Ask Your Doctor 198 (16.05.2017)

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1. N.N., Mangalore

*I am 31 years, married for 10 months. We are happily involved in physical union. But my wife has a problem. During union , in-spite of having long duration of foreplay, she has dryness in her private part and she feels pain. Initially, we used jelly but still she has pain. Most of the time, she does not even reach orgasm after having intercourse. We feel very much disappointment as she will not attain satisfaction. Kindly advice if we should contact a specialist for this problem.

** The desire to have sex in woman is dependant on many factors, most of which are emotional. In the same way low sex drive in women is also due to several reasons. It is not possible to suggest total solution for the problem. However let me list a few of the causes here:

• Your relationship with your wife may be the main issue. If her needs aren’t being met in the relationship, if the two of you don’t deal with problems openly and constructively, if she is not treated with respect and fairness, if you are self-absorbed or self-destructive – these common patterns destroy the intimacy and trust that keep sexual desire alive over the long term.

• Many women have been traumatized sexually at some point in their lives, and that experience may need to be dealt with now. It’s estimated that 1 in 3 women are sexually assaulted in some way during their lifetimes. If this is an issue for your wife, she deserves to be explored with professional help for many reasons beyond the sex drive. You may have to seek the help of family councellors.

• Some women were raised to believe that sexual desire is shameful or inappropriate. Women who’ve been unassertive about their sexuality in the past may prefer to sacrifice their sex lives rather than become assertive now about what’s required to satisfy their sexual needs.

• Stress is an enormous factor. The body naturally puts survival ahead of pleasure. The over-burdened adrenal glands can rob the body of the building blocks it uses to make certain hormones, which are vital to desire and sexual response. Changes in her routines, a new form of creative self-expression, help from you, working on unresolved problems, time you devote to her – the positive effects can be profound

• Open communication is so important in a relationship and this is especially true during this confusing time. Be open and share the feelings that seem beyond your control. Offer your help and be a part of the solution by asking for patience and encouragement while you both work toward becoming healthy and balanced. Be sure to show your love in other ways that have been meaningful to both of you. Facing this issue with openness and respect for each other will foster a mutual understanding and bring you closer.

2. J.M., Mangalore

*I am 30 years, married a year ago. Due to thick hymen issue we could not consummate our marriage. Gynaecologist did an in-clinic procedure to loose hymen. Although, we could insert upto 2 fingers (with pain) still penetration seems difficult even with lubricants (Lidocaine gel prescribed by doctor). Lately, I also go limp when I try to penetrate and resigned to the fact that penetration is impossible. This adds further pressure psychologically. What could we do to overcome this problem.

** It may be better to consult some other gynecologist to address the problem of your wife. Once it is solved, erectile dysfunction which you are having now may be resolved. If your problem continues, you may have to consult an urologist.

3. D.P., Dubai

*I am 36 years of age. When I was pregnent for my 2nd child I spotted some dark brownish patches on my cheeks (after 7 months). Some are telling because of harmonal changes. Now my child is 2 years. But Still I have that patches on my cheeks. I want to know is there any treatment available for that? Though I am always inside the house can I use daily sunscreen cream?

** These patches can be treated effectively. Consult a skin specialist. Do not use creams/lotions unless advised by the specialist.

4.D.N., Mangalore

*I am 27 years old. I have a problem of hemorrhoids. Since 1 year there is a small hemorrhoid on the external anal region. Please tell me some home remedies to remove it completely. Sometimes I feel itching and irritation.

**Piles also known as hemorrhoids are the swollen but normally present blood vessels in and around the anus and lower rectum. These stretch under pressure, similar to varicose veins in the legs. The increased pressure and swelling may result from straining to move the bowel. Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms and are incorrectly referred to as piles.

Piles usually are not dangerous or life threatening. In most cases the symptoms of piles will go away within a few days. Although many people have piles, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, the internal hemorrhoids may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding, or prolapsed, hemorrhoid. Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms.

