not hurt.
• Warts may appear within weeks or months after sexual contact
with an infected person.
Signs and symptoms of anal cancer are as follows:

• Sometimes there are no signs or symptoms.
• Anal bleeding, pain, itching, or discharge.
• Swollen lymph nodes in the anal or groin area.
• Changes in bowel habits or the shape of your stool.
Signs of penile cancer are as follows:
386
• First signs: changes in color, skin thickening, or a build-up of
tissue on the penis.
• Later signs: a growth or sore on the penis. It is usually painless,
but in some cases, the sore may be painful and bleed.
• There may be no symptoms until the cancer is quite advanced.
How do men get HPV?

HPV is passed on through genital contact—most often during vagi-
nal and anal sex. Since HPV usually causes no symptoms, most men
and women can get HPV—and pass it on—without realizing it. People
can have HPV even if years have passed since they had sex.
Is there a test for HPV in men?

Currently, there is no test designed or approved to find HPV in men.
The only approved HPV test on the market is for women, for use as
part of cervical cancer screening. There is no general test for men or
women to check one’s overall “HPV status.” But HPV usually goes away
on its own, without causing health problems. So an HPV infection that
is found today will most likely not be there a year or two from now.
Remember, HPV is very common in men and women. Most men with
HPV will never develop health problems from it. Finding out if you have
HPV is not as important as finding out if you have the diseases that it
can cause. Scientists are still studying how best to screen for penile and
anal cancers in men who may be at highest risk for those diseases.
Is there a test to find genital warts?

Most of the time, you can see genital warts. Some doctors may use
a vinegar solution to help find flat warts—but this test can sometimes
wrongly identify normal skin as a wart.
Is there a test to screen for HPV-related cancers in men?

Screening tests can find early signs of disease in people who are
not yet sick. Screening tests for penile or anal cancer are not widely
recommended.
Some experts recommend yearly anal Pap tests for gay, bisexual, and
HIV-positive men, since anal cancer is more common in these groups.
This test can find abnormal cells in the anus that could turn into can-
cer over time. If abnormal cells are found, they can be removed. The
387
Centers for Disease Control and Prevention (CDC) does not recommend
anal Pap tests because there is not enough research to show that re-
moving abnormal anal cells actually prevents anal cancer from devel-
oping in the future. More studies are needed to understand if anal Pap
tests and treatment of abnormal cells prevent anal cancer in men.
You can check for any abnormalities on your penis, scrotum, or
around the anus. See your doctor if you find warts, blisters, sores, ul-
cers, white patches, or other abnormal areas on your penis—even if
they do not hurt.
Is there a treatment or cure for HPV?

There is no treatment or cure for HPV. But there are ways to treat
the health problems caused by HPV in men.
Genital warts can be treated with medicine, removed (surgery), or
frozen off. Some of these treatments involve a visit to the doctor. Oth-
ers can be treated at home by the patient himself. No one treatment
is better than another. But warts often come back within a few months
after treatment—so several treatments may be needed. Treating geni-
tal warts may not necessarily lower a man’s chances of passing HPV
on to his sex partner. Because of this, some men choose not to treat
genital warts. If they are not treated, genital warts may go away on
their own, stay the same, or grow (in size or number). They will not
turn into cancer or threaten your health.
Penile and anal cancers can be treated with new forms of surgery,
radiation therapy, and chemotherapy. Often, two or more of these
treatments are used together. Patients should decide with their doc-
tors which treatments are best for them.
Are there ways to lower my chances of getting HPV?

Because HPV is so common and usually invisible, the only sure way
to prevent it is not to have sex. Even people with only one lifetime
sex partner can get HPV, if their partner was infected with HPV.
Condoms (used all the time and the right way) may lower your chances
of passing HPV to a partner or developing HPV-related diseases. But
HPV can infect areas that are not covered by a condom—so condoms
may not fully protect against HPV.
I heard about a new HPV vaccine—can it help me?

The new HPV vaccine was developed to protect against most cer-
vical cancers and genital warts. At this point, it is licensed to be used
388
only in girls and women, ages nine to twenty-six years. Studies are
now being done to find out if the vaccine is also safe in men, and if it
can protect them against genital warts and certain penile and anal
cancers. The U.S. Food and Drug Administration (FDA) will consider
licensing the vaccine for boys and men if there is proof that it is safe
and effective for them.
I just found out that my partner has HPV. What does it

mean for my health?
Partners usually share HPV. If you have been with your partner
for a long time, you probably have HPV already. Most sexually active
adults will have HPV at some time in their lives. Men with healthy
immune systems rarely develop health problems from HPV. But you
should check regularly for any abnormalities on your penis. If you have
a weak immune system or HIV, ask your doctor about checking for
anal and penile cancers.
If your partner is new, condoms may lower your chances of getting
HPV or developing HPV-related diseases. But not having sex is the
only sure way to avoid HPV.
Sources
American Cancer Society (ACS). Detailed Guide: Anal Cancer. What
are the Key Statistics about Anal Cancer?
ACS. Detailed Guide: Penile Cancer. What are the Key Statistics about
Penile Cancer?
ACS. Detailed Guide: Cervical Cancer. What are the Key Statistics
about Cervical Cancer?
Diseases Treatment Guidelines 2006. MMWR 2006;55(no. RR-11).
Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural his-
tory of cervicovaginal papilloma virus infection in young women. N
Engl J Med 1998;338:423–28.
Koutsky LA, Kiviat NB. Genital human papillomavirus. In: K. Holmes,
P. Sparling, P. Mardh et al (eds). Sexually Transmitted Diseases, 3rd
edition. New York: McGraw-Hill, 1999, p. 347–59.
Kiviat NB, Koutsky LA, Paavonen J. Cervical neoplasia and other STD-
related genital tract neoplasias. In: K. Holmes, P. Sparling, P. Mardh
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et al (eds). Sexually Transmitted Diseases, 3rd edition. New York:
McGraw-Hill, 1999, p. 811–31.
Myers ER, McCrory DC, Nanda K, Bastian L, Matchar DB. Math-
ematical model for the natural history of human papillomavirus in-
fection and cervical carcinogenesis. American Journal of Epidemiology
2000; 151(12):1158–71.
Watts DH, Brunham RC. Sexually transmitted diseases, including
HIV infection in pregnancy. In: K. Holmes, P. Sparling, P. Mardh et al
(eds). Sexually Transmitted Diseases, 3rd edition. New York: McGraw-
Hill, 1999, 1089–1132.
Section 33.9
Pubic Lice (Crabs)

“Facts about Pubic Lice” is reprinted from “Pubic ‘Crab’ Lice Fact
Sheet” and “Treatment” is reprinted from “Pubic ‘Crab’ Lice Treatment,”
Centers for Disease Control and Prevention, May 16, 2008.
Facts about Pubic Lice

What are pubic lice?
Also called crab lice or “crabs,” pubic lice are parasitic insects found
primarily in the pubic or genital area of humans. Pubic lice infesta-
tion is found worldwide and occurs in all races, ethnic groups, and
levels of society.
What do pubic lice look like?

Pubic lice have forms: the egg (also called a nit), the nymph, and
the adult.
390
Nit: Nits are lice eggs. They can be hard to see and are found firmly
attached to the hair shaft. They are oval and usually yellow to white.
Pubic lice nits take about six to ten days to hatch.
Nymph: The nymph is an immature louse that hatches from the

nit (egg). A nymph looks like an adult pubic louse but it is smaller.
Pubic lice nymphs take about two to three weeks after hatching to
mature into adults capable of reproducing. To live, a nymph must feed
on blood.
Adult: The adult pubic louse resembles a miniature crab when

viewed through a strong magnifying glass. Pubic lice have six legs;
their two front legs are very large and look like the pincher claws of
a crab. This is how they got the nickname “crabs.” Pubic lice are tan
to grayish-white in color. Females lay nits and are usually larger than
males. To live, lice must feed on blood. If the louse falls off a person,
it dies within one to two days.
Where are pubic lice found?

Pubic lice usually are found in the genital area on pubic hair; but
they may occasionally be found on other coarse body hair, such as hair
on the legs, armpits, mustache, beard, eyebrows, or eyelashes. Pubic
lice on the eyebrows or eyelashes of children may be a sign of sexual
exposure or abuse. Lice found on the head are generally head lice, not
pubic lice.
Animals do not get or spread pubic lice.
What are the signs and symptoms of pubic lice?

Signs and symptoms of pubic lice include the following:
• Itching in the genital area
• Visible nits (lice eggs) or crawling lice
How did I get pubic lice?

Pubic lice usually are spread through sexual contact and are most
common in adults. Pubic lice found on children may be a sign of sexual
exposure or abuse. Occasionally, pubic lice may be spread by close per-
sonal contact or contact with articles such as clothing, bed linens, or
towels that have been used by an infested person. A common misun-
derstanding is that pubic lice are spread easily by sitting on a toilet
391
seat. This would be extremely rare because lice cannot live long away
from a warm human body and they do not have feet designed to hold
onto or walk on smooth surfaces such as toilet seats.
Persons infested with pubic lice should be investigated for the pres-
ence of other sexually transmitted diseases.
How is a pubic lice infestation diagnosed?

A pubic lice infestation is diagnosed by finding a “crab” louse or
egg (nit) on hair in the pubic region or, less commonly, elsewhere on
the body (eyebrows, eyelashes, beard, mustache, armpit, perianal
area, groin, trunk, scalp). Pubic lice may be difficult to find because
there may be only a few. Pubic lice often attach themselves to more
than one hair and generally do not crawl as quickly as head and body
lice. If crawling lice are not seen, finding nits in the pubic area
strongly suggests that a person is infested and should be treated. If
you are unsure about infestation or if treatment is not successful, see
a health care provider for a diagnosis. Persons infested with pubic
lice should be investigated for the presence of other sexually trans-
mitted diseases.
Although pubic lice and nits can be large enough to be seen with
the naked eye, a magnifying lens may be necessary to find lice or eggs.
Treatment
A lice-killing lotion containing 1 percent permethrin or a mousse
containing pyrethrins and piperonyl butoxide can be used to treat
pubic (“crab”) lice. These products are available over-the-counter with-
out a prescription at a local drug store or pharmacy. These medica-
tions are safe and effective when used exactly according to the
instructions in the package or on the label.
Lindane shampoo is a prescription medication that can kill lice and
lice eggs. However, lindane is not recommended as a first-line therapy.
Lindane can be toxic to the brain and other parts of the nervous sys-
tem; its use should be restricted to patients who have failed treatment
with or cannot tolerate other medications that pose less risk. Lindane
should not be used to treat premature infants, persons with a seizure
disorder, women who are pregnant or breastfeeding, persons who have
very irritated skin or sores where the lindane will be applied, infants,
children, the elderly, and persons who weigh less than 110 pounds.
Malathion lotion 0.5% (Ovide®) is a prescription medication that can
kill lice and some lice eggs; however, malathion lotion (Ovide) currently
392
has not been approved by the U.S. Food and Drug Administration (FDA)
for treatment of pubic (“crab”) lice.
Ivermectin has been used successfully to treat lice; however,
ivermectin currently has not been approved by the FDA for treatment
of lice.
How to Treat Pubic Lice Infestations

Warning: See special instructions for treatment of lice and nits on
eyebrows or eyelashes. The lice medications described in this section
should not be used near the eyes.
1. Wash the infested area; towel dry.
2. Carefully follow the instructions in the package or on the la-
bel. Thoroughly saturate the pubic hair and other infested ar-
eas with lice medication. Leave medication on hair for the time
recommended in the instructions. After waiting the recom-
mended time, remove the medication by following carefully
the instructions on the label or in the box.
3. Following treatment, most nits will still be attached to hair
shafts. Nits may be removed with fingernails or by using a
fine-toothed comb.
4. Put on clean underwear and clothing after treatment.
5. To kill any lice or nits remaining on clothing, towels, or bed-
ding, machine-wash and machine-dry those items that the
infested person used during the two to three days before treat-
ment. Use hot water (at least 130°F) and the hot dryer cycle.
6. Items that cannot be laundered can be dry-cleaned or stored
in a sealed plastic bag for two weeks.
7. All sex partners from within the previous month should be
informed that they are at risk for infestation and should be
treated.
8. Persons should avoid sexual contact with their sex partner(s)
until both they and their partners have been successfully
treated and reevaluated to rule out persistent infestation.
9. Repeat treatment in nine to ten days if live lice are still found.
10. Persons with pubic lice should be evaluated for other sexually
transmitted diseases (STDs).
393
Special instructions for treatment of lice and nits found on eye-
brows or eyelashes:
• If only a few live lice and nits are present, it may be possible to
remove these with fingernails or a nit comb.
• If additional treatment is needed for lice or nits on the eye-
lashes, careful application of ophthalmic-grade petrolatum oint-
ment (only available by prescription) to the eyelid margins two
to four times a day for ten days is effective. Regular Vaseline
should not be used because it can irritate the eyes.
Section 33.10
Scabies
Reprinted from “Scabies,” Centers for
Disease Control and Prevention, February 4, 2008.
What is scabies?
Scabies is an infestation of the skin with the microscopic mite Sar-
coptes scabiei. Infestation is common, found worldwide, and affects
people of all races and social classes. Scabies spreads rapidly under
crowded conditions where there is frequent skin-to-skin contact be-
tween people, such as in hospitals, institutions, child-care facilities,
and nursing homes.
What are the signs and symptoms of scabies infestation?

• Pimple-like irritations, burrows, or rash of the skin, especially
the webbing between the fingers; the skin folds on the wrist, el-
bow, or knee; the penis, the breast, or shoulder blades.
• Intense itching, especially at night and over most of the body.
• Sores on the body caused by scratching. These sores can some-
times become infected with bacteria.
394
How did I get scabies?

By direct, prolonged, skin-to-skin contact with a person already
infested with scabies. Contact generally must be prolonged (a quick
handshake or hug will usually not spread infestation). Infestation is
easily spread to sexual partners and household members. Infestation
may also occur by sharing clothing, towels, and bedding.
Who is at risk for severe infestation?

People with weakened immune systems and the elderly are at risk
for a more severe form of scabies, called Norwegian or crusted sca-
bies. Scabies is spread more easily by persons who have Norwegian,
or crusted, scabies than by persons with other types of scabies.
How long will mites live?

Once away from the human body, mites usually do not survive more
than forty-eight to seventy-two hours. When living on a person, an
adult female mite can live up to a month.
Did my pet spread scabies to me?

No. Pets become infested with a different kind of scabies mite. If
your pet is infested with scabies, (also called mange) and they have
close contact with you, the mite can get under your skin and cause
itching and skin irritation. However, the mite dies in a couple of days
and does not reproduce. The mites may cause you to itch for several
days, but you do not need to be treated with special medication to kill
the mites. Until your pet is successfully treated, mites can continue
to burrow into your skin and cause you to have symptoms.
How soon after infestation will symptoms begin?

For a person who has never been infested with scabies, symptoms
may take four to six weeks to begin. For a person who has had sca-
bies before, symptoms appear within several days.
How is scabies infestation diagnosed?

Diagnosis is most commonly made by looking at the burrows or
rash. A skin scraping may be taken to look for mites, eggs, or mite fe-
cal matter (scybala) to confirm the diagnosis. Even if a skin scraping
395
or biopsy is taken and returns negative, it is still possible that you may
be infested. Typically, there are fewer than ten mites on the entire body
of an infested person; this makes it easy for an infestation to be missed.
However, persons with Norwegian, or crusted, scabies can be infested
with thousands of mites and should be considered highly infectious.
Can scabies be treated?

Yes. Several creams or lotions that are available by prescription
are approved by the U.S. Food and Drug Administration (FDA) to treat
scabies. Always follow the directions provided by your physician or
the directions on the package label or insert. Apply the medication to
a clean body from the neck down to the toes. After leaving the medi-
cation on the body for the recommended time, take a bath or shower
to wash off the cream or lotion. Put on clean clothes. All clothes, bed-
ding, and towels used by the infested person during the three days
before treatment should be washed in hot water and dried in a hot
dryer. A second treatment of the body with the same cream or lotion
may be necessary. Pregnant women and children are often treated
with milder scabies medications such as 5 percent permethrin cream.
Who should be treated for scabies?

Anyone who is diagnosed with scabies, as well as his or her sexual
partners and persons who have close, prolonged contact with the in-
fested person should also be treated. If your health care provider has
instructed family members to be treated, everyone should receive
treatment at the same time to prevent reinfestation.
How soon after treatment will I feel better?

Itching may continue for two to three weeks, and does not mean
that you are still infested. Your health care provider may prescribe
additional medication to relieve itching if it is severe.
396
Section 33.11
Syphilis
Excerpted from “Syphilis,” Centers for
Disease Control and Prevention, January 4, 2008.
What is syphilis?
Syphilis is a sexually transmitted disease (STD) caused by the bac-
terium Treponema pallidum. It has often been called “the great imita-
tor” because so many of the signs and symptoms are indistinguishable
from those of other diseases.
How common is syphilis?

In the United States, health officials reported over 36,000 cases of
syphilis in 2006, including 9,756 cases of primary and secondary (P&S)
syphilis. In 2006, half of all P&S syphilis cases were reported from
twenty counties and two cities; and most P&S syphilis cases occurred
in persons twenty to thirty-nine years of age. The incidence of P&S syphi-
lis was highest in women twenty to twenty-four years of age and in men
thirty-five to thirty-nine years of age. In 2006, 64 percent of the reported
P&S syphilis cases were among men who have sex with men (MSM).
How do people get syphilis?

Syphilis is passed from person to person through direct contact with
a syphilis sore. Sores occur mainly on the external genitals, vagina,
anus, or in the rectum. Sores also can occur on the lips and in the
mouth. Transmission of the organism occurs during vaginal, anal, or
oral sex. Pregnant women with the disease can pass it to the babies
they are carrying. Syphilis cannot be spread through contact with toi-
let seats, doorknobs, swimming pools, hot tubs, bathtubs, shared cloth-
ing, or eating utensils.
What are the signs and symptoms in adults?

Many people infected with syphilis do not have any symptoms for
years, yet remain at risk for late complications if they are not treated.
397
Although transmission occurs from persons with sores who are in the
primary or secondary stage, many of these sores are unrecognized.
Thus, transmission may occur from persons who are unaware of their
infection.
Primary stage: The primary stage of syphilis is usually marked

by the appearance of a single sore (called a chancre), but there may
be multiple sores. The time between infection with syphilis and the
start of the first symptom can range from ten to ninety days (aver-
age twenty-one days). The chancre is usually firm, round, small, and
painless. It appears at the spot where syphilis entered the body. The
chancre lasts three to six weeks, and it heals without treatment. How-
ever, if adequate treatment is not administered, the infection
progresses to the secondary stage.
Secondary stage: Skin rash and mucous membrane lesions char-

acterize the secondary stage. This stage typically starts with the de-
velopment of a rash on one or more areas of the body. The rash usually
does not cause itching. Rashes associated with secondary syphilis can
appear as the chancre is healing or several weeks after the chancre
has healed. The characteristic rash of secondary syphilis may appear
as rough, red, or reddish brown spots both on the palms of the hands
and the bottoms of the feet. However, rashes with a different appear-
ance may occur on other parts of the body, sometimes resembling
rashes caused by other diseases. Sometimes rashes associated with sec-
ondary syphilis are so faint that they are not noticed. In addition to
rashes, symptoms of secondary syphilis may include fever, swollen
lymph glands, sore throat, patchy hair loss, headaches, weight loss,
muscle aches, and fatigue. The signs and symptoms of secondary syphi-
lis will resolve with or without treatment, but without treatment, the
infection will progress to the latent and possibly late stages of disease.
Late and latent stages: The latent (hidden) stage of syphilis be-
gins when primary and secondary symptoms disappear. Without treat-
ment, the infected person will continue to have syphilis even though
there are no signs or symptoms; infection remains in the body. This
latent stage can last for years. The late stages of syphilis can develop
in about 15 percent of people who have not been treated for syphilis,
and can appear ten to twenty years after infection was first acquired.
In the late stages of syphilis, the disease may subsequently damage
the internal organs, including the brain, nerves, eyes, heart, blood
vessels, liver, bones, and joints. Signs and symptoms of the late stage
398
of syphilis include difficulty coordinating muscle movements, paraly-
sis, numbness, gradual blindness, and dementia. This damage may
be serious enough to cause death.
How does syphilis affect a pregnant woman and her baby?

The syphilis bacterium can infect the baby of a woman during her
pregnancy. Depending on how long a pregnant woman has been in-
fected, she may have a high risk of having a stillbirth (a baby born
dead) or of giving birth to a baby who dies shortly after birth. An in-
fected baby may be born without signs or symptoms of disease. How-
ever, if not treated immediately, the baby may develop serious problems
within a few weeks. Untreated babies may become developmentally
delayed, have seizures, or die.
How is syphilis diagnosed?

Some health care providers can diagnose syphilis by examining
material from a chancre (infectious sore) using a special microscope
called a dark-field microscope. If syphilis bacteria are present in the
sore, they will show up when observed through the microscope.
A blood test is another way to determine whether someone has
syphilis. Shortly after infection occurs, the body produces syphilis
antibodies that can be detected by an accurate, safe, and inexpensive
blood test. A low level of antibodies will likely stay in the blood for
months or years even after the disease has been successfully treated.
Because untreated syphilis in a pregnant woman can infect and pos-
sibly kill her developing baby, every pregnant woman should have a
blood test for syphilis.
What is the link between syphilis and human immunodefi-

ciency virus (HIV)?
Genital sores (chancres) caused by syphilis make it easier to trans-
mit and acquire HIV infection sexually. There is an estimated two- to
five-fold increased risk of acquiring HIV if exposed to that infection
when syphilis is present.
Ulcerative STDs that cause sores, ulcers, or breaks in the skin or
mucous membranes, such as syphilis, disrupt barriers that provide
protection against infections. The genital ulcers caused by syphilis can
bleed easily, and when they come into contact with oral and rectal
mucosa during sex, increase the infectiousness of and susceptibility to
HIV. Having other STDs is also an important predictor for becoming
399
HIV infected because STDs are a marker for behaviors associated with
HIV transmission.
What is the treatment for syphilis?

Syphilis is easy to cure in its early stages. A single intramuscular
injection of penicillin, an antibiotic, will cure a person who has had
syphilis for less than a year. Additional doses are needed to treat some-
one who has had syphilis for longer than a year. For people who are
allergic to penicillin, other antibiotics are available to treat syphilis.
There are no home remedies or over-the-counter drugs that will cure
syphilis. Treatment will kill the syphilis bacterium and prevent fur-
ther damage, but it will not repair damage already done.
Because effective treatment is available, it is important that per-
sons be screened for syphilis on an ongoing basis if their sexual be-
haviors put them at risk for STDs.
Persons who receive syphilis treatment must abstain from sexual
contact with new partners until the syphilis sores are completely
healed. Persons with syphilis must notify their sex partners so that
they also can be tested and receive treatment if necessary.
Will syphilis recur?

Having syphilis once does not protect a person from getting it
again. Following successful treatment, people can still be susceptible
to re-infection. Only laboratory tests can confirm whether someone
has syphilis. Because syphilis sores can be hidden in the vagina, rec-
tum, or mouth, it may not be obvious that a sex partner has syphilis.
Talking with a health care provider will help to determine the need
to be re-tested for syphilis after being treated.
How can syphilis be prevented?

eases, including syphilis, is to abstain from sexual contact or to be in
a long-term mutually monogamous relationship with a partner who
has been tested and is known to be uninfected.
Avoiding alcohol and drug use may also help prevent transmission
of syphilis because these activities may lead to risky sexual behavior.
It is important that sex partners talk to each other about their HIV
status and history of other STDs so that preventive action can be taken.
Genital ulcer diseases, like syphilis, can occur in both male and
female genital areas that are covered or protected by a latex condom,
400
as well as in areas that are not covered. Correct and consistent use
of latex condoms can reduce the risk of syphilis, as well as genital
herpes and chancroid, only when the infected area or site of poten-
tial exposure is protected.
Condoms lubricated with spermicides (especially Nonoxynol-9 or
N-9) are no more effective than other lubricated condoms in protect-
ing against the transmission of STDs. Use of condoms lubricated with
N-9 is not recommended for STD/HIV prevention. Transmission of an
STD, including syphilis, cannot be prevented by washing the genitals,
urinating, and/or douching after sex. Any unusual discharge, sore, or
rash, particularly in the groin area, should be a signal to refrain from
having sex and to see a doctor immediately.
Sources
Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2006. MMWR 2006;55(no. RR-11).
and Human Service, November 2007.
K. Holmes, P. Mardh, P. Sparling et al (eds). Sexually Transmitted
Diseases, 3rd Edition. New York: McGraw-Hill, 1999, chapters 33–37.
401
Section 33.12
Trichomoniasis
Reprinted from “Trichomoniasis,” Centers for
Disease Control and Prevention, December 17, 2007.
What is trichomoniasis?
Trichomoniasis is a common sexually transmitted disease (STD)
that affects both women and men, although symptoms are more com-
mon in women.
How common is trichomoniasis?

Trichomoniasis is the most common curable STD in young, sexu-
ally active women. An estimated 7.4 million new cases occur each year
in women and men.
How do people get trichomoniasis?

Trichomoniasis is caused by the single-celled protozoan parasite
Trichomonas vaginalis. The vagina is the most common site of infec-
tion in women, and the urethra (urine canal) is the most common site
of infection in men.
The parasite is sexually transmitted through penis-to-vagina in-
tercourse or vulva-to-vulva (the genital area outside the vagina) con-
tact with an infected partner. Women can acquire the disease from
infected men or women, but men usually contract it only from infected
women.
What are the signs and symptoms of trichomoniasis?

Most men with trichomoniasis do not have signs or symptoms;
however, some men may temporarily have an irritation inside the
penis, mild discharge, or slight burning after urination or ejaculation.
Some women have signs or symptoms of infection which include a
frothy, yellow-green vaginal discharge with a strong odor. The infec-
tion also may cause discomfort during intercourse and urination, as
402
well as irritation and itching of the female genital area. In rare cases,
lower abdominal pain can occur. Symptoms usually appear in women
within five to twenty-eight days of exposure.
What are the complications of trichomoniasis?

The genital inflammation caused by trichomoniasis can increase
a woman’s susceptibility to human immunodeficiency virus (HIV) in-
fection if she is exposed to the virus. Having trichomoniasis may in-
crease the chance that an HIV-infected woman passes HIV to her sex
partner(s).
How does trichomoniasis affect a pregnant woman and

her baby?
Pregnant women with trichomoniasis may have babies who are
born early or with low birth weight (low birth weight is less than 5.5
pounds).
How is trichomoniasis diagnosed?

For both men and women, a health care provider must perform a
physical examination and laboratory test to diagnose trichomoniasis.
The parasite is harder to detect in men than in women. In women, a
pelvic examination can reveal small red ulcerations (sores) on the
vaginal wall or cervix.
What is the treatment for trichomoniasis?

Trichomoniasis can usually be cured with prescription drugs, ei-
ther metronidazole or tinidazole, given by mouth in a single dose. The
symptoms of trichomoniasis in infected men may disappear within
a few weeks without treatment. However, an infected man, even a
man who has never had symptoms or whose symptoms have stopped,
can continue to infect or re-infect a female partner until he has been
treated. Therefore, both partners should be treated at the same time
to eliminate the parasite. Persons being treated for trichomoniasis
should avoid sex until they and their sex partners complete treat-
ment and have no symptoms. Metronidazole can be used by pregnant
women.
Having trichomoniasis once does not protect a person from getting
it again. Following successful treatment, people can still be suscep-
tible to re-infection.
403
How can trichomoniasis be prevented?

eases is to abstain from sexual contact, or to be in a long-term mutu-
ally monogamous relationship with a partner who has been tested and
is known to be uninfected.
Latex male condoms, when used consistently and correctly, can
reduce the risk of transmission of trichomoniasis.
Any genital symptom such as discharge or burning during urina-
tion or an unusual sore or rash should be a signal to stop having sex
and to consult a health care provider immediately. A person diagnosed
with trichomoniasis (or any other STD) should receive treatment and
should notify all recent sex partners so that they can see a health care
provider and be treated. This reduces the risk that the sex partners
will develop complications from trichomoniasis and reduces the risk
that the person with trichomoniasis will become re-infected. Sex
should be stopped until the person with trichomoniasis and all of his
or her recent partners complete treatment for trichomoniasis and have
no symptoms.
Sources
Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2006. MMWR 2006: 55 (No. RR-11).
Krieger JN and Alderete JF. Trichomonas vaginalis and trichomonia-
sis. In: K. Holmes, P. Markh, P. Sparling et al (eds). Sexually Trans-
mitted Diseases, 3rd Edition. New York: McGraw-Hill, 1999, 587–604.
404
Chapter 34
Sexual Dysfunction
Chapter Contents
Section 34.1—Erectile Dysfunction ............................................ 406
Section 34.2—Premature Ejaculation ........................................ 412
Section 34.3—Retrograde Ejaculation ....................................... 417
405
Section 34.1
Erectile Dysfunction
Excerpted from “Erectile Dysfunction,” National Institute of
Diabetes and Digestive and Kidney Diseases, National Institutes
of Health, NIH Publication No. 06-3923, December 2005.
Erectile dysfunction, sometimes called “impotence,” is the repeated

inability to get or keep an erection firm enough for sexual intercourse.
The word “impotence” may also be used to describe other problems
that interfere with sexual intercourse and reproduction, such as lack
of sexual desire and problems with ejaculation or orgasm. Using the
term erectile dysfunction makes it clear that those other problems are
not involved.
Erectile dysfunction, or ED, can be a total inability to achieve erec-
tion, an inconsistent ability to do so, or a tendency to sustain only brief
erections. These variations make defining ED and estimating its in-
cidence difficult. Estimates range from fifteen million to thirty mil-
lion, depending on the definition used.
In older men, ED usually has a physical cause, such as disease,
injury, or side effects of drugs. Any disorder that causes injury to the
nerves or impairs blood flow in the penis has the potential to cause
ED. Incidence increases with age: About 5 percent of forty-year-old
men and between 15 and 25 percent of sixty-five-year-old men expe-
rience ED. But it is not an inevitable part of aging.
ED is treatable at any age, and awareness of this fact has been
growing. More men have been seeking help and returning to nor-
mal sexual activity because of improved, successful treatments for
ED.
How does an erection occur?

The penis contains two chambers called the corpora cavernosa,
which run the length of the organ. A spongy tissue fills the cham-
bers. The corpora cavernosa are surrounded by a membrane, called
the tunica albuginea. The spongy tissue contains smooth muscles, fi-
brous tissues, spaces, veins, and arteries. The urethra, which is the
406
Sexual Dysfunction
channel for urine and ejaculate, runs along the underside of the cor-
pora cavernosa and is surrounded by the corpus spongiosum.
Erection begins with sensory or mental stimulation, or both. Im-
pulses from the brain and local nerves cause the muscles of the cor-
pora cavernosa to relax, allowing blood to flow in and fill the spaces.
The blood creates pressure in the corpora cavernosa, making the pe-
nis expand. The tunica albuginea helps trap the blood in the corpora
cavernosa, thereby sustaining erection. When muscles in the penis
contract to stop the inflow of blood and open outflow channels, erec-
tion is reversed.
What causes erectile dysfunction (ED)?

Since an erection requires a precise sequence of events, ED can
occur when any of the events is disrupted. The sequence includes nerve
impulses in the brain, spinal column, and area around the penis, and
response in muscles, fibrous tissues, veins, and arteries in and near
the corpora cavernosa.
Damage to nerves, arteries, smooth muscles, and fibrous tissues,
often as a result of disease, is the most common cause of ED. Dis-
eases—such as diabetes, kidney disease, chronic alcoholism, multiple
sclerosis, atherosclerosis, vascular disease, and neurologic disease—
account for about 70 percent of ED cases. Between 35 and 50 percent
of men with diabetes experience ED.
Lifestyle choices that contribute to heart disease and vascular prob-
lems also raise the risk of erectile dysfunction. Smoking, being over-
weight, and avoiding exercise are possible causes of ED.
Also, surgery (especially radical prostate and bladder surgery for
cancer) can injure nerves and arteries near the penis, causing ED.
Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead
to ED by harming nerves, smooth muscles, arteries, and fibrous tis-
sues of the corpora cavernosa.
In addition, many common medicines—blood pressure drugs, an-
tihistamines, antidepressants, tranquilizers, appetite suppressants,
and cimetidine (an ulcer drug)—can produce ED as a side effect.
Experts believe that psychological factors such as stress, anxiety,
guilt, depression, low self-esteem, and fear of sexual failure cause 10
to 20 percent of ED cases. Men with a physical cause for ED frequently
experience the same sort of psychological reactions (stress, anxiety,
guilt, depression). Other possible causes are smoking, which affects
blood flow in veins and arteries, and hormonal abnormalities, such
as not enough testosterone.
407
How is ED diagnosed?
Patient history: Medical and sexual histories help define the de-
gree and nature of ED. A medical history can disclose diseases that
lead to ED, while a simple recounting of sexual activity might distin-
guish among problems with sexual desire, erection, ejaculation, or
orgasm.
Using certain prescription or illegal drugs can suggest a chemical
cause, since drug effects account for 25 percent of ED cases. Cutting
back on or substituting certain medications can often alleviate the
problem.
Physical examination: A physical examination can give clues to

systemic problems. For example, if the penis is not sensitive to touch-
ing, a problem in the nervous system may be the cause. Abnormal
secondary sex characteristics, such as hair pattern or breast enlarge-
ment, can point to hormonal problems, which would mean that the
endocrine system is involved. The examiner might discover a circu-
latory problem by observing decreased pulses in the wrist or ankles.
And unusual characteristics of the penis itself could suggest the source
of the problem—for example, a penis that bends or curves when erect
could be the result of Peyronie disease.
Laboratory tests: Several laboratory tests can help diagnose ED.

Tests for systemic diseases include blood counts, urinalysis, lipid pro-
file, and measurements of creatinine and liver enzymes. Measuring
the amount of free testosterone in the blood can yield information
about problems with the endocrine system and is indicated especially
in patients with decreased sexual desire.
Other tests: Monitoring erections that occur during sleep (noctur-

nal penile tumescence) can help rule out certain psychological causes
of ED. Healthy men have involuntary erections during sleep. If noc-
turnal erections do not occur, then ED is likely to have a physical rather
than psychological cause. Tests of nocturnal erections are not com-
pletely reliable, however. Scientists have not standardized such tests
and have not determined when they should be applied for best results.
Psychosocial examination: A psychosocial examination, using

an interview and a questionnaire, reveals psychological factors. A
man’s sexual partner may also be interviewed to determine expecta-
tions and perceptions during sexual intercourse.
408
Sexual Dysfunction
How is ED treated?
Most physicians suggest that treatments proceed from least to most
invasive. For some men, making a few healthy lifestyle changes may
solve the problem. Quitting smoking, losing excess weight, and in-
creasing physical activity may help some men regain sexual function.
Cutting back on any drugs with harmful side effects is considered
next. For example, drugs for high blood pressure work in different
ways. If you think a particular drug is causing problems with erec-
tion, tell your doctor and ask whether you can try a different class of
blood pressure medicine.
Psychotherapy and behavior modifications in selected patients are
considered next if indicated, followed by oral or locally injected drugs,
vacuum devices, and surgically implanted devices. In rare cases, sur-
gery involving veins or arteries may be considered.
Psychotherapy: Experts often treat psychologically based ED us-

ing techniques that decrease the anxiety associated with intercourse.
The patient’s partner can help with the techniques, which include
gradual development of intimacy and stimulation. Such techniques
also can help relieve anxiety when ED from physical causes is being
treated.
Drug therapy: Drugs for treating ED can be taken orally, injected

directly into the penis, or inserted into the urethra at the tip of the
penis. In March 1998, the Food and Drug Administration (FDA) ap-
proved Viagra, the first pill to treat ED. Since that time, vardenafil
hydrochloride (Levitra®) and tadalafil (Cialis®) have also been ap-
proved. Additional oral medicines are being tested for safety and ef-
fectiveness.
Viagra, Levitra, and Cialis all belong to a class of drugs called phos-
phodiesterase (PDE) inhibitors. Taken an hour before sexual activity,
these drugs work by enhancing the effects of nitric oxide, a chemical
that relaxes smooth muscles in the penis during sexual stimulation
and allows increased blood flow.
While oral medicines improve the response to sexual stimulation,
they do not trigger an automatic erection as injections do. The recom-
mended dose for Viagra is 50 mg, and the physician may adjust this
dose to 100 mg or 25 mg, depending on the patient. The recommended
dose for either Levitra or Cialis is 10 mg, and the physician may ad-
just this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is
available for patients who take other medicines or have conditions that
409
may decrease the body’s ability to use the drug. Levitra is also avail-
able in a 2.5 mg dose.
None of these PDE inhibitors should be used more than once a day.
Men who take nitrate-based drugs such as nitroglycerin for heart prob-
lems should not use either drug because the combination can cause a
sudden drop in blood pressure. Also, tell your doctor if you take any
drugs called alpha-blockers, which are used to treat prostate enlarge-
ment or high blood pressure. Your doctor may need to adjust your ED
prescription. Taking a PDE inhibitor and an alpha-blocker at the same
time (within four hours) can cause a sudden drop in blood pressure.
Oral testosterone can reduce ED in some men with low levels of
natural testosterone, but it is often ineffective and may cause liver
damage. Patients also have claimed that other oral drugs—including
yohimbine hydrochloride, dopamine and serotonin agonists, and
trazodone—are effective, but the results of scientific studies to sub-
stantiate these claims have been inconsistent.
Many men achieve stronger erections by injecting drugs into the
penis, causing it to become engorged with blood. Drugs such as pa-
paverine hydrochloride, phentolamine, and alprostadil (marketed as
Caverject®) widen blood vessels. These drugs may create unwanted
side effects, however, including persistent erection (known as pri-
apism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes
enhance erection when rubbed on the penis.
A system for inserting a pellet of alprostadil into the urethra is
marketed as Muse®. The system uses a prefilled applicator to deliver
the pellet about an inch deep into the urethra. An erection will begin
within eight to ten minutes and may last thirty to sixty minutes. The
most common side effects are aching in the penis, testicles, and area
between the penis and rectum; warmth or burning sensation in the
urethra; redness from increased blood flow to the penis; and minor
urethral bleeding or spotting.
Vacuum devices: Mechanical vacuum devices cause erection by

creating a partial vacuum, which draws blood into the penis, engorg-
ing and expanding it. The devices have three components: a plastic cyl-
inder, into which the penis is placed; a pump, which draws air out of
the cylinder; and an elastic band, which is placed around the base of
the penis to maintain the erection after the cylinder is removed and
during intercourse by preventing blood from flowing back into the body.
One variation of the vacuum device involves a semirigid rubber
sheath that is placed on the penis and remains there after erection is
attained and during intercourse.
410
Sexual Dysfunction
Surgery: Surgery usually has one of three goals: to implant a de-
vice that can cause the penis to become erect, to reconstruct arteries
to increase flow of blood to the penis, or to block off veins that allow
blood to leak from the penile tissues.
Implanted devices, known as prostheses, can restore erection in
many men with ED. Possible problems with implants include mechani-
cal breakdown and infection, although mechanical problems have di-
minished in recent years because of technological advances.
Malleable implants usually consist of paired rods, which are in-
serted surgically into the corpora cavernosa. The user manually ad-
justs the position of the penis and, therefore, the rods. Adjustment does
not affect the width or length of the penis.
Inflatable implants consist of paired cylinders, which are surgically
inserted inside the penis and can be expanded using pressurized fluid.
Tubes connect the cylinders to a fluid reservoir and a pump, which
are also surgically implanted. The patient inflates the cylinders by
pressing on the small pump, located under the skin in the scrotum.
Inflatable implants can expand the length and width of the penis some-
what. They also leave the penis in a more natural state when not in-
flated.
Surgery to repair arteries can reduce ED caused by obstructions
that block the flow of blood. The best candidates for such surgery are
young men with discrete blockage of an artery because of an injury
to the crotch or fracture of the pelvis. The procedure is almost never
successful in older men with widespread blockage.
Surgery to veins that allow blood to leave the penis usually involves
an opposite procedure—intentional blockage. Blocking off veins (liga-
tion) can reduce the leakage of blood that diminishes the rigidity of
the penis during erection. However, experts have raised questions
about the long-term effectiveness of this procedure, and it is rarely
done.
411
Section 34.2
Premature Ejaculation
“Premature Ejaculation (PE),” is reprinted with permission from
www.urologyhealth.org. © 2008 American Urological Association, Inc.
Premature ejaculation (PE), is also known as rapid ejaculation,

premature climax, or early ejaculation. In the United States, PE af-
fects about one in five men ages eighteen to fifty-nine. Although the
problem is often assumed to be psychological, biology also may play
a role.
How does ejaculation occur?

Ejaculation, controlled by the central nervous system, happens
when sexual stimulation and friction provide impulses that are de-
livered to the spinal cord and into the brain.
Ejaculation has two phases.
Phase I (emission): The vas deferens (the tubes that store and
transport sperm from the testes) contract to squeeze the sperm to-
ward the base of the penis through the prostate gland. The seminal
vesicles release secretions that combine with the sperm to make se-
men. The ejaculation is unstoppable at this stage.
Phase II (ejaculation): The muscles at the base of the penis con-

tract forcing semen out of the penis (ejaculation and orgasm) while
the bladder neck contracts. Orgasm can occur without the delivery of
semen (ejaculation) from the penis. Normally, erections are lost fol-
lowing ejaculation.
What is premature ejaculation?

Premature ejaculation (PE) is characterized by a lack of volun-
tary control over ejaculation. Many men occasionally ejaculate sooner
than they or their partner would like during sexual activities. PE is
a frustrating problem that can reduce the enjoyment of sex, harm
412
Sexual Dysfunction
relationships, and affect quality of life. Occasional instances of PE
might not be cause for concern. However, when the problem occurs
frequently and causes distress to the man or his partner, treatment
may be of benefit.
What causes premature ejaculation?

Although the exact cause of premature ejaculation (PE) is not
known, new studies suggest that serotonin, a natural substance pro-
duced by nerves, is important. A breakdown of the actions of seroto-
nin in the brain may be a cause. Studies have found that high amounts
of serotonin in the brain slow the time to ejaculation while low
amounts of serotonin can produce a condition like PE.
Psychological factors also commonly contribute to PE. Temporary
depression, stress, unrealistic expectations about performance, a his-
tory of sexual repression, or an overall lack of confidence can cause
PE. Interpersonal dynamics may contribute to sexual function. PE can
be caused by a lack of communication between partners, hurt feelings,
or unresolved conflicts that interfere with the ability to achieve emo-
tional intimacy.
Can premature ejaculation develop later in life?

Premature ejaculation (PE) can occur at any age. Surprisingly,
aging appears not to be a cause of PE. However, the aging process
typically causes changes in erectile function and ejaculation. Erec-
tions may not be as firm or as large. Erections may be maintained
for a shorter period before ejaculating. The feeling that an ejacula-
tion is about to happen may be shorter. These factors can result in
an older man having an ejaculation earlier than when he was
younger.
Can both premature ejaculation and erectile dysfunction

affect a man at the same time?
Sometimes premature ejaculation (PE) may be a problem in men
who have erectile dysfunction (ED)—the inability to achieve and/or
maintain an erection sufficient for satisfactory sexual performance.
Some men do not understand that the loss of erection normally oc-
curs after ejaculation and may wrongly complain to their doctor that
they have ED when the actual problem is PE. It is recommended that
the ED be treated first if you experience both ED and PE, since the
PE may resolve on its own once the ED has been adequately treated.
413
When should a doctor be seen?

When premature ejaculation (PE) happens so frequently that it
interferes with your sexual pleasure, it becomes a medical problem
requiring the care of a doctor. To understand the problem, the doctor
will need to ask questions about your sexual history such as the fol-
lowing:
• How often does the PE occur?

• How long have you had this problem?
• Is the problem specific to one partner? Or does it happen with
every partner?
• Does PE occur with all or just some attempts at sexual rela-
tions?
• How much stimulation results in PE?
• What type of sexual activity (i.e., foreplay, masturbation, inter-
course, use of visual clues, etc.) is engaged in and how often?
• How has PE affected sexual activity?
• What is the quality of your personal relationships?
• How does PE affect your quality of life?
• Are there any factors that make PE worse or better (i.e., drugs,
alcohol, etc.)?
Usually, laboratory testing is not necessary unless the history and

a physical examination reveal something more complicated.
How to talk to your partner about premature ejaculation?

Premature ejaculation (PE) affects not only you but also your part-
ner and your sexual relationship. In an episode of PE, the intimacy
shared with a partner suddenly comes to a quick end. You might feel
angry, ashamed, and frustrated, and turn away from your partner. At
the same time, your partner may be upset with the rapid emotional
change, or the outcome of the sexual encounter.
Communication is not only important to successful diagnosis and
treatment, but can also help a partner understand the feelings of the
individual. Sometimes couple counseling or sex therapy may be use-
ful. Together a couple might develop techniques (for example, the
squeeze technique) that may prolong an erection. Most importantly,
414
Sexual Dysfunction
the couple should try to relax. Anxiety (especially performance anxi-
ety) only makes this condition worse.
What treatments are available?

