Dr Sean Cummings  
London, United Kingdom

Specialties: STD/STI HIV prevention

Interests: Hepatitis C, Men's Health, HIV Prevention
+44 (0) 20 7637 1600
London, United Kingdom
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Cialis gaining on Viagra

Oct 15, 2010 - 3 comments


Cialis gaining on Viagra

Cialis, the so called ‘weekend pill’ is overtaking Viagra as the erection pill of choice, according to an article in Psychology Today.

Recent studies show Cialis has overtaken Viagra as the number one prescription drug in Europe. Eli Lilly the company who produces Cialis also claims the drug has overtaken Viagra in sales in the U.S, though this is disputed by Pfizer who make Viagra.

In 2007 Viagra controlled 62% of the U.S. market, with Cialis at 26% and Levitra at 12% though it’s thought Cialis and Levitra have since increased in popularity.

What is Cialis?

Like Viagra and Levitra, Cialis is a pill used to treat erectile dysfunction but it is effective for a longer period of time, up to 36 hours, earning it the nickname ‘the weekend pill’.  Like the others it is prescribed on an ‘as needed’ basis but is also the only of the three that can be prescribed to be taken regularly; often men will take low doses of the pill on a daily basis. It should be taken at least 30 minutes before sexual activity.

It is based on an inhibitor called Tadalafil which improves the flow of blood to the penis. The pills are yellow tear drop shapes and smaller than Viagra’s well-known blue pill.

Cialis is the newest of the erectile dysfunction treatments. It was licensed in November 2003. (Levitra was licensed in August 2003 and Viagra in March 1998). Cialis comes in 5 mg, 10 mg, and 20 mg tablets. Most men start out using 10 mg tablets and either increase or decrease the dosage depending on effectiveness.

Viagra and Levitra

Viagra and Levitra are also based on inhibitors that increase the blood flow to the penis, sildenafil and vardenafil respectively.   Although different in appearance; Viagra is a blue diamond shape and levitra is round and yellow, both are similar and the effects of the erection tablets last on average four hours, though some studies suggest some benefit for up to 10 hours. It is recommended that those prescribed Viagra or Levitra take it half an hour to an hour before sexual activity.

Viagra comes in 25mg, 50mg, and 100mg tablets, with most men starting on the 50mg pill and changing doseage if necessary.

Levitra comes in 2.5mg, 5mg, 10mg, and 20mg pills. Levitra should be taken anywhere from 25 minutes to 1 hour prior to sexual activity, although some experts claim it is the fastest acting of the erectile dysfunction treatments and can be taken effectively as little as 15 minutes before sexual activity.

With its long lasting effect it is perhaps unsurprising that Cialis is surging in popularity. Surveys of men who’ve tried a range of erection treatments apparently confirm this.

According to Pyschology Today there have been eight separate studies that have compared Viagra and Cialis. In the studies each drug was used between 2 to 6 months and at the end of the period couples were asked which of the drugs they preferred. The consistent response was that couples preferred Cialis.

Another study, but which was funded by the makers of Cialis, found that men said they preferred their erection after taking Cialis compared to other drugs used to treat erectile dysfunction.

Success and side-effects

The drugs work in around 70% of men and have similar side effects. They have the potential to cause headaches, flushing, runny noses, stomach aches or even changes in vision. Doctors say these are common and should not be a reason to worry. None of the three drugs  should be taken with blood pressure medication or nitrates, including amyl nitrate (Poppers).

Find out more about the different medications available for erectile dysfunction here:-

Human Penile Worms

Oct 14, 2010 - 1 comments

A lovely little article appeared in this months International Journal of STD and AIDS (July 2010) written by Drs Samuel and Taylor from Kings College Hospital London.

They describe the case of a 56 year old man who had sex with other men and who complained of increased desire to pass urine, irritation in the urethra (the pipe that you wee through) and also pain on passing urine. All standard tests were negative but his symptoms persisted. Being a resourcefull fellow he collected his own urine and took it into clinic where a worm was found.

The "worm" was a 2 mm larva of a drain fly from the family Psychodidae which responded to appropriate treatment after successful identification at the London School of Hygiene and Tropical Medicine Reference Laboratory.

Drs Samuel and Taylor describe the larva as preferring wet, decaying vegetation in drains, sewage plants and cesspools and drains in bathrooms and kitchens to breed and lay eggs. The larvae may rarely contaminate human orifices.

Poor personal hygiene were suggested as perhaps being relevant to the contamination by the worm with the patient apparently mentioning drainage problems in his flat and poor personal attention to cleanliness.

The prize for the most interesting odd article goes to Drs Samuel and Taylor! Patients should beware though that this is incredibly rare and is fascinating precisely because it is so very unusual.

Erectile Dysfunction (Impotence) Treatments

Oct 06, 2010 - 24 comments

Erectile Dysfunction (Impotence) Treatments

This used to be called impotence until the rather more sensitive erectile dysfunction or “ED” phrase was coined. It actually is a better term because there is a range of ways in which your penis mail fail to live up to expectations, causing embarrassement and disappointment.