A thorough evaluation and proper diagnosis by the doctor is important when bleeding from the rectum or blood in the stool occurs. Bleeding is often due to hemorrhoids, but may also be a symptom of other digestive diseases. Consult a general surgeon. Many a times the problem of piles or other minor problems causing bleeding while passing motion can be treated with medicines. Surgical interventions are needed in certain conditions.

5. J.F., Mangalore

* I am 38 years of age. My son is 2years of age and has knock knees. He is very active in play. The doctor here says it is not possible to decide about the surgery till he is three years of age. Is surgery a must?

** A standing child whose knees touch but ankles do not, is usually said to have knock-knees. During childhood, knock-knees are a part of normal growth and development. In a child with knock knees, both the knees usually lean inwards to equal degrees. One knee, however, may "knock" less than the other, or may even remain straight. The problem usually becomes apparent when a child is 2 to 3 years old and may increase in severity until about the age of 4. During childhood, knock-knees usually develop as an effort to maintain balance, particularly when the child begins to walk or if the child's foot rolls inward or turns outward.

Knock-knees most often develop as a part of natural growth. The knock knees that develop as a result of growth rarely require intervention. Rarely infection to the bone, malnutrition like rickets, and injury to the epiphysis- the growing part of the bone may cause knock knees which require treatment early.

Overweight children are most likely to develop knock-knees, because their developing bones and joints have trouble supporting their weight and they tend to lean inward. Knock-knees usually correct themselves by the time a child is five years old. Occasionally, however, they persist into adolescence.

Severe knock-knees usually wind up restricting a child's physical activities. The child cannot run easily and may not want to participate in sports or other physical activities. If knock-knees persist into adolescence, problems of appearance as well as physical activity
Knock-knees are obvious when a child stands with the legs straight and the toes pointed forward. A physician can determine the severity of knock-knees by observing the position of the child's legs, knees, and ankles, and by measuring the distance between the child's inner ankle bones: the greater the distance between the ankles, the more severe the condition.

A mild case of knock-knees usually requires no treatment, since it often corrects itself. More severe knock-knees may require the use of orthopaedic appliances. The child's physician may prescribe a night brace, particularly if a family history of knock-knees exists. A night brace is attached to a shoe and works by pulling the knee up into a straight position. Orthopaedic shoes, usually equipped with a heel wedge and occasionally an arch pad, may also be recommended.

If braces and shoes do not correct knock-knees, surgery may be recommended. The surgery may involve either influencing growth or cutting and straightening the bone. For the best results, surgery should be performed when a girl is bout 10 years old and a boy about 11. This allows time for the bones to straighten on their own.

6. J.P., Kuwait

*I am 26 years old, married for two years. I just delivered a son and my question is we want to avoid pregnancy for few years. Just want to know if inserting loop is effective or not and is there is any side effects or complications?

** IUDs, also known as the coil or loop, provide long-term, effective and rapidly reversible contraception. Loops are small devices made from plastic and copper, they are placed inside the womb by a doctor and are effective immediately, offering 98-99% protection.
The IUD works by altering the consistency of cervical mucous, making it difficult for sperm to enter the cervix. It also makes the lining of the womb less receptive to a fertilised egg (gamete) and can adversely affest the sperm and egg before fertilization.

Once fitted, IUDs are effective for 3-5 years, depending on the type. Some IUDs are coated in a hormone similar to progesterone, called a progestogen, which acts as a contraceptive, adding to their effectiveness. IUDs are more suitable for women who have already had a baby and can usually be fitted about 6 weeks after the birth.

Loop is relatively the safe and best method for spacing the child birth compared to many other methods including pills. There can be minor side effects rarely like excessive menstrual bleeding, expulsion of the loop, penetration into the uterine musculature. The greatest advantage of loop is easy reversibility. The woman can conceive within a month or two after removal of the loop.

7. A.R., Pune

* My fiancé, 25 years, she gets pain while on her 1st day of period, which is normal, but to avoid pain she takes on pain killer. I want to know whether pain killer will have any effects on conception in future after marriage, or taking pain killer during periods is no harmful.

** The pain relievers can be safely used for a day or two during the onset of menstruation when the pain is unbearable. These do not cause habit or leave behind any effects hampering future fertility. However the tablets are to be bought and used as per the advice of the doctor.