There are several treatment choices for premature ejaculation:
psychological therapy, behavioral therapy, and medications. Be sure
to discuss these treatments with your doctor and together decide
which of the following options is best for you:
• Psychological therapy addresses feelings a man may have about
sexuality and sexual relationships.
• Behavioral therapy makes use of exercises to help a man de-
velop tolerance to stimulation and, as a result, delay ejacula-
tion.
• Medical therapy includes medications that are commonly used
to treat depression. In addition, topical anesthetic creams may
be used.
Psychological therapies: Psychological therapy can be used as

the only treatment or can be used together with medical therapy or
behavioral therapy. The focus of psychological therapy is to help you
to identify and solve any difficulties in your relationships that may
have added to the cause of premature ejaculation (PE). This therapy
can also help couples to talk about problems with intimacy that oc-
curred after PE began. Psychological therapy can also help a man
learn to be less anxious about his sexual performance and have
greater sexual confidence. Typically, a man will receive specific ad-
vice on how to enhance his and his partner’s sexual satisfaction.
Behavioral therapies: Behavioral therapy can play a key part

in the usual treatment of premature ejaculation. Exercises are effec-
tive; however, they may not always provide a lasting solution to the
problem. Also, they rely heavily on the cooperation of the partner,
which in some cases may be a problem.
With the squeeze method, an exercise developed by Masters and
Johnson, the partner stimulates the man’s penis until he is close to
ejaculation. At the point when he is about to ejaculate, the partner
squeezes the penis hard enough to make him partially lose his erec-
tion. The goal of this technique is to teach the man to become aware
of the sensations leading up to orgasm, and then begin to control and
delay his orgasm on his own.
415
With the stop-start method, the partner stimulates the man’s pe-
nis until just before ejaculation. The partner should then stop all
stimulation until the urge to ejaculate subsides. As the man regains
control, he instructs the partner to begin stimulating his penis again.
This procedure is repeated three times before allowing the man to
ejaculate on the fourth time. The couple repeats this exercise three
times a week, until the man has gained good control.
Medical therapies: Although not approved by the U.S. Food and

Drug Administration (FDA) for this purpose, drugs used for depres-
sion and anesthetic creams have been shown to delay ejaculation in
men with premature ejaculation (PE).
Medications are a relatively new form of treatment for PE. Doc-
tors first noticed that men and women who were taking drugs for the
treatment of depression (antidepressants) also had delayed orgasms.
Doctors then began to use these drugs “off-label” (this implies using
a medication for a different illness than what it was originally manu-
factured for) to treat PE. These medications include antidepressants
that affect serotonin such as fluoxetine, paroxetine, sertraline and
clomipramine.
If one medication fails to work, a second one is usually recom-
mended. If the second one fails, trying a third medication will not
likely be beneficial. An alternative is to combine medication with be-
havioral therapy and/or creams.
For use in PE, the doses of antidepressants are usually lower than
those recommended for the treatment of depression. Common side
effects of antidepressants can include nausea, dry mouth, drowsiness,
and reduced desire for sexual activity.
These drugs can be taken either every day or only taken before
sexual activity. Your doctor will decide how you should take the medi-
cation based on the frequency of intercourse. The best time for tak-
ing the antidepressant medications before sexual activity has not been
established, but most doctors will recommend from two to six hours
depending on the medication. Because PE can recur when the medi-
cation is not taken, you most likely will need to take it on a continu-
ing basis.
Local anesthetic creams can be used to treat PE. These creams are
applied to the head of the penis about twenty to thirty minutes be-
fore intercourse to lessen the sensitivity. Prior to sexual intercourse,
a condom (if used) may be removed and the penis washed clean of any
remaining cream. A loss of erection can occur if the anesthetic cream
is left on the penis for a longer period of time than recommended. Also,
416
Sexual Dysfunction
the anesthetic cream should not be left on the exposed penis during
vaginal intercourse since it may cause vaginal numbness.
See your urologist for evaluation and treatment for the biological
aspects of premature ejaculation.
Section 34.3
Retrograde Ejaculation
Excerpted from “Retrograde Ejaculation,”
Retrograde ejaculation refers to the entry of semen into the blad-

der instead of going out through the urethra during ejaculation.
Causes
Retrograde ejaculation may be caused by prior prostate or urethral
surgery, diabetes, some medications, including some drugs used to treat
hypertension (high blood pressure), and some mood-altering drugs.
The condition is relatively uncommon and may occur either par-
tially or completely. The presence of semen in the bladder is harm-
less. It mixes with the urine and leaves the body with normal
urination. Men with diabetes and those who have had genitourinary
tract surgery are at increased risk of developing the condition.
Symptoms
• Little or no semen discharged from the urethra in conjunction
with the male sexual climax (during ejaculation)
• Possible infertility
• Cloudy urine after sexual climax
Exams and Tests

A urinalysis performed on a urine specimen that is obtained shortly
after ejaculation will reveal a large amount of sperm in the urine.
417
Treatment
If retrograde ejaculation is caused by drugs, your doctor may rec-
ommend that you stop taking such drugs. This can make the prob-
lem go away.
Retrograde ejaculation caused by diabetes or after genitourinary
tract surgery may be treated with epinephrine-like drugs (such as
pseudoephedrine or imipramine).
Outlook (Prognosis)
If retrograde ejaculation is caused by medications, discontinuation
of the medication often restores normal ejaculation. If retrograde
ejaculation is caused by surgery or diabetes, it is often not correct-
able.
The condition may cause infertility.

Call for an appointment with your health care provider if you are
having difficulty conceiving a child or you are concerned about retro-
grade ejaculation.
Prevention
Maintaining good blood sugar control may help prevent this con-
dition in men who have diabetes. Avoiding drugs that cause retrograde
ejaculation will also prevent this condition.
418
Chapter 35
Penile Disorders
Chapter Contents
Section 35.1—Peyronie Disease.................................................. 420
Section 35.2—Balanitis, Phimosis, Priapism, and Other
Penis Problems .................................................... 424
Section 35.3—Penile Trauma ..................................................... 430
419
Section 35.1
Peyronie Disease
Reprinted from “Peyronie’s Disease,” National Institute of
Diabetes and Digestive and Kidney Diseases, National Institutes
of Health, NIH Publication No. 07-3902, September 2005.
Peyronie disease, a condition of uncertain cause, is characterized

by a plaque, or hard lump, that forms on the penis. The plaque devel-
ops on the upper or lower side of the penis in layers containing erec-
tile tissue. It begins as a localized inflammation and can develop into
a hardened scar.
Cases of Peyronie disease range from mild to severe. Symptoms
may develop slowly or appear overnight. In severe cases, the hard-
ened plaque reduces flexibility, causing pain and forcing the penis to
bend or arc during erection. In many cases, the pain decreases over
time, but the bend in the penis may remain a problem, making sexual
intercourse difficult. The sexual problems that result can disrupt a
couple’s physical and emotional relationship and lead to lowered self-
esteem in the man. In a small percentage of patients with the milder
form of the disease, inflammation may resolve without causing sig-
nificant pain or permanent bending.
The plaque itself is benign, or noncancerous. A plaque on the top
of the shaft (most common) causes the penis to bend upward; a plaque
on the underside causes it to bend downward. In some cases, the
plaque develops on both top and bottom, leading to indentation and
shortening of the penis. At times, pain, bending, and emotional dis-
tress prohibit sexual intercourse.
One study found Peyronie disease in 1 percent of men. Although the
disease occurs mostly in middle age, younger and older men can de-
velop it. About 30 percent of men with Peyronie disease develop fibro-
sis (hardened cells) in other elastic tissues of the body, such as on the
hand or foot. A common example is a condition known as Dupuytren
contracture of the hand. In some cases, men who are related by blood
tend to develop Peyronie disease, which suggests that genetic factors
might make a man vulnerable to the disease.
420
Penile Disorders
Men with Peyronie disease usually seek medical attention because
of painful erections and difficulty with intercourse. Since the cause
of the disease and its development are not well understood, doctors
treat the disease empirically; that is, they prescribe and continue
methods that seem to help. The goal of therapy is to keep the Peyronie
patient sexually active. Providing education about the disease and its
course often is all that is required. No strong evidence shows that any
treatment other than surgery is effective. Experts usually recommend
surgery only in long-term cases in which the disease is stabilized and
the deformity prevents intercourse.
A French surgeon, François de la Peyronie, first described Peyronie
disease in 1743. The problem was noted in print as early as 1687.
Early writers classified it as a form of impotence, now called erectile
dysfunction (ED). Peyronie disease can be associated with ED; how-
ever, experts now recognize ED as only one factor associated with the
disease—a factor that is not always present.
Course of the Disease

Many researchers believe the plaque of Peyronie disease develops
following trauma (hitting or bending) that causes localized bleeding
inside the penis. Two chambers known as the corpora cavernosa run
the length of the penis. The inner-surface membrane of the chambers
is a sheath of elastic fibers. A connecting tissue, called a septum, runs
between the two chambers and attaches at the top and bottom.
If the penis is abnormally bumped or bent, an area where the sep-
tum attaches to the elastic fibers may stretch beyond a limit, injuring
the lining of the erectile chamber and, for example, rupturing small
blood vessels. As a result of aging, diminished elasticity near the point
of attachment of the septum might increase the chances of injury.
The damaged area might heal slowly or abnormally for two rea-
sons: repeated trauma and a minimal amount of blood flow in the
sheath-like fibers. In cases that heal within about a year, the plaque
does not advance beyond an initial inflammatory phase. In cases that
persist for years, the plaque undergoes fibrosis, or formation of tough
fibrous tissue, and even calcification, or formation of calcium depos-
its.
While trauma might explain acute cases of Peyronie disease, it does
not explain why most cases develop slowly and with no apparent trau-
matic event. It also does not explain why some cases disappear quickly
or why similar conditions such as Dupuytren contracture do not seem
to result from severe trauma.
421
Some researchers theorize that Peyronie disease may be an autoim-
mune disorder.
Diagnosis and Evaluation

Doctors can usually diagnose Peyronie disease based on a physical
examination. The plaque is visible and palpable whether the penis is
flaccid or erect. Full evaluation, however, may require examination dur-
ing erection to determine the severity of the curvature. The erection
may be induced by injecting medicine into the penis or through self-
stimulation. Some patients may eliminate the need to induce an erec-
tion in the doctor’s office by taking a digital or Polaroid picture in the
home. The examination may include an ultrasound scan of the penis
to pinpoint the location and extent of the plaque and evaluate blood
flow throughout the penis.
Treatment
Because the course of Peyronie disease is different in each patient
and because some patients experience improvement without treat-
ment, medical experts suggest waiting one to two years or longer be-
fore attempting to correct it surgically. During that wait, patients often
are willing to undergo treatments whose effectiveness has not been
proven.
Experimental treatments: Some researchers have given vitamin

E orally to men with Peyronie disease in small-scale studies and have
reported improvements. Yet, no controlled studies have established
the effectiveness of vitamin E therapy. Similar inconclusive success
has been attributed to oral application of para-aminobenzoate, a sub-
stance belonging to the family of B-complex molecules.
Researchers have injected chemical agents such as verapamil, col-
lagenase, steroids, calcium channel blockers, and interferon alpha-2b
directly into the plaques. These interventions are still considered
unproven because studies included small numbers of patients and
lacked adequate control groups. Steroids, such as cortisone, have pro-
duced unwanted side effects, such as the atrophy or death of healthy
tissues. Another intervention involves iontophoresis, the use of a pain-
less current of electricity to deliver verapamil or some other agent
under the skin into the plaque.
Radiation therapy, in which high-energy rays are aimed at the plaque,
has also been used. Like some of the chemical treatments, radiation
422
Penile Disorders
appears to reduce pain, but it has no effect at all on the plaque itself
and can cause unwelcome side effects. Although the variety of agents
and methods used points to the lack of a proven treatment, new in-
sights into the wound healing process may one day yield more effec-
tive therapies.
Surgery: Peyronie disease has been treated surgically with some

success. The two most common surgical procedures are removal or
expansion of the plaque followed by placement of a patch of skin or
artificial material, and removal or pinching of tissue from the side of
the penis opposite the plaque, which cancels out the bending effect.
The first method can involve partial loss of erectile function, especially
rigidity. The second method, known as the Nesbit procedure, causes
a shortening of the erect penis.
Some men choose to receive an implanted device that increases
rigidity of the penis. In some cases, an implant alone will straighten
the penis adequately. In other cases, implantation is combined with
a technique of incisions and grafting or plication (pinching or folding
the skin) if the implant alone does not straighten the penis.
Most types of surgery produce positive results. But because com-
plications can occur, and because many of the phenomena associated
with Peyronie disease (for example, shortening of the penis) are not
corrected by surgery, most doctors prefer to perform surgery only on
the small number of men with curvature so severe that it prevents
sexual intercourse.
423
Section 35.2
Balanitis, Phimosis,
Priapism, and Other Penis Problems
“Penis Problems,” © 2008 Andrology Australia
(www.andrologyaustralia.org). All rights reserved.
Lumps, foreskin problems, and inflammation of the penis are com-

mon problems men can experience. Men who are not circumcised can
experience problems with their foreskin. Most inflammations and
lumps are not too serious and can easily be treated; however, some
penis problems can increase the risk of penis cancer. Priapism is an
erection that lasts more than three hours, and can cause damage to
the penis so must be treated promptly. If you have any changes in the
skin or foreskin of your penis, see your local doctor.
The Foreskin
At birth, the foreskin and the glans penis are joined. As boys start
growing, an increase in hormones contributes to the foreskin and glans
separating and the foreskin is then able to be pulled back. This hap-
pens in most boys at around three years of age.
The foreskin of an uncircumcised child should not forcibly be pulled
back as this can cause bleeding and injury. By forcefully retracting
the foreskin, scarring can happen which can then cause problems with
the foreskin retracting, which is called phimosis.
All uncircumcised adult men should have a genital examination
by their doctor and have their foreskin retracted to check for signs of
penis cancer.
Penis Lumps
There are different types of lumps and bumps that can appear on the
penis; many of them are harmless. If you are concerned about any lumps
on your penis, see your doctor to rule out sexually transmitted infections
and penis cancer, albeit rare. Some common lumps include the following.
424
Penile Disorders
Cysts: Sometimes the sebaceous glands on the penis and scrotum
can become enlarged and blocked, turning into cysts. These do not
usually need any treatment. Sometimes they can become painful and
infected if they continue to grow.
Ulcers: These appear as craters in the skin and often have a clear
liquid or pus in the crater (red wound or a sore).
A single ulcer is often quite serious and should be checked by a
doctor immediately. Causes of a single ulcer include syphilis, tropical
diseases, and penile cancer.
Multiple ulcers are more common and are less serious, but should
still be checked by a doctor straight away. Herpes is the most com-
mon cause of multiple penile ulcers.
Papules: These are small lumps that are raised on the skin and
most do not have a serious cause. One of the most common types of
papules is called pearly penile papules and these appear as one or
more rows of small, smooth lumps located in a circumference around
the back of the glans penis (head of the penis). These look very simi-
lar to, and are often mistaken for, genital warts. These papules are
not infectious and do not need to be treated.
Causes of other papules include psoriasis and sexually transmitted
infections such as genital warts. Genital warts are caused by the hu-
man papillomavirus (HPV). Warts can often happen in clusters and can
be very tiny. Genital warts are spread through skin-to-skin contact, so
it is important to use condoms if you or your partner are infected. In
women, HPV is associated with precancerous changes in the cervix.
Genital warts are treated by freezing them with liquid nitrogen. Al-
though this gets rid of the warts, it does not get rid of the virus and
warts may reappear on the skin or occur in the eye of the penis. This
may need an inspection of the inside of the penis to fully treat the warts.
Plaques: Plaques are raised lumps that are bigger than one centimeter
in diameter. They do not usually have a serious cause, but some are in-
fectious and can develop into more serious conditions such as penile can-
cer. Some causes of plaques include balanitis (see below) and eczema.
Balanitis
What is balanitis?
Balanitis is a very common inflammation of the glans penis (hel-
met of the penis) that can affect males at any age. This inflammation
425
can affect circumcised males, however, it is more common in men who
have not been circumcised.
What causes balanitis?

Balanitis often happens when the foreskin is not pulled back, or
is unable to be pulled back due to scarring, and the inside of the fore-
skin is not kept clean. Inflammation caused by a bacteria or fungus
is common and can be caused if the sensitive skin under the foreskin
collects sweat, dead skin, and bacteria. Balanitis can also be caused
by irritation from chemicals in soap, clothing, and the latex in con-
doms. Allergies to certain drugs, viruses such as human papilloma-
virus (which can cause genital warts), and obesity can also contribute
to balanitis.
In adults, balanitis can be a sign of diabetes. After urinating, some
urine may become trapped under the foreskin. The combination of a
moist area and glucose in the urine can lead to bacteria growing and
then infection. If you have balanitis and the condition keeps happen-
ing, speak to your doctor and ask to be tested for diabetes.
What are some of the signs of balanitis?

Men with balanitis may experience the following complaints:
• Inability to pull back the foreskin

• Itchiness
• Rash
• Sore or tender glans penis
• Redness or swelling
• Discharge from the penis
How is balanitis treated?

Treatment for balanitis depends on the cause of the inflamma-
tion. Most often, washing the penis and under the foreskin with
soap and warm water is recommended. If the cause is from allergic
reactions, try using different brands and other chemicals. If there
is an infection, the doctor may prescribe antibiotics or antifungal
medication. In severe cases of balanitis, circumcision may be recom-
mended.
426
Penile Disorders
To avoid future bouts of balanitis, do not use strong soaps and
chemicals, and pull back the foreskin and clean it daily.
What is balanitis xerotica obliterans (BXO)?

Balanitis xerotica obliterans (BXO) is not to be confused with bal-
anitis (inflammation of the glans penis). BXO is a rare condition where
scar tissue forms in the foreskin. A ring of white tissue develops at the
tip of the foreskin, tightening the foreskin at the tip, and this may pre-
vent the foreskin from retracting (phimosis). BXO may spread to the
glans penis, but this is not common.
It is important to speak to your doctor if you are concerned about
white scarring of your foreskin, to distinguish BXO from early penis
cancer. BXO is a progressive disease and it is usually treated by cir-
cumcision.
Phimosis
What is phimosis?
Phimosis is when the foreskin is too tight, or the tip of the foreskin
narrows and is unable to be pulled back to expose the head of the penis.
What causes phimosis?

Phimosis is often seen in children or young adults (primary or con-
genital phimosis). The condition is at its highest incidence rate be-
fore puberty.
Phimosis can also happen because of injury or damage that causes
the foreskin to tear (secondary or acquired phimosis). As the tear
heals, scar tissue forms which reduces the elasticity of the foreskin.
This scar tissue can then stop the foreskin from stretching open far
enough to pull back. The scarring from BXO can also cause phimosis.
Phimosis can often follow infection or inflammation such as bal-
anitis. Adult men with phimosis should be checked for balanitis, dia-
betes, and cancer.
Are there any other symptoms with phimosis?

Severe phimosis can cause pain when urinating, urinary retention,
urinary tract infections, and the skin on the penis can become infected.
In older men with severe phimosis, the foreskin can look swollen.
427
How is phimosis treated?

Phimosis can be treated with steroid creams applied once or twice
daily for a couple of weeks. Studies have shown that the creams have
a success rate of more than 85 percent, and this can increase if the
foreskin is gently stretched together with the cream application.
If the steroid creams do not work and phimosis is severe, circum-
cision is another option to consider.
Paraphimosis
What is paraphimosis?
Paraphimosis happens when the foreskin has been retracted be-
hind the head of the penis and cannot go back to its original position.
If the foreskin stays in this position, it can cause pain, swelling, and
can stop blood flow to the penis. This is a serious medical problem and
must be treated immediately or the penis can sustain long-term or
permanent damage.
What causes paraphimosis?

Paraphimosis can happen at any age, and can be caused by injury
to the head of the penis. It can also happen to infants if parents pull
back their foreskin and do not pull it forward again afterward.
How is paraphimosis treated?

The glans penis and the foreskin often swell up with paraphimo-
sis. It is important to apply ice to reduce the swelling and then try
and move the foreskin forward to the usual position. Other methods
used to reduce swelling include injecting medicine that lessens swell-
ing, or inserting a needle and releasing some blood. If the foreskin does
not return to its normal position, a surgeon may have to cut the fore-
skin to release it, or circumcision may be necessary.
Priapism
What is priapism?
Priapism is an erection that lasts for more than three hours and
is usually very painful. Blood becomes trapped in the penis and does
not return to circulation; it is not necessarily because of, or related
428
Penile Disorders
to, sexual stimulation. If priapism is not treated, it can lead to per-
manent damage to the erectile tissue and the inability to get an erec-
tion at all. Priapism can happen to males at any age.
What causes it?

The most common cause of priapism is drug treatments for erec-
tile dysfunction, in particular, penile injection treatments. About a
quarter of other cases of priapism are associated with medical condi-
tions such as advanced cancer, leukemia, and sickle cell anemia. Other
possible causes include damage to the nervous system, injury to the
penis, the use of some medicines, and illegal drugs. Sometimes the
cause of priapism is unknown.
How is it treated?
It is important to see a doctor straight away because the sooner
the prolonged erection is treated, the less damage will be done to the
erectile tissue. If treatment is sought within four to six hours, the
doctor may provide a decongestant medication to help the erection go
down. Another option is for the doctor to use a needle and syringe to
release the extra blood trapped in the penis. If this does not work,
surgery may be needed to try and avoid permanent damage to the
penis.
If priapism was caused by erectile dysfunction drugs, alternative
treatments should be used instead. Also, if priapism has been caused
by other medications, trying a different medication may help.
429
Section 35.3
Penile Trauma
“Penile Trauma” is reprinted with permission from
www.urologyhealth.org, © 2004 American Urological Association, Inc.
All rights reserved. Reviewed by David A. Cooke, M.D., March 2009.
While the penis is one of the least injured organs, it is not risk-
free. What can put it at risk? And how is it repaired? The following
information should tell you when it is imperative to see your doctor
about problems.
How does the penis normally function?

The two main functions of the penis are urinary and reproductive.
Inside the penis there are three tubes. One is called the urethra. It
is hollow and allows urine to flow from the bladder through the hole
in the prostate through the penis and to the outside. The two other
tubes are called the corpora cavernosa. The three tubes are wrapped
together by a very tough fibrous sheath called the tunica albuginea.
The corpora cavernosa are spongy tubes that are soft until filled with
blood during an erection. At the time of sexual activity the erection
of the penis allows it to be inserted into the woman’s vagina. In this
situation, the urethra acts as a channel for semen to be ejaculated
into the vagina. The penis facilitates conception and pregnancy and
also serves as a source of sexual pleasure for the man and his part-
ner.
What are the causes and symptoms of penile injury?

The penis is much less frequently injured than other parts of the
body such as the abdomen, legs, arms, and head. However, it can be
wounded as a result of various injuries, including automobile acci-
dents, gunshot wounds, burns, sexual activity, and, in the case of men-
tal disturbance, self-mutilation.
Perhaps the most common injury to the penis occurs during sexual
activity. In the flaccid state, injury to the penis is rare because of the
430
Penile Disorders
mobility and flexibility of the organ. During an erection, arterial blood
flow causes the penis to be come rigid, thus placing it at higher risk
for injury. Although there is no bone in the penis, urologists frequently
refer to the injury as a penile “fracture.” During vigorous thrusting,
the erect penis may accidentally slip out of the vagina. Due to the fast
action, the penis strikes the outside of the woman instead of being
reinserted into the vagina. The penis may then bend sharply despite
the erection. A typical sign of this problem is a sharp pain in the pe-
nis joined by a “popping” sound. The pain and sound are produced by
a rupture of the tunica albuginea, which is stretched tightly during
the time of an erection. The pain may last for a short time or it may
continue. The penis develops a collection of blood under the skin called
a hematoma, which can distort the appearance of the penis (eggplant
deformity). The injury is usually limited to one or both of the corpora
cavernosa and, on rare occasions, the urethra.
The penis can also be injured by tearing the suspensory ligament,
the structure that supports the organ at its base. Attached to the pelvic
bone, this ligament can rip if an erect penis is pushed down suddenly,
causing pain and bleeding.
Further injuries can occur if a man places a rubber tube or other
instrument around the base of the penis that is too tight or on for too
long. Cutting off the blood supply, it can produce a wound known as a
strangulation lesion. Also, if an object is inserted into the urethra, both
it and/or the penis can be injured.
How are injuries to the penis treated?

If a person sustains a penile injury, a urologist will take a thor-
ough medical history and complete a physical examination along with
blood and urine tests. The focus of any initial examination is to de-
fine the injury and assess the damage to the penis. Given that infor-
mation, the doctor may call for other tests, including a retrograde
urethrogram if he or she thinks the urethra is involved. This test is
performed by injecting a liquid radio contrast solution through the
opening at the top of the penis and then taking x-rays. If the x-ray
shows any leakage outside the urethra, it may indicate damage to that
part of the urinary tract.
Additional imaging techniques might include an ultrasound of the
penis, magnetic resonance imaging (MRI), or a special test called a
cavernosogram. In the latter test, a thin hypodermic needle is inserted
into one area of the penis before a radio contrast solution is injected
and x-rays taken.
431
If the injury is amputation of the penis, the amputated portion
should be wrapped in gauze soaked in sterile saline solution and
placed in a plastic bag. The plastic bag should then be put into a sec-
ond bag or cooler with an ice water slush. If reattachment of the pe-
nis is possible, the lower temperature produced by the slush will
increase the likelihood of successful reattachment. Penile reattach-
ment even after sixteen hours has been reported to be successful.
Historically, treatment for a penis fractured during sexual activ-
ity was nonsurgical management (e.g., cold compresses, pressure
dressings, penile splinting, and anti-inflammatory medications). To-
day, the treatment of choice will probably be for the individual to un-
dergo surgery since it has the best long-term results by lowering
complication rates often linked to nonsurgical approaches. The most
common surgical technique is to “deglove” the penis by making a cut
around the shaft near the glans penis and peeling back the skin to
the base to examine the inner surface. The surgeon will then evacu-
ate any hematoma that helps to make examination of any tears in
the tunica albuginea easier. If tears exist, they are repaired before the
skin is sewn back into position. A Foley catheter may be placed
through the penile urethra into the bladder to drain urine and allow
the penis to heal. With the entire penis bandaged, the patient will
probably remain in the hospital for one or two days, and go home with
or without the catheter. They may be given antibiotics and pain medi-
cation and will probably be asked to make a follow-up office visit with
their doctor.
For massive injuries to the penis, major reconstruction is frequently
possible by urologists experienced with this difficult surgery. How
closely the reconstructed penis can return to normal urinary or sexual
function varies greatly.
What can be expected after treatment for injuries to the

penis?
Most cases of fractured penis caused by sexual activity and most
other minor penile injuries will heal without problems. However, com-
plications can and do occur. Possible complications include: infection,
erectile dysfunction due to blockage of the nerve or blood supply to
the penis, priapism in which the penis becomes erect and stays erect
to the point of pain, fistula formation in which urine may leak out of
the urethra and through the skin of the penis to the outside, curva-
ture (chordee) of the penis after the injury has healed, or major loss
of skin, portion of the urethra, or corpora cavernosum. Failure for the
432
Penile Disorders
return of sufficient sexual function is dependent upon the degree of
injury to the arteries, nerves, and corpora cavernosum and whether
the patient was experiencing erectile dysfunction just prior to the
injury.
How frequent are penile injuries?

Unfortunately, doctors have not been able to gather meaningful
statistics as to how many penile injuries actually occur in the United
States.
How does a Foley catheter work?

Ever since E. B. Foley, a Minneapolis urologist, first introduced the
catheter bearing his name; doctors have had an effective way to effi-
ciently and continuously drain the urinary tract. Held in place by its
own configuration—primarily with a sterile, liquid-filled balloon—the
Foley can be inserted simply by passing the rubber tubing through
the urethra into the bladder. It remains there until the penis is healed.
How do I prevent penile injury?

Penile injuries related to sexual intercourse can be prevented in
most cases if your partner is simply aware of the possibility. If your
penis is erect and inadvertently slips from the vagina of your part-
ner, stop the thrusting immediately. For other injuries, caution on the
job, especially near machinery; defensive driving; and gun safety are
obvious precautions for the other types of injuries.
433
Chapter 36
Non-Cancerous
Prostate Disorders
Chapter Contents
Section 36.1—Benign Prostatic Hyperplasia ............................ 436
Section 36.2—Prostatitis ............................................................. 441
435
Section 36.1
Benign Prostatic Hyperplasia

Excerpted from “Understanding Prostate Changes: A Health
Guide for Men,” National Cancer Institute, September 15, 2004.
Revised by David A. Cooke, M.D., April 2009.
What Is Enlarged Prostate or BPH?

BPH stands for benign prostatic hyperplasia.
Benign means “not cancer,” and hyperplasia means too much
growth. The result is that the prostate becomes enlarged. BPH is not
linked to cancer and does not raise your chances of getting prostate
cancer—yet the symptoms for BPH and prostate cancer can be simi-
lar.
BPH Symptoms
BPH symptoms usually start after the age of fifty. They can include
the following:
• Trouble starting a urine stream or making more than a dribble
• Passing urine often, especially at night
• Feeling that the bladder has not fully emptied
• A strong or sudden urge to pass urine
• Weak or slow urine stream
• Stopping and starting again several times while passing urine
• Pushing or straining to begin passing urine
At its worst, BPH can lead to the following:

• A weak bladder
• Backflow of urine causing bladder or kidney infections
• Complete block in the flow of urine
• Kidney failure
436
Non-Cancerous Prostate Disorders
BPH affects most men as they get older. It can lead to urinary prob-
lems like those with prostatitis. By age sixty, many men have signs
of BPH. By age seventy, almost all men have some prostate enlarge-
ment.
The prostate starts out about the size of a walnut. By the time a
man is forty, it may have grown slightly larger, to the size of an apri-
cot. By age sixty, it may be the size of a lemon.
As a normal part of aging, the prostate enlarges and can press
against the bladder and the urethra. This can slow down or block urine
flow. Some men might find it hard to start a urine stream, even though
they feel the need to go. Once the urine stream has started, it may be
hard to stop. Other men may feel like they need to pass urine all the
time or are awakened during sleep with the sudden need to pass urine.
Early BPH symptoms take many years to turn into bothersome
problems. These early symptoms are a cue to see your doctor.
How Can BPH Be Treated?

About half the men with BPH eventually have symptoms that are
bothersome enough to need treatment. BPH cannot be cured, but
drugs or surgery can often relieve its symptoms. BPH symptoms do
not always grow worse.
There are three ways to manage BPH:
• Watchful waiting (regular follow-up with your doctor)
• Drug therapy
• Surgery
Talk with your doctor about the best choice for you. Your symptoms
may change over time, so be sure to tell your doctor about any new
changes.
Watchful Waiting
Men with mild symptoms of BPH who do not find them bothersome
often choose this approach.
Watchful waiting means getting annual checkups. The checkups
can include digital rectal exams (DREs) and other tests. Treatment
is started only if symptoms become too much of a problem.
If you choose to live with symptoms, these simple steps can help:
• Limit drinking in the evening, especially drinks with alcohol or
caffeine.
437
• Empty the bladder all the way when you pass urine.
• Use the restroom often. Don’t wait for long periods without
passing urine.
Some medications can make BPH symptoms worse, so talk with

your doctor or pharmacist about any medicines you are taking, includ-
ing the following:
• Over-the-counter cold and cough medicines (especially antihis-

tamines)
• Tranquilizers
• Antidepressants
• Blood pressure medicine
Drug Therapy
Millions of American men with mild to moderate BPH symptoms
have chosen prescription drugs over surgery since the early 1990s.
There are two main types of drugs used. One type relaxes muscles
near the prostate while the other type shrinks the prostate gland.
There is evidence that shows that taking both drugs together may
work best to keep BPH symptoms from getting worse.
Alpha-blockers: These drugs help relax muscles near the pros-

tate to relieve pressure and let urine flow more freely, but they don’t
shrink the size of the prostate. For many men, the drug can improve
urine flow and reduce symptoms within days. Possible side effects
include dizziness, headache, and fatigue.
5-alpha-reductase inhibitors: These drugs shrink the prostate.

They relieve symptoms by blocking an enzyme that acts on the male
hormone testosterone to boost organ growth. When the enzyme is
blocked, growth slows down. This helps shrink the prostate, reduce
blockage, and limit the need for surgery. Currently, two drugs of this
type are available: finasteride and dutasteride.
Taking one of these drugs for at least six months to one year can
increase urine flow and reduce your symptoms. They seem to work
best for men with very large prostates. You must continue to take the
drug to prevent symptoms from coming back.
One of the two drugs, finasteride, is also used to treat baldness in
men. It can cause these side effects in a small percentage of men:
438
• Decreased interest in sex
• Trouble getting or keeping an erection
• Smaller amount of semen with ejaculation
It’s important to note that taking these drugs can lower your pros-
tate specific antigen (PSA) test levels. There is also evidence that
finasteride lowers the risk of getting prostate cancer, but whether it
lowers the risk of dying from prostate cancer is still unclear.
Table 36.1. BPH Medications

Generic Brand
Category Activity Name Name
Alpha-blockers Relax muscles near doxazosin Cardura®
prostate tamsulosin Flomax®
alfuzosin Uroxatral®
terazosin Hytrin®
prazosin Minipress®
5-alpha-reductase Slows prostate growth, finasteride Proscar® or
inhibitors shrinks prostate Propecia®
dutasteride Avodart®
BPH surgery: The number of prostate surgeries has gone down

over the years. But operations for BPH are still one of the most com-
mon surgeries for American men. Surgery is used when symptoms are
severe or drug therapy has not worked well.
Types of surgeries include the following:
• Transurethral resection of the prostate (TURP): This is the most

common surgery for BPH. It accounts for 90 percent of all BPH
surgeries. It takes about ninety minutes. The doctor passes an
instrument through the urethra and trims away extra prostate
tissue. A spinal block is used to numb the area. Tissue is sent to
the laboratory to check for prostate cancer. TURP generally avoids
the two main dangers linked to other prostate surgeries, incon-
tinence (not being able to hold in urine) and impotence (not be-
ing able to have an erection). The recovery period for TURP is
much shorter as well.
• Transurethral incision of the prostate (TUIP): This is similar to
TURP. It is used on slightly enlarged prostate glands. The surgeon
439
places one or two small cuts in the prostate. This relieves pres-
sure without trimming away tissue. It has a low risk of side effects.
Like TURP, this treatment helps with urine flow by widening the
urethra.
• Transurethral needle ablation (TUNA): This burns away excess
prostate tissue using radio waves. It helps with urine flow, re-
lieves symptoms, and may have fewer side effects than TURP.
Most men need a catheter to drain urine for a period of time af-
ter the procedure.
• Transurethral microwave thermotherapy (TUMT): This uses
microwaves sent through a catheter to destroy excess prostate
tissue. This can be an option for men who should not have major
surgery because they have other medical problems.
• Transurethral electro-evaporation of the prostate (TUVP): This
uses electrical current to vaporize prostate tissue.
• Open prostatectomy: This means the surgeon removes the pros-
tate through a cut in the lower abdomen. This is done only in
very rare cases when obstruction is severe, the prostate is very
large, or other procedures can’t be done. General or spinal anes-
thesia is used and a catheter remains for three to seven days
after the surgery. This surgery carries a higher risk of complica-
tions than medical treatment. Tissue is sent to the laboratory to
check for prostate cancer.
Be sure to discuss options with your doctor and ask about the po-
tential short- and long-term benefits and risks with each procedure.
440
Section 36.2
Prostatitis
Excerpted from “Prostatitis: Disorders of the Prostate,” National
Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health, NIH Publication No. 08-4553, January 2008.
Prostatitis is a frequently painful condition that affects mostly

young and middle-aged men. Doctors may have difficulty diagnosing
prostatitis because the symptoms are not the same for every patient,
and many of the symptoms—such as painful or burning urination and
incomplete emptying of the bladder—could be signs of another dis-
ease.
What is the prostate?

The prostate is a walnut-sized gland that forms part of the male
reproductive system. The gland is made of two lobes, or regions, en-
closed by an outer layer of tissue. As Figure 36.1 and Figure 36.2 show,
the prostate is located in front of the rectum and just below the blad-
der, where urine is stored. The prostate also surrounds the urethra,
the canal through which urine and semen pass out of the body. The
prostate squeezes fluid into the urethra to help make up semen as
sperm move through during sexual climax.
Researchers estimate that 10 to 12 percent of men experience
prostatitis-like symptoms.1 The term “prostatitis” means inflamma-
tion of the prostate, but doctors use the term to describe four differ-
ent disorders.
What are the types of prostatitis?

Acute bacterial prostatitis: This is the least common of the four
types and is potentially life threatening. Fortunately, it is the easiest
to diagnose and treat effectively. Men with this disease often have
chills; fever; pain in the lower back and genital area; urinary frequency
and urgency, often at night; burning or painful urination; body aches;
and a demonstrable infection of the urinary tract as evidenced by
441
white blood cells and bacteria in the urine. The treatment is an anti-
microbial, a medicine that kills microbes—organisms that can be seen
only with a microscope, including bacteria, viruses, and fungi. Anti-
microbials include antibiotics and related medicines.
Chronic bacterial prostatitis: This is also relatively uncommon,

and occurs when bacteria find a spot on the prostate where they can
survive. Men have urinary tract infections that seem to go away but
then come back with the same bacteria. Treatment usually requires
the use of antimicrobials for a prolonged period of time. However,
antimicrobials do not always cure this condition.
Chronic prostatitis/chronic pelvic pain syndrome: This is the

most common but least understood form of prostatitis. It may be found
in men of any age. Its symptoms go away and then return without
warning, and it may be inflammatory or noninflammatory. In the in-
flammatory form, urine, semen, and prostatic fluid contain the kinds
of cells the body usually produces to fight infection, but no bacteria
can be found. In the noninflammatory form, not even the infection-
fighting cells are present.
Figure 36.1. Prostate, front view.
442
Asymptomatic inflammatory prostatitis: This is the diagno-
sis given when the patient does not complain of pain or discomfort
but has infection-fighting cells in his prostate fluid and semen. Doc-
tors usually find this form of prostatitis when looking for causes of
infertility or testing for prostate cancer.
How is prostatitis diagnosed?
A doctor performs a digital rectal exam (DRE) by inserting a gloved

and lubricated finger into the patient’s rectum, just behind the pros-
tate. The doctor can feel the prostate to see if it is swollen or tender
in spots.
The doctor can diagnose the bacterial forms of prostatitis by ex-
amining a urine sample with a microscope. The sample may also be
sent to a laboratory to perform a culture. In a urine culture, the bac-
teria are allowed to grow so they can be identified and tested for their
resistance to different types of antimicrobials.
To confirm the prostate infection, the doctor may obtain two urine
samples—before and after prostate massage. To perform a prostate
massage, the doctor will insert a gloved and lubricated finger into the
Figure 36.2. Prostate, side view.
443
rectum, as in a DRE, and stroke the prostate to release fluids from
the gland. The post-massage urine sample will contain prostate fluid.
If that second urine sample contains bacteria or infection-fighting cells
that were not present in the pre-massage urine sample, this suggests
the prostate contains infection.
To diagnose chronic prostatitis/chronic pelvic pain syndrome, the
doctor must rule out all other possible causes of urinary symptoms,
such as kidney stones, bladder disorders, and infections. Since many
different conditions must be considered, the doctor may order a full
range of tests, including ultrasound or magnetic resonance imaging
(MRI), biopsy, blood tests, and tests of bladder function.
If all other possible causes of a patient’s symptoms are ruled out,
the doctor may then diagnose chronic prostatitis/chronic pelvic pain
syndrome. To aid in understanding the symptoms and measuring the
effects of treatment, the doctor may ask a series of questions from a
standard questionnaire, the NIH-Chronic Prostatitis Symptom In-
dex.
How is prostatitis treated?

The bacterial forms of prostatitis are treated with antimicrobials.
Acute prostatitis may require a short hospital stay so that fluids and
antimicrobials can be given through an intravenous, or IV, tube. Af-
ter the initial therapy, the patient will need to take antimicrobials for
two to four weeks.
Chronic bacterial prostatitis requires a longer course of therapy.
The doctor may prescribe a low dose of antimicrobials for six months
to prevent recurrent infection. If a patient has trouble emptying his
bladder, the doctor may recommend medicine or surgery to correct
blockage.
Antimicrobials will not help nonbacterial prostatitis. Each patient
will have to work with his doctor to find an effective treatment. Chang-
ing diet or taking warm baths may help. The doctor may prescribe a
medicine called an alpha blocker to relax the muscle tissue in the
prostate. No single solution works for everyone with this condition.
No treatment is needed for asymptomatic inflammatory prostati-
tis.
Reference
1. McNaughton-Collins M, Joyce GF, Wise M, Pontari MA. Pros-
tatitis. In: Litwin MS, Saigal CS, editors. Urologic Diseases in
444
America. U.S. Department of Health and Human Services, Pub-
lic Health Service, National Institutes of Health, National Insti-
tute of Diabetes and Digestive and Kidney Diseases. Washington,
DC: U.S. Government Publishing Office, 2007; NIH Publication
No. 07–5512 pp. 9–42.
445
Chapter 37
Disorders of the
Scrotum and Testicles
Chapter Contents
Section 37.1—Epididymitis and Orchitis .................................. 448
Section 37.2—Hydrocele and Inguinal Hernia ......................... 453
Section 37.3—Spermatocele ........................................................ 459
Section 37.4—Testicular Failure ................................................ 463
Section 37.5—Testicular Torsion ............................................... 466
Section 37.6—Undescended Testicle .......................................... 468
Section 37.7—Varicocele ............................................................. 470
447
Section 37.1
Epididymitis and Orchitis

“Epididymitis and Orchitis” is reprinted with permission from
If you are a male and experiencing pain the scrotum or testicle,

then it might be attributed to epididymitis, orchitis or a combination
of the two. The information below will give you a head start in learn-
ing more about these conditions and aid in you in your discussions
with a urologist.
What are epididymitis, orchitis, and epididymo-orchitis?

Epididymitis is inflammation of the epididymis—the coiled tube
that collects sperm from the testicle and passes it on to the vas def-
erens. There are two forms of this disease, acute and chronic. Acute
epididymitis comes on suddenly with severe symptoms and subsides
with treatment. Chronic epididymitis is a long-standing condition,
usually of gradual onset, for which the symptoms can be improved
with treatment but may not completely be eradicated. Most cases of
epididymitis occur in adults.
Orchitis is inflammation of the testicle. It almost always comes on
suddenly and subsides with treatment. Chronic orchitis is not well
defined, and instead is considered to be one of the many conditions
related to chronic testicular pain (orchalgia).
Epididymo-orchitis is the sudden inflammation of both the epididy-
mis and the testicle.
What are the causes of such conditions?

Acute epididymitis is usually caused by a bacterial infection. In chil-
dren who haven’t reached puberty, the infection usually starts in the
bladder or kidney and then spreads to the testicle. This is often associ-
ated with a birth-related abnormality that predisposes to urinary tract
infection. In sexually active men, the most common infection causing
448
Disorders of the Scrotum and Testicles
epididymitis is a sexually transmitted disease such as gonorrhea or
chlamydia infection. These infections start in the urethra, causing
urethritis, which can then move into the testicle. In men over forty years
of age, the most common cause is bacteria from the urinary tract. Other
causes can include: bladder outlet obstruction due to enlargement of
the prostate; partial blockage of the urethra; or recent catheterization
of the urethra. In any of these cases, the original infection may not cause
symptoms, and the first sign of a problem may be epididymitis. Bacte-
rial epididymitis rarely occurs when a bacterial infection spreads from
the bloodstream into the epididymis, although this is the typical way
that tuberculosis infection can involve the epididymis. Epididymitis is
occasionally due to causes other than infection. Chemical epididymitis
occurs when sterile urine flows backward from the urethra to the epi-
didymis, which most commonly occurs with heavy lifting or straining.
The urine causes inflammation without infection. The drug amiodarone
also can cause a noninfectious epididymitis, and there are other cases
of noninfectious epididymitis without known cause.
Chronic epididymitis may develop after several episodes of acute
epididymitis that do not subside, but also can occur without any symp-
tomatic episodes of acute epididymitis or prior infection—in which case
the cause is unknown.
In most cases of acute orchitis, the testicle is inflamed due to the
spread of a bacterial infection from the epididymis, and therefore
“epididymo-orchitis” is the correct term. Although orchitis without
epididymitis can occur from a bacterial infection, orchitis without
epididymitis usually results from an infection related to the mumps
virus. “Mumps orchitis” occurs in approximately one-third of males
who contract mumps after puberty.
Acute epididymo-orchitis is usually a primary bacterial or tuber-
culous infection of the epididymis that has spread to the testicle to
involve both structures. Rarely, it can start in the testicle and spread
to the epididymis. Mumps orchitis does not spread to the epididymis.
What are the symptoms and how are they diagnosed?

Acute epididymitis and acute epididymo-orchitis: Symptoms
occur not only from the local infection, but also from the original source
of the infection. Common symptoms from the original source of the
infection include: urethral discharge and urethral pain or itching (from
urethritis); pelvic pain and urinary frequency, urgency or painful/burn-
ing urination (from infection of the bladder, called cystitis); fever,
perineal pain, urinary frequency, urinary urgency, or painful/burning
449
urination (from infection of the prostate, called prostatitis); fever and
flank pain (from infection of the kidney, called pyelonephritis). In some
cases, pain in the scrotum from the local infection is the only notice-
able symptom. The pain starts at the back of one testicle but can soon
spread to the entire testicle, the scrotum, and occasionally the groin.
Swelling, tenderness, redness, firmness, and warmth of the skin may
also accompany the pain. The entire scrotum can swell up with fluid
(hydrocele). To make the diagnosis, the doctor will ask you about your
medical history and examine you. The doctor may test a urine sample
and look at it under the microscope to assess for bacterial infection,
culture a urine sample as a more definitive way to see if there is bac-
terial infection, or examine a swab obtained from the urethra (if ure-
thritis is suggested by your symptoms). If your pain came on very
suddenly and severely, then an ultrasound, which is a noninvasive test
that uses sound waves to look at the epididymis and measure blood
flow, might be used to distinguish epididymitis from another condi-
tion called testicular torsion. This is managed very differently than
epididymitis, so making the distinction is very important. Tubercu-
lous epididymitis presents in the same way, although chemical and
amiodarone epididymitis are less severe.
Chronic epididymitis: The pain occurs only in the scrotal con-

tents, and is less severe and more localized than acute epididymitis.
Swelling, tenderness, redness, and warmth of the skin do not occur.
Additional tests may be used as for acute epididymitis, but are less
frequently required. In acute epididymitis the urine is usually in-
fected, whereas in chronic epididymitis it is usually not.
Acute orchitis: During the acute phase of mumps orchitis, symp-

toms include pain of varying severity, tenderness, and swelling. The pa-
rotiditis (swelling of facial glands) of mumps usually precedes orchitis by
three to seven days. Isolated orchitis from bacterial infection has the
same symptoms of acute epididymitis or epididymo-orchitis.
What are the treatment options?