Very technically, ED is defined as the inability to develop or keep an erection long enough for the desired sex to occur. This might include masturbation, public sex, penetration and oral sex. It really doesn’t matter why the erection is desired – but if you can’t reliably get one when you need one, then you have ED.

ED is probably the most common sexual problem that a man can experience. Overall, probably around 1 in 4 men have problems. Younger men tend to have more in the psychological problem area with negative embarrassing experiences being reinforced each time the erection fails. Older men have a much higher rate of ED with around 50% plus of men in the 50 to 70 age group in at least one US study reporting it. Remember that ED is a range of conditions – it’s not simply a “dead or alive” condition. Partial erections; erections which start off strong and then fail; erections which are fragile in the sense that it doesn’t take much to make them collapse, are common.

As I say, younger men generally have less physical reason to develop erectile failure. They usually will have strong erections but occasional psychological problems like “performance anxiety” where they worry whether an erection will occur will kick in and cause erectile collapse. Older men, sadly in my age bracket of 40 plus, will tend towards more physical causes with around 5% of us being totally unable to develop an erection of any sort at all.

The reasons for erectile dysfunction have become much clearer over the last 20 years or so. In fact, I’m so old that I can remember the days when as students we were taught that the majority of men with erectile problems had physical disease causing it. We then went almost full circle with the psychological argument taking precedence and suddenly all men with ED had “issues” which you could solve with a jolly good chat with a psychologist.

Luckily things really have changed and mainly with the meteoric arrival of the drug Viagra and then its relatives Cialis and Levitra. These drugs heralded the notion that although there might be a physical or a psychological problem, it was solvable and reliably so, by taking the medications.

The arrival of these medications also opened the box of shame and enabled men to discuss the issues rather more openly. As a GP in NHS practice I would frequently have female patients come to talk to me about their sexual problems and their male partner’s lack of erection.

What finally did become really very clear was that there was a range of interacting physical and psychological elements, all having impact on each other. Physical difficulty caused by disease and or medications would be compounded with realising that once you’d started there had to be the expected outcome which usually involved penetration and ejaculation. Consequently a combined medical and gray-haired psychologist lady approach would often help tease everything out. Unlike women, few men can fake sexual arousal because if the erection isn’t there, well, it’s a difficult one.

There are a number of well-known conditions that will cause or worsen ED. The main ones I’m afraid are self-induced. If you suffer from ED its is worth while having a medical examination and also some blood tests for hormone and sugar levels.

Stress is something that’s often talked about and is a very powerful damper of sexual functioning. It is an awkward one to get around though because its 2010 and life is a blur of work and getting to work and family and responsibility and money etc etc – you know the picture. If you can sort the stress out then its probable that your sexual functioning will return to normal.

Alcohol and recreational drugs are for lots of people the major culprits. I do love a drink but the painful fact is that alcohol, except in very small amounts is very toxic. It’s also very seductive, so that one drink which might just calm the nerves before a potential sexual encounter, will frequently become plenty of drinks, leaving your erection something only to be dreamed of. Depressive illnesses also encourage people to drink far too much alcohol and the combination of the two together really is not a good one.

Recreational drugs – ecstasy, cocaine, crystal meth are widely used. I saw a recent press release saying that cocaine had become the UK drug user’s drug of choice in 2010. The problem with these drugs is that they will often increase sexual desire and feeling of “sexiness” but they equally often will destroy the mechanism so your hydraulics don’t match up with what you’re experiencing in your head. As a result, especially with crystal meth people will become fantastically desperate to achieve firstly an erection and secondly ejaculation. Even if they do, this isn’t enough and as soon as they’re done they’re off on another sexual quest. The result is often unsafe very risky sex, genital injury and sometimes such complete disinhibition that STI’s or STD’s including the blood borne variety HIV and 2010’s new infectious darling, Hepatitis C become a routine.

Diseases such as diabetes, heart disease and high blood pressure also have a marked impact on erectile dysfunction rates. This happens via a combination of routes including the disease process itself and also the medications used to treat the conditions. Very many medications will have an adverse effect on both libido and erectile capability.

Luckily there are now a variety of devices and medications used to treat ED. Although using medications etc is not ideal, it does virtually guarantee an erection.

The medications fall into two main groups – oral and injectable/insertable.

The oral meds began with Viagra or sildenafil. This was the first of a group of drugs called phosphodieterase inhibitors or PD5 inhibitors for short. They work by allowing an increase of blood into the penis and maintaining the erection for longer. It’s a bit like filling a bath – if you turn the taps on full the bath will fill, even though the plug is out. Other drugs like Cialis and Levitra are variations on the same theme but with their own characteristics. Levitra and Viagra are very similar medications being prompt acting with a relatively short duration of action.

Cialis has a longer onset and longer overall effect – in some men up to 3 days. Doctors will try to tailor the medication according to your needs. So for the man who needs an erection in an hours time, Levitra or Viagra are the appropriate drugs. For the man who wants a more normal sexual response over time, then maybe twice weekly Cialis is the way forward.

Other drugs include the injectable Caverject – yep, you have to inject your penis – but the upside is a fantastic stiff erection that you can hang your hat on. Muse is a little pellet which you insert into the urethra – the pipe you pee through – and then massage your penis. Gives a reasonable injection, but stings and burns a little. Also, someone sucking you may end up with a rather medicinal taste…..