8. S.F. Mangalore

* I am 29 years of age. I suffer from PCOS since 2002 my periods are irregular and my BMI is 28, I got one son who is 5 years old. I got slightly hair growth on my face and chest. My GP has put me on metformin 500mg twice daily since then I lost some weight. I like to know what I have to do to get my periods regular. I want to plan for second child what are the chances for me to become pregnant again?

** Poly Cystic Ovaries syndrome(PCOS) or Stein- Leventhal syndrome is a condition in which there is an association between the presence of polycystic ovaries and signs of hirsutism, amenorrhea or oligomenorrhea and obesity. In this syndrome, other than an ovarian defect there can be biochemical, clinical, and endocrinal abnormalities. Although the condition is now referred to as polycystic ovary syndrome (PCOS) it may occur in women without ovarian cysts. Women with PCOS have abnormalities in the metabolism of androgens and estrogen and in the control of androgen production. High serum concentrations of androgenic hormones also may be encountered in these patients. PCOS is not a rare problem and approximately 6-10% of women in the developed countries have PCOS.

The extent of the problems associated with PCOS varies from woman to woman. However, there is effective treatment for the condition and it depends on the problems the individual has. Many of these women are able to conceive if the abnormalities are set right. The treatment can be medical with varieties of drugs- certain anti-diabetic agents like metformin, oral contraceptives etc. Other than medication, weight reduction, diet and exercises also are the part of treatment. Rarely surgery is done. Some of the women with PCOS are able to conceive if the hormonal abnormalities are set right. You may consult your gynecologist for this.

9. P. D. Mumbai

* I am 32 years of age. I have got pain under my ankle. The pain is severe when I get up in the morning. I cannot walk for sometime and after a while the pain reduces. What can I do for it?

**Pain in the heel is a common problem. Some people term it as calcanial spurs and a few name it as plantar fasciitis. Both these are almost same. It is generally believed that a bony spur projecting from the back or underside of the heel bone (the calcaneus) makes walking painful. The calcaneal spur is also called a heel spur.

Not all heel spurs cause symptoms. Some are discovered on X-rays taken for other purposes. Spurs probably result from excessive pulling or stretching of the calcaneal periosteum by a fibrous structure, the plantar fascia. The stretching may also result in pain along the inner border of the foot, when the term plantar fasciitis may be appropriate. Exact cause for the problem is not known. Painful heel are more commonly seen in those who stand for a long time. Predisposing factors to heel pain/plantar fasciitis include: flat, pronated feet, high arched feet, inappropriate shoes, running on the toes, hill running or running on the soft terrain, diabetes mellitus etc.

The problem of calcaneal spur is not due to deposits of calcium. It can not be solved by reducing calcium in the diet. Treatment is designed to reduce inflammation. If the pain is of sudden onset and is very severe ice packing may help. Anti-inflammatory agents can also help to reduce local inflammation as well as pain. The medications may be used only for short periods.

Heel lifts reduce stress on the Achilles tendon and relieve painful spurs at the back of the heel and donut-shaped shoe inserts take pressure off plantar spurs and relieve the pain in the heel. Physiotherapy in the form of moist heat also helps to reduce chronic dull aching pain.

Local steroids are to be used as the last resort. Steroids are to be infiltrated under aseptic precaution ideally by the specialist. Local steroid injection has no adverse reactions on the body. If proper care is not taken it may predispose infection which may worsen the condition.

10. P M L., Mangalore

* I am 32 years of age. I have 15month old child, I had caesarean section (indication big baby). I was advised not to conceive for at least two years. But I am pregnant now. Will there be any harm? What may have to be done?

** The traditional advice is that women should have no more than three caeserian sections and that they should wait a year after one section before becoming pregnant again. Many obstetricians still stick to this advice, and there is a body of evidence that supports waiting at least six months is sufficient before trying again to conceive. As you had caesarean surgery 15 months ago, there should not be any harm to continue with the present pregnancy.