Acute epididymitis and acute epididymo-orchitis: Treatment
in cases suspected to be from bacteria (most) includes at least two
weeks of antibiotics. Most cases can be treated with oral antibiotics
as an outpatient. Your doctor can choose one of several, including:
doxycycline, azithromycin, ofloxacin, ciprofloxacin, levofloxacin, or
trimethoprim-sulfamethoxazole. Tuberculous epididymitis is treated
450
with anti-tuberculous medications, although in many cases surgical
removal of the testicle (orchiectomy, which includes removal of the
epididymis) is required because the damage is so severe. Cases of se-
vere infection, with intractable pain, vomiting, very high fever, or over-
all severe illness, may require admission to the hospital. Aside from
treatment of amiodarone epididymitis by reducing the dose or stop-
ping the drug, there is no specific therapy for noninfectious epididymi-
tis. General therapy for epididymitis includes bed rest for one to two
days combined with elevation of the scrotum. The aim is to get the
inflamed epididymis above the level of the heart. This improves blood
flow out of the testicle, which promotes more rapid healing and re-
duces swelling and discomfort. Intermittent application of ice might
also be of assistance and, in cases due to infection, intake of plenty of
fluids. Nonsteroidal anti-inflammatory drugs such as ibuprofen or na-
proxen are useful since they not only relieve pain but also reduce the
inflammation that is the cause of the pain.
Chronic epididymitis: Primary therapy is with medications and

other treatments directed towards reducing the discomfort. Nonste-
roidal anti-inflammatory medications and local application of heat are
the mainstays of treatment. If symptoms persist, your physician may
recommend other medications to alter the perception of pain in the
area, or might refer you to a specialist in pain management. If all else
fails the epididymis can be surgically removed (epididymectomy) while
leaving the testicle in place.
Acute orchitis: There is no specific treatment for acute mumps

orchitis. In cases of bacterial infection, treatment is as for acute epi-
didymitis and acute epididymo-orchitis.
What can be expected after treatment?

Acute epididymitis and acute epididymo-orchitis: In the typi-
cal infectious case, it will take two to three days for you to notice im-
provement. If the redness does not subside and you do not start to feel
better by that time, contact your physician. Complete resolution of
symptoms will take longer. Discomfort can persist until the entire
course of antibiotics is completed, and the firmness and swelling can
takes months to resolve. Following the instructions to stay at bed rest
with scrotal elevation for the first one to two days will help speed
recovery. You should follow up with your physician after treatment. In
cases of tuberculous epididymitis that do not require orchiectomy, it
451
takes months to resolve on medications, and there will likely be some
shrinking of the testicle. Amiodarone epididymitis improves after re-
ducing the dose or stopping the drug, without any residual problems.
Chemical epididymitis also resolves completely.
Chronic epididymitis: Treatment is ongoing, and not curative.

You may need to take medications for years, or until the symptoms
resolve spontaneously. If epididymectomy is performed, relief of symp-
toms occurs in three out of four patients after a few weeks for surgi-
cal recovery. If surgery has not resolved your symptoms, then your
doctor will try medical therapy again.
Acute orchitis: Following the acute phase of mumps orchitis, the

pain resolves but there is often atrophy of the testicle.
What if the swelling and pain do not get better after the
first three days of antibiotics?
Most cases of acute epididymitis or epididymo-orchitis are treated
well by antibiotics, but in some cases a different antibiotic needs to
be used. Tuberculous epididymitis should also be considered when
symptoms do not resolve appropriately. On occasion, surgery needs
to be performed. If an abscess (pocket of pus) has formed, antibiotics
alone are rarely sufficient and surgery to drain the abscess or remove
part or all of the epididymis and testicle might be required. Other com-
plications that might require surgery include testicular infarction
(death of the testicle due to destruction of the blood vessels) and cu-
taneous fistula (infection that continues to drain out through the skin).
Can I pass the infection to my sexual partner?

If the acute epididymitis or epididymo-orchitis is from a sexually
transmitted disease (usually in sexually active men under forty years
of age), then your sexual partner needs to be treated as well since the
infection can be passed back and forth through sexual contact. The
urinary tract bacteria that cause other cases of epididymitis or
epididymo-orchitis are not sexually transmitted. Treatment of your
partner is not required, and there is no risk of infecting your partner.
Will the ability to father children be reduced?

The atrophy associated with mumps orchitis and tuberculous epi-
didymitis is associated with reduced production of sperm in the affected
452
testicle in some cases. After an episode of acute epididymitis or
epididymo-orchitis there can rarely be blockage of the epididymis,
which would reduce delivery of sperm from that testicle. In any of
these cases, if the other testicle is unaffected then most men are able
to father a child normally.
Will hormone production by the testicle be affected?

The ability of the affected testicle to produce testosterone is lost in
some men with atrophy associated with mumps orchitis and tubercu-
lous epididymitis. The rare epididymal blockage that occurs after acute
epididymitis or epididymo-orchitis does not affect hormone production.
Do epididymal or testicular infections lead to cancer?

There is no association of these infections with cancer.
Section 37.2
Hydrocele and Inguinal Hernia

“Hydrocele” is reprinted from “Hydrocele,” © 2009 A.D.A.M., Inc. Reprinted
with permission. “Inguinal Hernia” is reprinted from “Inguinal Hernia,”
© 2009 The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland,
OH 44195. All rights reserved. reprinted with permission. Additional in-
formation is available from the Cleveland Clinic Health Information Cen-
ter, 216-444-3771, toll-free 800-223-2273 extension 43771, or at http://my
.clevelandclinic.org/health.
Hydrocele
Alternative Names
Processus vaginalis; patent processus vaginalis
Definition
A hydrocele is a fluid-filled sack along the spermatic cord within
the scrotum.
453
Causes
Hydroceles are common in newborn infants.
During normal development, the testicles descend down a tube
from the abdomen into the scrotum. Hydroceles result when this tube
fails to close. Fluid drains from the abdomen through the open tube.
The fluid builds up in the scrotum, where it becomes trapped. This
causes the scrotum to become swollen.
Hydroceles normally go away a few months after birth, but their
appearance may worry new parents. Occasionally, a hydrocele may
be associated with an inguinal hernia.
Hydroceles may also be caused by inflammation or injury of the
testicle or epididymis, or by fluid or blood blockage within the sper-
matic cord. This type of hydrocele is more common in older men.
Symptoms
The main symptom is a painless, swollen testicle, which feels like
a water balloon. A hydrocele may occur on one or both sides.
Exams and Tests

During a physical exam, the doctor usually finds a swollen scrotum
that is not tender. Often, the testicle cannot be felt because of the sur-
rounding fluid. The size of the fluid-filled sack can sometimes be in-
creased and decreased by pressure to the abdomen or the scrotum.
If the size of the fluid collection varies, it is more likely to be asso-
ciated with an inguinal hernia.
Hydroceles can be easily demonstrated by shining a flashlight
(transillumination) through the enlarged portion of the scrotum. If
the scrotum is full of clear fluid, as in a hydrocele, the scrotum will
light up.
An ultrasound may be done to confirm the diagnosis.
Treatment
Hydroceles are usually not dangerous, and they are usually only
treated when they cause discomfort or embarrassment, or if they are
large enough to threaten the testicle’s blood supply.
One option is to remove the fluid in the scrotum with a needle, a
process called aspiration. However, surgery is generally preferred. As-
piration may be the best alternative for people who have certain sur-
gical risks.
454
Sclerosing (thickening or hardening) medications may be injected
after aspiration to close off the opening. This helps prevent the fu-
ture buildup of fluid.
Hydroceles associated with an inguinal hernia should be repaired
surgically as quickly as possible. Hydroceles that do not go away on
their own over a period of months should be evaluated for possible
surgery. A surgical procedure, called a hydrocelectomy, is often per-
formed to correct a hydrocele.
Outlook (Prognosis)
Generally, a simple hydrocele goes away without surgery. If sur-
gery is necessary, it is a simple procedure for a skilled surgeon, and
usually has an excellent outcome.
Complications may occur from hydrocele treatment.
Risks related to hydrocele surgery may include:
• blood clots;
• infection;
• injury to the scrotal tissue or structures.
Risks related to aspiration and sclerosing may include:

• infection;
• fibrosis;
• mild to moderate pain in the scrotal area;
• return of the hydrocele.

symptoms of hydrocele (to rule out other causes of a testicle lump).
Acute pain in the scrotum or testicles is a surgical emergency. If
enlargement of the scrotum is associated with acute pain, seek medi-
cal attention immediately.
References
Behrman RE. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, Pa:
WB Saunders; 2004.
455
Wein AJ. Campbell. Walsh Urology. 9th ed. St. Louis, Mo: WB Saunders;
2007.
Inguinal Hernia
What is an inguinal hernia?
An inguinal hernia is an abnormal bulge, or protrusion, that can
be seen and felt in the groin area (the area between the abdomen and
the thigh). An inguinal hernia develops when a portion of an inter-
nal organ such as the intestine, along with fluid, bulges through a
weakened area in the muscle wall of the abdomen.
Who is at risk for an inguinal hernia?

Some people, especially men, are born with a weakness in their
groin muscles. Ninety percent of the newborns who have inguinal her-
nias are boys. With or without this weakness, an inguinal hernia can
be caused by increasing pressure in the abdomen. Risk factors include:
• Being moderately to severely overweight

• Pregnancy
• Lifting heavy objects
• Persistent coughing, such as smoker’s cough
• Sneezing a lot, which may be common in a person with allergies
• Straining during bowel movement, which may be caused by con-
stipation or diarrhea
• For men, trying to urinate when there is a blockage caused by
an enlarged prostate
What are the symptoms of inguinal hernia?

Inguinal hernias are characterized by pain in the groin area when
coughing, sneezing, or lifting. Some people may notice a slight bulge
or protrusion in the groin area that can be pushed back in. Other
symptoms include constipation and blood in the stool.
How is an inguinal hernia diagnosed?

A physician’s physical examination is often enough to diagnose a
hernia. Sometimes hernia swelling is visible when you stand upright.
456
Usually, the hernia can be felt if you place your hand directly over it
and then bear down. Ultrasound may be used to see certain types of
hernias, and abdominal x-rays and computed axial tomography (CAT)
scans may be ordered to identify a bowel obstruction.
How is an inguinal hernia treated?

If the hernia bulge can be pushed back in and the symptoms are
tolerable, you may not need surgery. Your physician may suggest that
you wear a special belt or binder to support the area, and avoid heavy
lifting.
If the inguinal hernia symptoms are painful, the treatment is elec-
tive surgery. The surgery to correct the condition is performed under
general anesthesia, either on an outpatient basis or in the hospital.
(In some cases, the surgery may be performed under a local anesthe-
sia.) The surgery, called herniorrhaphy, repairs the opening in the
muscle wall. Inguinal herniorrhaphy is performed using a laparoscope,
a thin, telescope-like instrument that requires a small incision and
involves a short recovery time.
During laparoscopic surgery, three to six small (5 to 10 millime-
ter) incisions are made in the abdomen. The laparoscope and surgi-
cal instruments are inserted through these incisions. The surgeon is
guided by the laparoscope, which transmits a picture of the internal
organs on a monitor. The advantages of laparoscopic surgery include
smaller incisions, less risk of infection, less pain and scarring, and a
more rapid recovery.
Sometimes the weak area is reinforced with mesh or wire. This
operation is called hernioplasty.
Incarcerated and strangulated hernias: If the weakness in the

abdominal wall is small to moderate in size, a portion of intestine may
get trapped, or incarcerated. This is called an incarcerated hernia and
can cause problems such as severe pain, nausea, vomiting, or absence
of bowel movements.
If the intestine becomes incarcerated or trapped in the abdominal
wall defect, blood flow to the intestines may become blocked. This is
called a strangulated hernia. This type of hernia is often painful and
requires prompt surgery.
Surgery may be needed to remove part of the intestine if the her-
nia is incarcerated or strangulated. This surgery is called bowel re-
section. (Bowel is another word for intestine.) Bowel resection can also
be performed laparoscopically.
457
Recovering from surgery: Many patients are able to walk around
the day after hernia surgery. Generally, there are no dietary restric-
tions and the patient can resume his or her regular activities within
a week (with the exception of lifting). Complete recovery will take
three to four weeks, and hard labor and heavy lifting should be avoided
for at least three months after surgery. Surgery is no guarantee that
your hernia will not return, so preventive measures are especially
important to avoid a recurrence.
How can I prevent an inguinal hernia?

• If you are overweight, follow your physician’s advice for losing
weight.
• Avoid lifting, pulling, and pushing heavy objects. Use proper
lifting, pulling, and pushing techniques when needed. Bend at
your knees and lift using your legs rather than your back.
• Stop smoking and try to avoid coughing.
• Use deep breathing techniques to help control your coughing.
Obtain a medical prescription to treat the condition causing your
cough.
• Take medication to reduce allergies and sneezing.
• Avoid constipation by eating foods that are high in fiber, using
stool softeners, or drinking a natural stimulant beverage such
as prune juice. Use laxatives or enemas only if recommended by
your physician.
• For males, wear a jock strap or similar groin support.
• Adjust your occupational duties, if necessary.
When should I call the doctor?

If you have been diagnosed with a hernia, and you have the follow-
ing symptoms—nausea, vomiting, unable to have a bowel movement,
or pass gas—you may have a strangulated hernia or an obstruction.
These are medical emergencies. Call your doctor immediately.
458
Section 37.3
Spermatocele
“Spermatoceles” is reprinted with permission from
The male reproductive tract is responsible for the production,

maturation of sperm, and delivery of sperm. This tract is a complex
and highly integrated entity. Sperm are produced in the testicles and
then are transported through the genital ductal system to the penis
and out of the urethra during ejaculation. Each component of the re-
productive tract is highly specialized.
Abnormalities within the male reproductive tract may appear as
scrotal masses. Masses may be of little significance or may represent
life-threatening illnesses. It is necessary to follow a set course of ac-
tion to determine the nature of the masses and the most appropriate
treatment option. For example, testicular cancer is a source of great
concern and uniformly requires prompt intervention. Other masses,
such as varicoceles, can cause pain or impair reproductive function.
Spermatoceles are benign and generally painless masses that grow at
the top of the testicle. Thus, it is important for a patient to seek prompt
medical attention when he identifies a scrotal mass or abnormality
while performing testicular self-examination. The following informa-
tion will assist you when talking to a urologist about spermatoceles.
What is a spermatocele?
Spermatoceles, also known as spermatic cysts, are typically pain-
less, noncancerous (benign) cysts that grow from the epididymis near
the top of the testicle. Spermatoceles are typically smooth and they
are usually filled with a milky or clear colored fluid containing sperm.
Over time, spermatoceles may remain stable in size or they may grow.
If in fact the size becomes bothersome, or results in pain, then there
are several treatment options to rectify the problem. Spermatoceles
are generally no more than a nuisance rather than a serious medical
condition.
459
What can cause spermatoceles?

The precise cause of spermatoceles is not known. While spermato-
celes may form as a result of trauma or inflammation, these condi-
tions are certainly not required for spermatocele formation. Others
suggest that blockage of the efferent ducts and epididymis result in
spermatocele formation. Additionally, in utero exposure to diethylstil-
bestrol (DES), a synthetic form of estrogen, has also been suggested
as a possible cause.
How common are spermatoceles?

The precise incidence of spermatoceles is unknown, but an esti-
mated 30 percent of all men have this condition. Incidence increases
with age, with peak rates for the diagnosis of spermatoceles occur-
ring in men in their forties and fifties. No racial or ethnic predisposi-
tions to spermatocele formation are known.
What are the symptoms of spermatoceles?

Men with spermatoceles usually have no symptoms. However, when
associated symptoms are present, they may include scrotal heaviness
and/or pain.
How are spermatoceles diagnosed?

Spermatoceles are typically discovered through a man’s self-
examination of his testicles or at the time of an evaluation by a physi-
cian. Light can be shined through a spermatocele (transillumination),
indicating that the mass is not a solid tumor but more likely a be-
nign cyst. Ultrasound examination remains a very reliable means of
evaluation and is a relatively quick, noninvasive, and inexpensive test.
Other diagnostic imaging tests are not generally used although mag-
netic resonance imaging (MRI) can also be used as an adjunct in cases
where scrotal ultrasound is inconclusive.
How are spermatoceles treated?

Since spermatoceles generally do not cause discomfort and often
go unnoticed by patients, they rarely require treatment. Nevertheless,
some affected individuals do experience significant associated symp-
toms, such as bothersome size or pain. When intervention is indicated,
the available treatment options include:
460
• Medical therapy: Oral analgesics or anti-inflammatory agents
may be used to relieve pain associated with symptomatic sper-
matoceles. No other type of medical therapy is specifically indi-
cated for the treatment of spermatoceles.
• Surgical therapy: Spermatocelectomy involves surgical re-
moval of the spermatocele from the adjoining epididymal tissue.
The overall goal of surgical therapy is removal of the spermato-
cele with preservation of the continuity of the male reproductive
tract.
• Other therapies: Aspiration and sclerotherapy are two less
commonly utilized approaches to treat spermatoceles. Aspira-
tion involves puncture of the spermatocele with a needle and
withdrawal of its contents into a syringe. Sclerotherapy is per-
formed with subsequent injection of an irritating agent directly
into the spermatocele sac to cause it to heal or scar closed, re-
moving the spermatocele space and decreasing the odds of fluid
reaccumulation. Although several reports describe the effective-
ness and tolerability of these treatment options, they are gener-
ally not recommended. Spermatocele recurrence is a common
complication with both approaches, and chemical epididymitis
and pain are common complications with sclerotherapy. Fur-
thermore, aspiration and sclerotherapy have limited applicabil-
ity in men of reproductive age, due to the significant risk of
epididymal damage potentially leading to obstruction and re-
sultant subfertility.
What can be expected after surgical treatment?

Spermatocelectomy is typically performed as an outpatient proce-
dure, under a variety of possible anesthetic agents. Patients are gen-
erally discharged home with a pressure dressing consisting of an
athletic supporter filled with fluffy gauze. Ice packs are applied for
two to three days to minimize swelling. Oral pain medications are
generally used for one to two days postoperatively. Patients may
shower twenty-four to forty-eight hours after surgery, and a follow-
up visit is scheduled for one to two weeks after the procedure.
Potential complications of spermatocelectomy include fever, infec-
tion, bleeding (scrotal hematoma), and persistent pain. Furthermore,
inadvertent epididymal obstruction may result, which can lead to
subfertility or infertility. Therefore, intervention should be avoided in
men who still desire children. These complications may potentially
461
be minimized by use of meticulous surgical technique (including use
of an operating microscope or optical magnification).
Do spermatoceles lead to testicular cancer?

Spermatoceles are benign epididymal lesions. They are separate
and distinct from the testicle. Patients with spermatoceles do not have
an identified increased risk of testicular cancer.
Are any medications available to cure my spermatocele or

prevent the formation of additional ones?
Medications are available to treat associated discomfort or pain,
but no medication will lead to resolution or prevention of spermat-
oceles.
How often should I perform scrotal self-exams?

These exams should be performed at least once per month. Your
physician can instruct you in the specific technique. If you detect any
suspicious changes, such as increasing size or unusual firmness of
scrotal structures, contact your physician.
462
Section 37.4
Testicular Failure
Reprinted from “Testicular Failure,”
Alternative Names
Primary hypogonadism—male
Definition
Testicular failure is the inability of the testicles to produce sperm
or male hormones.
Causes
Testicular failure is uncommon. Causes include:
• certain drugs, including glucocorticoids, ketoconazole, and opioids;
• chromosome problems;
• diseases that affect the testicle, including mumps, orchitis, and
testicular cancer;
• injury to the testicles;
• testicular torsion.
The following things increase the risk for testicular failure:

• Activities that may cause constant, low-level injury to the scro-
tum, such as riding a motorcycle
• Frequent and heavy use of marijuana
• Undescended testicles at birth
Symptoms
• Decrease in height
463
• Enlarged breasts (gynecomastia)
• Infertility
• Lack of muscle mass
• Lack of sex drive (libido)
• Loss of armpit and pubic hair
• Slow development or absence of secondary male sex characteris-
tics (growth and distribution of hair, scrotal enlargement, penis
enlargement, voice changes)
Men may also notice they do not need to shave as frequently.
Exams and Tests

A physical examination may reveal:
• genitals that do not clearly look either male or female (usually

noted in infancy);
• abnormally small testicle;
• tumor or mass (group of cells) on or near the testicle.
Further testing may show decreased bone mineral density and frac-
tures. Blood tests may reveal low levels of testosterone and high lev-
els of follicle-stimulating hormone (FSH) and luteinizing hormone
(LH).
Testicular failure and low testosterone levels may be difficult to
diagnose in older men because testosterone levels normally fall with
age. The level of testosterone at which replacement therapy would be
likely to improve symptoms and other outcomes is unpredictable and
variable.
Treatment
Male hormone supplements may successfully treat some forms of
testicular failure. Men who take testosterone replacement therapy
need to be carefully monitored by a doctor. Testosterone may cause
overgrowth of the prostate gland and an abnormal increase in red
blood cells.
Avoiding a specific drug or activity known to cause the problem may
result in return of normal testicular function.
464
Outlook (Prognosis)
Many forms of testicular failure cannot be reversed. Hormone re-
placement therapy can help reverse symptoms, although it may not
restore fertility.
Testicular failure before the onset of puberty will stop normal body
growth, specifically the development of adult male characteristics.

symptoms of testicular failure.
Prevention
Avoid higher-risk activities if possible.
References
Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy
in adult men with androgen deficiency syndromes: an Endocrine So-
ciety clinical practice guideline. J Clin Endocrinol Metab. 2006
Jun;91(6):1995–2010.
465
Section 37.5
Testicular Torsion
Reprinted from “Testicular Torsion,”
Alternative Names
Torsion of the testis; testicular ischemia; testicular twisting
Definition
Testicular torsion is the twisting of the spermatic cord, which cuts
off the blood supply to the testicle and surrounding structures within
the scrotum.
Causes
Some men may be predisposed to testicular torsion as a result of
inadequate connective tissue within the scrotum. However, the con-
dition can result from trauma to the scrotum, particularly if signifi-
cant swelling occurs. It may also occur after strenuous exercise or may
not have an obvious cause.
The condition is more common during infancy (first year of life)
and at the beginning of adolescence (puberty).
Symptoms
• Sudden onset of severe pain in one testicle, with or without a
previous predisposing event
• Swelling within one side of the scrotum (scrotal swelling)
• Nausea or vomiting
• Light-headedness
Additional symptoms that may be associated with this disease:
466
• Testicle lump
• Blood in the semen
• Extremely tender and enlarged testicular region—more com-
mon on the right
• The testicle on the affected side is higher
Treatment
Surgery is usually required and should be performed as soon as
possible after symptoms begin. If surgery is performed within six
hours, most testicles can be saved.
During surgery, the testicle on the other (non-affected) side is usu-
ally also anchored as a preventive measure. This is because the non-
affected testicle is at risk of testicular torsion in the future.
Outlook (Prognosis)
If the condition is diagnosed quickly and immediately corrected,
the testicle may continue to function properly. After six hours of tor-
sion (impaired blood flow), the likelihood that the testicle will need
to be removed increases. However, even with less than six hours of
torsion, the testicle may lose its ability to function.
If the blood supply is cut off to the testicle for a prolonged pe-
riod of time, it may atrophy (shrink) and need to be surgically re-
moved. Atrophy of the testicle may occur days to months after the
torsion has been corrected. Severe infection of the testicle and scro-
tum is also possible if the blood flow is restricted for a prolonged
period.

Go to the emergency room or call the local emergency number (such
as 911) if testicular torsion symptoms occur.
Prevention
Use precautions to avoid trauma to the scrotum. Many cases are
not preventable.
467
References
Expert Panel on Urologic Imaging. Acute onset of scrotal pain (with-
out trauma, without antecedent mass). Reston, Va: American College
of Radiology; 2005. 4 p.
Ringdahl E. Testicular Torsion. Am Fam Physician. Nov 2006; 74(10):
1739–43.
Wein AJ. Campbell- Walsh Urology. 9th ed. St. Louis, Mo: WB Saunders;
2007.
Section 37.6
Undescended Testicle
“Undescended Testicle (Cryptorchidism),” by
Christopher Cooper, M.D. Reprinted with permission of the
University of Iowa Department of Urology, © 2006.
What is an undescended testicle?

When the testicle is formed it is located in the abdomen. In most
boys it comes down into the scrotum by birth. Even after birth some
testicles will still come down to the normal position in the scrotum
(most of these come down by four months of age). If a testicle is not
in the scrotum by six months of age, it is unlikely that it will come
down. This testicle is called an undescended testicle. If the testicle
can’t be felt at all, it is called a “cryptorchid testicle.” An undescended
testicle requires surgery, called “orchidopexy,” to place it in the scro-
tum.
Why is surgery necessary?

There are several reasons for placing an undescended testicle in
the scrotum.
Fertility: The temperature in the scrotum is less than up in the

abdomen. We know that the sperm-producing cells in the testicle do
468
better if they are in the cooler scrotal environment. Bringing the tes-
ticle down into the scrotum at an early age may improve the semen
quality and chances of fertility later in life.
Cancer: Undescended testicles have an increased chance of devel-

oping cancer later in life. It is unclear if early placement of the tes-
ticle in the scrotum decreases this chance of cancer. Placement of the
testicle in the scrotum does permit self-examination of the testicle and
earlier detection of testicular cancer should it occur.
Hernia: A hernia sac is almost always associated with an unde-

scended testicle. During the operation to bring the testicle down, this
hernia is routinely identified and fixed.
Protection: A testicle left in the abdomen may be at increased risk

for injury or torsion (twisting and cutting of its blood supply).
Cosmoses: Placement of the testicle in the scrotum makes the

scrotum look normal.
When should surgery be performed?

Since some testicles that are not descended at birth will come down,
it is best to wait until around six months of age. By this age if a tes-
ticle cannot be felt or is very high, it is unlikely that it will come down.
What is the surgery like?

In most cases the child will go home on the same day the surgery
is performed. A small incision is made in the groin and on the scro-
tum. No stitches will need to be removed. In some boys when the tes-
ticle can’t be felt (known as “cryptorchidism”), laparoscopy may be
used. Laparoscopy involves making an incision in the abdomen and
placing a lighted telescope through this incision to look for the miss-
ing testicle. If it is found (some testicles are absent), laparoscopy is
used for bringing it down into the scrotum.
What are some of the specific complications with orchi-

dopexy?
Wound infection or bleeding may occur with any operation. Injury
to the testicular blood vessels or vas deferens (the tube that carries
sperm) may occur when performing an orchidopexy. These structures
469
are delicate and avoidance of injury requires delicacy and precision
while performing the surgery. Rarely, there are some testicles that
don’t reach the scrotum after the first surgery and require a second
surgery (about a year later) to bring them into their normal scrotal
position.
Section 37.7
Varicocele
Excerpted from “Varicocele,” April 2007, reprinted with permission from
www.kidshealth.org. Copyright © 2007 The Nemours Foundation. This
information was provided by KidsHealth, one of the largest resources
online for medically reviewed health information written for parents, kids,
and teens. For more articles like this one, visit www.KidsHealth.org, or
www.TeensHealth.org.
What is a varicocele?
In all guys, there’s a structure that contains arteries, veins, nerves,
and tubes—called the spermatic cord—that provides a connection and
circulates blood to and from the testicles. Veins carry the blood flow-
ing from the body back toward the heart, and a bunch of valves in
the veins keep the blood flowing one way and stop it from flowing
backward. In other words, the valves regulate your blood flow and
make sure everything is flowing in the right direction.
But sometimes these valves can fail. When this happens, some of
the blood can flow in reverse. This backed-up blood can collect in pools
in the veins, which then causes the veins to stretch and get bigger, or
become swollen. This is called a varicocele (pronounced: var-uh-ko-
seel).
Who gets them?

Although they don’t happen to every guy, varicoceles are fairly com-
mon. They appear in about 15 percent of guys between fifteen and
twenty-five years old, and they mostly occur during puberty. That’s
because during puberty, the testicles grow rapidly and need more blood
470
delivered to them. If the valves in the veins in the scrotum aren’t func-
tioning quite as well as they should, the veins can’t handle transport-
ing this extra blood from the testicles. So, although most of the blood
continues to flow correctly, blood begins to back up, creating a varico-
cele.
An interesting fact is that varicoceles occur mostly on the left side
of the scrotum. This is because a guy’s body is organized so that blood
flow on that side of the scrotum is greater, so varicoceles happen more
often in the left testicle than the right. Although it’s less common, they
can sometimes occur on both sides.
What are the signs and symptoms?

In most cases, guys have no symptoms at all. A guy might not even
be aware that he has a varicocele. However, if there are symptoms,
they tend to occur during hot weather, after heavy exercise, or when
a guy has been standing or sitting for a long time. Signs include:
• a dull ache in the testicle(s);
• a feeling of heaviness or dragging in the scrotum;
• dilated veins in the scrotum that can be felt (described as feel-
ing like worms or spaghetti);
• discomfort in the testicle or on that particular side of the scro-
tum;
• the testicle is smaller on the side where the dilated veins are
(due to difference in blood flow).
What do doctors do?

It’s a good idea to get a testicular exam regularly, which is normally
part of a guy’s regular checkup. In addition to visually checking for
any unusual lumps or bumps, the doctor generally feels the testicles
and the area around them to make sure a guy’s equipment is in good
shape and there are no problems.
A testicular exam may be done while a guy is standing up so that
the scrotum is relaxed. (Some abnormalities like a varicocele can be
more easily felt in a standing position.) The doctor checks things like
the size, weight, and position of the testicles, and gently rolls each
testicle back and forth to feel for lumps or swelling. The doctor also
feels for any signs of tenderness along the epididymis, the tube that
transports sperm from the testicles.
471
The spermatic cord is also examined for any indication of swell-
ing. If the doctor suspects a varicocele, he or she might confirm sus-
picions by using a stethoscope to hear the blood flowing backward
through the faulty veins or might even use an ultrasound, which can
identify malfunction of the veins and also measure blood flow.
Do varicoceles cause permanent damage?

Although there is no way to prevent a varicocele, it usually needs
no special treatment. A varicocele is usually harmless and more than
likely won’t affect a guy’s ability to father a child. Some experts be-
lieve, though, that in some cases a varicocele might damage the tes-
ticle or decrease sperm production. In those cases, a doctor will
probably recommend surgery.
What if the doctor finds a varicocele?

Varicoceles are generally harmless, but if there is any pain and
swelling the doctor may prescribe an anti-inflammatory medication
to relieve it. If the varicocele is causing discomfort or aching, wear-
ing snug underwear (like briefs) or a jock strap for support may bring
relief. If pain is persistent and support doesn’t help, the doctor may
recommend a varicocelectomy (a surgical procedure to remove the
varicocele).
A varicocelectomy is done by a urologist (pronounced: yoo-rah-luh-
jist), a doctor who specializes in urinary and genital problems. The
procedure is usually done on an outpatient basis (meaning there’s no
need for an overnight stay in hospital). The patient usually undergoes
general or local anesthesia. To fix the problem, the doctor simply ties
off the affected vein to redirect the flow of blood into other normal
veins.
After surgery, the doctor probably will recommend that a guy wears
a scrotal support and places an ice pack on the area to bring down
any swelling. There may be discomfort in the testicle for a few weeks,
but after that, any aches and pains will go away and everything should
be back in full working order.
472
Part Four
Other Common Health

Concerns in Men
Chapter 38
Violence and Abuse
Chapter Contents
Section 38.1—Violence Is a Concern for Men ............................ 476
Section 38.2—Men Can Be Victims of Sexual Assault ............. 478
Section 38.3—Are You Being Abused? ....................................... 480
475
Section 38.1
Violence Is a Concern for Men

Reprinted from “Violence Prevention,”
National Women’s Health Information Center, July 17, 2008.
Consider the following:

• 86 percent of homicide deaths for victims eighteen to twenty-
four years of age are males.
• Homicide is the fifth leading cause of death for black males.
• Males are almost four times more likely than females to be
murdered.
• Suicide is the eighth leading cause of death for all U.S. men.
The statistics on violent deaths tell only part of the story, however.
Many more survive violence and are left with permanent physical and
emotional scars. Men also are more likely than women to commit acts
of violence. One nationwide survey found male students more likely
to have been involved in a physical fight than female students in the
twelve months preceding the survey.
Many people don’t talk about the fact that men are sometimes vic-
tims of intimate partner violence or sexual violence. Only 20 to 50 per-
cent of all the different forms of intimate partner violence are reported
to the police, and even fewer against men are reported. Although women
are more likely to be victims of sexual violence than men, this finding
may be influenced by the reluctance of men to report sexual violence.
Rape is a serious issue among incarcerated men. Many times, men who
are victims of these crimes remain silent and suffer alone.
Get Help for Violence in Your Life

Intimate Partner Violence—Including Domestic Violence
and Sexual Violence
Violence against anyone, in any form, is a crime, regardless of who
committed the violent act. It is always wrong, whether the abuser is
476
Violence and Abuse
a family member; someone you date; a current or past spouse, boy-
friend, or girlfriend; an acquaintance; or a stranger. You are not at
fault. You did not cause the abuse to occur, and you are not respon-
sible for the violent behavior of someone else. If you or someone you
know has been sexually, physically, or emotionally abused, seek help
from other family members and friends or community organizations.
Reach out for support or counseling. Talk with a doctor, especially if
you have been physically hurt. Learn how to minimize your risk of
becoming a victim of sexual assault or sexual abuse before you find
yourself in an uncomfortable or threatening situation. Keep in mind,
if you’re a victim of violence at the hands of someone you know or love
or you are recovering from an assault by a stranger, you are not alone.
Are You Violent?

Maybe you abuse somebody you love. Perhaps you lash out physi-
cally at others when angry. If you want to stop the cycle of violence in
your life, talk to your doctor. Your doctor can help you find a mental
health professional who can help you deal with your abuse.
Help Prevent Violence among Youth

Acts of violence have terrible and costly results for everyone in-
volved, including families, communities, and society. Preventing vio-
lence is a top public health priority in the United States. You can do
your part by being a good role model to the young men in your life.
Teach them early and often that there is no place for violence in a
relationship, and that violence of any kind is always wrong. Whether
you are a father, coach, teacher, uncle, older brother, or mentor, you
can make a real difference in a boy’s life. Many young men need ad-
vice and direction on how to behave toward women and their peers,
and they want to talk to you about it. You can share your experiences
and let them know what you’ve learned.
477
Section 38.2
Men Can Be Victims of Sexual Assault

“Male Survivors: Men Who Have Been Sexually Assaulted,”
© 2001 Men Can Stop Rape (www.mencanstoprape.org). Reprinted
with permission. Reviewed for currency in 2009.
Rape is a men’s issue for many reasons. For one, we don’t often talk
about the fact that men are sexually assaulted. We need to start rec-
ognizing the presence of male survivors and acknowledging their
unique experience.
The following questions and answers can help us all learn about
male survivors so that we stop treating them as invisible and start
helping them heal.
How often are men sexually assaulted?

While the numbers vary from study to study, most research sug-
gests that 10 to 20 percent of males will be sexually violated at some
point in their lifetimes. That translates into tens of thousands of boys
and men assaulted each year alongside hundreds of thousands of girls
and women.
If there are so many male survivors, why don’t I know any?

Like female survivors, most male survivors never report being as-
saulted. Perhaps worst of all, men fear being blamed for the assault
because they were not “man enough” to protect themselves in the face
of an attack.
Can a woman sexually assault a man?

Yes, but it’s not nearly as common as male-on-male assault. A re-
cent study shows that more than 86 percent of male survivors are
sexually abused by another male. That is not to say, however, that we
should overlook boys or men who are victimized by females. It may
be tempting to dismiss such experiences as wanted sexual initiation
(especially in the case of an older female assaulting a younger male),
478
Violence and Abuse
but the reality is that the impact of female-on-male assault can be
just as damaging.
Don’t only men in prison get raped?

While prison rape is a serious problem and a serious crime, many
male survivors are assaulted in everyday environments often by
people they know—friends, teammates, relatives, teachers, clergy,
bosses, or partners. As with female survivors, men are also sometimes
raped by strangers. These situations tend to be more violent and more
often involve a group of attackers rather than a single attacker.
How does rape affect men differently from women?

Rape affects men in many ways similar to women. Anxiety, anger,
sadness, confusion, fear, numbness, self-blame, helplessness, hopeless-
ness, suicidal feelings, and shame are common reactions of both male
and female survivors.
In some ways, though, men react uniquely to being sexually as-
saulted. Immediately after an assault, men may show more hostility
and aggression rather than tearfulness and fear. Over time, they may
also question their sexual identity, act out in a sexually aggressive
manner, and even downplay the impact of the assault.
Don’t men who get raped become rapists?

No! This is a destructive myth that often adds to the anxiety a male
survivor feels afterwards. Because of this myth, it is common for a
male survivor to fear that he is now destined to do to others what was
done to him.
While many convicted sex offenders have a history of being sexu-
ally abused, most male survivors do not become offenders. The truth
is that the great majority of male survivors have never and will never
sexually assault anyone.
If a man is raped by another man, does it mean he’s gay?

No! A man getting raped by another man says nothing about his
sexual orientation before the assault, nor does it change his sexual
orientation afterwards.
Rape is prompted by anger or a desire to intimidate or dominate,
not by sexual attraction or a rapist’s assumption about his intended
victim’s sexual preference.
479
Because of society’s confusion about the role that attraction plays
in sexual assault and whether victims are responsible for provoking
an assault, even heterosexual male survivors may worry that they
somehow gave off “gay vibes” that the rapist picked up and acted upon.
This is hardly the case.
How should I respond if a man tells me he has been as-

saulted?
The basics of supporting female survivors are the same for males.
Believe him. Don’t push and don’t blame. Be cautious about physical
contact until he’s ready. Ask him if he wants to report it to the au-
thorities and if he wants to talk to a counselor. If you need to, get coun-
seling for yourself as well.
Where can male survivors go for help?

Most community resources—local or campus-based rape crisis cen-
ters—have on-site counselors trained in working with male survivors.
Or they can refer survivors to professionals who can help. Know the
resources in your area to help male survivors heal.
Section 38.3
Are You Being Abused?

“Male Victims of Domestic Abuse,” © 2008 Domestic Abuse Helpline for
Men and Women. Reprinted with permission. The Domestic Abuse
Helpline for Men and Women offers a national 24-hour helpline for infor-
mation and support, referrals to other programs and resources, and other
supportive services. For additional information, call the Helpline at 888-
7HELPLINE (888-743-5754) or visit www.dahmw.info.
Have You Been Abused?

• Does your partner block an exit to keep you from leaving during
an argument? Open personal mail? Keep you from seeing friends
or family? Use name-calling?
480
Violence and Abuse
• Does your partner denigrate you in the presence of others? Say
no one else would want you? Threaten suicide if you were to
leave?
• Do you feel like you’re “walking on eggshells” around your part-
ner? Does she act like two different people (e.g., Dr. Jekyll/Mr.
Hyde)?
• Does she threaten that if you leave you will never see the chil-
dren again? Destroy or threaten to destroy your property?
• Have you been shoved, slapped, punched, bitten, or kicked?
Even once?
• Does your partner anger easily, especially when drinking or on
drugs?
If any number of these factors are true in your relationship, there

is a problem. Victims of intimate partner violence come from all walks
of life–all cultures, incomes, professions, ages, and religions. Intimate
partner violence is not always defined by who’s the stronger and/or
bigger person in the relationship. However, it is about one person
having and maintaining power and control over another person
through physical, psychological, and/or verbally abusive means.
Why Men Don’t Tell

Men typically face disbelief and ridicule when reporting abuse.
As a result, male victims of domestic abuse tend to make excuses
for injuries—”It was an accident”—when questioned by friends or
medical personnel, which only allows perpetrators to continue the
abuse.
Abusers are experts at making their victims feel like no one is on
their side. Feeling like no one cares can create a spiral of isolation—
the more you withdraw from friends and family, the less those who
care about you will be able to help.
Though you may have been injured far worse on an athletic field,
it is not the same thing as being physically attacked by your intimate
partner, which hurts emotionally as well as physically. Allowing this
pattern to continue can result in depression, substance abuse, loss of
confidence, and even suicide.
For over thirty years, domestic violence has been defined as “the
chronic abuse of power that men use to control women.” Public aware-
ness campaigns have focused solely on men as the perpetrators, never
481
as victims. And yet, a Department of Justice study indicates that over
834,000 men report being domestically assaulted annually. The gen-
eral public has been desensitized by sit-coms and commercials depict-
ing men being hit over the head with frying pans, kicked in the groin,
and slapped in the face by their intimate female partners. What mes-
sage does this give society? A woman hitting a man is humorous and
acceptable behavior. But it’s not. No one deserves to be abused, whether
man, woman, or child.
What You Can Do

• Keep a record of incidents of abuse.
• Take photographs.
• Always seek medical attention for your injuries, and be truthful
about what caused them.
• Tell family and friends what is happening.
• Avoid being provoked into physical retaliation. When it is safe
for you to do so, leave.
• Document! Document! Document!
Reasons Why Men Stay in Abusive Relationships

• Shame: What will people think? OR I don’t want to be laughed
at OR No one will believe me.
• Self-worth: I probably deserved it.
• Denial: I can handle it, it’s not that bad OR All I have to do is
leave the house until she cools down OR It’s premenstrual syn-
drome; the kids are giving her a hard time.
• Reluctance to give up the good: She is a really creative, or
loving, or wonderful person most of the time OR She didn’t mean
it.
• Inertia: It’s too hard to do anything about it OR I’m not ready
to change my life OR I’ll deal with it later.
482
Chapter 39
Mental Health Concerns
Chapter Contents
Section 39.1—Depression in Men ............................................... 484
Section 39.2—Obsessive-Compulsive Disorder ......................... 493
Section 39.3—Phobias ................................................................. 495
Section 39.4—Posttraumatic Stress Disorder ........................... 497
Section 39.5—Schizophrenia ...................................................... 499
483
Section 39.1
Depression in Men
Reprinted with permission from “Men and Depression,” a publication
of the Royal College of Psychiatrists, http://www.rcpsych.ac.uk. Copy-
right © 2008 Royal College of Psychiatrists. All rights reserved.
Introduction
This section is for any man who is depressed, their friends and their
family. Men seem to suffer from depression just as often as women, but
they are less likely to ask for help. This section gives some basic facts
about depression, how it affects men in particular, and how to get help.
Why Is It Important?
Depression causes a huge amount of suffering. It is a major rea-
son for people taking time off work. Many people who kill themselves
have been depressed—so it is potentially fatal. However, it is easy to
treat, and this is best done as early as possible.
What’s the Difference Between Just Feeling Miserable

and Being Depressed?
Everyone has times in their lives when they feel down or depressed.
It is usually for a good reason, does not dominate your life, and does
not last for a long time. However, if the depression goes on for a long
time, or becomes very severe, you may find yourself stuck and unable
to lift yourself out of the depression. This is what doctors call a “de-
pressive illness.” Some people suffer from manic depression (also
called bipolar affective disorder). They have periods of bad depression,
but also times of great “elation” and overactivity. These can be just
as harmful as the periods of depression.
What Are the Signs and Symptoms?

If you are depressed, you will probably notice some of the following:
484
• Mind:
• You feel unhappy, miserable, down, depressed. It just won’t
go away and can be worse at a particular time of day, often
first thing in the morning.
• You can’t enjoy anything.
• You can’t concentrate properly.
• You feel guilty about things that have nothing to do with you.
• You become pessimistic.
• You start to feel hopeless, and perhaps even suicidal.
• Body:
• You can’t get to sleep, and wake early in the morning and/or
throughout the night.
• You lose interest in sex.
• You can’t eat.
• You lose weight.
Other people may notice that you:
• perform less well at work;

• seem unusually quiet and unable to talk about things;
• worry about things more than usual;
• are more irritable than usual;
• complain more about vague physical problems;
• are not looking after yourself properly—you may not bother to
shave, wash your hair, look after your clothes.
How Is Depression Different for Men?

There is no evidence for a completely separate type of “male de-
pression.” However, there is evidence that some symptoms of depres-
sion are more common in men than in women. These include the
following:
• Irritability
• Sudden anger
• Increased loss of control
485
• Greater risk-taking
• Aggression
Men are also more likely to commit suicide.
Getting Help
Men seem to suffer from depression just as often as women, but
are less likely to ask for help. It may also be that men try to deal with
their depression by using drugs and alcohol. This might account for
the fact that, although men are diagnosed as having depression less
than women, they abuse drugs and alcohol rather more.
Men’s Attitudes and Behavior

Compared with women, men tend to be more competitive and con-
cerned with power and success. Most men don’t like to admit that they
feel fragile or that they need help. They feel that they should rely on
themselves, and that it is somehow weak to have to depend on some-
one else, even for a short time. So they are less likely to talk about
their feelings with their friends, their loved ones, or their doctors. This
may be why they don’t get the help they need.
This traditional view of how men should be—always tough and self-
reliant—is also held by some women. Some men worry that, if they
talk about their feelings of depression, their partner may reject them.
Even professionals may share this view, and do not spot depression
in men as often as they should.
How Do Men Cope?