Finally, vacuum pumps. These are rigid penis shaped devices slipped over the penis. You vacuum extract the air and suck blood into the penis, then slipped a tight **** ring over the base to keep the blood in. Surprisingly popular, though gives a cold, unattractive blue penis with frequent interruptions to re-inflate it. Not the most magical of moments.

Reducing risk of sexually transmitted infections and HIV in male and female sex workers

Sep 29, 2010 - 17 comments

Use of male and female sex workers is common throughout the world. Sex workers may be referred to as prostitutes, commercial sex workers, lap dancers, escorts etc but trade of sexual activity for money, food or drugs is the common factor.

A common assumption is that because of the frequency and number of change of sexual partners with commercial sex workers that they will be more exposed to sexually transmitted diseases and HIV and thus more likely to acquire, carry and spread STD/STI’s and HIV. As a clinician working in a clinic where I see many people, male and female, who have used sex workers, the concept of risk is one that generally occurs after the sexual event.

There is good evidence that male and female sex workers and their clients may represent a significant source of new HIV and other sexually transmitted infections. Condoms are very, very effective in reducing spread of STD’s and HIV but often they are not used for penetrative vaginal and or anal sex.

Many STD’s/ STI’s are easily treatable using modern antibiotic therapies. Ease of treatment however may miss the point. We know that gonorrhoea and also Chlamydia will increase the amount of HIV virus which is shed from both the cervix and also in semen of HIV infected men and women. Equally, concurrent infection with herpes 2 virus in the genital tract of either of the individuals will make HIV acquisition much more likely for a previously HIV negative partner.

Gonorrhoea, syphilis, chlamydia and herpes in the previously HIV negative individual engaging in unprotected penetrative sex with an HIV positive individual will markedly increase the chances of new HIV infection. These newly infected HIV positive individuals pose an exceptionally high risk of infecting other sexual partners because they are often unaware of the risks they have taken and unaware of the new HIV infection gaining rapid momentum in their body. New HIV infection will take a few weeks to generate often several million copies of HIV virus per ml of blood or semen making these individuals extremely infectious in the initial phase.

When contemplating exceptionally high background rates of STD and HIV in populations there is a correct tendency to view this as a feature of poverty and also developing societies such as Sub Saharan Africa etc. South Africa has the highest rate of HIV in the world. But there is a catch and that is that in different population pockets around the world, such as Washington DC in the USA, HIV infection rates in some sub-groups exceeds that of the South African HIV rate. Consequently, interventions to reduce the spread of HIV need to be universally applied and the notion that the highest rates are in the poorest countries is part of the picture.

Vickerman etc al, writing in the journal Sexually Transmitted Infections (2010:86:163-168) used mathematical modeling to estimate the impact of periodic presumptive treatment on the transmission of sexually transmitted infections and HIV amongst female sex workers. The female sex workers were of a group taken from Johannesburg.

The article started with the premise that periodic treatment of common STD’s / STI’s using antibiotics without pre-testing could reduce the rates of genital ulcer disease, gonorrhoea, Chlamydia. What was not known was whether reduction of these infections by interval treatments would also consequently reduce the rate of HIV transfer.

The conclusion reached was that whilst possibly optimistic assumptions had been made about the impact of blanket antibiotic use in high risk female sex worker populations in reducing onward HIV transmission, there was reason to believe that antibiotic interventions with good population coverage could noticeably reduce the HIV infection rate amongst female sex workers with previously inadequate STI and STD treatments.

Clearly the use of antibiotics themselves would only impact on the bacterial diseases and have no impact on HIV itself – but, because the bacterial diseases enhance the shedding and availability of HIV in cervical fluid and semen, reduction in bacterial contamination will reduce spread of HIV. This is not a substitute for condom use but as the accompanying Editorial points out, many vulnerable sex workers are often not in a position to enforce condom use.

A further weapon in the identification of early HIV before onward HIV transmission is the use of very early HIV testing methods. Confusion has reigned over the appropriate testing intervals and this has largely occurred because different and more sensitive HIV testing methods have become available over the last 30 years. The confusion has been compounded a little by the advice of government regulatory bodies in different countries who have tailored their advice to what they now about commonly used HIV testing methods on the ground.

In the UK 4th generation HIV testing methods using HIV 1 and 2 antibodies and also p24 antigen ( a core HIV viral protein) have been commonplace for many years and good experience has been gained with these tests.

A further advance has been the development for diagnostic purposes of an HIV 1 and 2 RNA PCR test which will identify extremely early HIV infection often before symptoms of Acute Retroviral Syndrome have appeared. This test can be performed from seven days post possible HIV exposure. The importance of such an early test is that it firstly enables early intervention in terms of medications if desired and secondly it allows for the opportunity to avoid infecting others.

Simultaneous early PCR testing will allow for detection of a host of bacterial and viral STD’s / STI’s such as herpes 1 and 2, trichomonas, gardnerella, Chlamydia, gonorrhoea, ureaplasma, mycoplasma, and hepatitis C and B.