In the vast majority of caesarean sections, the incision into the uterus is made horizontally into the lower segment of the uterus. Such an incision usually heals well in an otherwise healthy woman and is thought to be fully healed by three months.

In fact, the caesarean scar on the uterus continues to grow stronger and may cause fewer problems over time. The major problem of early pregnancy after a caesarean section is the rupture of the previous scar during or before delivery. The risks of the scar rupturing decrease as the gap between pregnancies increases.

The risk of scar rupture is significantly higher when the gap between pregnancies is less than six months. But the incidences of scar rupture are very small, which means that most women who have a smaller gap between pregnancies also have no major problems.

11. C. D., Mangalore

*I am now 35 years. I married in 2009. In 2010 I delivered a baby girl. It was normal delivery. We delayed our 2nd baby for 5 years. In 2015 mid we planned for 2nd baby. But I did not conceive. Last month we went to gynecologist. As per gynecologist we did the tests. My husband’s semen count was normal. She asked me for scanning. She told me there was no blockage. But still I am not conceiving. Every month we try. I have not taken any medicine for conceiving. My husband is having sugar around 140 - 150. Is it a problem? His age is 39. Doctor says we can conceive normally. Could you please advise us what other tests are to be carried out so that we can detect the exact problem?

** It is true that women of your age conceive normally and diabetes mellitus in either of the partners is not a hindrance to get a baby. But the chances of fertility gradually reduce and problems associated with pregnancy and child birth increase as the age of the woman advances. As you are already 35 years, it is ideal to have conception as early as possible. You may consult your gynecologist to assist you regarding this. You may be advised to undergo some more tests and if required you may be advised to take medicines that help in fertility. I hope you are aware about the –fertile period of a cycle- the possible days of fertility. Physical union on these days is ideal for conception.

12. J. C., UAE

*I am 35 years and I got married at the age of 30. The problem is that I have noticed one tiny vein becoming black at the tip of my penis. There is also a big fat vein at the top side of my penis. My wife is in India. I masturbate occasionally. Is this is the cause?

** Absolutely, it is normal to have veins on the penis. There are a large number of veins surrounding the penis and an especially large vein on the top of the penis called the dorsal vein of the penis.

In order to get an erection a large amount of blood is brought by arteries to the sinuses (spaces) in the body of the penis. This blood must then drain out of the penis through veins in order to allow the penis to become flaccid (soft) again. This is normal and not related to masturbation in any way.

13. N. P, Mangalore

* I am 26 years of age. I have two questions 1) I have a micropenis. The length of my penis when fully erect is between 3.5-4 inches. I would like to know if I will be able to have a normal married life as I am going to be married soon. Also I would like to know what is the minimum length required for effective sex. 2) I used to masturbate a lot, at least twice a day. But recently I have been developing back spasms after masturbation. I would like to know if frequent masturbation can cause any kidney harm, as I feel my pain is around the kidney region.

** Micropenis is a clinical term used to describe a very small penis. But many of the men who have small sized penis think that they have micro penis, but in fact it can be the normal size, may be less than the average. Despite the fact that researchers disagree on what constitutes and average penis size, a micropenis is considered in newborns to be around 3 /4 of an inch (1.9 centimeters) in length, and in adults to be less than 2.8 inches (7 centimeters) in length when flaccid and stretched. The length you achieve during erection is sufficient to have normal physical union. More over there are no medications or surgical options are available which can effectively enhance the size of the organ.
Sexual union is not a mechanical union. There are lot many emotional and psychological factors influence the marital union. Intimacy and affection is more important than the size of the organs.

Masturbation as it is does not cause back ache or spasms. The pain and spasm you get may be because you bend during masturbation. The wrong posture may be causing stress on the muscles of the back leading the spasms. Muscular spasms are no way related to kidney problem.

14. J.L., Mangalore

* I am 28 years, I am pregnant...few days back I have started noticing drops of blood when cleaning my nose...I do not have pain. There are just 2-3drops...then its clear...but it happens everyday morning. Is there any cause for it?