Instead of talking about how they feel, men may use alcohol or
drugs to feel better. This usually makes things worse, certainly in the
long run. Your work will suffer and alcohol often leads to irrespon-
sible, unpleasant, or dangerous behavior. Men may also focus more
on their work than their relationships or home life. This can cause
conflicts with your wife or partner. All of these things make depres-
sion more likely.
Relationships
For married men, research has shown that trouble in a marriage or
long-term relationship is the single most common problem associated
486
with depression. Men can’t cope with disagreements as well as women.
Arguments actually make men feel very physically uncomfortable.
They try to avoid arguments or difficult discussions. The partner will
want to talk about a problem, but he will do his best to avoid it. The
partner then feels ignored and tries to talk about it more, which makes
the man feel he is being nagged. So, he withdraws further, which
makes his partner feel even more ignored and so on. This vicious circle
can destroy a relationship.
Separation and Divorce

Men have traditionally seen themselves as being in control of their
families’ lives. However, the process of separation and divorce is most
often started by women. Of all men, those who are divorced are most
likely to kill themselves, probably because depression is more com-
mon and more severe in this group. This may be because, as well as
losing their main relationship:
• they often lose touch with their children;

• they may have to move to live in a different place;
• they often find themselves short of money.
These are stressful events in themselves, quite apart from the

stress of the breakup, and may bring on depression.
Sex
When men are depressed, they feel less good about their bodies
and less sexy. Many go off sex completely. Several recent studies
suggest that, in spite of this, men who are depressed have intercourse
just as often, but they don’t feel as satisfied as usual. A few depressed
men actually report an increase in sexual drive and intercourse,
possibly as a way of trying to make themselves feel better. Another
problem may be that some antidepressant drugs reduce sex drive
in a small number of men. However, the good news is that, as the
depression improves, so will sexual desire, performance, and satis-
faction.
It’s worth remembering that it can happen the other way around.
Impotence (difficulty in getting or keeping an erection) can bring about
depression. Again, this is a problem for which it is usually possible to
find effective help.
487
Pregnancy and Children

We have known for many years that some mothers feel severely
depressed after having a baby. It is only recently that we have real-
ized that more than one in ten fathers also suffer psychological prob-
lems during this time. This shouldn’t really be surprising. We know
that major events in people’s lives, even good ones like moving house,
can make you depressed. And this particular event changes your life
more than any other. Suddenly, you have to spend much more of your
time looking after your partner, and possibly other children, and you
may be very tired.
On an intimate level, new mothers tend to be less interested in sex
for a number of months. Simple tiredness is the main problem, al-
though you may take it personally and feel that you are being rejected.
You may have to adjust, perhaps for the first time, to taking second
place in your partner’s affections. You may also find that you can’t
spend so much time at work.
New fathers are more likely to become depressed if their partner
is depressed, if they aren’t getting along with their partner, or if they
are unemployed. This isn’t important just from the father’s point of
view. It will affect the mother and may have an impact on how the
baby grows and develops in the first few months.
Unemployment and Retirement

Leaving work, for any reason, can be stressful. Recent research has
shown that up to one in seven men who become unemployed will de-
velop a depressive illness in the next six months.
After relationship difficulties, unemployment is the thing most
likely to push a man into a serious depression—work is often the main
source of a man’s sense of worth and self-esteem. You may lose the
signs of your success, such as the company car. You may have to ad-
just to being at home, looking after children, while your wife or part-
ner becomes the breadwinner.
From a position of being in control, you may face a future over which
you have little, especially if it takes a long time to find another job.
You are more likely to become depressed if you are shy, if you don’t
have a close relationship, or if you don’t manage to find another job.
Depression itself can make it harder to get another job.
Even retiring from work at the usual age can be difficult for many
men, especially if your partner continues to work. It can be hard to ad-
just to losing the structure of your day and your contact with colleagues.
488
Gay Men and Depression

On the whole, gay men do not suffer from depression any more than
straight men. However, it seems that gay teenagers and young adults
are more likely to become depressed, possibly due to the stress of “com-
ing out.”
Suicide
Men are around three times more likely to kill themselves than
women. Suicide is commonest among men who are separated, wid-
owed, or divorced and is more likely if someone is a heavy drinker.
Over the last few years, men have become more likely to kill them-
selves, particularly those aged between sixteen and twenty-four years
and those between thirty-nine and fifty-four years. We don’t yet know
the reason for this.
We do know that around half the people who kill themselves will
have seen their doctor in the previous four weeks—although not nec-
essarily to discuss their emotional state. However, fewer men than
women will have seen their doctor in the year before their suicide. We
also know that about two out of three people who kill themselves will
have talked about it to friends or family.
Asking someone if he is feeling suicidal will not put the idea into
his head or make it more likely that he will kill himself. Even if some-
one is not very good at talking about how he is feeling, it is impor-
tant to ask if you have any suspicion—and to take such ideas seriously.
For a man who feels suicidal, there is nothing more demoralizing
than to feel that others do not take him seriously. He will often have
taken some time to pluck up the courage to tell anyone about it.
If you find yourself feeling so bad that you have thought about
suicide, it can be a great relief to talk about it.
Violence
Some studies have shown that men who commit violent crimes are
more likely to get depressed than men who don’t. However, we don’t
know if the depression makes their violence more likely, or if it’s just
the way they lead their lives.
Helping Men
Many men find it difficult to ask for help when they are de-
pressed—it can feel unmanly and weak. It may be easier for men to
489
ask for help if those who give that help take into account men’s spe-
cial needs.
Men who are depressed are more likely to talk about the physical
symptoms of their depression than the emotional and psychological
ones. This may be one reason why doctors sometimes don’t diagnose
it. If you are feeling wretched, don’t hold back—tell your doctor.
It can help to see depression as a result of chemical changes in the
brain and/or as the inevitable cost of living in a demanding and diffi-
cult world. It is nothing to do with being weak or unmanly and it can
be helped. Both talking and medication can be important ways to help
you get better.
If a depressed man is married, or in a steady relationship—straight
or gay—his partner should be involved so that she/he can understand
what is happening. This will make it less likely for the depression to
interfere with their relationship.
Some men don’t feel comfortable talking about themselves, and so
may be reluctant to consider psychotherapy. However, it is a power-
ful way of relieving depression and works well for many men.
Helping Yourself
Don’t bottle things up—if you’ve had a major upset in your life, try
to tell someone how you feel about it.
Keep active—get out of doors and get some exercise, even if it’s only
a walk. This will help to keep you physically fit and you will sleep bet-
ter. It can also help you not to dwell on painful thoughts and feelings.
Eat properly—you may not feel very hungry, but you should eat a
balanced diet, with lots of fruit and vegetables. It’s easy to lose weight
and run low on vitamins when you are depressed.
Avoid alcohol and drugs—alcohol may make you feel better for a
couple of hours, but it will make you more depressed in the long run.
The same goes for street drugs, particularly amphetamines, cocaine,
and ecstasy.
Don’t get upset if you can’t sleep—do something restful that you
enjoy, like listening to the radio or watching television. Use relaxation
techniques—if you feel tense all the time, try exercise, yoga, massage,
aromatherapy etc.
Do something you enjoy—set some time aside regularly each week
to do something you really enjoy: exercise, reading, a hobby.
Check out your lifestyle—a lot of people who have depression are
perfectionists and tend to drive themselves too hard. You may need
to set yourself more realistic targets and reduce your workload.
490
Take a break—this may be easier said than done, but it can be re-
ally helpful to get away and out of your normal routine for a few days.
Even a few hours can be helpful.
Read about depression—there are now many books and websites
about depression. Not only can they help you to cope, but they may
also help friends and relatives to understand what you are going
through.
Remember, in the long run, depression can be helpful—some people
come out of it stronger and coping better than before. You may see
situations and relationships more clearly, and may now have the
strength and wisdom to make important decisions and changes that
you were avoiding before.
Finding More Help

The best place to start is your doctor, who can go over your options
and discuss any worries you have about confidentiality.
Depression may be due to physical illness, so you need to get a
proper physical check-up. If you are already being treated for a physi-
cal illness, your doctor will need to know.
Any worries about confidentiality should be discussed with your
doctor.
Depression can be as much of an illness as pneumonia or break-
ing your leg. You shouldn’t feel embarrassed or ashamed about it. The
most important thing to remember is to ask for the help you need,
when you need it.
Remember—depression is common, it is treatable, and you are
entitled to the help you need.
References
Thase, F.E. Natural history and preventative treatment of recurrent
mood disorders. Annual Review of Medicine (1999). http://med.annual
reviews.org/cgi/content/full/50/1/453
NICE Clinical guideline 23: Depression—Management of depression
in primary and secondary care. December 2004 National Institute for
Clinical Excellence, London. http://www.nice.org.uk/page.aspx?o=235213
Anderson, I.M., et al. Effectiveness of antidepressants: evidence based
guidelines for treating depressive disorders with antidepressants.
Journal of Psychopharmacology (2000) 14 (1):3–20. http://www.sagepub
.co.uk/journals/details/j0102.html
491
Haddad, P., Lejoyeux, M., and Young, A., Problems stopping: antide-
pressant discontinuation reactions. British Medical Journal (1998)
316:1105–06. http://bmj.com/cgi/content/full/316/7138/1105
Luoma, J., Martin, C.E., and Pearson, J.L. Contact with mental health
and primary care providers before suicide: a review of the evidence.
American Journal of Psychiatry (2002) 159:6 909–16.
Moller-Leimkuhler, A.M., Barriers to help-seeking by men: a review
of sociocultural and clinical literature with particular reference to
depression. Journal of Affective Disorders (September 2002) Vol. 71,
Issues 1–3:1–9.
Winkler, D. et al. Gender differences in the psychopathology of de-
pressed inpatients. European Archives of Psychiatry and Clinical
Neurosciences (2003) 254, 209–14.
Ramchandani P., Stein A., Evans J., O’Connor T.G., Paternal depres-
sion in the postnatal period and child development: a prospective
population study. The Lancet (25 June 2005) Vol. 365, Issue 9478:2201–
05.
492
Section 39.2
Obsessive-Compulsive Disorder
Excerpted from “Anxiety Disorders,” National Institute of Mental Health,
National Institutes of Health, NIH Publication No. 06-3879, 2007.
People with obsessive-compulsive disorder (OCD) have persistent,

upsetting thoughts (obsessions) and use rituals (compulsions) to con-
trol the anxiety these thoughts produce. Most of the time, the rituals
end up controlling them.
For example, if people are obsessed with germs or dirt, they may
develop a compulsion to wash their hands over and over again. If they
develop an obsession with intruders, they may lock and relock their
doors many times before going to bed. Being afraid of social embar-
rassment may prompt people with OCD to comb their hair compul-
sively in front of a mirror—sometimes they get “caught” in the mirror
and can’t move away from it. Performing such rituals is not pleasur-
able. At best, it produces temporary relief from the anxiety created
by obsessive thoughts.
Other common rituals are a need to repeatedly check things, touch
things (especially in a particular sequence),or count things. Some com-
mon obsessions include having frequent thoughts of violence and
harming loved ones, persistently thinking about performing sexual
acts the person dislikes, or having thoughts that are prohibited by
religious beliefs. People with OCD may also be preoccupied with or-
der and symmetry, have difficulty throwing things out (so they accu-
mulate), or hoard unneeded items.
Healthy people also have rituals, such as checking to see if the stove
is off several times before leaving the house. The difference is that
people with OCD perform their rituals even though doing so inter-
feres with daily life and they find the repetition distressing. Although
most adults with OCD recognize that what they are doing is sense-
less, some adults and most children may not realize that their behav-
ior is out of the ordinary.
OCD affects about 2.2 million American adults,1 and the problem
can be accompanied by eating disorders,6 other anxiety disorders, or
depression.2,4 It strikes men and women in roughly equal numbers and
493
usually appears in childhood, adolescence, or early adulthood.2 One-
third of adults with OCD develop symptoms as children, and research
indicates that OCD might run in families.3
The course of the disease is quite varied. Symptoms may come and
go, ease over time, or get worse. If OCD becomes severe, it can keep a
person from working or carrying out normal responsibilities at home.
People with OCD may try to help themselves by avoiding situations
that trigger their obsessions, or they may use alcohol or drugs to calm
themselves.4,5
OCD usually responds well to treatment with certain medications
and/or exposure-based psychotherapy, in which people face situations
that cause fear or anxiety and become less sensitive (desensitized) to
them. The National Institute of Mental Health (NIMH) is support-
ing research into new treatment approaches for people whose OCD
does not respond well to the usual therapies. These approaches in-
clude combination and augmentation (add-on) treatments, as well as
modern techniques such as deep brain stimulation.
References
1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, se-
verity, and comorbidity of twelvemonth DSM-IV disorders in
the National Comorbidity Survey Replication (NCS-R). Archives
of General Psychiatry. 2005; 62(6):617–27.
2. Robins LN, Regier DA, eds. Psychiatric Disorders in America:
the Epidemiologic Catchment Area Study. New York: The Free
Press, 1991.
3. The NIMH Genetics Workgroup. Genetics and mental disor-
ders, NIH Publication No. 98-4268. Rockville, MD: National
Institute of Mental Health, 1998.
4. Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety
disorders and their comorbidity with mood and addictive disor-
ders. British Journal of Psychiatry Supplement. 1998;34:24–28.
5. Kushner MG, Sher KJ, Beitman BD. The relation between al-
cohol problems and the anxiety disorders. American Journal of
Psychiatry. 1990;147(6):685–95.
6. Wonderlich SA, Mitchell JE. Eating disorders and comorbidity:
Empirical, conceptual, and clinical implications. Psychopharma-
cology Bulletin. 1997;33(3):381–90.
494
Section 39.3
Phobias
Social Phobia (Social Anxiety Disorder)

Social phobia, also called social anxiety disorder, is diagnosed when
people become overwhelmingly anxious and excessively self-conscious
in everyday social situations. People with social phobia have an in-
tense, persistent, and chronic fear of being watched and judged by
others and of doing things that will embarrass them. They can worry
for days or weeks before a dreaded situation. This fear may become
so severe that it interferes with work, school, and other ordinary ac-
tivities, and can make it hard to make and keep friends.
While many people with social phobia realize that their fears about
being with people are excessive or unreasonable, they are unable to
overcome them. Even if they manage to confront their fears and be
around others, they are usually very anxious beforehand, are intensely
uncomfortable throughout the encounter, and worry about how they
were judged for hours afterward.
Social phobia can be limited to one situation (such as talking to
people, eating or drinking, or writing on a blackboard in front of oth-
ers) or may be so broad (such as in generalized social phobia) that
the person experiences anxiety around almost anyone other than the
family.
Physical symptoms that often accompany social phobia include
blushing, profuse sweating, trembling, nausea, and difficulty talking.
When these symptoms occur, people with social phobia feel as though
all eyes are focused on them.
Social phobia affects about fifteen million American adults.1 Women
and men are equally likely to develop the disorder,2 which usually
begins in childhood or early adolescence.3 There is some evidence that
genetic factors are involved.4 Social phobia is often accompanied by
other anxiety disorders or depression,3,5 and substance abuse may
develop if people try to self-medicate their anxiety.5,6
495
Social phobia can be successfully treated with certain kinds of psy-
chotherapy or medications.
Specific Phobias
A specific phobia is an intense, irrational fear of something that
actually poses little or no threat. Some of the more common specific
phobias are heights, escalators, tunnels, highway driving, closed-in
places, water, flying, dogs, spiders, and injuries involving blood. People
with specific phobias may be able to ski the world’s tallest mountains
with ease but be unable to go above the fifth floor of an office build-
ing. While adults with phobias realize that these fears are irrational,
they often find that facing, or even thinking about facing, the feared
object or situation brings on a panic attack or severe anxiety.
Specific phobias affect around 19.2 million American adults1 and
are twice as common in women as men.2 They usually appear in child-
hood or adolescence and tend to persist into adulthood.1,3 The causes
of specific phobias are not well understood, but there is some evidence
that the tendency to develop them may run in families.4
If the feared situation or feared object is easy to avoid, people with
specific phobias may not seek help; but if avoidance interferes with
their careers or their personal lives, it can become disabling and treat-
ment is usually pursued.
Specific phobias respond very well to carefully targeted psycho-
therapy.
References
verity, and comorbidity of twelvemonth DSM-IV disorders in
the National Comorbidity Survey Replication (NCS-R). Ar-
chives of General Psychiatry. 2005; 62(6):617–27.
2. Bourdon KH, Boyd JH, Rae DS, et al. Gender differences in
phobias: Results of the ECA community survey. Journal of
Anxiety Disorders. 1998;2:227–41.
3. Robins LN, Regier DA, eds. Psychiatric Disorders in America:
the Epidemiologic Catchment Area Study. New York: The Free
Press, 1991.
4. Kendler KS, Walters EE, Truett KR, et al. A twin family study
of self-report symptoms of panic-phobia and somatization. Be-
havior Genetics. 1995;25(6):499–515.
496
5. Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety
disorders and their comorbidity with mood and addictive dis-
orders. British Journal of Psychiatry Supplement. 1998;34:24–
28.
6. Kushner MG, Sher KJ, Beitman BD. The relation between al-
cohol problems and the anxiety disorders. American Journal
of Psychiatry. 1990;147(6):685–95.
Section 39.4
Posttraumatic Stress Disorder

Post-traumatic stress disorder (PTSD) develops after a terrifying

ordeal that involved physical harm or the threat of physical harm.
The person who develops PTSD may have been the one who was
harmed, the harm may have happened to a loved one, or the person
may have witnessed a harmful event that happened to loved ones or
strangers.
PTSD was first brought to public attention in relation to war vet-
erans, but it can result from a variety of traumatic incidents, such as
mugging, rape, torture, being kidnapped or held captive, child abuse,
car accidents, train wrecks, plane crashes, bombings, or natural di-
sasters such as floods or earthquakes.
People with PTSD may startle easily, become emotionally numb
(especially in relation to people with whom they used to be close), lose
interest in things they used to enjoy, have trouble feeling affection-
ate, be irritable, become more aggressive, or even become violent. They
avoid situations that remind them of the original incident, and anni-
versaries of the incident are often very difficult. PTSD symptoms seem
to be worse if the event that triggered them was deliberately initi-
ated by another person, as in a mugging or a kidnapping.
Most people with PTSD repeatedly relive the trauma in their
thoughts during the day and in nightmares when they sleep. These
497
are called flashbacks. Flashbacks may consist of images, sounds,
smells, or feelings, and are often triggered by ordinary occurrences,
such as a door slamming or a car backfiring on the street. A person
having a flashback may lose touch with reality and believe that the
traumatic incident is happening all over again.
Not every traumatized person develops full-blown or even minor
PTSD. Symptoms usually begin within three months of the incident
but occasionally emerge years afterward. They must last more than
a month to be considered PTSD. The course of the illness varies. Some
people recover within six months, while others have symptoms that
last much longer. In some people, the condition becomes chronic.
PTSD affects about 7.7 million American adults,1 but it can occur
at any age, including childhood.2 Women are more likely to develop
PTSD than men,3 and there is some evidence that susceptibility to
the disorder may run in families.4 PTSD is often accompanied by de-
pression, substance abuse, or one or more of the other anxiety disor-
ders.
Certain kinds of medication and certain kinds of psychotherapy
usually treat the symptoms of PTSD very effectively.
References
verity, and comorbidity of twelve-month DSM-IV disorders in
the National Comorbidity Survey Replication (NCS-R). Archives
of General Psychiatry. 2005; 62(6):617–27.
2. Margolin G, Gordis EB. The effects of family and community
violence on children. Annual Review of Psychology.
2000;51:445–79.
3. Davidson JR. Trauma: The impact of post-traumatic stress
disorder. Journal of Psychopharmacology. 2000;14(2 Suppl
1):S5–S12.
4. Yehuda R. Biological factors associated with susceptibility to
posttraumatic stress disorder. Canadian Journal of Psychia-
try. 1999;44(1):34–39.
498
Section 39.5
Schizophrenia
Excerpted from “Schizophrenia,” National Institute of
Mental Health, National Institutes of Health, April 3, 2008.
What Is Schizophrenia?
Schizophrenia is a chronic, severe, and disabling brain disorder
that has been recognized throughout recorded history. It affects about
1 percent of Americans.1
People with schizophrenia may hear voices other people don’t hear
or they may believe that others are reading their minds, controlling
their thoughts, or plotting to harm them. These experiences are ter-
rifying and can cause fearfulness, withdrawal, or extreme agitation.
People with schizophrenia may not make sense when they talk, may
sit for hours without moving or talking much, or may seem perfectly
fine until they talk about what they are really thinking. Because many
people with schizophrenia have difficulty holding a job or caring for
themselves, the burden on their families and society is significant as
well.
Available treatments can relieve many of the disorder’s symptoms,
but most people who have schizophrenia must cope with some residual
symptoms as long as they live. Nevertheless, this is a time of hope
for people with schizophrenia and their families. Many people with
the disorder now lead rewarding and meaningful lives in their com-
munities. Researchers are developing more effective medications and
using new research tools to understand the causes of schizophrenia
and to find ways to prevent and treat it.
What Are the Symptoms of Schizophrenia?

The symptoms of schizophrenia fall into three broad categories:
• Positive symptoms are unusual thoughts or perceptions, includ-

ing hallucinations, delusions, thought disorder, and disorders of
movement.
499
• Negative symptoms represent a loss or a decrease in the ability
to initiate plans, speak, express emotion, or find pleasure in ev-
eryday life. These symptoms are harder to recognize as part of
the disorder and can be mistaken for laziness or depression.
• Cognitive symptoms(or cognitive deficits) are problems with at-
tention, certain types of memory, and the executive functions
that allow us to plan and organize. Cognitive deficits can also be
difficult to recognize as part of the disorder but are the most
disabling in terms of leading a normal life.
When Does It Start and Who Gets It?

Psychotic symptoms (such as hallucinations and delusions) usually
emerge in men in their late teens and early twenties and in women in
their mid-twenties to early thirties. They seldom occur after age forty-
five and only rarely before puberty, although cases of schizophrenia in
children as young as five have been reported. In adolescents, the first
signs can include a change of friends, a drop in grades, sleep problems,
and irritability. Because many normal adolescents exhibit these behav-
iors as well, a diagnosis can be difficult to make at this stage. In young
people who go on to develop the disease, this is called the “prodromal”
period.
Research has shown that schizophrenia affects men and women
equally and occurs at similar rates in all ethnic groups around the world.2
Are People with Schizophrenia Violent?

People with schizophrenia are not especially prone to violence and
often prefer to be left alone. Studies show that if people have no record
of criminal violence before they develop schizophrenia and are not
substance abusers, they are unlikely to commit crimes after they be-
come ill. Most violent crimes are not committed by people with schizo-
phrenia, and most people with schizophrenia do not commit violent
crimes. Substance abuse always increases violent behavior, regard-
less of the presence of schizophrenia. If someone with paranoid schizo-
phrenia becomes violent, the violence is most often directed at family
members and takes place at home.
What Causes Schizophrenia?

Like many other illnesses, schizophrenia is believed to result from
a combination of environmental and genetic factors. All the tools of
500
modern science are being used to search for the causes of this disor-
der.
Can Schizophrenia Be Inherited?

Scientists have long known that schizophrenia runs in families. It
occurs in 1 percent of the general population but is seen in 10 per-
cent of people with a first-degree relative (a parent, brother, or sis-
ter) with the disorder. People who have second-degree relatives (aunts,
uncles, grandparents, or cousins) with the disease also develop schizo-
phrenia more often than the general population. The identical twin
of a person with schizophrenia is most at risk, with a 40 to 65 per-
cent chance of developing the disorder.3
Although there is a genetic risk for schizophrenia, it is not likely
that genes alone are sufficient to cause the disorder. Interactions be-
tween genes and the environment are thought to be necessary for
schizophrenia to develop. Many environmental factors have been sug-
gested as risk factors, such as exposure to viruses or malnutrition in
the womb, problems during birth, and psychosocial factors, like stress-
ful environmental conditions.
Do People with Schizophrenia Have Faulty Brain Chemis-

try?
It is likely that an imbalance in the complex, interrelated chemi-
cal reactions of the brain involving the neurotransmitters dopamine
and glutamate (and possibly others) plays a role in schizophrenia.
Neurotransmitters are substances that allow brain cells to commu-
nicate with one another. Basic knowledge about brain chemistry and
its link to schizophrenia is expanding rapidly and is a promising area
of research.
How Is Schizophrenia Treated?

Because the causes of schizophrenia are still unknown, current
treatments focus on eliminating the symptoms of the disease.
Antipsychotic Medications
Antipsychotic medications have been available since the mid-1950s.
They effectively alleviate the positive symptoms of schizophrenia.
While these drugs have greatly improved the lives of many patients,
they do not cure schizophrenia.
501
Everyone responds differently to antipsychotic medication. Some-
times several different drugs must be tried before the right one is
found. People with schizophrenia should work in partnership with
their doctors to find the medications that control their symptoms best
with the fewest side effects.
The older antipsychotic medications include chlorpromazine (Thora-
zine®), haloperidol (Haldol®), perphenazine (Etrafon®, Trilafon®),
and fluphenazine (Prolixin®). The older medications can cause ex-
trapyramidal side effects, such as rigidity, persistent muscle spasms,
tremors, and restlessness.
In the 1990s, new drugs, called atypical antipsychotics, were de-
veloped that rarely produced these side effects. The first of these new
drugs was clozapine (Clozaril®). It treats psychotic symptoms effec-
tively even in people who do not respond to other medications, but it
can produce a serious problem called agranulocytosis, a loss of the
white blood cells that fight infection. Therefore, patients who take
clozapine must have their white blood cell counts monitored every
week or two. The inconvenience and cost of both the blood tests and
the medication itself has made treatment with clozapine difficult for
many people, but it is the drug of choice for those whose symptoms
do not respond to the other antipsychotic medications, old or new.
Some of the drugs that were developed after clozapine was intro-
duced—such as risperidone (Risperdal®), olanzapine (Zyprexa®),
quetiapine (Seroquel®), sertindole (Serdolect®), and ziprasidone
(Geodon®)—are effective and rarely produce extrapyramidal symp-
toms and do not cause agranulocytosis; but they can cause weight
gain and metabolic changes associated with an increased risk of dia-
betes and high cholesterol.4
People respond individually to antipsychotic medications, although
agitation and hallucinations usually improve within days and delu-
sions usually improve within a few weeks. Many people see substan-
tial improvement in both types of symptoms by the sixth week of
treatment. No one can tell beforehand exactly how a medication will
affect a particular individual, and sometimes several medications
must be tried before the right one is found.
When people first start to take atypical antipsychotics, they may
become drowsy; experience dizziness when they change positions; have
blurred vision; or develop a rapid heartbeat, menstrual problems, a
sensitivity to the sun, or skin rashes. Many of these symptoms will
go away after the first days of treatment, but people who are taking
atypical antipsychotics should not drive until they adjust to their new
medication.
502
Length of treatment: Like diabetes or high blood pressure,
schizophrenia is a chronic disorder that needs constant management.
At the moment, it cannot be cured, but the rate of recurrence of psy-
chotic episodes can be decreased significantly by staying on medica-
tion. Although responses vary from person to person, most people with
schizophrenia need to take some type of medication for the rest of their
lives as well as use other approaches, such as supportive therapy or
rehabilitation.
Relapses occur most often when people with schizophrenia stop
taking their antipsychotic medication because they feel better, or only
take it occasionally because they forget or don’t think taking it regu-
larly is important. It is very important for people with schizophrenia
to take their medication on a regular basis and for as long as their
doctors recommend. If they do so, they will experience fewer psychotic
symptoms.
No antipsychotic medication should be discontinued without talk-
ing to the doctor who prescribed it, and it should always be tapered
off under a doctor’s supervision rather than being stopped all at once.
There are a variety of reasons why people with schizophrenia do
not adhere to treatment. If they don’t believe they are ill, they may
not think they need medication at all. If their thinking is too disor-
ganized, they may not remember to take their medication every day.
If they don’t like the side effects of one medication, they may stop tak-
ing it without trying a different medication. Substance abuse can also
interfere with treatment effectiveness. Doctors should ask patients
how often they take their medication and be sensitive to a patient’s
request to change dosages or to try new medications to eliminate
unwelcome side effects.
Psychosocial Treatment
Numerous studies have found that psychosocial treatments can
help patients who are already stabilized on antipsychotic medications
deal with certain aspects of schizophrenia, such as difficulty with com-
munication, motivation, self-care, work, and establishing and main-
taining relationships with others. Learning and using coping
mechanisms to address these problems allows people with schizophre-
nia to attend school, work, and socialize. Patients who receive regu-
lar psychosocial treatment also adhere better to their medication
schedule and have fewer relapses and hospitalizations. A positive re-
lationship with a therapist or a case manager gives the patient a re-
liable source of information, sympathy, encouragement, and hope, all
503
of which are essential for managing the disease. The therapist can
help patients better understand and adjust to living with schizophre-
nia by educating them about the causes of the disorder, common symp-
toms or problems they may experience, and the importance of staying
on medications.
Illness management skills: People with schizophrenia can take

an active role in managing their own illness. Once they learn basic
facts about schizophrenia and the principles of schizophrenia treat-
ment, they can make informed decisions about their care. If they are
taught how to monitor the early warning signs of relapse and make
a plan to respond to these signs, they can learn to prevent relapses.
Patients can also be taught more effective coping skills to deal with
persistent symptoms.
Rehabilitation: Rehabilitation emphasizes social and vocational

training to help people with schizophrenia function more effectively
in their communities. Because people with schizophrenia frequently
become ill during the critical career-forming years of life (ages eigh-
teen to thirty-five) and because the disease often interferes with nor-
mal cognitive functioning, most patients do not receive the training
required for skilled work. Rehabilitation programs can include voca-
tional counseling, job training, money management counseling, assis-
tance in learning to use public transportation, and opportunities to
practice social and workplace communication skills.
Family education: Patients with schizophrenia are often dis-

charged from the hospital into the care of their families, so it is impor-
tant that family members know as much as possible about the disease
to prevent relapses. Family members should be able to use different
kinds of treatment adherence programs and have an arsenal of coping
strategies and problem-solving skills to manage their ill relative effec-
tively. Knowing where to find outpatient and family services that sup-
port people with schizophrenia and their caregivers is also valuable.
Cognitive behavioral therapy: Cognitive behavioral therapy is

useful for patients with symptoms that persist even when they take
medication. The cognitive therapist teaches people with schizophre-
nia how to test the reality of their thoughts and perceptions, how to
“not listen” to their voices, and how to shake off the apathy that often
immobilizes them. This treatment appears to be effective in reducing
the severity of symptoms and decreasing the risk of relapse.
504
Addendum to Schizophrenia January 2007

Aripiprazole (Abilify®) is another atypical antipsychotic medica-
tion used to treat the symptoms of schizophrenia and manic or mixed
(manic and depressive) episodes of bipolar I disorder. Aripiprazole is
in tablet and liquid form. An injectable form is used in the treatment
of symptoms of agitation in schizophrenia and manic or mixed epi-
sodes of bipolar I disorder.
References
1. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ,
Goodwin FK. The de facto US mental and addictive disorders
service system. Epidemiologic catchment area prospective 1-
year prevalence rates of disorders and services. Arch Gen Psy-
chiatry. 1993 Feb; 50(2):85–94.
2. Mueser KT, McGurk SR. Schizophrenia. Lancet. 2004 Jun
19;363(9426):2063–72.
3. Cardno AG, Gottesman II. Twin studies of schizophrenia:
from bow-and-arrow concordances to star wars Mx and func-
tional genomics. Am J Med Genet. 2000 Spring; 97(1):12–17.
4. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck
RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD,
Severe J, Hsiao JK; Clinical Antipsychotic Trials of Interven-
tion Effectiveness (CATIE). Effectiveness of antipsychotic drugs
in patients with chronic schizophrenia. N Engl J Med. 2005
Sep 22;353(12):1209–23.
505
Chapter 40
Male Menopause
Women may not be the only ones who suffer the effects of chang-
ing hormones. Some doctors are noticing that their male patients are
reporting some of the same symptoms that women experience in
menopause.
The medical community is currently debating whether or not men
really do go through a well-defined menopause. Doctors have reported
that male patients receiving hormone replacement therapy (testoster-
one) have reported relief of some of the symptoms associated with so-
called male menopause.
What is male menopause?

Since men do not go through a well-defined period referred to as
menopause, some physicians refer to this problem as androgen (tes-
tosterone) decline in the aging male. Men do experience a decline in
the production of the male hormone testosterone with aging, but this
also occurs with some disease states, such as diabetes. Along with the
decline in testosterone, some men experience symptoms such as fa-
tigue, weakness, depression, and sexual problems. The relationship
“Male Menopause,” © 2009 The Cleveland Clinic Foundation, 9500 Euclid

Avenue, Cleveland, OH 44195. All rights reserved. Reprinted with permission.
Additional information is available from the Cleveland Clinic Health Informa-
tion Center, 216-444-3771, toll-free 800-223-2273 extension 43771, or at http://
my.clevelandclinic.org/health.
507
of these symptoms to the decreased testosterone levels is still contro-
versial.
Unlike menopause in women, which represents a well-defined pe-
riod in which hormone production stops completely, male hormone
(testosterone) decline is a slower process. The testes, unlike the ova-
ries, do not stop making testosterone. In addition to testosterone, the
testes of a healthy male may be able to make sperm well into his eight-
ies or longer.
However, as a result of disease, subtle changes in the function of
the testes may occur as early as forty-five to fifty years of age, and
more dramatically after the age of seventy in some men.
How is male menopause diagnosed?

To make the diagnosis, the doctor will perform a physical exam and
ask about symptoms. He or she may order other diagnostic tests to
rule out any medical problems that may be contributing to the condi-
tion. The doctor will then order a series of blood tests, which may in-
clude several hormone levels, including a blood testosterone level.
Can male menopause be treated?

If testosterone levels are low, testosterone replacement therapy
may help relieve such symptoms as loss of interest in sex (decreased
libido), depression, and fatigue. But, as with hormone replacement
therapy in women, testosterone replacement therapy does have some
potential risks and side effects. Replacing testosterone may worsen
prostate cancer, for example.
If you or a loved one is considering androgen replacement therapy,
talk to a doctor to learn more. Your doctor may also recommend cer-
tain lifestyle changes, such as a new diet or exercise program, or other
medications, such as an antidepressant, to help with some of the symp-
toms of male menopause.
508
Chapter 41
Male Pattern Baldness
What is baldness or hair loss?

Hair loss can happen on any part of the body for a variety of rea-
sons, and can range from being mild to severe. Male (and female)
pattern baldness is hair loss specifically from the head. Extreme
forms of hair loss happen when there is hair loss all over the head
and body.
What is male pattern hair loss?

Male pattern hair loss (also known as androgenetic alopecia) is a
progressive hair thinning condition and is the most common type of
hair loss in men.
Male pattern hair loss typically begins at the forehead, with the
hairline gradually receding along the sides to form an “M” shape. The
remaining hair may become finer and shorter, with hair at the crown
(back) of the head also beginning to thin. The amount of hair loss can
vary among men and is usually influenced by an individual’s genetic
makeup. In severe cases, the receding forehead hairline may eventu-
ally extend to the thinned crown, leaving a horseshoe pattern of hair
around the sides of the head.
There are slight variations in how male pattern hair loss can hap-
pen:
“Male Pattern Baldness,” © 2008 Andrology Australia (www.andrologyaustralia

.org). All rights reserved. Reprinted with permission.
509
• Frontal baldness: Hair loss happens from the hairline at the
forehead but not at the crown.
• Vertex baldness: Hair loss happens at the crown but not the
hairline at the forehead.
Usually, most men will have a combination of both types of hair

loss patterns.
What causes hair loss?

There are many different causes of hair loss, including certain ill-
nesses (including disorders of the immune system), stress as a result
of major surgery, chemotherapy, radiotherapy, hormonal problems,
fungal infections, and as a side-effect of some medications. Scarring
from burns can also cause permanent hair loss.
Hair loss in patches, sudden hair loss, breaking of hair shafts, or
hair loss associated with redness, scaling, or pain are likely to be caused
by specific health conditions.
What causes male pattern hair loss?

While it is not completely understood why the hair follicles on
men’s heads stop producing new hair, the male hormone dihydrotes-
tosterone (DHT) is thought to play a part.
Testosterone, the most important male sex hormone (androgen)
in men, is responsible for the growth of bone and muscles, sexual func-
tion, and for producing physical characteristics in men including
facial and body hair. In the body, testosterone is converted to DHT
by an enzyme (5-alpha reductase). DHT acts on different organs in
the body, including the hair follicles and cells in the prostate. For rea-
sons we don’t understand, hair follicles sometimes become more
sensitive to DHT, slowing down hair production and producing
weaker, shorter hair. Sometimes hair growth stops completely. It is
not clear why different hair follicles are affected at different times,
making the balding process gradual, or why only scalp hairs are af-
fected.
Is thinning hair and hair loss reversible?

Thinning hair or loss of hair is not reversible, but there are medi-
cations to treat male pattern hair loss that can stop or slow baldness.
Some men may even experience new hair growth with treatments.
510
Should I be concerned about hair loss?

Many men accept male pattern hair loss as a normal part of ag-
ing. For some men, for a variety of reasons, their concern for their hair
loss prompts them to seek treatment for cosmetic reasons to try and
stop or slow further hair loss.
If you start to lose your hair suddenly, if your hair loss happens in
clumps or is significant enough that you notice large amounts falling
out, it is not male pattern hair loss. It is recommended that you dis-
cuss these types of hair loss with your doctor. Further investigation
may be needed to determine the cause.
What is the emotional impact on men experiencing hair

loss?
While hair loss is a normal part of the ageing process for most men,
it can be distressing for some, particularly if it is excessive or hap-
pens at an early age. Men experiencing hair loss can feel less confi-
dent, less attractive, and may think it makes them look older. While
many men accept that they are losing their hair, a small number may
suffer from depression as a result. It is recommended that men speak
to a counselor if they are feeling upset or they are obsessing about
their hair loss.
How is hair loss treated?

There are a number of treatments available for hair loss, and treat-
ments often work well in most cases. Men usually seek treatment for
cosmetic rather than medical reasons.
Wigs and hairpieces: Hair weaving, hairpieces, or a change of

hairstyle may disguise hair loss and is generally the least expensive
and safest treatment for male pattern hair loss.
Surgery: Hair transplantation involves removing tiny plugs of hair

from areas where it continues to grow and inserting them in bald ar-
eas. This can cause minor scarring and carries some risk of skin in-
fection. Multiple transplantation sessions are usually needed and can
be expensive. Results, however, are often excellent and permanent.
Choosing a surgeon with experience in this operation is recommended.
Medications: There are medications that can be used to treat male

pattern hair loss that tend to have results in stopping or slowing hair
511
loss, with new hair growth happening in some men. The two main
medications used to treat male pattern hair loss are finasteride and
minoxidil.
Finasteride—also known as Propecia®—is an oral medication that
works by blocking the conversion of testosterone to DHT. The hair
follicles are then not affected by DHT and can enlarge back to nor-
mal. About two in three men who take finasteride every day experi-
ence some hair re-growth. About one in three men experience no hair
re-growth, but most don’t experience any further hair loss. Finasteride
has no effect in about one in one hundred men. The chances are there-
fore quite high that finasteride will help hair re-grow or at least stop
more hair from falling out.
Most men do not notice any effects from taking finasteride for up
to four months. It can take up to one to two years for full hair re-
growth to happen. Any improvement in hair growth is usually great-
est over the crown than over the frontal areas of the scalp. If treatment
is stopped, the balding process will begin again, meaning if success-
ful, treatment needs to be ongoing to continue hair re-growth. Side
effects are uncommon, but about two in one hundred men taking
finasteride experience a loss of sex drive (libido).
Finasteride taken at a higher dose (marketed as Proscar®) is also
commonly taken by men to treat benign prostate enlargement, and
has been found to reduce the risk of developing prostate cancer. How-
ever, research has found that men who do develop prostate cancer
while taking the drug have an increased risk of the cancer being more
aggressive.1 However, whether this arises because finasteride induces
more aggressive disease, or simply because finasteride makes it
easier to detect more aggressive disease earlier is not certain.2 Nev-
ertheless, men taking finasteride for hair loss should not be worried
as the dose of finasteride given for hair loss is much lower than what
is used to treat prostate enlargement, but should speak to their doc-
tor if they have any concerns. The low dose used for treating hair loss
does not seem to have an effect on the development of prostate can-
cer.
Minoxidil—also known as Rogaine®, Hair a-gain®, Hair Retreva®—
is a lotion that is rubbed onto the head. There is debate as to how well
it works, but it is believed about half of the men who use minoxidil
experience a delay in further balding. About fifteen in one hundred
men have good hair re-growth, while hair loss continues in about one
in three users.
Minoxidil needs to be rubbed onto the scalp every day, and taken
continually for four months before results are noticeable. As with
512
finasteride, treatment needs to be ongoing for hair growth to continue.
Any new hair that does re-grow tends to fall out two months after
treatment is stopped. Side effects are uncommon, but minoxidil can
cause skin irritation or a rash in some men.
Is there a link between male pattern hair loss and prostate

cancer?
Because testosterone through the action of DHT is involved in the
growth of the prostate and hair growth, some preliminary studies have
been done to see if men who are balding are at an increased risk of
prostate cancer. An Australian study found a link between men with
vertex hair loss (hair loss from the crown only) and prostate cancer.3
There were no associations found between prostate cancer and men
with frontal hair loss, or frontal hair loss together with vertex hair
loss. The reason for this link between vertex hair loss and prostate
cancer is not clear and further studies are needed.
What are the myths about male pattern hair loss?

Standing on your head lessens hair loss: The “blood-flow”
theory, which led men to stand on their heads in the 1980s, can be
found in the advertising for many of the ineffective hair loss treat-
ments on the market, but again is an unfounded myth in the treat-
ment of male pattern baldness. While minoxidil is suspected for
working, in part, by increasing blood flow to hair follicles, there is no
evidence that standing on one’s head can stop hair loss or cause hair
to re-grow.
Hair loss comes from your mother’s side of the family: There
is a myth that hair loss is a genetic trait passed down from the
mother’s side of the family. Genetics is the cause of male pattern hair
loss, but a number of genes are responsible, and genes are most likely
contributed by both parents. The condition does run in families, so if
there is a close relative with male pattern hair loss, then there is a
higher risk another relative will develop the condition.
Hair loss happens in men with high testosterone levels:

Some men think they are losing their hair because they have higher
levels of the male sex hormone testosterone. High levels of testoster-
one are not linked with hair loss. However, some studies have shown
that men with high levels of “free” testosterone (only 2 percent of the
513
total amount of testosterone produced by the body) are more likely
to have vertex hair loss (from the crown only).
References
1. Thompson IM et al. The influence of Finasteride on the devel-
opment of prostate cancer. NEJM 2003; 349: 213–22.
2. Lucia MS et al. Finasteride and high-grade prostate cancer
in the Prostate Cancer Prevention Trial. J Natl Cancer Inst
2007;99:1375–83.
3. Giles GG, Severi G, Sinclair R, English DR, McCredie MRE,
Johnson W, Boyle P, Hopper JL. Androgenetic alopecia and pros-
tate cancer: findings from an Australian case-control study.
Cancer Epidemiology, Biomarkers & Prevention 2002; 11: 549–
53.
514
Chapter 42
Sex-Linked Genetic Disorders
Chapter Contents
Section 42.1—Color Vision Deficiency ....................................... 516
Section 42.2—Fragile X Syndrome............................................. 519
Section 42.3—Hemophilia ........................................................... 522
Section 42.4—Klinefelter Syndrome .......................................... 525
Section 42.5—Muscular Dystrophy ............................................ 527
515
Section 42.1
Color Vision Deficiency

“Color Vision Deficiency,” © 2006 American Optometric Association
(www.aoa.org). Reprinted with permission.
Color vision deficiency is the inability to distinguish certain shades

of color or in more severe cases, see colors at all. The term “color blind-
ness” is also used to describe this visual condition, but very few people
are completely color blind.
Most people with color vision deficiency can see colors, but they
have difficulty differentiating between:
• particular shades of reds and greens (most common); or
• blues and yellows (less common).
People who are totally color blind, a condition called achromatop-

sia, can only see things as black and white or in shades of gray.
The severity of color vision deficiency can range from mild to se-
vere depending on the cause. It will affect both eyes if it is inherited
and usually just one if the cause for the deficiency is injury or illness.
Color vision is possible due to photoreceptors in the retina of the
eye known as cones. These cones have light-sensitive pigments that
enable us to recognize color. Found in the macula, the central portion
of the retina, each cone is sensitive to either red, green, or blue light,
which the cones recognize based upon light wavelengths.
Normally, the pigments inside the cones register differing colors
and send that information through the optic nerve to the brain, en-
abling you to distinguish countless shades of color. But if the cones
lack one or more light-sensitive pigments, you will be unable to see
one or more of the three primary colors, thereby causing a deficiency
in your color perception.
The most common form of color deficiency is red-green. This does
not mean that people with this deficiency cannot see these colors at
all; they simply have a harder time differentiating between them. The
difficulty they have in correctly identifying them depends on how dark
or light the colors are.
516
Another form of color deficiency is blue-yellow. This is a rarer and
more severe form of color vision loss than red-green since persons with
blue-yellow deficiency frequently have red-green blindness too. In both
cases, it is common for people with color vision deficiency to see neu-
tral or gray areas where a particular color should appear.
What causes color vision deficiency?

Usually, color deficiency is an inherited condition caused by a com-
mon X-linked recessive gene, which is passed from a mother to her
son. But disease or injury damaging the optic nerve or retina can also
result in loss of color recognition. Some specific diseases that can cause
color deficits are:
• diabetes;
• glaucoma;
• macular degeneration;
• Alzheimer disease;
• Parkinson disease;
• multiple sclerosis;
• chronic alcoholism;
• leukemia;
• sickle cell anemia.
Other causes for color vision deficiency include:
• Medications: Certain medications such as drugs used to treat

heart problems, high blood pressure, infections, nervous disor-
ders, and psychological problems can affect color vision.
• Aging: The ability to see colors can gradually lessen with age.
• Chemical exposure: Contact with certain chemicals such as
fertilizers and styrene have been known to cause loss of color vi-
sion.
In the majority of cases, genetics is the predominate cause for

color deficiency. About 8 percent of Caucasian males are born with
some degree of color deficiency. Women are typically just carriers of
the color deficient gene, though approximately 0.5 percent of women
have color vision deficiency. When the deficiency is hereditary, the
517
severity generally remains constant throughout life. Inherited color
vision deficiency does not lead to additional vision loss or blindness.
How is color vision deficiency diagnosed?

Color deficiency can be diagnosed through a comprehensive eye
examination. Testing will include the use of a series of specially de-
signed pictures composed of colored dots, called pseudoisochromatic
plates, which include hidden numbers or embedded figures that can
only be correctly seen by persons with normal color vision.
Pseudoisochromatic testing plates: The patient is asked to look
for numbers among the various colored dots, which help distinguish
between red, green, and blue color deficiencies. Individuals with nor-
mal color vision will see a number, while those with a deficiency do
not see it. On some plates, a person with normal color vision may see
one number, while a person with a deficiency sees a different num-
ber.
Pseudoisochromatic plate testing can be used to determine if a color
vision deficiency exists and the type of deficiency. However, additional
testing may be needed to determine the exact nature and degree of
color deficiency.
It is possible for a person to have poor color vision and not know
it. Quite often, people with red-green deficiency aren’t even aware of
their problem since they’ve learned to see the “right” color. For ex-
ample, tree leaves are green, so they call the color they see green.
Also, parents may not suspect the condition in their children until
a situation causes confusion or misunderstanding. Early detection of
color deficiency is vital since many learning materials rely heavily on
color perception or color coding. That is one reason that the Ameri-
can Optometric Association recommends a comprehensive optomet-
ric examination before a child begins school.
How is color vision deficiency treated?

There is no cure for inherited color deficiency. But if the cause is
an illness or eye injury, treating these conditions may improve color
vision.
Using special tinted eyeglasses or wearing a red-tinted contact lens
on one eye can increase some people’s ability to differentiate between
colors, though nothing can make you truly see the deficient color.
Most color-deficient persons compensate for their inability to distin-
guish certain colors with color cues and details that are not consciously
518
evident to people with normal color vision. There are ways to work
around the inability to see certain colors by:
• Organizing and labeling clothing, furniture, or other colored ob-

jects (with the help of friends or family) for ease of recognition.
• Remembering the order of things rather than their color can
also increase the chances of correctly identifying colors. For ex-
ample, a traffic light has red on top, yellow in the middle, and
green on the bottom.
Though color vision deficiency can be a frustration and may limit

participation in some occupations, in most cases it is not a serious
threat to vision and can be adapted to your lifestyle with time, pa-
tience, and practice.
Section 42.2
Fragile X Syndrome
Reprinted from “Learning About Fragile X Syndrome,”
National Human Genome Research Institute, April 10, 2008.
What is fragile X syndrome?

Fragile X syndrome is the most common form of inherited mental
retardation in males and is also a significant cause of mental retar-
dation in females. It affects about one in four thousand males and one
in eight thousand females and occurs in all racial and ethnic groups.
Nearly all cases of fragile X syndrome are caused by an alteration
(mutation) in the FMR1 gene where a DNA segment, known as the
CGG triplet repeat, is expanded. Normally, this DNA segment is re-
peated from five to about forty times. In people with fragile X syn-
drome, however, the CGG segment is repeated more than two hundred
times. The abnormally expanded CGG segment inactivates (silences)
the FMR1 gene, which prevents the gene from producing a protein
called fragile X mental retardation protein. Loss of this protein leads
519
to the signs and symptoms of fragile X syndrome. Both boys and girls
can be affected, but because boys have only one X chromosome, a single
fragile X is likely to affect them more severely.
What are the symptoms of fragile X syndrome?

A boy who has the full FMR1 mutation has fragile X syndrome and
will have moderate mental retardation. They have a particular facial
appearance, characterized by a large head size, a long face, prominent
forehead and chin, and protruding ears. In addition, males who have
fragile X syndrome have loose joints (joint laxity) and large testes
(after puberty).
Affected boys may have behavioral problems such as hyperactiv-
ity, hand flapping, hand biting, temper tantrums, and autism. Other
behaviors in boys after they have reached puberty include poor eye
contact, perseverative speech, problems in impulse control, and dis-
tractibility. Physical problems that have been seen include eye, ortho-
pedic, heart, and skin problems.
Girls who have the full FMR1 mutation have mild mental retar-
dation.
Family members who have fewer repeats in the FMR1 gene may
not have mental retardation, but may have other problems. Women
with less severe changes may have premature menopause or difficulty
becoming pregnant.
Both men and women may have problems with tremors and poor
coordination.
What does it mean to have a fragile X premutation?

People with about fifty-five to two hundred repeats of the CGG
segment are said to have an FMR1 premutation (an intermediate
variation of the gene). In women, the premutation is liable to expand
to more than two hundred repeats in cells that develop into eggs. This
means that women with the FMR1 premutation have an increased
risk of having a child with fragile X syndrome. By contrast, the
premutation CGG repeat in men remains at the same size or short-
ens as it is passed to the next generation.
Males and females who have a fragile X premutation have normal
intellect and appearance. A few individuals with a premutation have
subtle intellectual or behavioral symptoms, such as learning difficul-
ties or social anxiety. The difficulties are usually not socially debili-
tating, and these individuals may still marry and have children.
520
Males who have a premutation with fifty-nine to two hundred CGG
trinucleotide repeats are usually unaffected and are at risk for fragile X–
associated tremor/ataxia syndrome (FXTAS). The fragile X–associated
tremor/ataxia syndrome (FXTAS) is characterized by late onset, pro-
gressive cerebellar ataxia, and intention tremor in males who have a
premutation. Other neurologic findings include short-term memory
loss, executive function deficits, cognitive decline, parkinsonism, pe-
ripheral neuropathy, lower-limb proximal muscle weakness, and auto-
nomic dysfunction.
The degree to which clinical symptoms of fragile X are present (pen-
etrance) is age related; symptoms are seen in 17 percent of males aged
fifty to fifty-nine years, in 38 percent of males aged sixty to sixty-nine
years, in 47 percent of males aged seventy to seventy-nine years, and
in 75 percent or males aged eighty years or older. Some female pre-
mutation carriers may also develop tremor and ataxia.
Females who have a premutation usually are unaffected, but may
be at risk for premature ovarian failure and FXTAS. Premature ova-
rian failure (POF) is defined as cessation of menses before age forty
years, has been observed in carriers of premutation alleles. A review
by Sherman (2005) concluded that the risk for POF was 21 percent
in premutation carriers compared to a 1 percent for the general popu-
lation.
How is fragile X syndrome diagnosed?

There are very few outward signs of fragile X syndrome in babies,
but one is a tendency to have a large head circumference. An experi-
enced geneticist may note subtle differences in facial characteristics.
Mental retardation is the hallmark of this condition and, in females,
this may be the only sign of the problem.
A specific genetic test (polymerase chain reaction [PCR]) can now
be performed to diagnose fragile X syndrome. This test looks for an
expanded mutation (called a triplet repeat) in the FMR1 gene.
How is fragile X syndrome treated?

There is no specific treatment available for fragile X syndrome.
Supportive therapy for children who have fragile X syndrome includes
the following:
• Special education and anticipatory management including avoid-

ance of excessive stimulation to decrease behavioral problems.
521
• Medication to manage behavioral issues, although no specific
medication has been shown to be beneficial.
• Early intervention, special education, and vocational training.
• Vision, hearing, connective tissue problems, and heart problems
when present are treated in the usual manner.
Is fragile X syndrome inherited?

This condition is inherited in an X-linked dominant pattern. A con-
dition is considered X-linked if the mutated gene that causes the dis-
order is located on the X chromosome, one of the two sex chromosomes.
The inheritance is dominant if one copy of the altered gene in each
cell is sufficient to cause the condition. In most cases, males experi-
ence more severe symptoms of the disorder than females. A striking
characteristic of X-linked inheritance is that fathers cannot pass X-
linked traits to their sons.
Section 42.3
Hemophilia
Reprinted from “Learning about Hemophilia,”
National Human Genome Research Institute, August 1, 2008.
What is hemophilia?
Hemophilia is a bleeding disorder that slows down the blood clot-
ting process. People who have hemophilia often have longer bleeding
after an injury or surgery. People who have severe hemophilia have
spontaneous bleeding into the joints and muscles. Hemophilia occurs
more commonly in males than in females.
The two most common types of hemophilia are hemophilia A (also
known as classic hemophilia) and hemophilia B (also known as Christ-
mas disease). People who have hemophilia A have low levels of a blood
clotting factor called factor eight (FVIII). People who have hemophilia
B have low levels of factor nine (FIX).
522
The two types of hemophilia are caused by permanent gene
changes (mutations) in different genes. Mutations in the FVIII gene
cause hemophilia A. Mutations in the FIX gene cause hemophilia B.
Proteins made by these genes have an important role in the blood clot-
ting process. Mutations in either gene keep clots from forming when
there is an injury, causing too much bleeding that can be difficult to
stop.
Hemophilia A is the most common type of this condition. One in
5,000 to 10,000 males worldwide have hemophilia A. Hemophilia B
is less common, and it affects 1 in 20,000 to 34,500 males worldwide.
What are the symptoms of hemophilia?

Symptoms of hemophilia include prolonged oozing after injuries,
tooth extractions. or surgery; renewed bleeding after initial bleeding
has stopped; easy or spontaneous bruising; and prolonged bleeding.
In both severe hemophilia A and severe hemophilia B, the most
frequent symptom is spontaneous joint bleeding. Other serious sites
of bleeding include the bowel, the brain, and soft tissues. These types
of bleeding can lead to throwing up blood or passing blood in the stool,
stroke, and sudden severe pain in the joints or limbs. Painful bleed-
ing into the soft tissues of the arms and legs can lead to nerve dam-
age.
Individuals who have severe hemophilia are usually diagnosed
within the first year of life. People who have moderate hemophilia do
not usually have spontaneous bleeding, but they do have longer bleed-
ing and oozing after small injuries. They are usually diagnosed be-
fore they reach five or six years.
Individuals who have mild hemophilia do not have spontaneous
bleeding. If they are not treated they may have longer bleeding when
they have surgery, teeth removed, or major injuries. Individuals with
mild hemophilia may not be diagnosed until later in life.
How is hemophilia diagnosed?

Hemophilia A and B are diagnosed by measuring factor clotting
activity. Individuals who have hemophilia A have low factor VIII clot-
ting activity. Individuals who have hemophilia B have low factor IX
clotting activity.
Genetic testing is also available for the factor VIII gene and the
factor IX gene. Genetic testing of the FVIII gene finds a disease-causing
mutation in up to 98 percent of individuals who have hemophilia A.
523
Genetic testing of the FIX gene finds disease-causing mutations in
more than 99 percent of individuals who have hemophilia B.
Genetic testing is usually used to identify women who are carriers
of a FVIII or FIX gene mutation, and to diagnose hemophilia in a fe-
tus during a pregnancy (prenatal diagnosis). It is sometimes used to
diagnose individuals who have mild symptoms of hemophilia A or B.
What is the treatment for hemophilia?

There is currently no cure for hemophilia. Treatment depends on
the severity of hemophilia.
Treatment may involve slow injection of a medicine called
desmopressin (DDAVP) by the doctor into one of the veins. DDAVP
helps to release more clotting factor to stop the bleeding. Sometimes,
DDAVP is given as a medication that can be breathed in through the
nose (nasal spray).
People who have moderate to severe hemophilia A or B may need
to have an infusion of clotting factor taken from donated human blood
or from genetically engineered products called recombinant clotting
factors to stop the bleeding. If the potential for bleeding is serious, a
doctor may give infusions of clotting factor to avoid bleeding (preven-
tive infusions) before the bleeding begins. Repeated infusions may be
necessary if the internal bleeding is serious.
When bleeding has damaged joints, physical therapy is used to help
them function better. Physical therapy helps to keep the joints mov-
ing and prevents the joints from becoming frozen or badly deformed.
Sometimes the bleeding into joints damages them or destroys them.
In this situation, the individual may be given an artificial joint.
When a person who has hemophilia has a small cut or scrape, us-
ing pressure and a bandage will take care of the wound. An ice pack
can be used when there are small areas of bleeding under the skin.
Researchers have been working to develop a gene replacement
treatment (gene therapy) for hemophilia A. Research of gene therapy
for hemophilia A is now taking place. The results are encouraging.
Researchers continue to evaluate the long-term safety of gene thera-
pies. The hope is that there will be a genetic cure for hemophilia in
the future.
Individuals who have hemophilia A and B are living much longer
and with less disability than they did thirty years ago. This is because
of the use of the intravenous infusion of factor VIII concentrate, home
infusion programs, prophylactic treatment, and improved patient
education.
524
Is hemophilia inherited?
Hemophilia is inherited in an X-linked recessive pattern. A condi-
tion is considered X-linked when the gene mutation that causes it is
located on the X chromosome, one of the two sex chromosomes. In
males (who have only one X chromosome), one altered copy of the gene
in each cell is enough to cause the condition. Since females have two
X chromosomes, a mutation must be present in both copies of the gene
to cause the hemophilia. Males are affected by X-linked recessive dis-
orders much more frequently than females. A major characteristic of
X-linked inheritance is that fathers cannot pass X-linked traits to
their sons.
A female who is a carrier has a one in two (50 percent) chance to
pass on her X chromosome with the gene mutation for hemophilia A
or B to a boy who will be affected. She has a one in two (50 percent)
chance to pass on her X chromosome with the normally functioning
gene to a boy who will not have hemophilia.
Section 42.4
Klinefelter Syndrome
Reprinted from “Learning about Klinefelter Syndrome,”
National Human Genome Research Institute, May 27, 2008.
What is Klinefelter syndrome?

Klinefelter syndrome is a condition that occurs in men as a re-
sult of an extra X chromosome. The most common symptom is infer-
tility.
Humans have forty-six chromosomes, which contain all of a per-
son’s genes and DNA. Two of these chromosomes, the sex chromo-
somes, determine a person’s gender. Both of the sex chromosomes in
females are called X chromosomes. (This is written as XX.) Males have
an X and a Y chromosome (written as XY). The two sex chromosomes
help a person develop fertility and the sexual characteristics of their
gender.
525
Most often, Klinefelter syndrome is the result of one extra X (writ-
ten as XXY). Occasionally, variations of the XXY chromosome count
may occur, the most common being the XY/XXY mosaic. In this varia-
tion, some of the cells in the male’s body have an additional X chro-
mosome, and the rest have the normal XY chromosome count. The
percentage of cells containing the extra chromosome varies from case
to case. In some instances, XY/XXY mosaics may have enough nor-
mally functioning cells in the testes to allow them to father children.
Klinefelter syndrome is found in about one out of every five hun-
dred to one thousand newborn males. The additional sex chromosome
results from a random error during the formation of the egg or sperm.
About half of the time the error occurs in the formation of sperm, while
the remainder are due to errors in egg development. Women who have
pregnancies after age thirty-five have a slightly increased chance of
having a boy with this syndrome.
What are the symptoms of Klinefelter syndrome?

Males who have Klinefelter syndrome may have the following
symptoms: small, firm testes; a small penis; sparse pubic, armpit, and
facial hair; enlarged breasts (called gynecomastia); tall stature; and
abnormal body proportions (long legs, short trunk).
School-age children may be diagnosed if they are referred to a doc-
tor to evaluate learning disabilities. The diagnosis may also be con-
sidered in the adolescent male when puberty is not progressing as
expected. Adult males may come to the doctor because of infertility.
Klinefelter syndrome is associated with an increased risk for breast
cancer, a rare tumor called extragonadal germ cell tumor, lung dis-
ease, varicose veins, and osteoporosis. Men who have Klinefelter syn-
drome also have an increased risk for autoimmune disorders such as
lupus, rheumatoid arthritis, and Sjögren syndrome.
How is Klinefelter syndrome diagnosed?

A chromosomal analysis (karyotype) is used to confirm the diag-
nosis. In this procedure, a small blood sample is drawn. White blood
cells are then separated from the sample, mixed with tissue culture
medium, incubated, and checked for chromosomal abnormalities, such
as an extra X chromosome.
The chromosome analysis looks at a number of cells, usually at
least twenty, which allows for the diagnosis of genetic conditions in
both the full and mosaic state. In some cases, low-level mosaicism may
526
be missed. However, if mosaicism is suspected (based on hormone lev-
els, sperm counts, or physical characteristics), additional cells can be
analyzed from within the same blood draw.
How is Klinefelter syndrome treated?

Testosterone therapy is used to increase strength, promote mus-
cular development, grow body hair, improve mood and self esteem,
increase energy, and improve concentration.
Most men who have Klinefelter syndrome are not able to father
children. However, some men with an extra X chromosome have fa-
thered healthy offspring, sometimes with the help of infertility spe-
cialists.
Most men who have Klinefelter syndrome can expect to have a
normal and productive life. Early diagnosis, in conjunction with edu-
cational interventions, medical management, and strong social sup-
port, will optimize each individual’s potential in adulthood.
Section 42.5
Muscular Dystrophy
Excerpted from “Muscular Dystrophy: Hope Through Research,”
National Institute of Neurological Disorders and Stroke, August 19, 2008.
What is muscular dystrophy?

Muscular dystrophy (MD) refers to a group of more than thirty
genetic diseases that cause progressive weakness and degeneration
of skeletal muscles used during voluntary movement. The word dys-
trophy is derived from the Greek dys, which means “difficult” or
“faulty,” and troph, or “nourish.” These disorders vary in age of onset,
severity, and pattern of affected muscles. All forms of MD grow worse
as muscles progressively degenerate and weaken. The majority of
patients eventually lose the ability to walk.
Some types of MD also affect the heart, gastrointestinal system,
endocrine glands, spine, eyes, brain, and other organs. Respiratory and
527
cardiac diseases are common, and some patients may develop a swal-
lowing disorder. MD is not contagious and cannot be brought on by
injury or activity.
What causes MD?

All of the muscular dystrophies are inherited and involve a muta-
tion in one of the thousands of genes that program proteins critical
to muscle integrity. The body’s cells don’t work properly when a pro-
tein is altered or produced in insufficient quantity (or sometimes miss-
ing completely). Many cases of MD occur from spontaneous mutations
that are not found in the genes of either parent, and this defect can
be passed to the next generation.
Genes are like blueprints: they contain coded messages that de-
termine a person’s characteristics or traits. They are arranged along
twenty-three rod-like pairs of chromosomes, with one half of each
pair being inherited from each parent. Each half of a chromosome
pair is similar to the other, except for one pair, which determines
the sex of the individual. Muscular dystrophies can be inherited in
three ways:
• Autosomal dominant inheritance occurs when a child receives

a normal gene from one parent and a defective gene from the
other parent. Autosomal means the genetic mutation can occur
on any of the twenty-two non-sex chromosomes in each of the
body’s cells. Dominant means only one parent needs to pass along
the abnormal gene in order to produce the disorder. In families
where one parent carries a defective gene, each child has a 50
percent chance of inheriting the gene and therefore the disorder.
Males and females are equally at risk and the severity of the
disorder can differ from person to person.
• Autosomal recessive inheritance means that both parents must
carry and pass on the faulty gene. The parents each have one de-
fective gene but are not affected by the disorder. Children in
these families have a 25 percent chance of inheriting both cop-
ies of the defective gene and a 50 percent chance of inheriting
one gene and therefore becoming a carrier, able to pass along the
defect to their children. Children of either sex can be affected by
this pattern of inheritance.
• X-linked (or sex-linked) recessive inheritance occurs when a
mother carries the affected gene on one of her two X chromosomes
528
and passes it to her son (males always inherit an X chromosome
from their mother and a Y chromosome from their father, while
daughters inherit an X chromosome from each parent). Sons of
carrier mothers have a 50 percent chance of inheriting the dis-
order. Daughters also have a 50 percent chance of inheriting the
defective gene but usually are not affected, since the healthy X
chromosome they receive from their father can offset the faulty
one received from their mother. Affected fathers cannot pass an
X-linked disorder to their sons but their daughters will be carri-
ers of that disorder. Carrier females occasionally can exhibit
milder symptoms of MD.
How many people have MD?

MD occurs worldwide, affecting all races. Its incidence varies, as
some forms are more common than others. Its most common forms
in children, Duchenne and Becker muscular dystrophy, alone affect
approximately 1 in every 3,500 to 5,000 boys, or between 400 and 600
live male births each year in the United States.1 Some types of MD
are more prevalent in certain countries and regions of the world. Most
muscular dystrophies are familial, meaning there is some family his-
tory of the disease.
How does MD affect muscles?

Muscles are made up of thousands of muscle fibers. Each fiber is
actually a number of individual cells that have joined together dur-
ing development and are encased by an outer membrane. Muscle fi-
bers that make up individual muscles are bound together by connective
tissue.
Although MD can affect several body tissues and organs, it most
prominently affects the integrity of muscle fibers. The disease causes
muscle degeneration, progressive weakness, fiber death, fiber branch-
ing and splitting, phagocytosis (in which muscle fiber material is bro-
ken down and destroyed by scavenger cells), and, in some cases,
chronic or permanent shortening of tendons and muscles. Also, over-
all muscle strength and tendon reflexes are usually lessened or lost
due to replacement of muscle by connective tissue and fat.
How do the muscular dystrophies differ?

There are nine major groups of the muscular dystrophies. The dis-
orders are classified by the extent and distribution of muscle weakness,
529
age of onset, rate of progression, severity of symptoms, and family his-
tory (including any pattern of inheritance). Although some forms of MD
become apparent in infancy or childhood, others may not appear until
middle age or later. Overall, incidence rates and severity vary, but each
of the dystrophies causes progressive skeletal muscle deterioration, and
some types affect cardiac muscle.
There are four forms of MD that begin in childhood.
Duchenne MD: Duchenne MD is the most common childhood form

of MD, as well as the most common of the muscular dystrophies over-
all, accounting for approximately 50 percent of all cases. It affects
approximately one in 3,500 male births. Because inheritance is X-
linked recessive (caused by a mutation on the X, or sex, chromosome),
Duchenne MD primarily affects boys, although girls and women who
carry the defective gene may show some symptoms. About one-third
of the cases reflect new mutations and the rest run in families. Sis-
ters of boys with Duchenne MD have a 50 percent chance of carrying
the defective gene.
Duchenne MD usually becomes apparent when an affected child
begins to walk. Progressive weakness and muscle wasting (a decrease
in muscle strength and size) caused by degenerating muscle fibers
begins in the upper legs and pelvis before spreading into the upper
arms. Other symptoms include loss of some reflexes, a waddling gait,
frequent falls and clumsiness (especially when running), difficulty
when rising from a sitting or lying position or when climbing stairs,
changes to overall posture, impaired breathing, lung weakness, and
cardiomyopathy (heart muscle weakness that interferes with pump-
ing ability). Many children are unable to run or jump. The wasting
muscles, in particular the calf muscle (and, less commonly, muscles
in the buttocks, shoulders, and arms), may be enlarged by an accu-
mulation of fat and connective tissue, causing them to look larger and
healthier than they actually are (called pseudohypertrophy). As the
disease progresses, the muscles in the diaphragm that assist in
breathing and coughing may weaken. Patients may experience breath-
ing difficulties, respiratory infections, and swallowing problems. Bone
thinning and scoliosis (curving of the spine) are common. Some chil-
dren are mildly mentally impaired. Between ages three and six, chil-
dren may show brief periods of physical improvement followed by
progressive muscle degeneration. Children with Duchenne MD are
typically wheelchair-bound by age twelve and usually die in their late
teens or early twenties from progressive weakness of the heart muscle,
respiratory complications, or infection.
530
Duchenne MD results from an absence of the muscle protein
dystrophin. Blood tests of children with Duchenne MD show an ab-
normally high level of creatine kinase, which is apparent from birth.
Becker MD: Becker MD is less severe than but closely related to

Duchenne MD. Persons with Becker MD have partial but insufficient
function of the protein dystrophin. The disorder usually appears
around age eleven but may occur as late as age twenty-five, and pa-
tients generally live into middle age or later. The rate of progressive,
symmetric (on both sides of the body) muscle atrophy and weakness
varies greatly among affected individuals. Many patients are able to
walk until they are in their mid-thirties or later, while others are
unable to walk past their teens. Some affected individuals never need
to use a wheelchair. As in Duchenne MD, muscle weakness in Becker
MD is typically noticed first in the upper arms and shoulders, upper
legs, and pelvis.
Early symptoms of Becker MD include walking on one’s toes, fre-
quent falls, and difficulty rising from the floor. Calf muscles may ap-
pear large and healthy as deteriorating muscle fibers are replaced by
fat, and muscle activity may cause cramps in some people. Cardiac
and mental impairments are not as severe as in Duchenne MD.
Congenital MD: Congenital MD refers to a group of autosomal

recessive muscular dystrophies that are either present at birth or
become evident before age two. They affect both boys and girls. The
degree and progression of muscle weakness and degeneration vary
with the type of disorder. Weakness may be first noted when chil-
dren fail to meet landmarks in motor function and muscle control.
Muscle degeneration may be mild or severe and is restricted prima-
rily to skeletal muscle. The majority of patients are unable to sit or
stand without support, and some affected children may never learn
to walk.
Patients with congenital MD may develop contractures (chronic
shortening of muscles or tendons around joints, which prevents the
joints from moving freely), scoliosis, respiratory and swallowing dif-
ficulties, and foot deformities. Some patients have normal intellectual
development while others become severely impaired. Weakness in
diaphragm muscles may lead to respiratory failure. Congenital MD
may also affect the central nervous system, causing vision and speech
problems, seizures, and structural changes in the brain. Some chil-
dren with the disorders die in infancy while others may live into adult-
hood with only minimal disability.
531
Emery-Dreifuss MD: Emery-Dreifuss MD primarily affects boys.
The disorder has two forms: one is X-linked recessive and the other
is autosomal dominant.
Onset of Emery-Dreifuss MD is usually apparent by age ten, but
symptoms can appear as late as the mid-twenties. This disease causes
slow but progressive wasting of the upper arm and lower leg muscles
and symmetric weakness. Contractures in the spine, ankles, knees,
elbows, and back of the neck usually precede significant muscle weak-
ness, which is less severe than in Duchenne MD. Contractures may
cause elbows to become locked in a flexed position. The entire spine
may become rigid as the disease progresses. Other symptoms include
shoulder deterioration, toe-walking, and mild facial weakness. Serum
creatine kinase levels may be moderately elevated. Nearly all Emery-
Dreifuss MD patients have some form of heart problem by age thirty,
often requiring a pacemaker or other assistive device. Female carri-
ers of the disorder often have cardiac complications without muscle
weakness. Patients often die in mid-adulthood from progressive pul-
monary or cardiac failure.
Youth/adolescent-onset muscular dystrophies are classified two
ways.
Facioscapulohumeral MD (FSHD): FSHD initially affects mus-

cles of the face (facio), shoulders (scapulo), and upper arms (humera)
with progressive weakness. Also known as Landouzy-Dejerine disease,
this third most common form of MD is an autosomal dominant disor-
der. Life expectancy is normal, but some individuals become severely
disabled. Disease progression is typically very slow, with intermittent
spurts of rapid muscle deterioration. Onset is usually in the teenage
years but may occur as late as age forty. Muscles around the eyes and
mouth are often affected first, followed by weakness around the lower
shoulders and chest. A particular pattern of muscle wasting causes
the shoulders to appear to be slanted and the shoulder blades to ap-
pear winged. Muscles in the lower extremities may also become weak-
ened. Reflexes are impaired only at the biceps and triceps. Changes
in facial appearance may include the development of a crooked smile,
a pouting look, flattened facial features, or a mask-like appearance.
Some patients cannot pucker their lips or whistle and may have dif-
ficulty swallowing, chewing, or speaking. Other symptoms may in-
clude hearing loss (particularly at high frequencies) and lordosis, an
abnormal swayback curve in the spine. Contractures are rare. Some
FSHD patients feel severe pain in the affected limb. Cardiac muscles
are not affected, and the pelvic girdle is rarely significantly involved.
532
An infant-onset form of FSHD can also cause retinal disease and some
hearing loss.
Limb-girdle MD: Limb-girdle MD refers to more than a dozen

inherited conditions marked by progressive loss of muscle bulk and
symmetrical weakening of voluntary muscles, primarily those in the
shoulders and around the hips. At least three forms of autosomal
dominant limb-girdle MD (known as type 1) and eight forms of auto-
somal recessive limb-girdle MD (known as type 2) have been identi-
fied. Some autosomal recessive forms of the disorder are now known
to be due to a deficiency of any of four dystrophin-glycoprotein com-
plex proteins called the sarcoglycans.
The recessive limb-girdle muscular dystrophies occur more fre-
quently than the dominant forms, usually begin in childhood or the
teenage years, and show dramatically increased levels of serum cre-
atine kinase. The dominant limb-girdle muscular dystrophies usu-
ally begin in adulthood. In general, the earlier the clinical signs
appear, the more rapid the rate of disease progression. Limb-girdle
MD affects both males and females. Some forms of the disease pro-
gress rapidly, resulting in serious muscle damage and loss of the
ability to walk, while others advance very slowly over many years
and cause minimal disability, allowing a normal life expectancy. In
some cases, the disorder appears to halt temporarily, but symptoms
then resume.
Weakness is typically noticed first around the hips before spread-
ing to the shoulders, legs, and neck. Patients develop a waddling gait
and have difficulty when rising from chairs, climbing stairs, or car-
rying heavy objects. Patients fall frequently and are unable to run.
Contractures at the elbows and knees are rare but patients may de-
velop contractures in the back muscles, which gives them the appear-
ance of a rigid spine. Proximal reflexes (closest to the center of the
body) are often impaired. Some patients also experience cardiomyopa-
thy and respiratory complications. Intelligence remains normal. Most
persons with limb-girdle MD become severely disabled within twenty
years of disease onset.
There are three forms of MD that usually begin in adulthood.
Distal MD: Distal MD, also called distal myopathy, describes a

group of at least six specific muscle diseases that primarily affect dis-
tal muscles (those farthest away from the shoulders and hips) in the
forearms, hands, lower legs, and feet. Distal dystrophies are typically
less severe, progress more slowly, and involve fewer muscles than
533
other forms of MD, although they can spread to other muscles. Distal
MD can affect the heart and respiratory muscles, and patients may
eventually require the use of a ventilator. Patients may not be able
to perform fine hand movement and have difficulty extending the fin-
gers. As leg muscles become affected, walking and climbing stairs
become difficult and some patients may be unable to hop or stand on
their heels. Onset of distal MD, which affects both men and women,
is typically between the ages of forty and sixty years. In one form of
distal MD, a muscle membrane protein complex called dysferlin is
known to be lacking.
Although distal MD is primarily an autosomal dominant disorder,
autosomal recessive forms have been reported in young adults. Symp-
toms are similar to those of Duchenne MD but with a different pat-
tern of muscle damage. An infantile-onset form of autosomal recessive
distal MD has also been reported. Slow but progressive weakness is
often first noticed around age one, when the child begins to walk, and
continues to progress very slowly throughout adult life.
Myotonic MD: Myotonic MD, also known as Steinert disease and

dystrophia myotonica, may be the most common adult form of MD.
Myotonia, or an inability to relax muscles following a sudden contrac-
tion, is found only in this form of MD. People with myotonic MD can
live a long life, with variable but slowly progressive disability. Typi-
cal disease onset is between ages twenty and thirty, but it may de-
velop earlier. Myotonic MD affects the central nervous system and
other body systems, including the heart, adrenal glands and thyroid,
eyes, and gastrointestinal tract. Muscles in the face and the front of
the neck are usually first to show weakness and may produce a hag-
gard, “hatchet” face and a thin, swan-like neck. Wasting and weak-
ness noticeably affect forearm muscles. Other symptoms include
cardiac complications, difficulty swallowing, droopy eyelids (called
ptosis), cataracts, poor vision, early frontal baldness, weight loss, im-
potence, testicular atrophy, mild mental impairment, and increased
sweating. Patients may also feel drowsy and have an excess need to
sleep.
This autosomal dominant disease affects both men and women.
Females may have irregular menstrual periods and may be infertile.
The disease occurs earlier and is more severe in successive genera-
tions. A childhood form of myotonic MD may become apparent between
ages five and ten. Symptoms include general muscle weakness (par-
ticularly in the face and distal muscles), lack of muscle tone, and men-
tal impairment.
534
Oculopharyngeal MD (OPMD): OPMD generally begins in a per-
son’s forties or fifties and affects both men and women. In the United
States, the disease is most common in families of French-Canadian
descent and among Hispanic residents of northern New Mexico. Pa-
tients first report drooping eyelids, followed by weakness in the fa-
cial muscles and pharyngeal muscles in the throat, causing difficulty
swallowing. The tongue may atrophy and changes to the voice may
occur. Eyelids may droop so dramatically that some patients compen-
sate by tilting back their heads. Patients may have double vision and
problems with upper gaze, and others may have retinitis pigmentosa
(progressive degeneration of the retina that affects night vision and
peripheral vision) and cardiac irregularities. Muscle weakness and
wasting in the neck and shoulder region is common. Limb muscles
may also be affected. Persons with OPMD may find it difficult to walk,
climb stairs, kneel, or bend. Those persons most severely affected will
eventually lose the ability to walk.
How are the muscular dystrophies diagnosed?

Both the patient’s medical history and a complete family history
should be thoroughly reviewed to determine if the muscle disease is
secondary to a disease affecting other tissues or organs or is an in-
herited condition. It is also important to rule out any muscle weak-
ness resulting from prior surgery, exposure to toxins, or current
medications that may affect the patient’s functional status. Thorough
clinical and neurological exams can rule out disorders of the central
and/or peripheral nervous systems, identify any patterns of muscle
weakness and atrophy, test reflex responses and coordination, and look
for contractions.
Various laboratory tests may be used to confirm the diagnosis of
MD.
Blood and urine tests can detect defective genes and help identify
specific neuromuscular disorders. For example:
• The level of serum aldolase, an enzyme involved in the break-
down of glucose, is measured to confirm a diagnosis of skeletal
muscle disease. High levels of the enzyme, which is present in
most body tissues, are noted in patients with MD and some
forms of myopathy.
• Creatine kinase is an enzyme that leaks out of damaged muscle.
Elevated creatine kinase levels may indicate muscle damage,
including some forms of MD, before physical symptoms become
535
apparent. Levels are significantly increased in patients in the
early stages of Duchenne and Becker MD. Testing can also de-
termine if a young woman is a carrier of the disorder.
• Myoglobin is measured when injury or disease in skeletal
muscle is suspected. Myoglobin is an oxygen-binding protein
found in cardiac and skeletal muscle cells. High blood levels of
myoglobin are found in patients with MD.
• Polymerase chain reaction (PCR) can detect mutations in the
dystrophin gene. Also known as molecular diagnosis or genetic
testing, PCR is a method for generating and analyzing multiple
copies of a fragment of DNA.
• Serum electrophoresis is a test to determine quantities of vari-
ous proteins in a person’s DNA. A blood sample is placed on spe-
cially treated paper and exposed to an electric current. The
charge forces the different proteins to form bands that indicate
the relative proportion of each protein fragment.
Electron microscopy can identify changes in subcellular compo-

nents of muscle fibers. Electron microscopy can also identify changes
that characterize cell death, mutations in muscle cell mitochondria,
and an increase in connective tissue seen in muscle diseases such as
MD. Changes in muscle fibers that are evident in a rare form of dis-
tal MD can be seen using an electron microscope.
Exercise tests can detect elevated rates of certain chemicals fol-
lowing exercise and are used to determine the nature of the MD or
other muscle disorder.
Genetic testing looks for genes known to either cause or be associ-
ated with inherited muscle disease. DNA analysis and enzyme assays
can confirm the diagnosis of certain neuromuscular diseases, includ-
ing MD. Genetic linkage studies can identify whether a specific ge-
netic marker on a chromosome and a disease are inherited together.
They are particularly useful in studying families with members in
different generations who are affected. An exact molecular diagnosis
is necessary for some of the treatment strategies that are currently
being developed.
Genetic counseling can help parents who have a family history of
MD determine if they are carrying one of the mutated genes that cause
the disorder.
Magnetic resonance imaging (MRI) is used to examine muscle qual-
ity, any atrophy or abnormalities in size, and fatty replacement of muscle
tissue, as well as to monitor disease progression.
536
Muscle biopsies are used to monitor the course of disease and treat-
ment effectiveness.
Immunofluorescence testing can detect specific proteins such as
dystrophin within muscle fibers. Following biopsy, fluorescent mark-
ers are used to stain the sample that has the protein of interest.
Neurophysiology studies can identify physical and/or chemical
changes in the nervous system.
How are the muscular dystrophies treated?

There is no specific treatment that can stop or reverse the progres-
sion of any form of MD. All forms of MD are genetic and cannot be
prevented. Treatment is aimed at keeping the patient independent
for as long as possible and preventing complications that result from
weakness, reduced mobility, and cardiac and respiratory difficulties.
Treatment may involve a combination of approaches, including physi-
cal therapy, drug therapy, and surgery.
Assisted ventilation is often needed to treat respiratory muscle
weakness that accompanies many forms of MD, especially in the later
stages. Patients on a ventilator may also require the use of a gastric
feeding tube.
Drug therapy may be prescribed to delay muscle degeneration.
Corticosteroids such as prednisone can slow the rate of muscle dete-
rioration in Duchenne MD and help children retain strength and pro-
long independent walking by as much as several years. However, these
medicines have side effects such as weight gain and bone fragility that
can be especially troubling in children. Immunosuppressive drugs
such as cyclosporin and azathioprine can delay some damage to dy-
ing muscle cells. Drugs that may provide short-term relief from myo-
tonia (muscle spasms and weakness) include mexiletine; phenytoin;
baclofen, which blocks signals sent from the spinal cord to contract
the muscles; dantrolene, which interferes with the process of muscle
contraction; and quinine. (Drugs for myotonia are not effective in
myotonic MD but work well for myotonia congenita, a genetic neuro-
muscular disorder characterized by the slow relaxation of the mus-
cles.) Anticonvulsants, also known as antiepileptics, are used to control
seizures and some muscle activity. Commonly prescribed oral anticon-
vulsants include carbamazepine, phenytoin, clonazepam, gabapentin,
topiramate, and felbamate. Respiratory infections may be treated with
antibiotics.
Physical therapy can help prevent deformities, improve movement,
and keep muscles as flexible and strong as possible. Options include
537
passive stretching, postural correction, and exercise. A program is
developed to meet the individual patient’s needs. Therapy should be-
gin as soon as possible following diagnosis, before there is joint or
muscle tightness.
Dietary changes have not been shown to slow the progression of
MD. Proper nutrition is essential, however, for overall health. Lim-
ited mobility or inactivity resulting from muscle weakness can con-
tribute to obesity, dehydration, and constipation. A high-fiber,
high-protein, low-calorie diet combined with recommended fluid in-
take may help. MD patients with swallowing or breathing disorders
and those persons who have lost the ability to walk independently
should be monitored for signs of malnutrition.
Occupational therapy may help some patients deal with progres-
sive weakness and loss of mobility. Some individuals may need to learn
new job skills or new ways to perform tasks while other persons may
need to change jobs. Assistive technology may include modifications
to home and workplace settings and the use of motorized wheelchairs,
wheelchair accessories, and adaptive utensils.
Corrective surgery is often performed to ease complications from
MD.
• Tendon or muscle-release surgery is recommended when a con-

tracture becomes severe enough to lock a joint or greatly impair
movement.
• Patients with either Emery-Dreifuss or myotonic MD may even-
tually require a pacemaker to treat cardiac problems.
• Surgery to reduce the pain and postural imbalance caused by
scoliosis may help some patients.
• Persons with myotonic MD often develop cataracts, a clouding
of the lens of the eye that blocks light. Cataract surgery in-
volves removing the cloudy lens to improve the person’s ability
to see.
What is the prognosis?

The prognosis varies according to the type of MD and the speed of
progression. Some types are mild and progress very slowly, allowing
normal life expectancy, while others are more severe and result in
functional disability and loss of ambulation. Life expectancy may de-
pend on the degree of muscle weakness and any respiratory and/or
cardiac complications.
538
What research is being done?

Drug-based therapy to delay muscle wasting: Progressive loss
of muscle mass is primarily responsible for reduced quality and length
of life in MD. In the absence of a genetic cure, drug treatment strate-
gies designed to slow this muscle degeneration can have substantial
impact on quality of life.
Corticosteroids are known to extend the ability of Duchenne MD
patients to walk by up to two years, but steroids have substantial side
effects and their mechanism of action is unknown. NIH-funded sci-
entists have established clinical standards for steroid treatment of
Duchenne MD. A recent study identified one mechanism of steroid
action, raising the prospect that a modified steroid may be designed
to minimize or eliminate side effects.
Researchers at the National Institute of Neurological Disorders
and Stroke (NINDS) and several universities are exploring the po-
tential of using agents that inhibit enzymes that degrade muscle as
a treatment for various types of MD.
Scientists are also exploring several other drugs that may help
delay the loss of muscle mass.
Enhancing natural muscle repair mechanisms: Skeletal muscle

has the ability to repair itself, but its regeneration and repair mecha-
nisms are progressively depleted during the course of several types of
MD. Understanding the repair mechanisms may provide new thera-
pies to slow, and possibly stabilize, muscle degeneration.
NIH-supported studies have provided a broad understanding of the
mechanisms of muscle regeneration. Additional NIH-funded studies
are identifying points in the regeneration-repair pathways that can
be targeted by either drug or gene therapy for muscle rescue.
Cell-based therapy: The muscle cells of MD patients often lack

a critical protein, such as dystrophin in Duchenne MD or sarcoglycan
in the limb-girdle MDs. Scientists are exploring the possibility that
the missing protein can be replaced by introducing muscle stem cells
capable of making the missing protein in new muscle cells. Such new
cells would be protected from the progressive degeneration charac-
teristic of MD and potentially restore muscle function in affected per-
sons.
The natural regenerative capacity of muscle provides possibili-
ties for treatment of MD. Attempts to take muscle precursor cells
from fathers of Duchenne patients and implant them into patients’
539
muscles originally failed. However, more recent studies have fo-
cused on using stem cells to try to restore missing proteins in MD
patients. Researchers have shown that stem cells can be used to
deliver a functional dystrophin gene to skeletal muscles of dystro-
phic mice.
Gene replacement therapy: A true cure for Duchenne, congeni-

tal, and limb-girdle MD might be obtained if the defective dystrophin
gene could be replaced by a functional gene. The large size of the
dystrophin gene and the early inability of gene-delivery systems (vi-
ral vectors) to target muscle have been substantive barriers to devel-
opment of gene therapy for Duchenne MD.
Over the last several years, a mini-dystrophin gene (one that is
small enough for a viral carrier to deliver it) has proven successful in
animal models of Duchenne MD. Viral delivery systems are much
better today than they once were (viral vector delivery can set off a
serious immune response). As a result, NIH-funded researchers have
made important progress in delivering a dystrophin mini-gene to
muscles of a mouse model of Duchenne MD.
Scientists also are using high-throughput screening (HTS) to find
drugs that increase the muscle production of the protein utrophin,
which is similar to dystrophin and can help compensate for its loss.
HTS lets scientists test hundreds of chemical compounds quickly to
find leads for further drug development.
Genetic modification therapy to bypass inherited muta-

tions: Approximately 80 percent of Duchenne MD patients have
mutations in the dystrophin gene that causes it to function improp-
erly and stop producing the dystrophin protein. By manipulating the
protein synthesis process, production of a gene that “reads through”
the genetic mutation that stops production can result in functional
dystrophin.
Two strategies are currently under study to bypass dystrophin
mutations. First, the antibiotic gentamicin has been shown to be ef-
fective in causing the synthesis machinery to ignore the premature
stop signal and produce functional dystrophin. This strategy may be
useful in about 15 percent of Duchenne MD patients. An NINDS-
funded clinical trial using gentamicin in Duchenne MD patients is
under way. Second, a more recent approach uses splicing technology
to skip past the mutations in the dystrophin gene to a point where
the genetic information is complete and can produce a functional pro-
tein. This strategy has shown promise in a mouse model of Duchenne
540
MD. As many as 80 percent of patients could benefit from this new
technology.
References
on Birth Defects and Developmental Disabilities, July 27, 2005.
541
Chapter 43
Sleep Apnea
What Is Sleep Apnea?

Sleep apnea is a common disorder in which you have one or more
pauses in breathing or shallow breaths while you sleep.
Breathing pauses can last from a few seconds to minutes. They of-
ten occur five to thirty times or more an hour. Typically, normal breath-
ing then starts again, sometimes with a loud snort or choking sound.
Sleep apnea usually is a chronic (ongoing) condition that disrupts
your sleep three or more nights each week. You often move out of deep
sleep and into light sleep when your breathing pauses or becomes
shallow.
This results in poor sleep quality that makes you tired during the
day. Sleep apnea is one of the leading causes of excessive daytime
sleepiness.
Overview
Sleep apnea often goes undiagnosed. Doctors usually can’t detect
the condition during routine office visits. Also, there are no blood tests
for the condition.
Most people who have sleep apnea don’t know they have it because
it only occurs during sleep. A family member and/or bed partner may
first notice the signs of sleep apnea.
Reprinted from “Sleep Apnea,” National Heart Lung and Blood Institute,
National Institutes of Health, February 2008.
543
The most common type of sleep apnea is obstructive sleep apnea. This
most often means that the airway has collapsed or is blocked during
sleep. The blockage may cause shallow breathing or breathing pauses.
When you try to breathe, any air that squeezes past the blockage
can cause loud snoring. Obstructive sleep apnea happens more often
in people who are overweight, but it can affect anyone.
Central sleep apnea is a less common type of sleep apnea. It hap-
pens when the area of your brain that controls your breathing doesn’t
send the correct signals to your breathing muscles. You make no ef-
fort to breathe for brief periods.
Central sleep apnea often occurs with obstructive sleep apnea, but
it can occur alone. Snoring doesn’t typically happen with central sleep
apnea.
This chapter mainly focuses on obstructive sleep apnea.
Outlook
Untreated sleep apnea can do the following:
• Increase the risk for high blood pressure, heart attack, stroke,
obesity, and diabetes
• Increase the risk for or worsen heart failure
• Make irregular heartbeats more likely
• Increase the chance of having work-related or driving accidents
Lifestyle changes, mouthpieces, surgery, and/or breathing devices

can successfully treat sleep apnea in many people.
Other Names for Sleep Apnea

• Sleep-disordered breathing
• Cheyne-Stokes breathing
What Causes Sleep Apnea?

When you’re awake, throat muscles help keep your airway stiff and
open so air can flow into your lungs. When you sleep, these muscles
are more relaxed. Normally, the relaxed throat muscles don’t stop your
airway from staying open to allow air into your lungs.
But if you have obstructive sleep apnea, your airways can be blocked
or narrowed during sleep because:
544
Sleep Apnea
• Your throat muscles and tongue relax more than normal.
• Your tongue and tonsils (tissue masses in the back of your
mouth) are large compared to the opening into your windpipe.
• You’re overweight. The extra soft fat tissue can thicken the wall
of the windpipe. This causes the inside opening to narrow and
makes it harder to keep open.
• The shape of your head and neck (bony structure) may cause a
smaller airway size in the mouth and throat area.
• The aging process limits the ability of brain signals to keep your
throat muscles stiff during sleep. This makes it more likely that
the airway will narrow or collapse.
Not enough air flows into your lungs when your airways are fully
or partly blocked during sleep. This can cause loud snoring and a drop
in your blood oxygen levels.
When the oxygen drops to dangerous levels, it triggers your brain
to disturb your sleep. This helps tighten the upper airway muscles
and open your windpipe. Normal breaths then start again, often with
a loud snort or choking sound.
The frequent drops in oxygen levels and reduced sleep quality trig-
ger the release of stress hormones. These compounds raise your heart
rate and increase your risk for high blood pressure, heart attack,
stroke, and irregular heartbeats. The hormones also raise the risk for
or worsen heart failure.
Untreated sleep apnea also can lead to changes in how your body
uses energy. These changes increase your risk for obesity and diabe-
tes.
Who Is at Risk for Sleep Apnea?

It’s estimated that more than twelve million American adults have
obstructive sleep apnea. More than half of the people who have this
condition are overweight.
Sleep apnea is more common in men. One out of twenty-five middle-
aged men and one out of fifty middle-aged women have sleep apnea.
Sleep apnea becomes more common as you get older. At least one
out of ten people over the age of sixty-five has sleep apnea. Women
are much more likely to develop sleep apnea after menopause.
African Americans, Hispanics, and Pacific Islanders are more likely
to develop sleep apnea than Caucasians.
545
If someone in your family has sleep apnea, you’re more likely to
develop it.
People who have small airways in their noses, throats, or mouths
also are more likely to have sleep apnea. Smaller airways may be due
to the shape of these structures or allergies or other medical condi-
tions that cause congestion in these areas.
Small children often have enlarged tonsil tissues in the throat. This
can make them prone to developing sleep apnea.
Other risk factors for sleep apnea include smoking, high blood pres-
sure, and risk factors for stroke or heart failure.
What Are the Signs and Symptoms of Sleep Apnea?

Major Signs and Symptoms
One of the most common signs of obstructive sleep apnea is loud
and chronic (ongoing) snoring. Pauses may occur in the snoring. Chok-
ing or gasping may follow the pauses.
The snoring usually is loudest when you sleep on your back; it may
be less noisy when you turn on your side. Snoring may not happen
every night. Over time, the snoring may happen more often and get
louder.
You’re asleep when the snoring or gasping occurs. You will likely
not know that you’re having problems breathing or be able to judge
how severe the problem is. Your family members or bed partner will
often notice these problems before you do.
Not everyone who snores has sleep apnea.
Another common sign of sleep apnea is fighting sleepiness during
the day, at work, or while driving. You may find yourself rapidly fall-
ing asleep during the quiet moments of the day when you’re not ac-
tive.
Other Signs and Symptoms

Others signs and symptoms of sleep apnea may include the follow-
ing:
• Morning headaches
• Memory or learning problems and not being able to concen-
trate
• Feeling irritable, depressed, or having mood swings or personal-
ity changes
546
Sleep Apnea
• Urination at night
• A dry throat when you wake up
In children, sleep apnea can cause hyperactivity, poor school per-

formance, and aggressiveness. Children who have sleep apnea also
may have unusual sleeping positions, bedwetting, and may breathe
through their mouths instead of their noses during the day.
How Is Sleep Apnea Diagnosed?

Doctors diagnose sleep apnea based on your medical and family
histories, a physical exam, and results from sleep studies. Usually,
your primary care doctor evaluates your symptoms first. He or she
then decides whether you need to see a sleep specialist.
These specialists are doctors who diagnose and treat people with
sleep problems. Such doctors include lung, nerve, or ear, nose, and
throat specialists. Other types of doctors also can be sleep special-
ists.
Medical and Family Histories

Your doctor will ask you and your family questions about how you
sleep and how you function during the day. To help your doctor, con-
sider keeping a sleep diary for one to two weeks. Write down how much
you sleep each night, as well as how sleepy you feel at various times
during the day.
Your doctor also will want to know how loudly and often you snore
or make gasping or choking sounds during sleep. Often you’re not
aware of such symptoms and must ask a family member or bed part-
ner to report them.
If you’re a parent of a child who may have sleep apnea, tell your
child’s doctor about your child’s signs and symptoms.
Let your doctor know if anyone in your family has been diagnosed
with sleep apnea or has had symptoms of the disorder.
Many people aren’t aware of their symptoms and aren’t diagnosed.
Physical Exam
Your doctor will check your mouth, nose, and throat for extra or
large tissues. The tonsils often are enlarged in children with sleep
apnea. A physical exam and medical history may be all that’s needed
to diagnose sleep apnea in children.
547
Adults with the condition may have an enlarged uvula or soft pal-
ate. The uvula is the tissue that hangs from the middle of the back of
your mouth. The soft palate is the roof of your mouth in the back of
your throat.
Sleep Studies
A sleep study is the most accurate test for diagnosing sleep apnea.
It captures what happens with your breathing while you sleep.
A sleep study is often done in a sleep center or sleep lab, which
may be part of a hospital. You may stay overnight in the sleep center.
Polysomnogram
A polysomnogram, or PSG, is the most common study for diagnos-
ing sleep apnea. This test records the following:
• Brain activity
• Eye movement and other muscle activity
• Breathing and heart rate
• How much air moves in and out of your lungs while you’re
sleeping
• The amount of oxygen in your blood
A PSG is painless. You will go to sleep as usual, except you will have
sensors on your scalp, face, chest, limbs, and finger. The staff at the sleep
center will use the sensors to check on you throughout the night.
A sleep specialist reviews the results of your PSG to see whether
you have sleep apnea and how severe it is. He or she will use the re-
sults to plan your treatment.
How Is Sleep Apnea Treated?

Goals of Treatment
The goals of treating obstructive sleep apnea are to:
• restore regular breathing during sleep;
• relieve symptoms such as loud snoring and daytime sleepiness.
Treatment may help other medical problems linked to sleep ap-

nea, such as high blood pressure. Treatment also can reduce your risk
for heart disease, stroke, and diabetes.
548
Sleep Apnea
Specific Types of Treatment

Lifestyle changes, mouthpieces, breathing devices, and/or surgery
are used to treat sleep apnea. Currently, there are no medicines to
treat sleep apnea.
Lifestyle changes and/or mouthpieces may be enough to relieve
mild sleep apnea. People who have moderate or severe sleep apnea
also will need breathing devices or surgery.
Lifestyle changes: If you have mild sleep apnea, some changes
in daily activities or habits may be all that you need. Avoid alcohol
and medicines that make you sleepy. They make it harder for your
throat to stay open while you sleep. Lose weight if you’re overweight
or obese. Even a little weight loss can improve your symptoms. Sleep
on your side instead of your back to help keep your throat open. You
can sleep with special pillows or shirts that prevent you from sleep-
ing on your back. Keep your nasal passages open at night with nose
sprays or allergy medicines, if needed. Talk to your doctor about
whether these treatments might help you. Stop smoking.
Mouthpiece: A mouthpiece, sometimes called an oral appliance,

may help some people who have mild sleep apnea. Your doctor also
may recommend a mouthpiece if you snore loudly but don’t have sleep
apnea.
A dentist or orthodontist can make a custom-fit plastic mouthpiece
for treating sleep apnea. (An orthodontist specializes in correcting
teeth or jaw problems.) The mouthpiece will adjust your lower jaw and
your tongue to help keep your airways open while you sleep.
If you use a mouthpiece, it’s important that you check with your
doctor about discomfort or pain while using the device. You may need
periodic office visits so your doctor can adjust your mouthpiece to fit
better.
Breathing devices: Continuous positive airway pressure (CPAP)

is the most common treatment for moderate to severe sleep apnea in
adults. A CPAP machine uses a mask that fits over your mouth and
nose, or just over your nose. The machine gently blows air into your
throat.
The air presses on the wall of your airway. The air pressure is ad-
justed so that it’s just enough to stop the airways from becoming nar-
rowed or blocked during sleep.
Treating sleep apnea may help you stop snoring. But stopping
snoring doesn’t mean that you no longer have sleep apnea or can stop
549
using CPAP. Sleep apnea will return if CPAP is stopped or not used
correctly.
Usually, a technician will come to your home to bring the CPAP
equipment. The technician will set up the CPAP machine and adjust
it based on your doctor’s orders. After the initial setup, you may need
to have the CPAP adjusted on occasion for the best results.
CPAP treatment may cause side effects in some people. These side
effects include a dry or stuffy nose, irritated skin on your face, sore
eyes, and headaches. If your CPAP isn’t properly adjusted, you may
get stomach bloating and discomfort while wearing the mask.
If you’re having trouble with CPAP side effects, work with your
sleep specialist, his or her nursing staff, and the CPAP technician.
Together, you can take steps to reduce these side effects. These steps
include adjusting the CPAP settings or the size/fit of the mask, or
adding moisture to the air as it flows through the mask. A nasal spray
may relieve a dry, stuffy, or runny nose.
There are many different kinds of CPAP machines and masks. Be
sure to tell your doctor if you’re not happy with the type you’re us-
ing. He or she may suggest switching to a different kind that may work
better for you.
People who have severe sleep apnea symptoms generally feel much
better once they begin treatment with CPAP.
Surgery: Some people who have sleep apnea may benefit from
surgery. The type of surgery and how well it works depend on the cause
of the sleep apnea.
Surgery is done to widen breathing passages. It usually involves
removing, shrinking, or stiffening excess tissue in the mouth and
throat or resetting the lower jaw.
Surgery to shrink or stiffen excess tissue in the mouth or throat is
done in a doctor’s office or a hospital. Shrinking tissue may involve
small shots or other treatments to the tissue. A series of such treat-
ments may be needed to shrink the excess tissue. To stiffen excess tis-
sue, the doctor makes a small cut in the tissue and inserts a small
piece of stiff plastic.
Surgery to remove excess tissue is only done in a hospital. You’re
given medicine that makes you sleep during the surgery. After sur-
gery, you may have throat pain that lasts for one to two weeks.
Surgery to remove the tonsils, if they’re blocking the airway, may
be very helpful for some children. Your child’s doctor may suggest
waiting some time to see whether these tissues shrink on their own.
This is common as small children grow.
550
Sleep Apnea
Living with Sleep Apnea

Obstructive sleep apnea can be very serious. However, following
an effective treatment plan can often improve your quality of life quite
a bit.
Treatment can improve your sleep and relieve daytime tiredness.
It also may make you less likely to develop high blood pressure, heart
disease, and other health problems linked to sleep apnea.
Treatment may improve your overall health and happiness as well
as your quality of sleep (and possibly your family’s quality of sleep).
Ongoing Health Care Needs

Follow up with your doctor regularly to make sure your treatment
is working. Tell him or her if the treatment is causing side effects that
you can’t handle.
This ongoing care is especially important if you’re getting continu-
ous positive airway pressure (CPAP) treatment. It may take a while
before you adjust to using CPAP.
If you aren’t comfortable with your CPAP device or it doesn’t seem to
be working, let your doctor know. You may need to switch to a different
device or mask. Or, you may need treatment to relieve CPAP side effects.
Try not to gain weight. Weight gain can worsen sleep apnea and
require adjustments to your CPAP device. In contrast, weight loss may
relieve your sleep apnea.
Until your sleep apnea is properly treated, know the dangers of
driving or operating heavy machinery while sleepy.
If you’re having any type of surgery that requires medicine to put
you to sleep, let your surgeon and doctors know you have sleep ap-
nea. They might have to take extra steps to make sure your airway
stays open during the surgery.
How Can Family Members Help?

Often, people with sleep apnea don’t know they have it. They’re
not aware that their breathing stops and starts many times while
they’re sleeping. Family members or bed partners usually are the first
to notice signs of sleep apnea.
Family members can do many things to help a loved one who has
sleep apnea:
• Let the person know if he or she snores loudly during sleep or
has breathing stops and starts.
551
• Encourage the person to get medical help.
• Help the person follow the doctor’s treatment plan, including
CPAP.
• Provide emotional support.
552
Chapter 44
Urologic Concerns
Chapter Contents
Section 44.1—Kidney Stones ...................................................... 554
Section 44.2—Urethral Stricture ............................................... 557
Section 44.3—Urinary Incontinence .......................................... 561
553
Section 44.1
Kidney Stones
“Kidney Stones,” by Bernard Fallon, M.D. Reprinted with
permission of the University of Iowa Department of Urology, © 2006.
Kidney stones are a major health problem, affecting up to 10 per-

cent of all Americans at some time in their lives. Men are affected
three times as often as women, and most frequent stone formers have
their first stone in their twenties. Kidney stones are more common
during hot weather, but can occur at any time of the year.
A kidney stone is a collection of mineral salts and protein that col-
lect to form a solid crystalline mass. They can start as tiny stones that
pass in the urine unnoticed, or they may grow to a size that cannot
be passed and become symptomatic. Most kidney stones are composed
of calcium-containing crystals, but some are due to metabolic distur-
bances, which may cause stone composed of uric acid, or chronic uri-
nary tract infections, which may cause stone made of phosphate.
If a stone grows large enough it can get caught in the kidney or
the ureter (the tube that drains the kidney into the bladder). Once it
gets caught, the stone may partially or completely block the flow of
urine. This blockage causes pain that is usually felt in the middle of
the back or side and may radiate toward the groin. Sometimes the
pain can be so severe as to cause nausea and vomiting. Fevers and
chills may accompany a stone that is associated with infection. If a
stone that is blocking urine flow is left untreated it can cause dam-
age to the kidney or ureter.
If your symptoms sound like you may have a stone your doctor may
perform a full history and physical examination, check laboratory tests
on your blood and urine, and order x-rays. The x-ray tests often in-
clude a plain film and/or computed tomography (CT) scan of your
abdomen. Other tests that may be considered include intravenous
pyelography (IVP) or an ultrasound of your kidneys to detect block-
age.
If your stone is relatively small (5 mm or less, or less than one-
fifth of an inch), your doctor may decide to treat your symptoms with
pain medications and allow the stone to pass on its own. Your doctor
554
Urologic Concerns
may ask you to urinate into a strainer so that if you pass a stone, it
can be caught and analyzed, which will give important information
as to why you formed the stone. Most stones that are 5 mm or less
(less than one-fifth of an inch) will pass on their own, usually within
a few days, sometimes a few weeks. Smaller stones pass more quickly.
If the stone is large, or continues to cause problems or appears
infected, your doctor may refer you to a urologist, who may elect to
perform a procedure during which a small tube is placed in your ure-
ter via a scope. This tube can serve to allow the urine to pass, which
alleviates pain, and may allow the ureter to dilate, letting the stone
pass as well.
Until the advent of more modern techniques in the early 1980s,
most stones were treated with open surgery. Now, the majority of
stones can be treated without open surgery or with minimally inva-
sive endoscopic techniques (see “Lithotripsy” section). Many of these
procedures are same-day surgery, allowing you to return home the
same day.
Preventing future stones from forming is a very important part of
stone management, and cooperation with your doctor’s advice is vi-
tal to staying stone-free. Many stones can be prevented by maintain-
ing adequate oral fluid intake, especially water or citrus juices like
lemonade. Your doctor may ask you to collect your urine for a twenty-
four-hour period so that more information can be gained about why
you are forming stones. After reviewing the results with you, your
doctor may re-emphasize adequate oral fluid intake, or he/she may
prescribe a medication to correct any abnormalities found during the
twenty-four-hour collection.
Decreasing dietary protein and salt intake in the diet also helps
to reduce the likeliness of recurrent stones. Calcium is found in most
stones (about 80 percent), but it is not necessary to restrict dietary
calcium unless you ingest an unusually large amount.
Treatment with Lithotripsy

Lithotripsy is a treatment for kidney stones which has been in wide
use since 1982. Lithotripsy works without open surgery. Kidney stones
can be broken up with shock waves, and then the stone fragments pass
out of the body in the urine.
Lithotripsy is generally performed on an outpatient basis, often
using sedation, but most frequently under a general anesthetic. The
process uses a device called a lithotriptor. Because all the energy is
generated by a machine outside the body and no incisions are made,
555
the process is called extracorporeal shock wave lithotripsy (ESWL).
This treatment can be used to break stones located in the kidney or
in the ureter. Stones that are larger than 1.5 centimeters (one-half
inch) may be too large to fully break up with one treatment, and might
be better treated by some other method, including open surgery. ESWL
can be used in adults and in children, but care must be used to avoid
injuring adjacent organs, such as the lungs, in children.
Lithotriptors generate shock waves by various mechanisms but all
fragment stones based on the same principles. Shock waves travel
easily through the soft tissues of the body with minimal damage to
surrounding structures, but are focused on the kidney stones. The
stones absorb the energy from these waves and break up. Small stone
fragments are then passed in the urine. The treatment is rarely pain-
ful, but passing the stone fragments may be.
Depending on the location and size of the stone, as well as the num-
ber of fragments produced, your doctor may or may not place a stent
in your ureter (the tube that connects the kidney to the bladder to
drain urine). A stent is a small plastic tube that allows the kidney to
drain into the bladder and the stones to pass around the tube. The
stent is located entirely on the inside and will have to be removed in
the clinic at a later time, using a scope passed into the bladder. Re-
moval of the stent is done without anesthesia, and is slightly uncom-
fortable, but takes only about one minute.
Kidney stones are crystalline masses that form from minerals and
proteins in the urine. Stones come in various sizes and compositions.
Certain types of stones will respond to this treatment better than oth-
ers. Most kidney stones are very small, less than one-quarter of an
inch, and pass without the need for lithotripsy or any other treatment.
If you have kidney stones that are too large to pass, lithotripsy may
make removal fairly simple. Your recovery time will be much shorter
than with surgery. However, this procedure does not alter the reasons
that the stones formed. To prevent future stones, follow the therapy
and dietary changes that your healthcare provider suggests. The most
important suggestion will be a large fluid intake, which results in a
lot of urine output and dilution of the chemicals which may produce
stones.
556
Urologic Concerns
Section 44.2
Urethral Stricture
“Urethral Stricture,” November 2008, reprinted with permission
of the University of Michigan Health System Department of Urology.
© 2008 Regents of the University of Michigan.
The urethra is the tube that carries urine from the bladder (through
the penis in males) to the outside of the body. A urethral stricture can
occur anywhere in the urethra. A urethral stricture is a scarred or
hardened area that causes narrowing of the caliber of the urethra.
The stricture eventually reduces or obstructs the flow of urine out of
the bladder, making it difficult to urinate. The bladder therefore must
work harder to push the urine through the narrowed area of the ure-
thra (the stricture).
There are many causes of urethral strictures:
• Trauma to the urethra or penis (blunt or penetrating urogenital

trauma)
• Urethral injury associated with traumatic pelvic fractures (mo-
tor vehicle accidents, falls, industrial injuries, etc.)
• Straddle injury or direct trauma to the perineum
• Recurrent urinary tract infections
• Sexually transmitted diseases
• Lichen sclerosis (balanitis xerotica obliterans or BXO)
• Congenital abnormalities of the urethra or penis
• Catheterization or instrumentation of the urethra
• Surgical procedures
• Prior treatment for urethral diseases, such as urethral stric-
ture or urethral cancer
• Prior reconstructive surgery for congenital abnormalities of
the urethra or penis (hypospadias, chordee, epispadias)
557
• Prior gender reassignment surgery
• Prior urologic surgery
• Unknown causes of urethral scarring (idiopathic)
If a urethral stricture is not treated appropriately, the increased

strain on the bladder can damage and weaken the bladder muscle.
This can lead to a number of serious health problems such as urinary
retention (inability to pass urine), urinary incontinence (leakage of
urine), inflammation or infection of the urinary tract, reflux (urine
backs up into the kidneys), and kidney failure.
Symptoms and Signs

Symptoms and signs of a urethral stricture may include a weak or
slow urine stream, hesitation or trouble starting urination, taking a long
time to urinate and empty the bladder, sense of incomplete emptying,
dribbling, urgency, irritation or burning during urination, urinary fre-
quency during the day and at night, or urinary retention. Sometimes
one may intermittently or continuously leak urine because the blad-
der is full beyond its capacity and overflow incontinence occurs. Some-
times a urethral stricture is diagnosed when a healthcare provider
cannot insert a catheter through the urethra into the bladder.
Evaluation
Evaluation of men with urethral injury or with a known or sus-
pected urethral stricture may include a combination of:
• physical examination;
• urinalysis, urine culture, urine cytology (examination of the
urine for signs of infection, blood, and other abnormalities);
• uroflowmetry (mechanical measurement of urine output and
flow rate):
• ultrasound postvoid residual (measures the residual urine in
the bladder after one tries to empty completely);
• radiologic imaging (x-rays to identify anatomy of the urethra,
bladder, and urinary tract):
• retrograde urethrogram (RUG);
• cystogram;
558
Urologic Concerns
• voiding cystourethrogram (VCUG);
• ultrasound (US);
• fiberoptic urethroscopy and cystoscopy (visual inspection of
the interior of the urethra and bladder using a flexible instru-
ment (cystoscope) that is inserted into the urethra using local
anesthesia);
• laboratory studies (blood tests)—blood urea nitrogen (BUN),
creatinine, others.
It is very important to have an accurate diagnosis and evaluation

of the length and location of a urethral stricture. Once a urethral stric-
ture is diagnosed, your urologist will determine any further evalua-
tion that is needed. Options for treatment will be presented and
discussed with you. Several treatment options are available for men
with urethral strictures. Some urethral strictures can be managed
using a single procedure. If a stricture returns after one or more treat-
ments, it is called a recurrent stricture. Without appropriate treat-
ment, a stricture will recur almost 100 percent of the time. Strategies
for prevention of a recurrent stricture will also be discussed with you.
Temporary Management
Temporary management options for urethral strictures include:
• Catheterization: A thin, flexible, plastic tube (catheter) is

inserted into the urethra to temporarily drain urine from the
bladder.
• Suprapubic catheter: A thin, flexible, plastic tube (catheter)
is inserted into the bladder through the abdomen to temporarily
drain urine.
Treatment Options
Treatment options for urethral stricture disease include:
• Dilation: A balloon catheter or dilators(plastic or metal) are in-

serted into the urethra to gradually stretch (dilate) the
strictured area in the urethra.
• Obturation: A thin, flexible, plastic tube (catheter) is inserted
into the urethra on a regular basis to keep the stricture open.
559
• Urethrotomy (endoscopic internal urethrotomy or inci-
sion):
• A minimally invasive procedure where an incision is made
in the scar tissue in the urethra to open the stricture.
• This is done through a fiberoptic cystoscope (endoscope)
placed in the urethra with anesthesia.
• Urethroplasty or open urethral reconstruction:
• Anastomotic urethroplasty (the narrowed section of the ure-
thra is surgically opened or removed, and the urethra is re-
paired with a tissue graft or flap).
• Substitution urethroplasty (buccal mucosa graft [BMG],
genital or other full-thickness skin grafts, or vascularized
preputial or genital skin flaps).
• One, two, or multiple-staged reconstructive procedures.
• Perineal urethrostomy: A surgical procedure that creates a
permanent and wider opening in the urethra in the perineum
(the space between the anus and the scrotum).
Long-Term Follow-Up
After the urethral stricture has been treated, frequent follow-up
exams will be needed during the first year and then periodically there-
after to ensure that the stricture does not recur.
560
Urologic Concerns
Section 44.3
Urinary Incontinence
Excerpted from “Urinary Incontinence in Men,” National
Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health, NIH Publication No. 07-5280, June 2007.
Urinary incontinence (UI) is the accidental leakage of urine. At

different ages, males and females have different risks for developing
UI. In childhood, girls usually develop bladder control at an earlier
age than boys, and bedwetting—or nocturnal enuresis—is less com-
mon in girls than in boys. However, adult women are far more likely
than adult men to experience UI because of anatomical differences
in the pelvic region and the changes induced by pregnancy and child-
birth. Nevertheless, many men do suffer from incontinence. Its preva-
lence increases with age, but UI is not an inevitable part of aging.
UI is a treatable problem. To find a treatment that addresses the
root of the problem, you need to talk with your health care provider.
The three forms of UI are as follows:
• Stress incontinence, which is the involuntary loss of urine dur-
ing actions—such as coughing, sneezing, and lifting—that put
abdominal pressure on the bladder.
• Urge incontinence, which is the involuntary loss of urine fol-
lowing an overwhelming urge to urinate that cannot be halted.
• Overflow incontinence, which is the constant dribbling of urine
usually associated with urinating frequently and in small amounts.
What Causes UI in Men?

For the urinary system to do its job, muscles and nerves must work
together to hold urine in the bladder and then release it at the right time.
Nerve Problems
Any disease, condition, or injury that damages nerves can lead to
urination problems. Nerve problems can occur at any age.
561
Figure 44.1. Male urinary tract, front and side views.
Men who have had diabetes for many years may develop nerve
damage that affects their bladder control.
Stroke, Parkinson disease, and multiple sclerosis all affect the brain
and nervous system, so they can also cause bladder emptying problems.
Overactive bladder is a condition in which the bladder squeezes
at the wrong time. The condition may be caused by nerve problems,
or it may occur without any clear cause. A person with overactive blad-
der may have any two or all three of the following symptoms:
• Urinary frequency: Urination eight or more times a day or
two or more times at night
• Urinary urgency: The sudden, strong need to urinate immedi-
ately
• Urge incontinence: Urine leakage that follows a sudden,
strong urge to urinate
Spinal cord injury may affect bladder emptying by interrupting the

nerve signals required for bladder control.
Prostate Problems
The prostate is a male gland about the size and shape of a walnut.
It surrounds the urethra just below the bladder, where it adds fluid
562
Urologic Concerns
to semen before ejaculation. Any of the following problems with the
prostate can cause urinary incontinence:
• Benign prostatic hyperplasia (BPH): The prostate gland
commonly becomes enlarged as a man ages. This condition is
called benign prostatic hyperplasia (BPH) or benign prostatic
hypertrophy. As the prostate enlarges, it may squeeze the ure-
thra and affect the flow of the urinary stream. The lower uri-
nary tract symptoms (LUTS) associated with the development
of BPH rarely occur before age forty, but more than half of men
in their sixties and up to 90 percent in their seventies and eight-
ies have some LUTS. The symptoms vary, but the most common
ones involve changes or problems with urination, such as a hesi-
tant, interrupted, weak stream; urgency and leaking or dribbling;
more frequent urination, especially at night; and urge inconti-
nence. Problems with urination do not necessarily signal block-
age caused by an enlarged prostate. Women don’t usually have
urinary hesitancy and a weak stream or dribbling.
• Radical prostatectomy: The surgical removal of the entire
prostate gland—called radical prostatectomy—is one treatment
for prostate cancer. In some cases, the surgery may lead to erec-
tion problems and UI.
• External beam radiation: This procedure is another treat-
ment method for prostate cancer. The treatment may result in
either temporary or permanent bladder problems.
Prostate Symptom Scores

If your prostate could be involved in your incontinence, your
healthcare provider may ask you a series of standardized questions,
either the International Prostate Symptom Score or the American
Urological Association (AUA) Symptom Scale. Some of the questions
you will be asked for the AUA Symptom Scale will be the following:
• Over the past month or so, how often have you had to urinate
again in less than two hours?
• Over the past month or so, from the time you went to bed at
night until the time you got up in the morning, how many times
did you typically get up to urinate?
• Over the past month or so, how often have you had a sensation of
not emptying your bladder completely after you finished urinating?
563
• Over the past month or so, how often have you had a weak uri-
nary stream?
• Over the past month or so, how often have you had to push or
strain to begin urinating?
Your answers to these questions may help identify the problem or

determine which tests are needed. Your symptom score evaluation can
be used as a baseline to see how effective later treatments are at re-
lieving those symptoms.
How Is UI Diagnosed?
Medical history: The first step in solving a urinary problem is
talking with your healthcare provider. Your general medical history,
including any major illnesses or surgeries, and details about your con-
tinence problem and when it started will help your doctor determine
the cause. You should talk about how much fluid you drink a day and
whether you use alcohol or caffeine. You should also talk about the
medicines you take, both prescription and nonprescription, because
they might be part of the problem.
Voiding diary: You may be asked to keep a voiding diary, which

is a record of fluid intake and trips to the bathroom, plus any episodes
of leakage. Studying the diary will give your healthcare provider a
better idea of your problem and help direct additional tests.
Physical examination: A physical exam will check for prostate

enlargement or nerve damage. In a digital rectal exam, the doctor
inserts a gloved finger into the rectum and feels the part of the pros-
tate next to it. This exam gives the doctor a general idea of the size
and condition of the gland. To check for nerve damage, the doctor may
ask about tingling sensations or feelings of numbness and may check
for changes in sensation, muscle tone, and reflexes.
EEG and EMG: Your doctor might recommend other tests, including
an electroencephalogram (EEG), a test where wires are taped to the fore-
head to sense dysfunction in the brain. In an electromyogram (EMG), the
wires are taped to the lower abdomen to measure nerve activity in muscles
and muscular activity that may be related to loss of bladder control.
Ultrasound: For an ultrasound, or sonography, a technician holds

a device, called a transducer, that sends harmless sound waves into
564
Urologic Concerns
the body and catches them as they bounce back off the organs inside
to create a picture on a monitor. In abdominal ultrasound, the tech-
nician slides the transducer over the surface of your abdomen for
images of the bladder and kidneys. In transrectal ultrasound, the
technician uses a wand inserted in the rectum for images of the pros-
tate.
Urodynamic testing: Urodynamic testing focuses on the bladder’s

ability to store urine and empty steadily and completely, and on your
sphincter control mechanism. It can also show whether the bladder
is having abnormal contractions that cause leakage. The testing in-
volves measuring pressure in the bladder as it is filled with fluid
through a small catheter. This test can help identify limited bladder
capacity, bladder overactivity or underactivity, weak sphincter mus-
cles, or urinary obstruction. If the test is performed with EMG sur-
face pads, it can also detect abnormal nerve signals and uncontrolled
bladder contractions.
How Is UI Treated?
No single treatment works for everyone. Your treatment will de-
pend on the type and severity of your problem, your lifestyle, and your
preferences, starting with the simpler treatment options. Many men
regain urinary control by changing a few habits and doing exercises
to strengthen the muscles that hold urine in the bladder. If these be-
havioral treatments do not work, you may choose to try medicines or
a continence device—either an artificial sphincter or a catheter. For
some men, surgery is the best choice.
Behavioral treatments: For some men, avoiding incontinence is
as simple as limiting fluids at certain times of the day or planning
regular trips to the bathroom—a therapy called timed voiding or blad-
der training. As you gain control, you can extend the time between
trips. Bladder training also includes Kegel exercises to strengthen the
pelvic muscles, which help hold urine in the bladder. Extensive stud-
ies have not yet conclusively shown that Kegel exercises are effective
in reducing incontinence in men, but many clinicians find them to be
an important element in therapy for men.
How Do You Do Kegel Exercises?

The first step is to find the right muscles. Imagine that you are
trying to stop yourself from passing gas. Squeeze the muscles you
565
would use. If you sense a “pulling” feeling, those are the right muscles
for pelvic exercises.
Do not squeeze other muscles at the same time or hold your breath.
Also, be careful not to tighten your stomach, leg, or buttock muscles.
Squeezing the wrong muscles can put more pressure on your bladder
control muscles. Squeeze just the pelvic muscles.
Pull in the pelvic muscles and hold for a count of 3. Then relax for
a count of 3. Repeat, but do not overdo it. Work up to three sets of ten
repeats. Start doing your pelvic muscle exercises lying down. This
position is the easiest for doing Kegel exercises because the muscles
then do not need to work against gravity. When your muscles get stron-
ger, do your exercises sitting or standing. Working against gravity is
like adding more weight.
Be patient. Do not give up. It takes just five minutes, three times
a day. Your bladder control may not improve for three to six weeks,
although most people notice an improvement after a few weeks.
Medicines
Medicines can affect bladder control in different ways. Some medi-
cines help prevent incontinence by blocking abnormal nerve signals
that make the bladder contract at the wrong time, while others slow
the production of urine. Still others relax the bladder or shrink the
prostate. Before prescribing a medicine to treat incontinence, your
doctor may consider changing a prescription you already take. For
example, diuretics are often prescribed to treat high blood pressure
because they reduce fluid in the body by increasing urine production.
Some men may find that switching from a diuretic to another kind of
blood pressure medicine takes care of their incontinence.
If changing medicines is not an option, your doctor may choose from
the following types of drugs for incontinence:
• Alpha-blockers: Terazosin (Hytrin®), doxazosin (Cardura®),
tamsulosin (Flomax®), and alfuzosin (Uroxatral®) are used to
treat problems caused by prostate enlargement and bladder out-
let obstruction. They act by relaxing the smooth muscle of the
prostate and bladder neck, allowing normal urine flow and pre-
venting abnormal bladder contractions that can lead to urge in-
continence.
• 5-alpha reductase inhibitors: Finasteride (Proscar®) and
dutasteride (Avodart®) work by inhibiting the production of
the male hormone DHT, which is thought to be responsible for
566
Urologic Concerns
prostate enlargement. These 5-alpha reductase inhibitors may
help to relieve voiding problems by shrinking an enlarged pros-
tate.
• Imipramine: Marketed as Tofranil®, this drug belongs to a
class of drugs called tricyclic antidepressants. It relaxes muscles
and blocks nerve signals that might cause bladder spasms.
• Antispasmodics: Propantheline (Pro-Banthine®), tolterodine
(Detrol LA®), oxybutynin (Ditropan XL®), darifenacin (Enablex®),
trospium chloride (Sanctura®), and solifenacin succinate
(VESIcare®) belong to a class of drugs that work by relaxing the
bladder muscle and relieving spasms. Their most common side
effect is dry mouth, although large doses may cause blurred vi-
sion, constipation, a fast heartbeat, headache, and flushing.
Surgical Treatments
Surgical treatments can help men with incontinence that results
from nerve-damaging events, such as spinal cord injury or radical
prostatectomy.
Figure 44.2. Artificial sphincter
567
Artificial sphincter: Some men may eliminate urine leakage with
an artificial sphincter, an implanted device that keeps the urethra
closed until you are ready to urinate. This device can help people who
have incontinence because of weak sphincter muscles or because of
nerve damage that interferes with sphincter muscle function. It does
not solve incontinence caused by uncontrolled bladder contractions.
Surgery to place the artificial sphincter requires general or spinal
anesthesia. The device has three parts: a cuff that fits around the
urethra, a small balloon reservoir placed in the abdomen, and a pump
placed in the scrotum. The cuff is filled with liquid that makes it fit
tightly around the urethra to prevent urine from leaking. When it is
time to urinate, you squeeze the pump with your fingers to deflate
the cuff so that the liquid moves to the balloon reservoir and urine
can flow through the urethra. When your bladder is empty, the cuff
automatically refills in the next two to five minutes to keep the ure-
thra tightly closed.
Figure 44.3. Urinary diversion
568
Urologic Concerns
Male sling: Surgery can improve some types of urinary inconti-
nence in men. In a sling procedure, the surgeon creates a support for
the urethra by wrapping a strip of material around the urethra and
attaching the ends of the strip to the pelvic bone. The sling keeps con-
stant pressure on the urethra so that it does not open until the pa-
tient consciously releases the urine.
Urinary diversion: If the bladder must be removed or all blad-

der function is lost because of nerve damage, you may consider sur-
gery to create a urinary diversion. In this procedure, the surgeon
creates a reservoir by removing a piece of the small intestine and di-
recting the ureters to the reservoir. The surgeon also creates a stoma,
an opening on the lower abdomen where the urine can be drained
through a catheter or into a bag.
569
Chapter 45
“Women’s” Concerns:
Men Are at Risk, Too
Chapter Contents
Section 45.1—Body Image Issues ............................................... 572
Section 45.2—Gynecomastia: A Breast Disorder in Men ......... 573
Section 45.3—Osteoporosis in Men ............................................ 575
571
Section 45.1
Body Image Issues

Reprinted from “Body Image Issues,” National
Women’s Health Information Center, July 17, 2008.
Did you know that men, like women, can struggle with body im-
age issues? Some men secretly live with an eating disorder or body
dysmorphic disorder—conditions that not only can harm your health,
but also interfere with daily living. People with body image disorders
often isolate themselves from others and can suffer from depression
and other mental health problems.
Eating Disorders
Eating disorders involve extreme emotions, attitudes, and behav-
iors surrounding weight and food issues. Many more women than men
have anorexia and bulimia. But binge eating disorder affects men and
women equally. With binge eating disorder, people overeat well beyond
the point of feeling full. Sometimes, people try to make up for their
binges by dieting or not eating. Body weight ranges from normal to
severely obese.
Body Dysmorphic Disorder

People with body dysmorphic disorder have extreme concern over
a real or imagined “flaw” in appearance. Men and women are affected
equally, but focus concern on different parts of the body. Men tend to
be preoccupied by their skin, hair, nose, and genitals. People with this
condition often feel “ugly” and can be self-conscious around others.
Obsession with food or how you look is no way to live. If you have
body image issues, don’t let shame or embarrassment keep you from
seeking help. Medicines and counseling can help people with eating
disorders and body image disorders.
572
“Women’s” Concerns: Men Are at Risk, Too
Section 45.2
Gynecomastia:
A Breast Disorder in Men
Excerpted from “Gynecomastia,”
Definition
Gynecomastia is the development of abnormally large breasts in
males.
Considerations
The condition may occur in one or both breasts and begins as a
small lump beneath the nipple, which may be tender. The breasts of-
ten enlarge unevenly. Gynecomastia during puberty is not uncommon
and usually goes away over a period of months.
In newborns, breast development may be associated with milk flow
(galactorrhea). This condition usually lasts for a couple of weeks, but
in rare cases may last until the child is two years old.
Causes
The most common cause of gynecomastia is puberty.
Other causes include:
• chronic liver disease;
• exposure to anabolic steroid hormones;
• exposure to estrogen hormone;
• genetic disorders;
• kidney failure;
• marijuana use;
• side effects of some medications;
• testosterone (male hormone) deficiency.
573
Rare causes include:
• genetic defects;
• overactive thyroid;
• tumors.
Home Care
Apply cold compresses and use analgesics as your health care pro-
vider recommends if swollen breasts are also tender.

Call your health care provider if the breasts have developed ab-
normally or if there is swelling or pain in one or both breasts.
Note: Gynecomastia in children who have not yet reached puberty
should always be checked by a health care provider.
What to Expect at Your Office Visit

Your health care provider will take a medical history and perform
a physical examination.
Medical history questions may include:
• Is one or both breasts involved?
• What is the age and gender of the patient?
• What medications is the person taking?
• How long has gynecomastia been present?
• Is the gynecomastia staying the same, getting better, or getting
worse?
• What other symptoms are present?
Testing may not be necessary, but the following tests may be done
to rule out certain diseases:
• blood hormone level tests;
• breast ultrasound;
• liver and kidney function studies;
• mammogram.
574
Intervention
If an underlying condition is found, it is treated. Gynecomastia
during puberty usually goes away on its own; however, persistent,
extreme, or uneven breast enlargement may be embarrassing for an
adolescent boy. Breast reduction surgery may be recommended.
After Seeing Your Health Care Provider

If your health care provider made a diagnosis related to gyneco-
mastia, you may want to note that diagnosis in your personal medi-
cal record.
Section 45.3
Osteoporosis in Men
Reprinted from “Osteoporosis in Men,” National Institute of
Arthritis, Musculoskeletal and Skin Diseases, National Institutes
of Health, August 2008.
Osteoporosis is a disease that causes the skeleton to weaken and

the bones to break. It poses a significant threat to more than two
million men in the United States. After age fifty, 6 percent of all men
will experience a hip fracture and 5 percent will have a vertebral frac-
ture as a result of osteoporosis.
Despite these compelling figures, a majority of American men view
osteoporosis solely as a “woman’s disease,” according to a 1996 Gallup
Poll. Moreover, among men whose lifestyle habits put them at in-
creased risk, few recognize the disease as a significant threat to their
mobility and independence.
Osteoporosis is called a “silent disease” because it progresses with-
out symptoms until a fracture occurs. It develops less often in men than
in women because men have larger skeletons, their bone loss starts
later and progresses more slowly, and they have no period of rapid hor-
monal change and bone loss. However, in the last few years the prob-
lem of osteoporosis in men has been recognized as an important public
575
health issue, particularly in light of estimates that the number of men
above the age of seventy will continue to increase as life expectancy
continues to rise.
Clearly, more information is needed about the causes and treat-
ment of osteoporosis in men, and researchers are beginning to turn
their attention to this long-neglected group.
For example, in 1999, the National Institutes of Health launched
a major research effort that will attempt to answer some of the many
remaining questions. The seven-year, multisite study will follow more
than five thousand men ages sixty-five and older to determine how
much the risk of fracture in men is related to bone mass and struc-
ture, biochemistry, lifestyle, tendency to fall, and other factors.
The results of such studies will help doctors to better understand
how to prevent, manage, and treat osteoporosis in men.
What Causes Osteoporosis?

Bone is constantly changing—that is, old bone is removed and re-
placed by new bone. During childhood, more bone is produced than
removed, so the skeleton grows in both size and strength. For most
people, bone mass peaks during the third decade of life. By this age,
men typically have accumulated more bone mass than women. After
this point, the amount of bone in the skeleton typically begins to de-
cline slowly as removal of old bone exceeds formation of new bone.
Men in their fifties do not experience the rapid loss of bone mass
that women do in the years following menopause. By age sixty-five
or seventy, however, men and women are losing bone mass at the same
rate, and the absorption of calcium, an essential nutrient for bone
health throughout life, decreases in both sexes. Excessive bone loss
causes bone to become fragile and more likely to fracture.
Fractures resulting from osteoporosis most commonly occur in the
hip, spine, and wrist, and can be permanently disabling. Hip fractures
are especially dangerous. Perhaps because such fractures tend to oc-
cur at older ages in men than in women, men who sustain hip frac-
tures are more likely than women to die from complications.
Primary and Secondary Osteoporosis

There are two main types of osteoporosis: primary and secondary.
In cases of primary osteoporosis, either the condition is caused by age-
related bone loss (sometimes called senile osteoporosis) or the cause is
unknown (idiopathic osteoporosis). The term “idiopathic osteoporosis”
576
is used only for men less than seventy years old; in older men, age-
related bone loss is assumed to be the cause.
The majority of men with osteoporosis have at least one (sometimes
more than one) secondary cause. In cases of secondary osteoporosis,
the loss of bone mass is caused by certain lifestyle behaviors, diseases,
or medications. The most common causes of secondary osteoporosis
in men include exposure to glucocorticoid medications, hypogonadism
(low levels of testosterone), alcohol abuse, smoking, gastrointestinal
disease, hypercalciuria, and immobilization.
Causes of Secondary Osteoporosis in Men

• Glucocorticoid medications
• Other immunosuppressive drugs
• Hypogonadism (low testosterone levels)
• Excessive alcohol consumption
• Smoking
• Chronic obstructive pulmonary disease and asthma
• Cystic fibrosis
• Gastrointestinal disease
• Hypercalciuria
• Anticonvulsant medications
• Thyrotoxicosis
• Hyperparathyroidism
• Immobilization
• Osteogenesis imperfecta
• Homocystinuria
• Neoplastic disease
• Ankylosing spondylitis and rheumatoid arthritis
• Systemic mastocytosis
Glucocorticoid medications: Glucocorticoids are steroid medi-

cations used to treat diseases such as asthma and rheumatoid arthri-
tis. Bone loss is a very common side effect of these medications. The
bone loss these medications cause may be due to their direct effect on
bone, muscle weakness or immobility, reduced intestinal absorption of
577
calcium, a decrease in testosterone levels, or, most likely, a combina-
tion of these factors.
When glucocorticoid medications are used on an ongoing basis,
bone mass often decreases quickly and continuously, with most of the
bone loss in the ribs and vertebrae. Therefore, people taking these
medications should talk to their doctor about having a bone mineral
density (BMD) test. Men should also be tested to monitor testoster-
one levels, as glucocorticoids often reduce testosterone in the blood.
A treatment plan to minimize loss of bone during long-term gluco-
corticoid therapy may include using the minimal effective dose, and
discontinuing the drug or administering it through the skin, if possible.
Adequate calcium and vitamin D intake is important, as these nutri-
ents help reduce the impact of glucocorticoids on the bones. Other pos-
sible treatments include testosterone replacement and osteoporosis
medication. Alendronate and risedronate are two bisphosphonate
medications approved by the U.S. Food and Drug Administration (FDA)
for use by men and women with glucocorticoid-induced osteoporosis.
Hypogonadism: Hypogonadism refers to abnormally low levels

of sex hormones. It is well known that loss of estrogen causes os-
teoporosis in women. In men, reduced levels of sex hormones may also
cause osteoporosis.
While it is natural for testosterone levels to decrease with age,
there should not be a sudden drop in this hormone that is comparable
to the drop in estrogen experienced by women at menopause. How-
ever, medications like glucocorticoids, cancer treatments (especially
for prostate cancer), and many other factors can affect testosterone
levels. Testosterone replacement therapy may be helpful in prevent-
ing or slowing bone loss. Its success depends on factors such as age
and how long testosterone levels have been reduced. Also, it is not yet
clear how long any beneficial effect of testosterone replacement will
last. Therefore, doctors usually treat the osteoporosis directly, using
medications approved for this purpose.
Recent research suggests that estrogen deficiency may also be a cause
of osteoporosis in men. For example, estrogen levels are low in men with
hypogonadism and may play a part in bone loss. Osteoporosis has been
found in some men who have rare disorders involving estrogen. There-
fore, the role of estrogen in men is under active investigation.
Alcohol abuse: There is a wealth of evidence that alcohol abuse

may decrease bone density and lead to an increase in fractures. Low
bone mass is common in men who seek medical help for alcohol abuse.
578
In cases where bone loss is linked to alcohol abuse, the first goal
of treatment is to help the patient stop—or at least reduce—his con-
sumption of alcohol. More research is needed to determine whether
bone lost to alcohol abuse will rebuild once drinking stops, or even
whether further damage will be prevented. It is clear, though, that
alcohol abuse causes many other health and social problems, so quit-
ting is ideal. A treatment plan may also include a balanced diet with
lots of calcium- and vitamin D-rich foods, a program of physical exer-
cise, and smoking cessation.
Smoking: Bone loss is more rapid, and rates of hip and vertebral
fracture are higher, among men who smoke, although more research
is needed to determine exactly how smoking damages bone. Tobacco,
nicotine, and other chemicals found in cigarettes may be directly toxic
to bone, or they may inhibit absorption of calcium and other nutri-
ents needed for bone health. Quitting is the ideal approach, as smok-
ing is harmful in so many ways. As with alcohol, it is not known whether
quitting smoking leads to reduced rates of bone loss or to a gain in
bone mass.
Gastrointestinal disorders: Several nutrients—including amino

acids, calcium, magnesium, phosphorous, and vitamins D and K—are
important for bone health. Diseases of the stomach and intestines can
lead to bone disease when they impair absorption of these nutrients.
In such cases, treatment for bone loss may include taking supplements
to replenish these nutrients.
Hypercalciuria: Hypercalciuria is a disorder that causes too much

calcium to be lost through the urine, which makes the calcium un-
available for building bone. Patients with hypercalciuria should talk
to their doctor about having a BMD test and, if bone density is low,
discuss treatment options.
Immobilization: Weight-bearing exercise is essential for main-

taining healthy bones. Without it, bone density may decline rapidly.
Prolonged bed rest (following fractures, surgery, spinal cord injuries,
or illness) or immobilization of some part of the body often results in
significant bone loss. It is crucial to resume weight-bearing exercise
(such as walking, jogging, dancing, and lifting weights) as soon as
possible after a period of prolonged bed rest. If this is not possible,
you should work with your doctor to minimize other risk factors for
osteoporosis.
579
How Is Osteoporosis Diagnosed in Men?

Osteoporosis can be effectively treated if it is detected before sig-
nificant bone loss has occurred. A medical workup to diagnose os-
teoporosis will include a complete medical history, x-rays, and urine
and blood tests. The doctor may also order a BMD (bone mineral den-
sity) test. This test can identify osteoporosis, determine your risk for
fractures (broken bones), and measure your response to osteoporosis
treatment. The most widely recognized bone mineral density test is
called a dual-energy x-ray absorptiometry or DXA test. It is painless:
a bit like having an x-ray, but with much less exposure to radiation.
It can measure bone density at your hip and spine.
It is increasingly common for women to be diagnosed with os-
teoporosis or low bone mass using a BMD test, often at midlife when
doctors begin to watch for signs of bone loss. In men, however, the di-
agnosis is often not made until a fracture occurs or a man complains
of back pain and sees his doctor. This makes it especially important
for men to inform their doctors about risk factors for developing os-
teoporosis, loss of height or change in posture, a fracture, or sudden
back pain.
What Are the Risk Factors for Men?

Several risk factors have been linked to osteoporosis in men:
• Chronic diseases that affect the kidneys, lungs, stomach, and in-
testines or alters hormone levels.
• Regular use of certain medications, such as glucocorticoids.
• Undiagnosed low levels of the sex hormone testosterone.
• Unhealthy lifestyle habits: smoking, excessive alcohol use, low
calcium intake, inadequate physical exercise.
• Age—the older you are, the greater your risk.
• Race—Caucasian men appear to be at particularly high risk,
but all men can develop this disease.
Some doctors may be unsure how to interpret the results of a BMD

test in men, because it is not known whether the World Health Orga-
nization guidelines used to diagnose osteoporosis or low bone mass
in women are also appropriate for men. Although controversial, the
International Society for Clinical Densitometry recommends using
separate guidelines when interpreting BMD test results in men.
580
What Treatments Are Available?

Once a man has been diagnosed with osteoporosis, his doctor may
prescribe one of the medications approved by the FDA for this dis-
ease. Alendronate and risedronate have been approved to treat the
disease in men, postmenopausal women, and in men and women with
glucocorticoid-induced osteoporosis. Teriparatide is approved to treat
osteoporosis in men and women who are at increased risk of fracture.
The treatment plan will also likely include the nutrition, exercise,
and lifestyle guidelines for preventing bone loss listed at the end of
this section.
If bone loss is due to glucocorticoid use, the doctor may prescribe
a bisphosphonate (e.g., alendronate or risedronate), monitor bone den-
sity and testosterone levels, and suggest using the minimum effec-
tive dose of glucocorticoid. The doctor may also suggest discontinuing
the drug when practical, and/or administering it topically (through
the skin).
Other possible prevention or treatment approaches include calcium
and/or vitamin D supplements and regular physical activity.
If osteoporosis is the result of another condition (such as testoster-
one deficiency) or exposure to certain other medications, the doctor
may design a treatment plan to address the underlying cause.
How Can Osteoporosis Be Prevented?

There have been fewer research studies on osteoporosis in men
than in women. However, experts agree that all people should take
the following steps to preserve their bone health:
• Avoid smoking, reduce alcohol intake, and increase your level of
physical activity.
• Ensure a daily calcium intake that is adequate for your age.
• Ensure an adequate intake of vitamin D. Normally, the body
makes enough vitamin D from exposure to as little as ten minutes
of sunlight a day. If exposure to sunlight is inadequate, dietary vi-
tamin D intake should be between 200 and 600 IU (International
Units) per day (See Table 45.1). In one quart of fortified milk and
most multivitamins there are 400 IU of vitamin D.
• Engage in a regular regimen of weight-bearing exercises in
which bones and muscles work against gravity. This might in-
clude walking, jogging, racquet sports, stair climbing, team
581
sports, lifting weights, and using resistance machines. A doctor
should evaluate the exercise program of anyone already diag-
nosed with osteoporosis to determine if twisting motions and im-
pact activities, such as those used in golf, tennis, or basketball,
need to be curtailed.
• Discuss with your doctor the use of medications that are known
to cause bone loss, such as glucocorticoids.
• Recognize and seek treatment for any underlying medical condi-
tions that affect bone health.
Table 45.1. Recommendations for Calcium and Vitamin D Intake
Age Calcium (mg) Vitamin D (IU)

19–30 1,000 200
31–50 1,000 200
51–70 1,200 400
70+ 1,200 600
Upper limit 2,500 2,000
Source: National Academy of Sciences, 1997
582
Part Five
Additional Help
and Information
Chapter 46
Glossary of Terms
Related to Men’s Health
abnormality: A growth or area of tissue that is not normal. An ab-

normality may be cancer or likely to become cancer.1
acute: Acute often means urgent. An acute disease happens suddenly.
It lasts a short time. Acute is the opposite of chronic, or long lasting.4
adjuvant therapy: Treatment given after the main treatment to help
cure a disease.1
allergy: An abnormally high sensitivity to certain substances, such
as pollens or foods. Common signs of allergies may include sneezing,
itching, and skin rashes.2
anesthesia: A drug administered for medical purposes that causes
a partial or total loss of feeling.2
aneurysm: A weak or thin spot on an artery wall that has stretched
or ballooned out from the wall and filled with blood, or damage to an
artery leading to pooling of blood between the layers of the blood ves-
sel walls.3
The terms in this glossary were excerpted from “Lung Cancer Glossary,”
National Cancer Institute, July 8, 2008 [marked 1]; “Real Men Wear Gowns Glos-
sary,” Agency for Healthcare Research and Quality, accessed August 28, 2008
[marked 2]; “Stroke: Hope through Research,” National Institute of Neurologi-
cal Disorders and Stroke, National Institutes of Health, NIH Publication No. 99-
2222, August 20, 2008 [marked 3]; and “Urologic Diseases Dictionary,” National
Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of
Health, September 2004 [marked 4].
585
antibiotic: A drug, such as penicillin or streptomycin, that can de-
stroy or prevent the growth of bacteria. Antibiotics are widely used
to prevent and treat infectious diseases.2
antibodies: Proteins in the body made by the immune system that
fight infection and disease.1
anticoagulants: A drug therapy used to prevent the formation of
blood clots that can become lodged in cerebral arteries and cause
strokes.3
aphasia: The inability to understand or create speech, writing, or
language in general due to damage to the speech centers of the brain.3
apraxia: A movement disorder characterized by the inability to per-
form skilled or purposeful voluntary movements, generally caused by
damage to the areas of the brain responsible for voluntary movement.3
arteriography: An x-ray of the carotid artery taken when a special
dye is injected into the artery.3
atherosclerosis: A blood vessel disease characterized by deposits of
lipid material on the inside of the walls of large- to medium-sized ar-
teries which make the artery walls thick, hard, brittle, and prone to
breaking.3
atrial fibrillation: Irregular beating of the left atrium, or left up-
per chamber, of the heart.3
balloon dilation: A treatment for benign prostatic hyperplasia or
prostate enlargement. A tiny balloon is inflated inside the urethra to
make it wider so urine can flow more freely from the bladder.4
benign prostatic hyperplasia (BPH): An enlarged prostate not
caused by cancer. BPH can cause problems with urination because the
prostate squeezes the urethra at the opening of the bladder.4
biological therapy: Treatment to boost the immune system’s power
to fight infections and other diseases. It can also be used to lessen side
effects of some treatments. Also called immunotherapy, biotherapy, or
biological response modifier (BRM) therapy.1
biopsy: To remove cells or tissues from the body for testing and ex-
amination under a microscope.1
bronchi: The large airways connecting the windpipe to the lungs. The
single form is bronchus.1
586
Glossary of Terms Related to Men’s Health
bronchoscopy: A way to look at the inside of the windpipe, the bron-
chi, and/or the lungs using a lighted tube. The tube is inserted through
the patient’s nose or mouth. Bronchoscopy may be used to find can-
cer or as part of some treatments.1
carcinogen: Something that causes cancer.1
carotid artery: An artery, located on either side of the neck, that
supplies the brain with blood.3
carotid endarterectomy: Surgery used to remove fatty deposits
from the carotid arteries.3
CAT scan: A set of detailed pictures of areas inside the body, taken from
different angles. The pictures are made by a computer linked to an x-
ray machine. Other names for a CAT scan are computerized axial tomog-
raphy, computed tomography (CT scan), and computerized tomography.1
catheter: A tube that is inserted through the urethra to the bladder
to drain urine.4
cerebral blood flow (CBF): The flow of blood through the arteries
that lead to the brain, called the cerebrovascular system.3
cerebrospinal fluid (CSF): Clear fluid that bathes the brain and
spinal cord.3
cerebrovascular disease: A reduction in the supply of blood to the
brain either by narrowing of the arteries through the buildup of plaque
on the inside walls of the arteries, called stenosis, or through block-
age of an artery due to a blood clot.3
chemoprevention: Using things such as drugs or vitamins to try to
prevent or slow down cancer. Chemoprevention may be used to help
keep someone from ever getting cancer. It is also used to help keep
some cancers from coming back.1
chemotherapy: Using drugs to treat cancer.1
cholesterol: A waxy substance, produced naturally by the liver and
also found in foods, that circulates in the blood and helps maintain
tissues and cell membranes. Excess cholesterol in the body can con-
tribute to atherosclerosis and high blood pressure.3
chronic: Lasting a long time. Chronic diseases develop slowly. Chronic
kidney disease may develop over many years and lead to end-stage
renal disease.4
587
clinical trial: A kind of research study where patients volunteer to
test new ways of screening for, preventing, finding, or treating a dis-
ease. Also called a clinical study.1
cystinuria: A condition in which urine contains high levels of the
amino acid cystine. If cystine does not dissolve in the urine, it can build
up to form kidney stones.4
cystitis: Inflammation of the bladder, causing pain and a burning
feeling in the pelvis or urethra.4
cystocele: Fallen bladder. When the bladder falls or sags from its
normal position down to the pelvic floor, it can cause either urinary
leakage or urinary retention.4
diabetes mellitus: A condition characterized by high blood glucose
(sugar) resulting from the body’s inability to use glucose efficiently.
In type 1 diabetes, the pancreas makes little or no insulin; in type 2
diabetes, the body is resistant to the effects of available insulin.4
diagnosis: The act of identifying or determining the nature and cause
of a disease or injury through evaluating the patient’s history, an ex-
amination, and a review of laboratory data.2
dysphagia: Trouble swallowing.1
dyspnea: Shortness of breath.1
edema: The swelling of a cell that results from the influx of large
amounts of water or fluid into the cell.3
elective surgery: A surgery that is optional, not required.2
embolic stroke: A stroke caused by an embolus.3
embolus: A free-roaming clot that usually forms in the heart.3
emphysema: A disease that affects the tiny air sacs in the lungs.
Emphysema makes it harder to breathe. People who smoke have a
greater chance of getting emphysema.1
enuresis: Urinary incontinence not caused by a physical disorder.4
erectile dysfunction: The inability to get or maintain an erection
for satisfactory sexual intercourse. Also called impotence.4
erection: Enlargement and hardening of the penis caused by increased
blood flow into the penis and decreased blood flow out of it as a re-
sult of sexual excitement.4
588
extracorporeal shockwave lithotripsy (ESWL): A nonsurgical
procedure using shock waves to break up kidney stones.4
first line therapy: The first course of treatment used against a dis-
ease.1
functional magnetic resonance imaging (fMRI): A type of imag-
ing that measures increases in blood flow within the brain.3
gene: The basic unit of heredity. Genes decide eye color and other
traits. Genes also play a role in how high a person’s risk is for certain
diseases.1
gene therapy: Treatment that changes a gene. Gene therapy is used
to help the body fight cancer. It also can be used to make cancer cells
more sensitive to treatment.1
genitals: Sex organs, including the penis and testicles in men and
the vagina and vulva in women.4
health history: A regularly updated record of a person’s past and
present health status.2
hematuria: Blood in the urine, which can be a sign of a kidney stone
or other urinary problem.4
hemiparesis: Weakness on one side of the body.3
hemiplegia: Complete paralysis on one side of the body.3
hemorrhagic stroke: Sudden bleeding into or around the brain.3
high-density lipoprotein (HDL): Also known as the good choles-
terol; a compound consisting of a lipid and a protein that carries a
small percentage of the total cholesterol in the blood and deposits it
in the liver.3
hormone: A natural chemical produced in one part of the body and
released into the blood to trigger or regulate particular functions of
the body.4
hydronephrosis: Swelling at the top of the ureter, usually because
something is blocking the urine from flowing into or out of the blad-
der.4
hypercalciuria: Abnormally large amounts of calcium in the urine.4
hyperoxaluria: Unusually large amounts of oxalate in the urine,
leading to kidney stones.4
589
hypertension (high blood pressure): Characterized by persistently
high arterial blood pressure defined as a measurement greater than
or equal to 140 mm/Hg systolic pressure over 90 mm/Hg diastolic pres-
sure.3
hypospadias: A birth defect in which the opening of the urethra,
called the urinary meatus, is on the underside of the penis instead of
at the tip.4
immune system: The complex group of organs and cells that defends
the body against infections and other diseases.1
immunosuppressant: A drug given to suppress the natural re-
sponses of the body’s immune system. Immunosuppressants are given
to transplant patients to prevent organ rejection and to patients with
autoimmune diseases like lupus.4
impotence: See erectile dysfunction.4
incontinence: Loss of bladder or bowel control; the accidental loss
of urine or feces.4
ischemia: A loss of blood flow to tissue, caused by an obstruction of
the blood vessel, usually in the form of plaque stenosis or a blood clot.3
ischemic stroke: Ischemia in the tissues of the brain.3
kidney: A bean-shaped organ that filters waste products from the
body and forms urine that is passed into the bladder. Human beings
are born with two kidneys, one on each side of the lower back.1
kidney stone: A stone that develops from crystals that form in urine
and build up on the inner surfaces of the kidney, in the renal pelvis,
or in the ureters.4
larynx: Voice box. The larynx is part of the breathing system and is
found in the throat.1
lithotripsy: A method of breaking up kidney stones using shock
waves or other means.4
lobe: A part of an organ, such as the lung.1
lobectomy: Surgery to remove a lobe of an organ.1
low-density lipoprotein (LDL): Also known as the bad cholesterol; a
compound consisting of a lipid and a protein that carries the majority
590
of the total cholesterol in the blood and deposits the excess along the
inside of arterial walls.3
lymph nodes: Small glands that help the body fight infection and
disease. They filter a fluid called lymph and contain white blood cells.1
magnetic resonance imaging (MRI) scan: A type of imaging in-
volving the use of magnetic fields to detect subtle changes in the wa-
ter content of tissues.3
medical record: A file that contains a patient’s medical history and
care.2
mesothelioma: A tumor in the lining of the chest or abdomen (stom-
ach area).1
metastasis: When cancer spreads to other parts of the body.1
necrosis: A form of cell death resulting from anoxia, trauma, or any
other form of irreversible damage to the cell; involves the release of
toxic cellular material into the intercellular space, poisoning surround-
ing cells.3
neoadjuvant therapy: Treatment given before the main treatment
to help cure a disease.1
nephrotic syndrome: A collection of symptoms that indicate kidney
damage. Symptoms include high levels of protein in the urine, lack
of protein in the blood, and high blood cholesterol.4
neuron: The main functional cell of the brain and nervous system,
consisting of a cell body, an axon, and dendrites.3
neuroprotective agents: Medications that protect the brain from
secondary injury caused by stroke.3
neutropenia: An abnormal decrease in a type of white blood cells.
The body needs white blood cells to fight disease and infection.1
outpatient surgery: A procedure in which the patient is not required
to stay overnight in a hospital; also called same-day surgery.2
oxalate: A chemical that combines with calcium in urine to form the
most common type of kidney stone (calcium oxalate stone).4
pancreas: A large gland that helps digest food and also makes some
important hormones.1
591
pelvis: The bowl-shaped bone that supports the spine and holds up
the digestive, urinary, and reproductive organs. The legs connect to
the body at the pelvis.4
penis: The male organ used for urination and sex.4
peripheral neuropathy: Numbness, tingling, burning, or weakness
that usually begins in the hands or feet. Some anticancer drugs can
cause this problem.1
Peyronie disease: A plaque (hardened area) that forms on the pe-
nis, preventing that area from stretching. During erection, the penis
bends in the direction of the plaque, or the plaque may lead to inden-
tation and shortening of the penis.4
plaque: Fatty cholesterol deposits found along the inside of artery
walls that lead to atherosclerosis and stenosis of the arteries.3
pleural effusion: When too much fluid collects between the lining
of the lung and the lining of the inside wall of the chest.1
pneumonectomy: Surgery to remove a lung.1
preventive medical test: Tests designed to rule out or avoid disease.
For example, screening for high blood pressure and treating it before
it causes serious health problems is an example of a preventive medi-
cal test. 2
prognosis: A prediction of the probable outcome of a disease.2
prostate: In men, a walnut-shaped gland that surrounds the urethra
at the neck of the bladder. The prostate supplies fluid that goes into
semen.4
prostate cancer: Cancer that begins in the prostate.1
prostate-specific antigen (PSA): A protein made only by the pros-
tate gland. High levels of PSA in the blood may be a sign of prostate
cancer.4
prostatitis: Inflammation of the prostate gland. Chronic prostatitis
means the prostate gets inflamed over and over again. The most com-
mon form of prostatitis is not associated with any known infecting
organism.4
proteinuria: A condition in which the urine contains large amounts
of protein, a sign that the kidneys are not functioning properly.4
592
radiation: The emission of energy in waves or particles. Often used
to treat cancer cells.1
recurrence: When cancer comes back after a period when no cancer
could be found.1
resection: Surgery to remove tissue, an organ, or part of an organ.1
side effect: An effect of a drug, chemical, or other medicine that is
in addition to its intended effect, especially an effect that is harmful
or unpleasant.2
specialist: A doctor who devotes attention to a particular class of
diseases or patients.2
stage: How much cancer is in the body and how far it has spread.1
stenosis: Narrowing of an artery due to the buildup of plaque on the
inside wall of the artery.3
stress urinary incontinence: Leakage of urine caused by actions—
such as coughing, laughing, sneezing, running, or lifting—that place
pressure on the bladder from inside the body. Stress urinary inconti-
nence can result from either a cystocele (fallen bladder) or weak
sphincter muscles.4
subarachnoid hemorrhage: Bleeding within the meninges, or outer
membranes, of the brain into the clear fluid that surrounds the brain.3
symptom: Something that indicates the presence of a disorder or
disease.2
thrombolytics: Drugs used to treat an ongoing, acute ischemic stroke
by dissolving the blood clot causing the stroke and thereby restoring
blood flow through the artery.3
thrombosis: The formation of a blood clot in one of the cerebral ar-
teries of the head or neck that stays attached to the artery wall until
it grows large enough to block blood flow.3
thrombotic stroke: A stroke caused by thrombosis.3
total serum cholesterol: A combined measurement of a person’s
high-density lipoprotein (HDL) and low-density lipoprotein (LDL).3
transcranial magnetic stimulation (TMS): A small magnetic cur-
rent delivered to an area of the brain to promote plasticity and heal-
ing.3
593
transient ischemic attack (TIA): A short-lived stroke that lasts
from a few minutes up to twenty-four hours; often called a mini-
stroke.3
ultrasound: A technique that bounces safe, painless sound waves off
organs to create an image of their structure.
ureters: Tubes that carry urine from the kidneys to the bladder.4
urethra: The tube that carries urine from the bladder to the outside
of the body.4
urethritis: Inflammation of the urethra.4
urge urinary incontinence: Urinary leakage when the bladder con-
tracts unexpectedly by itself.4
urinalysis: A test of a urine sample that can reveal many problems
of the urinary tract and other body systems.4
urinary frequency: Urination eight or more times a day.4
urinary tract infection (UTI): An illness caused by harmful bacte-
ria growing in the urinary tract.4
urinary tract: The system that takes wastes from the blood and car-
ries them out of the body in the form of urine. The urinary tract in-
cludes the kidneys, ureters, bladder, and urethra.4
urinary urgency: Inability to delay urination.4
urine: Liquid waste product filtered from the blood by the kidneys,
stored in the bladder, and expelled from the body through the ure-
thra by the act of voiding or urinating.4
vaccine: A substance meant to help the immune system respond to
and resist disease.1
vasodilators: Medications that increase blood flow to the brain by
expanding or dilating blood vessels.3
594
Chapter 47
Directory of Agencies
That Provide Information
about Men’s Health
General
American Academy of Men’s Health Network
Family Physicians P.O. Box 75972
P.O. Box 11210 Washington, DC 20013
Shawnee Mission, KS 66207-1210 Website:
Toll-Free: 800-274-2237 www.menshealthnetwork.org
Phone: 913-906-6000 E-mail:
Fax: 913-906-6075 [email protected]
Website: http://www.aafp.org
National Heart, Lung, and
Centers for Disease Control Blood Institute
and Prevention P.O. Box 30105
1600 Clifton Road, NE Bethesda, MD 20824-0105
Atlanta, GA 30333 Phone: 301-592-8573
Toll-Free: 800-311-3435 Website: www.nhlbi.nih.gov
Phone: 404-639-3311
Website: http://www.cdc.gov
The information in this chapter was compiled from various sources deemed
accurate. All contact information was verified and updated in March 2009. In-
clusion does not imply endorsement. This list is intended to serve as a starting
point for information gathering; it is not comprehensive.
595
National Institute of U.S. Food and Drug Admin-

Neurological Disorders istration
and Stroke 10903 New Hampshire Ave.
NIH Neurological Institute Silver Spring, MD 20903
P.O. Box 5801 Toll-Free: 888-INFO-FDA
Bethesda, MD 20824 (888-463-6332)
Toll-Free: 800-352-9424 Website: http://www.fda.gov
Phone: 301-496-5751
TTY: 301-468-5981 Alzheimer Disease
Website: http://www.ninds.nih.gov
Alzheimer’s Association
National Kidney and Uro- 225 N. Michigan Ave., Fl. 17
logic Diseases Information Chicago, IL 60601-7633
Clearinghouse Toll-Free: 800-272-3900
3 Information Way Phone: 312-335-8700
Bethesda, MD 20892-3580 Fax: 866-699-1246
Toll-Free: 800-891-5390 TDD: 312-335-5886
Fax: 703-738-4929 Website: http://www.alz.org
TTY: 866-569-1162 E-mail: [email protected]
Website:
www.kidney.niddk.nih.gov Alzheimer’s Disease Educa-
E-mail: tion and Referral Center
[email protected] P.O. Box 8250
Silver Spring, MD 20907
National Women’s Health Toll-Free: 800-438-4380
Information Center Fax: 301-495-3334
Toll-Free: 800-994-9662 Website: http://www.nia.nih.gov/
TDD: 888-220-5446 alzheimers
Website: http://
www.4woman.gov National Institute on Aging
Building 31, Room 5C27
NIH Senior Health 31 Center Drive, MSC 2292
Website: http:// Bethesda, MD 20892
www.nihseniorhealth.gov Phone: 301-496-1752
Fax: 301-496-1072
TTY: 800-222-4225
Website: http://www.nia.nih.gov
596
Directory of Agencies That Provide Information about Men’s Health
Cancer Sudden Cardiac Arrest
Association
American Cancer Society 1133 Connecticut Avenue, NW
Website: http://www.cancer.org 11th Floor
Washington, DC 20036
Cancer Information Service Toll-Free: 866-972-SCAA (7222)
National Cancer Institute (NCI) Website:
NCI Public Inquiries Office www.suddencardiacarrest.org
6116 Executive Boulevard E-mail:
MSC 8322 [email protected]
Room 3036A
Bethesda, MD 20892-8322 Diabetes
Toll-Free: 800-4CANCER
(800-422-6237) American Diabetes
TTY: 800-332-8615 Association (ADA)
Website: http://www.cancer.gov Attn: National Call Center
E-mail: 1701 North Beauregard Street
[email protected] Alexandria, VA 22311
Toll-Free: 800-DIABETES (342-
Cardiovascular Disorders 2383)
Website: www.diabetes.org
American Heart Association
National Center National Diabetes
7272 Greenville Avenue Education Program
Dallas, TX 75231 1 Information Way
Toll-Free: 800-AHA-USA-1 Bethesda, MD 20814-9692
(800-242-8721) Toll-Free: 800-438-5383
Website: http:// Website: http://
www.americanheart.org www.ndep.nih.gov
American Stroke
Association
National Center
7272 Greenville Avenue
Dallas TX 75231
Toll-Free: 888-4-STROKE
(888-478-7653)
Website: http://
www.strokeassociation.org
597
Human Immunodeficiency American Urological

Virus/Acquired Association (AUA)
Immunodeficiency 1000 Corporate Boulevard
Linthicum, MD 21090
Syndrome (HIV/AIDS) Toll-Free: 866-RING-AUA
AIDSinfo (746-4282)
P.O. Box 6303 Phone: 410-689-3700
Rockville, MD 20849-6303 Fax: 410-689-3800
Toll-Free: 800-HIV-0440 Website: www.auanet.org or
(800-448-0440) www.urologyhealth.org
Phone: 301-519-0459 E-mail: [email protected]
Fax: 301-519-6616
TTY: 888-480-3739 National Association for
Website: http://aidsinfo.nih.gov Continence
E-mail: P.O. Box 1019
[email protected] Charleston, SC 29402-1019
Toll-Free: 800-BLADDER
Kidney and Urologic (252-3337)
Phone: 843-377-0900
Disorders Website: http://www.nafc.org
American Association of E-mail:
Kidney Patients [email protected]
3505 East Frontage Road
Suite 315 National Kidney and
Tampa, FL 33607 Urologic Diseases
Toll-Free: 800-749-2257 Information Clearinghouse
Phone: 813-636-8100 3 Information Way
Fax: 813-636-8122 Bethesda, MD 20892-3580
Website: http://www.aakp.org Toll-Free: 800-891-5390
E-mail: [email protected] Fax: 703-738-4929
TTY: 866-569-1162
American Kidney Fund Website: http://
6110 Executive Boulevard www.kidney.niddk.nih.gov
Suite 1010 E-mail:
Rockville, MD 20852 [email protected]
Toll-Free: 800-638-8299
Phone: 301-881-3052
Fax: 301-881-0898
Website: http://
www.kidneyfund.org
598
National Kidney Muscular Dystrophy
Foundation, Inc.
30 East 33rd Street Muscular Dystrophy
New York, NY 10016 Association
Toll-Free: 800-622-9010 3300 East Sunrise Drive
Phone: 212-889-2210 Tucson, AZ 85718-3208
Website: http://www.kidney.org Toll-Free: 800-344-4863
Phone: 520-529-2000
Mental Health Concerns Fax: 520-529-5300
Website: http://www.mda.org
National Institute of Mental E-mail: [email protected]
Health (NIMH)
6001 Executive Boulevard, National Institute of
Room 8184, MSC 9663 Arthritis and Musculoskel-
Bethesda, MD 20892-9663 etal and Skin Diseases
Toll-Free: 866-615-6464 (NIAMS)
Phone: 301-443-4513 National Institutes of Health,
Fax: 301-443-4279 DHHS
TTY: 866-415-8051 or 31 Center Dr., Rm. 4C02
301-443-8431 MSC 2350
Website: http://www.nimh.nih Bethesda, MD 20892-2350
.gov Toll-Free: 877-22-NIAMS
E-mail: [email protected] (226-4267)
Phone: 301-496-8190
Substance Abuse and Website: http://www.niams.nih
Mental Health Services .gov
Administration E-mail:
Health Information Network [email protected]
P.O. Box 2345
Rockville, MD 20847-2345 Parent Project Muscular
Toll-Free: 877-SAMHSA-7 Dystrophy (PPMD)
(877-726-4727) 158 Linwood Plaza, Suite 220
Fax: 240-221-4292 Fort Lee, NJ 07024
TTY: 800-487-4889 Toll-Free: 800-714-KIDS (5437)
Website: http://www.samhsa.gov Phone: 201-944-9985
E-mail: [email protected] Fax: 201-944-9987
Website: http://
www.parentprojectmd.org
E-mail:
[email protected]
599
Nutrition Prostate Disorders

American Dietetic American Urological
Association Association (AUA)
120 South Riverside Plaza, 1000 Corporate Boulevard
Suite 2000 Linthicum, MD 21090
Chicago, IL 60606-6995 Toll-Free: 866-RING-AUA
Toll-Free: 800-877-1600 (746-4282)
Website: http://www.eatright.org Phone: 410-689-3700
Fax: 410-689-3800
Food and Nutrition Website: www.auanet.org or
Information Center www.urologyhealth.org
U.S. Department of Agriculture E-mail: [email protected]
Agricultural Research Service,
National Agricultural Library Prostatitis Foundation
10301 Baltimore Avenue 1063 30th Street, Box 8
Room 105 Smithshire, IL 61478
Beltsville, MD 20705-2351 Toll-Free: 888-891-4200
Phone: 301-504-5719 Fax: 309-325-7184
Website: http:// Website: http://
www.nal.usda.gov/fnic www.prostatitis.org
Physical Fitness
Us Too! International, Inc.
President’s Council on (Prostate Cancer Survivors)
Physical Fitness and Sports 5003 Fairview Avenue
Department W Downers Grove, IL 60515
200 Independence Avenue, SW, Toll-Free: 800-80-US-TOO
Room 738-H (808-7866)
Washington, DC 20201-0004 Phone: 630-795-1002
Phone: 202-690-9000 Website: www.ustoo.org
Website: http://www.fitness.gov
600
Sexual Dysfunction Brain Attack Coalition
31 Center Drive
American Association of Sex Room 8A07
Educators, Counselors, and Bethesda, MD 20892-2540
Therapists (AASECT) Phone: 301-496-5751
P.O. Box 1960 Fax: 301-402-2186
Ashland, VA 23005-1960 Website: http://www.stroke-site
Phone: 804-752-0026 .org
Fax: 804-752-0056
Website: www.aasect.org National Stroke Association
9707 East Easter Lane, Suite B
Society for Sex Therapy and Centennial, CO 80112-3747
Research Toll-Free: 800-STROKES
409 12th St., S.W., PO Box 96920 (787-6537)
Washington, DC 20090-6920 Phone: 303-649-9299
Phone: 202-863-1644 Fax: 303-649-1328
Website: http:// Website: http://www.stroke.org
www.sstarnet.org/ E-mail: [email protected]
Stroke
American Stroke
Association: A Division of
American Heart Association
7272 Greenville Avenue
Dallas, TX 75231-4596
Toll-Free: 888-4STROKE
(478-7653)
Fax: 214-706-5231
Website: http://
www.strokeassociation.org
E-mail:
[email protected]
601
Index
Index
Page numbers followed by ‘n’ indicate ADA see American Diabetes

a footnote. Page numbers in italics Association
indicate a table or illustration. A.D.A.M., Inc., publications
chancroid 365n
A circumcision 329n
diet and disease 62n
AAFP see American Academy of gynecomastia 573n
Family Physicians hydrocele 453n
AASECT see American Association retrograde ejaculation 417n
of Sex Educators, Counselors, and safe sex 140n
Therapists testicular failure 463n
ABCDE memory device 50–52 testicular torsion 466n
abdominal aortic aneurysm, addiction, described 132–33
screening tests 30 “Adding Physical Activity to
Abilify (aripiprazole) 505 Your Life” (CDC) 85n
abnormality, defined 585 adjuvant therapy
“About High Blood Cholesterol” breast cancer 230–32
(CDC) 116n colorectal cancer 197
“About High Blood Pressure” defined 585
(CDC) 121n “Adult Immunization Questions and
ACEI see angiotensin converting Answers” (National Foundation for
enzyme inhibitors Infectious Diseases) 40n
achromatopsia 516 aerobic activity, described 90–91
acquired immune deficiency aflatoxin, liver cancer 202
syndrome (AIDS), overview 381–85 age factor
acute, defined 585 alcohol use 104–5
acute bacterial prostatitis, Alzheimer disease 302
described 441–42 benign prostatic hyperplasia 436–37
acute orchitis, described 450 cholesterol levels 118
605
age factor, continued alpha-beta blockers,
colorectal cancer 31–32, 193 hypertension 123
coronary artery disease 160 alpha blockers
diabetes mellitus 280–81 benign prostatic
driving skills 241–42 hyperplasia 438, 439
erectile dysfunction 406 hypertension 123
influenza vaccine 45 urinary incontinence 566
liver cancer 203 alprostadil 410
penile cancer 214 Alzheimer, Alois 301
premature ejaculation 412, 413 Alzheimer disease,
sleep apnea 545 overview 301–6
sleep requirements 96 Alzheimer’s Association,
spermatocele 460 contact information 596
suicide 294–95 Alzheimer’s Disease Education
varicoceles 470 and Referral Center, contact
weight management 71 information 596
Agency for Healthcare Research “Alzheimer’s Disease Fact
and Quality (AHRQ), publications Sheet” (NIA) 301n
choosing doctors 18n American Academy of Family
glossary 585n Physicians (AAFP), contact
health checklist 28n information 595
medications safety 23n American Association of
aggressive driving, overview Kidney Patients, contact
130–31 information 598
AHRQ see Agency for Healthcare American Association of Sex
Research and Quality Educators, Counselors, and
AIDS see acquired immune Therapists (AASECT),
deficiency syndrome contact information 601
AIDSinfo, contact American Cancer Society,
information 598 website address 597
“Alcohol: Frequently Asked American Chemical Society, life
Questions” (CDC) 100n expectancy publication 6n
alcoholism, versus alcohol American Diabetes Association
abuse 103 (ADA), contact information 597
alcohol use American Dietetic Association,
cirrhosis 202, 318 contact information 600
coronary artery disease 161 American Heart Association,
diet and nutrition 61 contact information 597
health checklist 30 American Kidney Fund,
hypertension 125 contact information 598
impaired driving 245–46 American Lung Association,
liver damage 65 pneumonia publication 287n
osteoporosis 578–79 American Optometric Association,
overview 100–110 color vision deficiency
stroke 269 publication 516n
water injuries 257, 258 American Osteopathic Association,
alfuzosin 439, 566 indoor tanning publication 137n
allergies, defined 585 American Stroke Association, contact
alpha-1 antitrypsin deficiency 274 information 597, 601
606
Index
American Urological “Anxiety Disorders” (NIMH)
Association (AUA) 493n, 495n, 497n
contact information 598, 600 aphasia, defined 586
publications apolipoprotein E 302
epididymitis 448n apraxia, defined 586
orchitis 448n Arand, Donna L. 94
penile trauma 430n Aricept (donepezil) 304
premature ejaculation 412n aripiprazole 505
prostate cancer screening 34n aromatase inhibitors,
spermatocele 459n breast cancer 232
“Am I at Risk?” (NHLBI) 271n arrhythmia, described 163
amyloid plaques 301 arteriography, defined 586
anabolic steroids, overview 134–36 artificial sphincter 567, 568
anal cancer, human asbestos, lung cancer 187
papillomavirus 385–86 ascites, cirrhosis 316
androgenetic alopecia 509 aspiration, spermatocele 461
Andrology Australia, publications assisted reproduction,
male pattern baldness 509n described 354–55
penis problems 424n asymptomatic inflammatory
anesthesia, defined 585 prostatitis, described 443
aneurysm, defined 585 atherosclerosis
angina, described 158 defined 586
angiography described 264
coronary artery disease 164–65 atrial fibrillation
liver cancer 204 defined 586
angioplasty, coronary stroke 267–68
artery disease 166 AUA see American Urological
angiotensin antagonists, Association
hypertension 123 Avastin (bevacizumab)
angiotensin converting colorectal cancer 198
enzyme inhibitors (ACEI), lung cancer 192
hypertension 123 Avodart (dutasteride) 439, 566
antibiotic medications azathioprine 537
chancroid 367
chlamydia 370
defined 586 B
epididymitis 450–51, 452
gonorrhea 377 baclofen 537
infertility 354 bacterial pneumonia, described 288
orchitis 450–51, 452 balanitis
pneumonia 287, 290 described 328
syphilis 40 overview 425–27
antibodies, defined 586 balanitis xerotica obliterans 427
anticoagulants, defined 586 balloon dilation, defined 586
antidepressant medications, banded gastroplasty, described 82
premature ejaculation 416 barium enema
antipsychotic medications, colorectal cancer 195
schizophrenia 501–2, 505 described 34
anxiety disorder, described 495–97 basal cell carcinoma, described 139
607
basal sleep need, described 93–94 blood glucose monitors,
Becker muscular dystrophy, gender differences 11–12
described 531 blood pressure readings
behavioral changes, described 122
obesity 79–80 kidney disease 308
behavioral therapy see also hypertension
premature ejaculation 415–16 blood tests
urinary incontinence 565 cirrhosis 317
benign prostatic hyperplasia coronary artery disease 164
(BPH) heart failure 171
defined 586 liver cancer 204
incontinence 563 muscular dystrophy 535
overview 436–40 prostate cancer 178
prostate cancer 177 testicular cancer 222
Berg, Christine 39 BMI see body mass index
beta blockers, “Body Image Issues”
hypertension 123 (NWHIC) 572n
bevacizumab 198 body mass index (BMI)
bile acid sequestrants, chart 74
cholesterol levels 120 cholesterol levels 119
binge drinking, described 102–3 described 28, 67
biological therapy hypertension 124–25
cancer treatment 197 overview 73–75
defined 586 bone health
penile cancer 218 physical activity 88
biopsy tobacco use 111
breast cancer 227 see also osteoporosis
cirrhosis 317 bone mineral density test,
defined 586 osteoporosis 580
liver cancer 204 bone scans, lung cancer 190
lung cancer 189 Bonnet, Michael H. 94
muscular dystrophy 537 BPH see benign prostatic
penile cancer 215 hyperplasia
prostate cancer 178 Brain Attack Coalition,
testicular cancer 222 contact information 601
“Birth Control: Condom” breast cancer,
(Nemours Foundation) 336n overview 226–32
birth control methods “Breast Cancer in Men”
effectiveness 335 (NCI) 226n
overview 334–43 breathing devices,
“Birth Control Methods: sleep apnea 549–50
How Well Do They Work?” Bressert, Steve 126n
(Nemours Foundation) 334n bronchi, defined 586
blood cholesterol see cholesterol; bronchial pneumonia 287
high-density lipoprotein (HDL) bronchodilators, described 274
cholesterol; low-density bronchoscopy
lipoprotein (LDL) cholesterol; defined 587
total serum cholesterol lung cancer 189
blood clotting factor 522 bupropion 115
608
Index
Bureau of Labor Statistics, catheters
occupational injuries coronary artery
publication 250n disease 164–65
defined 587
heart disease 11
C urethral stricture 559
urinary tract 433
CABG see coronary artery CAT scan see computed
bypass grafting axial tomography scan
calcium, osteoporosis 62, Caverject (alprostadil) 410
581–82, 582 cavernosogram 431
calcium channel blockers, CBF see cerebral blood flow
hypertension 123 CDC see Centers for Disease
calories, obesity 76 Control and Prevention
Camptosar 191 Centers for Disease Control
cancer and Prevention (CDC)
alcohol use 108 contact information 595
diet and nutrition 62–65 publications
human papillomavirus 385 alcohol 100n
indoor tanning devices 138–39 cancer 149n
overweight 73 causes of death 146n
physical activity 87 chlamydia 368n
tobacco use 111 cholesterol levels 116n
vasectomy reversal 347–48 colorectal cancer screening 31n
see also breast cancer; colorectal diabetes mellitus 277n
cancer; liver cancer; lung fire injuries 236n
cancer; melanoma; penile genital herpes 371n
cancer; prostate cancer; skin gonorrhea 375n
cancer; testicular cancer heart disease 156n
“Cancer among Men” (CDC) 149n HIV/AIDS 381n
Cancer Information Service, human papillomavirus 385n
contact information 597 hypertension 121n
carbamazepine 537 impaired driving 241n
carboplatin 192 influenza 44n, 284n
carcinogen, defined 587 physical activity 85n
cardiac arrest, pubic lice 390n
overview 172–74 scabies 394n
cardiac rehabilitation, stroke 263n
described 166 sun protection 137n
cardiomyopathy, weight loss syphilis 397n
surgery 82 tobacco use 110n
cardiopulmonary resuscitation trichomoniasis 402n
(CPR), water injuries 258 water related injuries 256n
cardiovascular disease cerebral blood flow (CBF),
physical activity 87 defined 587
tobacco use 111 cerebrospinal fluid (CSF), defined 587
Cardura (doxazosin) 439, 566 cerebrovascular disease, defined 587
carotid artery, defined 587 “Chancroid” (A.D.A.M., Inc.) 365n
carotid endarterectomy, defined 587 chancroid, overview 365–67
609
Chantix (varenicline) 115 circumcision
“Check Your Medicines: Tips chancroid 366
for Using Medicines Safely” described 214, 325
(AHRQ) 23n overview 329–32
chemoembolization, penile cancer 217
liver cancer 207, 209 “Circumcision”
chemoprevention, defined 587 (A.D.A.M., Inc.) 329n
chemotherapy cirrhosis
breast cancer 230 liver cancer 202
colorectal cancer 197 overview 315–19
defined 587 cisplatin 191
liver cancer 208, 210 Classen, John B. 282
lung cancer 190 Cleveland Clinic, publications
penile cancer 218 inguinal hernia 453n
testicular cancer 224 male menopause 507n
Cheyne-Stokes breathing 544 clinical trials
“Chlamydia” (CDC) 368n breast cancer 229
chlamydia, overview 368–71 colorectal cancer 199
Chlamydia trachomatis 368 defined 588
chlorpromazine 502 gender differences,
cholesterol health issues 7–15
Alzheimer disease 302 liver cancer 205, 211
coronary artery disease 160 penile cancer 218–19
defined 587 prostate cancer 182
diabetes mellitus 281 prostate cancer screening 37–40
overview 116–20 testicular cancer 225
overweight 72 clonazepam 537
screening tests 29 clozapine 502
stroke 268 Clozaril (clozapine) 502
see also high-density lipoprotein Cognex (tacrine) 304
(HDL) cholesterol; low-density cognitive behavioral therapy,
lipoprotein (LDL) cholesterol; schizophrenia 504
total serum cholesterol colonoscopy
“Choosing a Doctor” colorectal cancer 195, 198
(AHRQ) 18n described 33–34
chromium 82 color blindness, described 516
chronic, defined 587 colorectal cancer
chronic bacterial prostatitis, overview 193–99
described 442 screening tests 29, 31–34
chronic epididymitis, “Colorectal Cancer: Basic Facts
described 450 on Screening” (CDC) 31n
chronic obstructive “Colorectal Cancer: Frequently
pulmonary disease (COPD) Asked Questions” (NIH Senior
overview 271–76 Health) 193n
tobacco use 111 “Color Vision Deficiency”
chronic pelvic pain syndrome, (American Optometric
described 442 Association) 516n
Cialis (tadalafil) 409 color vision deficiency,
cigarette smoking see tobacco use overview 516–19
610
Index
colostomy, described 196–97 counseling
computed axial tomography erectile dysfunction 409
scan (CAT scan; CT scan) HIV/AIDS 383–84
defined 587n premature ejaculation 415
kidney stones 554 in vitro fertilization 362
liver cancer 204 CPAP see continuous positive
lung cancer 188–89, 190 airway pressure
prostate cancer 181 CPR see cardiopulmonary
condoms resuscitation
chancroid 367 crabs see pubic lice
chlamydia 370 creatine kinase test 535–36
genital herpes 373 cryosurgery
gonorrhea 378 liver cancer 207, 209
HIV/AIDS 383 lung cancer 191
human papillomavirus 389 penile cancer 217
overview 336–39 prostate cancer 181
safe sex 140–41 cryptorchidism
syphilis 400–401 overview 468–70
trichomoniasis 404 testicular cancer 221
congenital muscular CSF see cerebrospinal fluid
dystrophy, described 531 CT scan see computed axial
continuous positive airway tomography scan
pressure (CPAP) 549–50 Cushing syndrome, weight
contraception see birth control management 70
methods; condoms cyclosporin 537
Cooke, David A. 201n, 430n, 436n cystinuria, defined 588
Cooper, Christopher 468n cystitis, defined 588
Cooper, Jean 11–12 cystocele, defined 588
COPD see chronic obstructive cysts, penis lumps 425
pulmonary disease cytochrome CYP3A 10
coronary artery bypass grafting
(CABG), coronary artery
disease 166 D
coronary artery disease
(CAD), overview 158–67 dantrolene 537
“Coronary Artery Disease” darifenacin 567
(NHLBI) 158n Dayton, Andrew 14
coronary heart disease, defensive driving, described 249
diet and nutrition 63–64 dementia, described 301
corpora cavernosa Department of Justice (DOJ)
described 214, 430 see US Department of Justice
erectile dysfunction 407 depression
penile trauma 431 overview 484–92
corpus spongiosum physical activity 88
described 214 screening tests 29
erectile dysfunction 407 suicide 293
corticosteroids, muscular desmopressin (DDAVP) 524
dystrophy 537 detoxification, described 133
cortisone 134 Detrol LA (tolterodine) 567
611
DHT see dihydrotestosterone “Does Sex Make a Difference?”
diabetes mellitus (FDA) 7n
coronary artery disease 160 DOJ see US Department of Justice
defined 588 domestic abuse, overview 480–82
hypertension 125 Domestic Abuse Helpline for Men
kidney disease 308 and Women, domestic abuse
overview 277–82 victims publication 480n
overweight 72 donepezil 304
physical activity 87 double contrast barium enema
screening tests 29 colorectal cancer 195
stroke 268 described 34
weight loss surgery 82 doxazosin 439, 566
Diabetes Prevention Program 280 DRE see digital rectal examination
diagnosis, defined 588 drinking problem, described 104
dialysis, kidney disease 309 “Driving Defensively” (National
diastolic blood pressure, Safety Council) 241n
described 122 drug abuse
“Diet and Disease” cirrhosis 318
(A.D.A.M., Inc.) 62n impaired driving 245–46
diet and exercise, infertility 360
health checklist 30 overview 132–36
diet and nutrition “Drugs of Abuse/Uses and
cholesterol levels 117, 118–19 Effects” (DOJ) 132n
colorectal cancer 194 drunk, described 103
diseases 62–65 Duchenne muscular dystrophy,
hypertension 125 described 530–31
muscular dystrophy 538 ductal carcinoma in situ,
overview 56–61 described 226
prostate cancer 177 dutasteride 438, 439, 566
dietary supplements, dysphagia, defined 588
fertility 356, 358 dyspnea, defined 588
digital rectal examination
(DRE)
described 34–36, 178 E
prostatitis 443–44
research 38–39 early ejaculation 412
dihydrotestosterone EBCT see electron beam
(DHT) 510, 512, 566 computed tomography
diphtheria, vaccination 41–43 echocardiography, coronary
disease risks artery disease 164
alcohol use 104 edema
gender differences 14 cirrhosis 316
distal muscular dystrophy, defined 588
described 533–37 ejaculation
Ditropan XL (oxybutynin) 567 described 412
diuretics fertility 358–59
hypertension 123 see also premature ejaculation;
weight management 82 retrograde ejaculation
doctors see physicians EKG see electrocardiogram
612
Index
elective surgery, defined 588 “Erectile Dysfunction”
electrocardiogram (EKG) (NIDDK) 406n
coronary artery disease 163–65 erectile tissue, described 214
heart failure 171 erection
electroencephalogram (EEG), defined 588
urinary incontinence 564 described 430
electromyogram (EMG), ERSPC see European
urinary incontinence 564 Randomized Study of
electron beam computed Screening for Prostate Cancer
tomography (EBCT), essential hypertension, described 122
coronary artery disease 164 estrogen, Alzheimer disease 305–6
embolic stroke, defined 588 estrogen progesterone receptor test,
embolus, defined 588 breast cancer 228
Emery-Dreifuss muscular ESWL see extracorporeal
dystrophy, described 532 shockwave lithotripsy
emotional concerns ethnic factors
erectile dysfunction 407 causes of death 147–48
hair loss 511 diabetes mellitus 278–79, 281
premature ejaculation 413 prostate cancer 176–77
weight management 70 suicide 295–96
emphysema, defined 588 Etrafon (perphenazine) 502
Enablex (darifenacin) 567 European Randomized Study of
endocrine system, described 324 Screening for Prostate Cancer
end-stage renal disease (ESRD), (ERSPC) 39
described 309 “Evolutionary Forces behind Lower
energy balance Male Life Expectancy” (University
described 68 of Michigan Health System) 4n
obesity 75–76 “Excessive Alcohol Use and Risks to
enuresis, defined 588 Men’s Health” (CDC) 100n
environmental factors Exelon (rivastigmine) 304
chronic obstructive external beam radiation,
pulmonary disease 274 incontinence 563
weight management 69 extracorporeal shockwave
ephedra 82 lithotripsy (ESWL), defined 589
epididymis, described 324
epididymitis
described 328 F
gonorrhea 376
overview 448–53 facioscapulohumeral muscular
“Epididymitis and Orchitis” dystrophy, described 532–33
(AUA) 448n “Facts about Vasectomy Safety”
epididymo-orchitis, described 448–53 (NICHD) 339n
erectile dysfunction (impotence) Fallon, Bernard 554n
defined 588 fall prevention
depression 487 overview 234–35
overview 406–11 physical activity 88–89
Peyronie disease 357 familial hypercholesterolemia 120
premature ejaculation 413 FDA see US Food and Drug
prostate cancer 180 Administration (FDA)
613
fecal occult blood test “Frequently Asked Questions:
colorectal cancer 195 Basics about Diabetes”
described 33 (CDC) 277n
felbamate 537 “Frequently Asked Questions:
fiber Preventing Diabetes” (CDC) 277n
cancer 62–63 FSHD see facioscapulohumeral
coronary heart disease 63 muscular dystrophy
fibrates, triglycerides 120 functional magnetic resonance
financial considerations imaging (fMRI), defined 589
condoms 339
fire injuries 237
vasectomy reversal 346 G
finasteride
benign prostatic gabapentin 537
hyperplasia 438, 439 galantamine 304
hair loss 512–13 gallstones, overweight 73
urinary incontinence 566 gamete intrafallopian transfer
“Finding Your Way to a (GIFT), described 354
Healthier You” (USDA) 56n gametes, described 323
“Fire Deaths and Injuries gastric bypass surgery,
Fact Sheet” (CDC) 236n described 82–83
fire injuries, prevention tips 236–41 Gemzar 191
first line therapy, defined 589 gender factor
5-alpha reductase inhibitors causes of death 146–48
benign prostatic cholesterol levels 118
hyperplasia 438, 439 genital herpes 372
urinary incontinence 566–67 health risks 7–15
5-fluorouracil, colorectal cancer 198 heart failure 170
flexible sigmoidoscopy, described 33 homicides 150–52, 151–53
Flomax (tamsulosin) 439, 566 kidney stones 554
flu see influenza life expectancy 4–5
FluMist 44–47, 285 liver cancer 203
fluphenazine 502 sleep apnea 545
fMRI see functional magnetic suicide 294
resonance imaging genes
Foley catheters, Alzheimer disease 304
penile trauma 432–33 defined 589
Food and Drug Administration see also heredity
(FDA) see US Food and Drug gene therapy
Administration (FDA) defined 589
Food and Nutrition Information hemophilia 524
Center, contact information 600 muscular dystrophy 540
food groups, described 56–58 genetic factors see heredity
foreskin, described 325, 424 genetic testing
see also circumcision; penis hemophilia 523–24
fragile X syndrome, overview 519–22 muscular dystrophy 536
Framingham Heart Study 156 “Genital Herpes” (CDC) 371n
“Frequently Asked Questions genital herpes, overview 371–74
about Drug Abuse” (NIDA) 132n genitals, defined 589
614
Index
genital warts heavy drinking, described 102
human papillomavirus 385–86 hematuria, defined 589
penile papules 425 hemiparesis, defined 589
Geodon (ziprasidone) 502 hemiplegia, defined 589
gestational diabetes, described hemophilia, overview 522–25
278–79 hemorrhagic stroke
“Getting Tested” (NHLBI) 271n defined 589
GIFT see gamete intrafallopian described 264–65
transfer hepatectomy, described 206, 207
ginkgo biloba 305 hepatic arterial infusion,
glomerular filtration rate (GFR) 308 liver cancer 207, 209
“Gonorrhea” (CDC) 375n hepatitis
gonorrhea, overview 375–78 liver cancer 202
Gram stain, gonorrhea 377 vaccinations 41–42
“Gynecomastia” (A.D.A.M., Inc.) 573n hepatitis A, described 312–13
gynecomastia, overview 573–75 hepatitis B
described 313
overview 379–81
H “Hepatitis B” (Nemours
Foundation) 379n
Haemophilus ducreyi 365 hepatitis C, described 314
Hair a-gain (minoxidil) 512 hepatitis D, described 314–15
hair loss, overview 509–14 hepatitis E, described 315
Hair Retreva (minoxidil) 512 hepatocytes, described 201
Haldol (haloperidol) 502 HER2 test, breast cancer 228
haloperidol 502 hereditary nonpolyposis
HDL cholesterol see high-density colorectal cancer (HNPCC)
lipoprotein (HDL) cholesterol 198–99
health checklist, described 30–31 heredity
“Health Effects of Cigarette breast cancer 227
Smoking” (CDC) 110n cholesterol levels 118, 120
health history, defined 589 chronic obstructive pulmonary
health insurance disease 274
see insurance coverage colorectal cancer 194, 198–99
healthy eating plan, color vision deficiency 517–18
described 76–78 coronary artery disease 160
heart attack fragile X syndrome 519–22
described 162 hemophilia 525
overview 167–69 hypertension 126
heart disease kidney disease 308
gender differences 11, 15 liver cancer 203
overview 156–74 muscular dystrophy 528–29
overweight 71–72 prostate cancer 182
stroke 267 schizophrenia 501
heart failure sleep apnea 546
described 162 stroke 269
overview 169–71 suicide 294
“Heart Failure: Frequently Asked testicular cancer 221
Questions” (NIH Senior Health) 169n weight management 69–70
615
herpes simplex virus, “How Much Sleep Do We Really
genital herpes 371–74 Need?” (National Sleep
herpes zoster (shingles), Foundation) 93n
vaccination 42–43 “How to Perform a Testicular
“High Blood Cholesterol Self-Examination” (Nemours
Prevention” (CDC) 116n Foundation) 53n
high blood pressure see hypertension HPV see human papillomavirus
“High Blood Pressure” (CDC) 121n “HPV and Men” (CDC) 385n
high-density lipoprotein (HDL) Huang, Shiew-Mei 10–11
cholesterol human immunodeficiency
defined 589 virus (HIV)
overview 116–20 chancroid 366
HIV see human gender differences,
immunodeficiency virus treatments 13–14
“HIV and AIDS: Are You at Risk?” gonorrhea 376
(CDC) 381n human papillomavirus 386
HNPCC see hereditary overview 381–85
nonpolyposis colorectal cancer screening tests 29–30
Hollinger, Katherine 14 syphilis 399–400
Home Safety Council, publications trichomoniasis 403
falls safety 234n human papillomavirus (HPV)
fire prevention 236n overview 385–90
homicides, violence penile cancer 214
prevention 476–77 penile papules 425
“Homicide Trends in the U.S.: vaccination 41
Trends by Gender” (DOJ) 150n Hycamtin 191
hoodia 82 hydrocele
“Hormone Abuse Overview” described 328
(Hormone Foundation) 134n overview 453–56
Hormone Foundation, anabolic “Hydrocele”
steroids publication 134n (A.D.A.M., Inc.) 453n
hormones hydronephrosis, defined 589
anabolic steroids 134 hypercalciuria
arrhythmia 9 defined 589
defined 589 osteoporosis 579
erectile dysfunction 407 hyperoxaluria, defined 589
infertility 351 hypertension (high blood pressure)
Klinefelter syndrome 527 coronary artery disease 160
puberty 324 defined 590
weight management 70 kidney disease 308
hormone therapy overview 121–26
breast cancer 230 overweight 72
infertility 354 screening tests 29
male menopause 508 sodium intake 64–65
prostate cancer 181 stroke 267
“How Does COPD Affect hypogonadism, osteoporosis 578
Breathing?” (NHLBI) 271n hypospadias
“How Much Physical Activity Do defined 590
Adults Need?” (CDC) 85n described 328
616
Index
hypothyroidism, weight “Inguinal Hernia”
management 70 (Cleveland Clinic) 453n
Hytrin (terazosin) 439, 566 insulin resistance, coronary
artery disease 160
insurance coverage
I second opinions 25
vasectomy reversal 346
IBS see irritable bowel syndrome intracerebral hemorrhage,
ICSI see intracytoplasmic described 264
sperm injection intracytoplasmic sperm
idiopathic osteoporosis, injection (ICSI), described 354
described 576–77 intrauterine insemination (IUI),
imipramine 567 described 354
immune system intravenous pyelography,
bacterial pneumonia 288 kidney stones 554
colorectal cancer 198 investigational new drugs,
defined 590 gender differences 12–13
human papillomavirus 386 in vitro fertilization (IVF)
vasectomy 342–43 counseling 362
vasectomy reversal 347 described 354
immunizations iontophoresis, Peyronie disease 422
health checklist 31 irritable bowel syndrome (IBS),
overview 40–43 gender factor 7, 9
see also vaccines ischemia, defined 590
immunofluorescence test 537 ischemic stroke
immunosuppressants, defined 590 defined 590
immunotherapy see biological described 264
therapy IUI see intrauterine insemination
“Impaired Driving” (CDC) 241n ivermectin 393
impotence see erectile dysfunction IVF see in vitro fertilization
incontinence
defined 590
prostate cancer 180 J
see also stress urinary incontinence;
urge urinary incontinence jaundice, cirrhosis 316
indoor tanning devices 138–39
infertility, overview 351–62
infiltrating ductal carcinoma, K
described 226
inflammatory breast cancer, Kegel exercises, urinary
described 226 incontinence 565–66
influenza (flu) “Key Facts about Seasonal Flu
overview 284–87 Vaccine” (CDC) 44n
vaccinations 41–43 “Key Facts about Seasonal
vaccine overview 44–47 Influenza (Flu)” (CDC) 284n
inguinal hernia kidney disease, overview 307–10
described 328 “Kidney Disease Information”
hydrocele 454–55 (National Kidney Disease
overview 456–58 Education Program) 307n
617
kidneys, defined 590 life expectancy
kidney stones calorie restrictions 6
defined 590 evolutionary forces 4–5
overview 554–56 physical activity 89
“Kidney Stones” (Fallon) 554n lifestyles
kidney transplantation, described chronic obstructive
309–10 pulmonary disease 275
Klinefelter syndrome, cirrhosis 318
overview 525–27 coronary artery disease 165
Knutson, Kristen L. 95 hypertension 122
Korvick, Joyce 9 infertility 354
Kripke, Daniel 95 obesity 75–76
Kruger, Daniel J. 4–5 physical activity 85–92
sleep apnea 549
stress management 126
L limb-girdle muscular
dystrophy, described 533
LAIV see live attenuated lindane shampoo 392
influenza vaccine lithotripsy
larynx, defined 590 defined 590
laser therapy, penile cancer 217 described 555–56
latex condoms see condoms live attenuated influenza
Laughren, Thomas 10 vaccine (LAIV) 44–48, 285
laxatives, weight liver cancer
management 82 cirrhosis 317
LDL cholesterol see low-density hepatitis B 380
lipoprotein (LDL) cholesterol overview 201–11
“Leading Causes of Death in liver disease
Males, United States, see cirrhosis; hepatitis
2004” (CDC) 146n liver transplantation,
“Learning About Fragile X described 206, 207
Syndrome” (National lobar pneumonia 287
Human Genome Research lobectomy, defined 590
Institute) 519n lobes, defined 590
“Learning about Hemophilia” low-density lipoprotein
(National Human Genome (LDL) cholesterol
Research Institute) 522n defined 590–91
“Learning about Klinefelter overview 116–20
Syndrome” (National Human lung cancer, overview 185–92
Genome Research Institute) “Lung Cancer: Frequently
525n Asked Questions” (NIH
Legato, Marianne J. 8, 15 Senior Health) 185n
“Let Sleep Work for You” “Lung Cancer Glossary” (NCI) 585n
(National Sleep luteinizing hormone releasing
Foundation) 93n agonists, breast cancer 232
leucovorin, colorectal lymph nodes
cancer 198 chancroid 366
Levitra (vardenafil defined 591
hydrochloride) 409–10 penile cancer 216
618
Index
M medications, continued
driving skills 242
magnetic resonance erectile dysfunction 407, 409–10
imaging (MRI) gender differences 8–10
cirrhosis 317 genital herpes 373
defined 591 hair loss 511–13
liver cancer 204 health checklist 30–31
lung cancer 190 hepatitis B 381
muscular dystrophy 536 hypertension 123–24, 126
penile trauma 431 infertility 360
spermatocele 460 kidney disease 309
Ma-huang 82 muscular dystrophy 537–38
malathion 392–93 osteoporosis 577–78
“Male Infertility” premature ejaculation 416–17
(Wald; Sandlow) 351n prostatitis 444
male menopause pubic lice 392–93
described 358 retrograde ejaculation 418
overview 507–8 safety considerations 23–24
“Male Menopause” scabies 396
(Cleveland Clinic) 507n schizophrenia 501–2, 505
“Male Pattern Baldness” smoking cessation 115
(Andrology Australia) 509n spermatocele 461
male pattern baldness, stress management 126
overview 509–14 trichomoniasis 403
“Male Reproductive System” urinary incontinence 566
(Nemours Foundation) 323n weight management 70, 80–82
male sling 569 see also drug abuse
“Male Survivors: Men Who melanoma
Have Been Sexually Assaulted” described 139
(Men Can Stop Rape) 478n self-examination 50–52
“Male Victims of Domestic Abuse” see also cancer
(Domestic Abuse Helpline for memantine 304
Men and Women) 480n “Men and Depression” (Royal
Marghoob, Ashfaq A. 52 College of Psychiatrists) 484n
measles, vaccination 41–43 “Men and Heart Disease Fact
mediastinoscopy, lung cancer 190 Sheet” (CDC) 156n
medical devices Men Can Stop Rape, sexual
erectile dysfunction 410 assault survivors
gender differences 11–12 publication 478n
sleep apnea 549–50 Men’s Health Network,
medical records, defined 591 contact information 595
medications “Men: Stay Healthy at Any
benign prostatic hyperplasia 438 Age - Your Checklist for
cholesterol levels 119–20 Health” (AHRQ) 28n
chronic obstructive pulmonary Meridia (sibutramine) 82
disease 274 mesothelioma, defined 591
cirrhosis 316 metabolic syndrome
colorectal cancer 198 coronary artery disease 160
coronary artery disease 166 overweight 72–73
619
metastasis, defined 591 National Cancer Institute (NCI)
metastatic liver cancer, contact information 597
described 202 publications
metastatic prostate cancer, benign prostatic
described 176 hyperplasia 436n
metronidazole 403 breast cancer 226n
mexiletine 537 glossary 585n
mild cognitive impairment 304–5 liver cancer 201n
Miller, Margaret 8, 10, 13 penile cancer 214n
Minipress (prazosin) 439 prostate cancer screening 37n
minoxidil 512–13 testicular cancer 220n
moderate drinking, described 101 “National Census of Fatal
Mohs surgery, penile cancer 217 Occupational Injuries in 2007”
monoclonal antibodies (Bureau of Labor Statistics) 250n
breast cancer 230–31 National Diabetes Education
colorectal cancer 198 Program, contact information 597
motility, described 352–53 National Foundation for Infectious
motor vehicle accidents Diseases, adult immunizations
alcohol use 107 publication 40n
prevention tips 241–49 National Heart, Lung, and
mouthpieces, sleep apnea 549 Blood Institute (NHLBI)
MRI see magnetic resonance contact information 595
imaging publications
mumps chronic obstructive
orchitis 449 pulmonary disease 271n
vaccination 41–43 coronary artery disease 158n
muscle-strengthening activity, heart attack 167n
described 91–92 sleep apnea 543n
muscular dystrophy, weight management 67n
overview 527–41 National Highway Traffic Safety
Muscular Dystrophy Association, Administration (NHTSA),
contact information 599 aggressive driving publication 130n
“Muscular Dystrophy: Hope National Human Genome Research
Through Research” (National Institute, publications
Human Genome Research fragile X syndrome 519n
Institute) 527n hemophilia 522n
Muse (alprostadil) 410 Klinefelter syndrome 525n
myatonic muscular dystrophy, muscular dystrophy 527n
described 534 National Institute of Arthritis
mycoplasma pneumonia, and Musculoskeletal and Skin
described 289 Diseases (NIAMS)
contact information 599
osteoporosis publication 575n
N National Institute of Child Health
and Human Development (NICHD),
Namenda (memantine) 304 publications
National Association for sexually transmitted
Continence, contact diseases 364n
information 598 vasectomy 339n
620
Index
National Institute of Diabetes and National Women’s Health
Digestive and Kidney Diseases Information Center (NWHIC)
(NIDDK) contact information 596
contact information 596 publications
publications body image issues 572n
erectile dysfunction 406n second opinions 24n
glossary 585n smoking cessation 110n
liver diseases 311n violence prevention 476n
Peyronie disease 420n Navelbine 191
prostatitis 441n NCI see National Cancer Institute
urinary incontinence 561n necrosis, defined 591
National Institute of Mental needle aspiration
Health (NIMH) breast cancer 227
contact information 599 lung cancer 189
publications Nemours Foundation, publications
obsessive compulsive birth control methods 334n
disorder 493n condoms 336n
phobias 495n hepatitis B 379n
posttraumatic stress male reproductive system 323n
disorder 497n testicular self-examination 53n
schizophrenia 499n varicocele 470n
suicide 293n neoadjuvant therapy, defined 591
National Institute of Neurological nephrons, described 307
Disorders and Stroke (NINDS) nephrotic syndrome, defined 591
contact information 596 nervous system inhibitors,
glossary publication 585n hypertension 123
National Institute on Aging (NIA) Nesse, Randolph 4
contact information 596 neurofibrillary tangles 301
publications neurons, defined 591
Alzheimer disease 301n neuroprotective agents,
older drivers 241n defined 591
National Institute on Drug Abuse neutropenia, defined 591
(NIDA), drug abuse publication NHLBI see National Heart,
132n Lung, and Blood Institute
National Kidney and Urological NHTSA see National Highway
Diseases Information Traffic Safety Administration
Clearinghouse NIA see National Institute on Aging
contact information 598 niacin (nicotinic acid), cholesterol
National Kidney Disease levels 120
Education Program, kidney NICHD see National Institute
disease publication 307n of Child Health and Human
National Kidney Foundation, Development
contact information 599 nicotine substitutes 115
National Safety Council, defensive NIDA see National Institute
driving publication 241n on Drug Abuse
National Sleep Foundation, sleep NIDDK see National Institute
requirements publication 93n of Diabetes and Digestive
National Stroke Association, contact and Kidney Diseases
information 601 Niederhuber, John E. 37
621
NIH Senior Health osteoarthritis, overweight 73
publications osteoporosis
colorectal cancer 193n calcium 62
heart failure 169n overview 575–82
lung cancer 185n “Osteoporosis in Men” (NIAMS) 575n
prostate cancer 175n “Outcomes from Stroke” (CDC) 263n
website address 596 outpatient surgery, defined 591
NIMH see National Institute of overflow incontinence, described 561
Mental Health overweight
NINDS see National Institute of coronary artery disease 160
Neurological Disorders and Stroke diabetes mellitus 281
nitroglycerin 410 overview 67–84
nonseminomas, described 220, 223 “Overweight and Obesity”
nutrition facts labels, (NHLBI) 67n
described 59–61 oxalate, defined 591
NWHIC see National Women’s oxaliplatin, colorectal cancer 198
Health Information Center oxybutynin 567
oxygen treatment, chronic
obstructive pulmonary disease 275
O
oat cell cancer, described 186 P
obesity
coronary artery disease 160 Paget disease of nipple, described 226
diabetes mellitus 281 pain management
overview 67–84 liver cancer 205
prostate cancer 177 stroke 266
screening tests 28 palliative therapy,
obsessive compulsive disorder liver cancer 205, 208
(OCD), overview 493–94 pancreas, defined 591
occupational injuries, papaverine hydrochloride 410
overview 250–55 papules, penis lumps 425
OCD see obsessive para-aminobenzoate, Peyronie
compulsive disorder disease 422
oculopharyngeal muscular paraphimosis, described 428
dystrophy, described 535 Parent Project Muscular Dystrophy
olanzapine 502 (PPMD), contact information 599
“Older Drivers” (NIA) 241n partial hepatectomy, described 206
open prostatectomy, described 440 patent processus vaginalis 453
OPMD see oculopharyngeal PCOS see polycystic ovarian
muscular dystrophy syndrome
oral appliances, sleep apnea 549 pelvic inflammatory disease
orchidopexy, undescended testicle 468 (PID), gonorrhea 376
orchiectomy pelvis, defined 592
breast cancer 232 penile cancer
epididymitis 451 human papillomavirus 385–86
testicular cancer 222 overview 214–19
orchitis, overview 448–53 “Penile Cancer” (NCI) 214n
orlistat 82 “Penile Trauma” (AUA) 430n
622
Index
penile trauma, overview 430–33 physical examination
penis erectile dysfunction 408
defined 592 infertility 353
described 325 liver cancer 204
see also circumcision; foreskin male menopause 508
penis lumps, described 424–25 penile cancer 215
“Penis Problems” (Andrology penile trauma 431
Australia) 424n Peyronie disease 422
percutaneous ethanol injection, sleep apnea 547–48
liver cancer 207 testicular cancer 221
perineal urethrostomy, described 560 urethral stricture 558
peripheral neuropathy, defined 592 urinary incontinence 564
peritoneal dialysis 309 physicians
permethrin 392 choices 18–22
perphenazine 502 second opinions 24–25
PET scan see positron PID see pelvic inflammatory
emission tomography scan disease
de la Peyronie, François 421 pituitary gland, reproductive
Peyronie disease system 326
defined 592 plaque, coronary artery
described 357 disease 158
overview 420–23 plaques
“Peyronie’s Disease” defined 592
(NIDDK) 420n penis lumps 425
pharmacokinetics, described 10 plaques and tangles 301
phentolamine 410 PLCO see Prostate, Lung,
phenytoin 537 Colorectal, and Ovarian
phimosis Cancer Screening Trial
described 214, 424 pleural effusion, defined 592
overview 427–28 Pneumocystis carinii pneumonia
phobias, described 495–97 (PCP), described 289
phosphodiesterase inhibitors pneumonectomy, defined 592
409–10 pneumonia
photodynamic therapy, overview 287–91
lung cancer 190 vaccination 41–43
physical activity polycystic ovarian syndrome
cholesterol levels 119 (PCOS), weight management 70
chronic obstructive polymerase chain reaction test 536
pulmonary disease 275 polyps, colorectal cancer 193–94
coronary artery disease 160 polysomnogram, sleep apnea 548
diet and nutrition 58 portal hypertension, cirrhosis 316
hypertension 125 positron emission tomography
obesity 78–79 scan (PET scan), lung cancer
overview 85–92 188
weight management 68–70 posthitis, described 328
“Physical Activity and Health” posttraumatic stress disorder
(CDC) 85n (PTSD), overview 497–98
physical activity cholesterol PPMD see Parent Project
levels 118 Muscular Dystrophy
623
prazosin 439 prostate cancer
pre-diabetes, described 281 defined 592
prednisone, muscular hair loss 513
dystrophy 537 overview 175–83
pregnancy screening tests 34–40
alcohol use 105 “Prostate Cancer: Frequently
chlamydia 369 Asked Questions” (NIH
depression 488 Senior Health) 175n
gonorrhea 377 “Prostate Cancer
hypertension 123 Screening” (AUA) 34n
investigational new prostatectomy, described 440
drugs 12–13 prostate gland
prevention 334–43 defined 592
syphilis 399 depicted 442, 443
trichomoniasis 403 described 324, 441
weight management 71 incontinence 562–63
prehypertension, see also benign prostatic
described 122 hyperplasia
“Premature Ejaculation prostate-specific antigen (PSA)
(PE)” (AUA) 412n benign prostatic hyperplasia 439
premature ejaculation, defined 592
overview 412–17 described 34–36, 178
President’s Council on Physical research 38–39
Fitness and Sports, contact prostatitis
information 600 defined 592
preventive medical tests, overview 441–45
defined 592 “Prostatitis: Disorders of the
priapism Prostate” (NIDDK) 441n
described 410 Prostatitis Foundation, contact
overview 428–29 information 600
primary atypical pneumonia 289 “Protect Yourself from the Sun”
primary care physicians, (CDC) 137n
described 19–20 “Proteins Could Relate to Increased
primary hypogonadism 463 Longevity in Women” (American
primary osteoporosis, Chemical Society) 6n
described 576–77 proteinuria, defined 592
Pro-Banthine proXeed 358
(propantheline) 567 PSA see prostate-specific antigen
processus vaginalis 453 PTSD see posttraumatic stress
progesterone, breast cancer 232 disorder
prognosis, defined 592 puberty
Prolixin (fluphenazine) 502 described 326
propantheline 567 gynecomastia 573–75
Propecia (finasteride) 439, 512 testicular torsion 466
prophylactics see condoms varicoceles 470–71
Proscar (finasteride) 439, 566 “Pubic ‘Crab’ Lice Fact Sheet”
Prostate, Lung, Colorectal, and (CDC) 390n
Ovarian Cancer Screening Trial “Pubic ‘Crab’ Lice Treatment”
(PLCO) 37–40 (CDC) 390n
624
Index
pubic lice (crabs), overview 390–94 reproductive problems
pulmonary rehabilitation, chronic alcohol use 108
obstructive pulmonary overweight 73
disease 274–75 reproductive system,
overview 323–28
resection, defined 593
Q retrograde ejaculation
described 356
quetiapine 502 overview 417–18
quinine 537 “Retrograde Ejaculation”
(A.D.A.M., Inc.) 417n
rickettsia 290
R risk factors
breast cancer 226–27
racial factor colorectal cancer 32
causes of death 147–48 coronary artery
diabetes mellitus 278–79, 281 disease 159–61
occupational injuries 255 diabetes mellitus 278–79
prostate cancer 176–77 fire injuries 237
suicide 295–96 kidney disease 308
water injuries 256–57 lung cancer 186–87
radiation, defined 593 osteoporosis 580
radiation therapy prostate cancer 176–77
breast cancer 230 stroke 267–69
liver cancer 208, 210 suicide 296
lung cancer 190 testicular cancer 221
penile cancer 217–18 water injuries 256–57
Peyronie disease 422–23 “Risk Factors” (CDC) 263n
prostate cancer 180–82 Risperdal (risperidone) 502
testicular cancer 223 risperidone 502
radical inguinal orchiectomy, rivastigmine 304
testicular cancer 222 Rogaine (minoxidil) 512
radical prostatectomy Roux-en-Y gastric bypass,
described 180 described 82–83
incontinence 563 Royal College of Psychiatrists,
radiofrequency ablation, depression publication 484n
liver cancer 206–7 rubbers see condoms
radionuclide scanning, rubella, vaccination 41–43
lung cancer 190
radiosensitizers, penile
cancer 218 S
radon, lung cancer 187
rapid ejaculation 412 “Safe Sex” (A.D.A.M., Inc.) 140n
Razadyne (galantamine) 304 “Safe Steps to Reduce Falls”
“Real Men Wear Gowns (Home Safety Council) 234n
Glossary” (AHRQ) 585n safety considerations
recurrence, defined 593 fall prevention 234–35
relapse, smoking cessation 115 occupational injuries 250–55
Reminyl (galantamine) 304 water injuries 256–61
625
SAMHSA see Substance Abuse sertindole 502
and Mental Health Services sertraline hydrochloride,
Administration posttraumatic stress disorder 10
Sanctura (trospium chloride) 567 serum electrophoresis test 536
Sandlow, Jay I. 351n sexual activity
Sarcoptes scabiei 394 penile trauma 430–32
“Scabies” (CDC) 394n safety concerns 140–42
scabies, overview 394–96 sexual assault, overview 478–80
“Schizophrenia” (NIMH) 499n “Sexually Transmitted Diseases
schizophrenia, overview 499–505 (STDs)” (NICHD) 364n
sclerotherapy, spermatocele 461 sexually transmitted diseases (STDs)
Scope, Alon 52 condoms 338–39
screening tests described 140–42
abdominal aortic aneurysm 30 epididymitis 449
cholesterol levels 29 overview 364–65
colorectal cancer 29, 31–34 screening tests 29
depression 29 shingles see herpes zoster
diabetes mellitus 29 sibutramine 82
human immunodeficiency side effects
virus 29–30 antidepressant medications 416
hypertension 29 cancer treatment 179–80, 197
obesity 28 defined 593
prostate cancer 34–40 FluMist 46–47
sexually transmitted gastric bypass surgery 83
diseases (STD) 29 influenza vaccine 46–47
see also tests liver cancer treatment 208–10
scrotum, described 324–25 medications 24
secondary hypertension, vaccinations 43
described 122 sigmoidoscopy
secondary osteoporosis, colorectal cancer 195, 198
described 576–77 described 33
secondhand smoke, lung cancer 187 “Signs and Symptoms of Stroke”
second opinions, described 24–25 (CDC) 263n
Seldane (terfenadine) 9 skin cancer
“Self-Examination: indoor tanning devices 138–39
How to Spot Skin Cancer” self-examination 50–52
(Skin Cancer Foundation) 50n Skin Cancer Foundation,
self-examinations self-examination procedures
skin cancer 50–52 publication 50n
testicles 53–54 sleep apnea
semen, described 324–25 coronary artery disease 161
seminal vesicles, described 324–25 overview 543–52
seminomas, described 220, 223 overweight 73
sentinal lymph node biopsy, weight loss surgery 82
penile cancer 218–19 “Sleep Apnea” (NHLBI) 543n
Serdolect (sertindole) 502 sleep-disordered breathing 544
serotonin, premature sleep habits
ejaculation 413 physical activity 88
Seroquel (quetiapine) 502 weight management 71
626
Index
sleep requirements, statistics
overview 93–97 alcohol use 107
sleep studies, sleep apnea 548 Alzheimer disease 301
small cell lung cancer, described anabolic steroid use 136
185–86 cancer 149
“Smoking and How to Quit: causes of death 146–48, 149
How to Quit” (National chronic obstructive pulmonary
Women’s Health Information disease 271
Center) 110n erectile dysfunction 406
“Smoking and How to Quit: fire injuries 236
What Happens When You Quit genital herpes 371–72
Smoking?” (National Women’s gonorrhea 375
Health Information Center) 110n heart attack 169
smoking cessation, heart disease 156
overview 113–16 heart failure 170
see also tobacco use hemophilia 523
snoring, sleep apnea 546 homicides 150–52, 152–53
social anxiety disorder, human papillomavirus 386
described 495–97 hypertension 121
Society for Sex Therapy impaired driving 245–46
and Research, contact muscular dystrophy 529
information 601 occupational injuries 250–55,
socioeconomic status 251, 253
mortality rates 5 posttraumatic stress
sleep duration 95 disorder 498
solifenacin succinate 567 premature ejaculation 412
specialists, defined 593 spermatocele 460
sperm stroke 263
condoms 337 sudden cardiac arrest 172
described 326 suicide 293
infertility 351–53 syphilis 397
vasectomy 342–43 testicular cancer 220
spermatic cysts 459 trichomoniasis 402
“Spermatocele” (AUA) 459n violence 476
spermatoceles, overview 459–62 stenosis
spirometry, chronic obstructive defined 593
pulmonary disease 272–73 described 264
stages steroids
breast cancer 228–29 chronic obstructive
colorectal cancer 195–96 pulmonary disease 274
defined 593 described 134–36
liver cancer 205–8 osteoporosis 577–78
lung cancer 189–90 Peyronie disease 422
penile cancer 215–16 stool test, described 33
prostate cancer 178–79 “Stop Aggressive Driving
syphilis 398–99 Planner” (NHTSA) 130n
standard drink, described 101 strangulation lesion, described 431
statin drugs, cholesterol Streptococcus pneumoniae 288
levels 119 stress, coronary artery disease 161
627
stress incontinence, described 561 surgical procedures, continued
stress management, overview 126–28 erectile dysfunction 411
stress tests, coronary artery disease hair loss 511
163–64 incontinence 567–69
stress urinary incontinence, inguinal hernia 457
defined 593 kidney stones 555–56
stroke liver cancer 206–7
defined 589, 590, 593 obesity 82–83
overview 263–69 penile cancer 217
overweight 72 Peyronie disease 422, 423
see also transient ischemic prostate cancer 180
attack sleep apnea 550
“Stroke” (CDC) 263n spermatocele 461
“Stroke Facts” (CDC) 263n testicular cancer 223
“Stroke: Hope trough Research” testicular torsion 467
(NINDS) 585n undescended testicle 468–70
subarachnoid hemorrhage urethral stricture 559–60
defined 593 vasectomy 339–43
described 264–65 vasectomy reversal 345–50
Substance Abuse and Mental “Symptoms” (NHLBI) 271n
Health Services Administration symptoms, defined 593
(SAMHSA) “Syphilis” (CDC) 397n
contact information 599 syphilis, overview 397–401
suicide publication 293n systolic blood pressure,
sudden cardiac arrest, described 122
overview 172–74
Sudden Cardiac Arrest Association
cardiac arrest publication 172n T
contact information 597
“Sudden Cardiac Arrest Facts” tacrine 304
(Sudden Cardiac Arrest tadalafil 409
Association) 172n “Taking Action” (NHLBI) 271n
suicide tamoxifen, breast cancer 232
alcohol use 107 tamsulosin 439, 566
depression 489 tanning devices 138–39
overview 293–99 Tavris, Dale 11
“Suicide in the U.S.: Statistics Taxol 191
and Prevention” (NIMH) 293n Taxotere 191
“Suicide Warning Signs” Tdap see tetanus diphtheria
(SAMHSA) 293n acellular pertussis
sun protection, overview 137–39 tegaserod maleate 9
surgical procedures Temple, Robert 13
benign prostatic terazosin 439, 566
hyperplasia 439–40 terfenadine 9
breast cancer 229–30 testicles, described 324
chronic obstructive testicular cancer
pulmonary disease 275 described 327–28
colorectal cancer 196–97 overview 220–25
coronary artery disease 166 spermatocele 462
628
Index
”Testicular Cancer: Questions tests, continued
and Answers” (NCI) 220n prostatitis 443
“Testicular Failure” syphilis 399
(A.D.A.M., Inc.) 463n testicular failure 464
testicular failure, overview 463–65 trichomoniasis 403
testicular ischemia 466 urethral stricture 558–59
testicular self-examination urinary incontinence 564–65
described 53–54 see also blood tests; screening
spermatocele 460, 462 tests
testicular torsion tetanus, vaccination 41–43
described 327 tetanus diphtheria acellular
overview 466–68 pertussis (Tdap), vaccination 41
“Testicular Torsion” T-helper cells, HIV/AIDS 381
(A.D.A.M., Inc.) 466n “Think Safe Be Safe: Fire
testicular twisting 466 Prevention Tips” (Home
testosterone Safety Council) 236n
arrhythmia 9 thoracentesis, lung cancer 189
described 324 thoracotomy, lung cancer 189
erectile dysfunction 407, 410 Thorazine (chlorpromazine) 502
hair loss 513 thrombolytics, defined 593
Klinefelter syndrome 527 thrombosis, defined 593
male menopause 508 thrombotic stroke, defined 593
tests TIA see transient ischemic attack
breast cancer 228–29 tinidazole 403
chancroid 367 “Tips for Better Managing Your
chlamydia 369 Stress” (Bressert) 126n
chronic obstructive TMS see transcranial magnetic
pulmonary disease stimulation
272–73 tobacco use
cirrhosis 317 cholesterol levels 119
colorectal cancer 195 chronic obstructive pulmonary
color vision deficiency 518 disease 273, 274
coronary artery disease 163–65 coronary artery disease 160
erectile dysfunction 408 health checklist 30
fragile X syndrome 521 health risks 110–13
genital herpes 373 hypertension 125–26
genital warts 387 lung cancer 186–87
gonorrhea 377 osteoporosis 579
heart failure 170–71 penile cancer 215
HIV/AIDS 383–84 stroke 268
hydrocele 454 weight management 70–71
kidney disease 308 see also smoking cessation
kidney stones 554 Tofranil (imipramine) 567
Klinefelter syndrome 526 tolterodine 567
liver cancer 203–4 “Tools to Help You Build a
lung cancer 188–89 Healthier Life: How to Get a
muscular dystrophy 535–37 Second Opinion” (National
osteoporosis 580 Women’s Health Information
penile trauma 431 Center) 24n
629
topiramate 537 type 2 diabetes, described 278
torsades de pointes 9 “Types of Stroke” (CDC) 263n
torsion of testes 466
total hepatectomy,
described 206, 207 U
total serum cholesterol,
defined 593 ugly duckling memory
transcranial magnetic device 51–52
stimulation (TMS), defined 593 “The Ugly Duckling Sign:
transient ischemic attack (TIA) An Early Melanoma
defined 594 Recognition Tool” (Skin
described 265 Cancer Foundation) 50n
see also stroke ulcerative colitis, colorectal
transurethral incision of cancer 194
prostate (TUIP) 439–40 ulcers, penis lumps 425
transurethral microwave ultrasound
thermotherapy (TUMT) 440 cirrhosis 317
transurethral needle ablation defined 594
(TUNA) 440 kidney stones 554
transurethral resection liver cancer 204
of prostate (TURP) 439 penile trauma 431
travel considerations, spermatocele 460
vaccinations 43 testicular cancer 222
“Treatment” (CDC) 263n urinary incontinence 564–65
“Treatment Options” ultraviolet light,
(NHLBI) 271n sun protection 137–38
Treponema pallidum 397 “Understanding Prostate Changes:
Trichomonas vaginalis 402 A Health Guide for Men”
“Trichomoniasis” (CDC) 402n (NCI) 436n
trichomoniasis, overview 402–4 undescended testicle
triglycerides, fibrates 120 overview 468–70
Trilafon (perphenazine) 502 testicular cancer 221
trospium chloride 567 “Undescended Testicle
“The Truth about Indoor (Cryptorchidism)” (Cooper) 468n
Tanning” (American Osteopathic University of Michigan Health
Association) 137n System, publications
TUIP see transurethral life expectancy 4n
incision of prostate urethral stricture 557n
TUMT see transurethral ureters
microwave thermotherapy defined 594
TUNA see transurethral needle described 307
ablation urethra
tunica albuginea defined 594
described 430 described 214, 325, 430
erectile dysfunction 407 penile trauma 431
penile trauma 431 “Urethral Stricture” (University of
TURP see transurethral Michigan Health System) 557n
resection of prostate urethral stricture, overview 557–60
type 1 diabetes, described 278 urethritis, defined 594
630
Index
urethroplasty, described 560 V
urethrotomy, described 560
urge incontinence, described vaccines
561, 562 defined 594
urge urinary incontinence, diabetes mellitus 282
defined 594 hepatitis 319
urinalysis, defined 594 hepatitis B 380
urinary diversion 568, 569 human papillomavirus 388–89
urinary frequency, defined 594 influenza 285–86
urinary incontinence, overview pneumonia 290–91
561–69 see also immunizations
“Urinary Incontinence Valle, Adamo 6
in Men” (NIDDK) 561n vardenafil hydrochloride 409
urinary tract varenicline 115
defined 594 varicella, vaccination 42–43
depicted 562 varices, cirrhosis 316
urinary tract infections “Varicocele” (Nemours
(UTI), defined 594 Foundation) 470n
urinary urgency, defined 594 varicoceles
urine, defined 594 described 327, 357, 359
urodynamic testing, infertility 354
urinary incontinence 565 overview 470–72
“Urologic Diseases Dictionary” vas deferens, described 324–25
(NIDDK) 585n vasectomy
urologists overview 339–43
described 178 reversal 345–50, 355, 357,
penile trauma 431 360–61
varicoceles 472 “Vasectomy Reversals:
Uroxatral (alfuzosin) 439, 566 Frequently Asked
“U.S. Cancer Screening Trial Questions” (Wald) 345n
Shows No Early Mortality Benefit vasodilators
from Annual Prostate Cancer defined 594
Screening” (NCI) 37n hypertension 124
USDA see US Department of verapamil,
Agriculture Peyronie disease 422
US Department of Agriculture Verbalis, Joseph 7, 9
(USDA), diet and nutrition VESIcare (solifenacin
publication 56n succinate) 567
US Department of Justice (DOJ), Viagra 409
publications violence
drug abuse 132n depression 489
homicide statistics 150n overview 476–77
US Food and Drug Administration schizophrenia 500
(FDA) “Violence Prevention”
contact information 596 (NWHIC) 476n
gender publication 7n viral hepatitis, overview 311–15
Us Too! International, Inc., “Viral Hepatitis: A through E and
contact information 600 Beyond” (NIDDK) 311n
UTI see urinary tract infections viral pneumonia, described 288–89
631
vitamin C, diet and nutrition 63 “What Is COPD?” (NHLBI) 271n
vitamin D, osteoporosis 581–82, 582 “What Is Pneumonia?” (American
vitamin E, Peyronie disease 422 Lung Association) 287n
voiding diary, urinary incontinence “What You Need to Know about
564 Liver Cancer” (NCI) 201n
withdrawal, described 133–34
work injuries see occupational
W injuries
Wald, Moshe 345n, 351n
“Warning Signs: The ABCDEs of
X
Melanoma” (Skin Cancer
Foundation) 50n Xenical (orlistat) 82
watchful waiting x-rays
benign prostatic hyperplasia cirrhosis 317
437–38 coronary artery disease 164
prostate cancer 180 heart failure 171
“Water-Related Injuries Fact kidney stones 554
Sheet” (CDC) 256n
water safety, overview 256–61
Wax, Craig 138–39 Y
weight management
cholesterol levels 117, 119 Youngstedt, Shawn 95
health checklist 30
hypertension 124–25
overview 67–84 Z
physical activity 86–87
“What I Need to Know about Zelnorm (tegaserod maleate) 9
Cirrhosis of the Liver” ziprasidone 502
(NIDDK) 311n Zoloft (sertraline hydrochloride) 10
“What Is a Heart Attack?” zygote, described 327
(NHLBI) 167n Zyprexa (olanzapine) 502
632

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Health Reference Series

Library of Congress Cataloging-in-Publication Data

Electronic or mechanical reproduction, including photography, recording, or any other in-

Printed in the United States

Part I: Overview of Men’s Health and Wellness

Chapter 2—Does Gender Make a Difference

Chapter 4—Recommended Screenings and Vaccinations

Chapter 5—Self-Examinations Can Lead to Early

Chapter 6—Nutrition and Wellness .......................................... 55

Chapter 7—Managing Your Weight: Avoiding

Part II: Leading Causes of Death in Men

Chapter 24—Suicide .................................................................... 293

Part III: Reproductive and Sexual Concerns

Chapter 31—Vasectomy Reversal .............................................. 345

Chapter 34—Sexual Dysfunction ............................................... 405

Chapter 35—Penile Disorders .................................................... 419

Chapter 36—Non-Cancerous Prostate Disorders ..................... 435

Chapter 37—Disorders of the Scrotum and Testicles .............. 447

Part IV: Other Common Health Concerns in Men

Chapter 40—Male Menopause ................................................... 507

Chapter 43—Sleep Apnea ........................................................... 543

Chapter 45—“Women’s” Concerns: Men Are at Risk, Too ....... 571

Part V: Additional Help and Information

About This Book

Part I: Overview of Men’s Health and Wellness summarizes male

Part IV: Other Common Health Concerns in Men discusses a number

Part V: Additional Help and Information includes a glossary of terms

About the Health Reference Series

A Note about Spelling and Style

Locating Information within the Health Reference Series

Our Advisory Board

Health Reference Series Update Policy

Men and Life Expectancy

Evolutionary Forces behind

Despite research efforts to find modern factors that would explain

Biological Forces May

Scientists in Spain and Italy have identified a group of proteins

Does Gender Make a

Gender as a Starting Point

Drugs and Gender Differences

Medical Devices and Gender Differences

Studies of Both Sexes

Table 2.1. Gender Differences in Disease Risk

Source: National Institutes of Health

Men, Women, and Heart Disease

It is important to choose your doctor with care, because quality

Quick Check for Quality

Doctors and Health Plans

Decide What You Want and Need in a Doctor

Make a List of Doctors

Contact the Doctors’ Offices

Once You Leave the Doctor’s Office, Follow Up

Urgent or Emergency Care Centers

Tips for Using Medicines Safely

Take a List or a Bag with All Your Medicines When You

Ask Questions about Your Medicines

Make Sure Your Medicine Is What the Doctor Ordered

Ask How to Use the Medicine Correctly

Ask about Possible Side Effects