** It is better you consult an ENT specialist at the earliest. The problem may not be related to pregnancy directly. The most common causes for nose bleeds are dryness (often caused by indoor heat in the winter) and nose picking. These two things work together - nose picking occurs more often when mucus in the nose is dry and crusty.

Other, less common causes include injuries, inflammation from colds, allergies or drug use. Most nosebleeds occur in the front part of the nose and stop in a few minutes. A few nosebleeds stem from large vessels in the back of the nose. In such cases the bleeding will be in larger quantities. These nosebleeds can be dangerous.

15. V.M. Bangalore

* I am 27 years of age. I have problem in dirty smell on sexual organs. I am married recently. The smell started two to three month of marriage.

** Troublesome odor in the sexual organ in women can be caused by several factors. The most common cause is vaginal bacterial overgrowth known as bacterial vaginosis, which has a "fishy" or "musty" smell. "Fishy" smells can also result from vaginal infections, such as trichomonia vaginalis, and in some women, from semen in the vagina. The vagina could also smell "yeasty" because of vaginal yeast overgrowths. Synthetic underwear, pantyhose, tights, and exercise clothes do not allow air to circulate around the vulva (the outer lips of the vagina). A moist, sweaty environment promotes overgrowths of normal skin bacteria that could cause vaginal odor.

A physical exam by a doctor can determine whether vaginal odor is being caused by something that is treatable with a medication, such as for bacterial vaginosis, trichomonas, or yeast. In these cases, the unpleasant smell usually goes away after the treatment. The physical exam can also detect other health problems that might cause unusual body odors.

Some basic steps to prevent the vaginal odor caused by overgrowths of normal skin bacteria are to:

• Wash the region with warm water and unscented, gentle soap with mild antibacterial action.
• Wear underwear and exercise clothes made from materials that "breathe," such as cotton.
• Wear loose pajama bottoms or a night gown.
Don't douche. If deemed necessary, douching should be done only under the direction of a health care provider. Otherwise, douching is not recommended.

16. R. B., Mumbai

* I am a married woman with three children, age is 34 years. In the last September I was diagnosed with lichen planus on my skin and in my mouth. I consulted a doctor, who advised me steroid shots it helped and healed but now I see new ones here and their on my skin not as bad as I got it the first time but the one in my mouth healed on one side but still the same on the other side of my cheek. Two days ago I noticed new spot on the side of my tongue and on the side where it was clear I am scared why this is happening to me and when this should go and would it come back more?

** Lichen planus appears as shiny, flat-topped bumps that often have an angular shape. These bumps have a reddish-purplish color with a shiny cast due to a very fine scale. The disease can occur anywhere on the skin, but often favors the inside of the wrists and ankles, the lower legs, back, and neck. The mouth, genital region, hair and nails are affected in some individuals. Thick patches may occur, especially on the shins. Blisters may rarely occur. Bumps may appear in areas of trauma on some individuals. About 20 percent of the time lichen planus of the skin causes minimal symptoms and needs no treatment. However, in many cases the itching can be constant and intense.

This disease occurs most often in men and women between the ages of 30 and 70 years. It is uncommon in the very young and elderly.
• There is no known cure for skin lichen planus, but treatment is often effective in relieving itching and improving the appearance of the rash until it goes away. Since every case of lichen planus is different, no one treatment does the job. Topical corticosteroids are very useful. Antihistamines may be prescribed to relieve itching. Extensive cases may require the use of oral corticosteroid (cortisone, prednisone) for a number of weeks. This usually shortens the duration of the outbreak. For severe cases powerful treatments include photo chemotherapy light treatment (PUVA), the retinoids drugs. (Other helpful measures include soothing baths and the application of wet dressings (tap water, Burows solution 1:40) to the affected areas to help reduce itching. Also, the use of lotions containing anti-itch ingredients such as menthol, pramoxine and phenol may be helpful.

• As it heals, lichen planus often leaves a dark brown discoloration of the skin. Like the bumps themselves, these stains may eventually fade with time without treatment. About one out of five people will have a second attack of lichen planus. Lichen planus of the mouth most commonly affects the inside of the cheeks, gums and tongue. Oral lichen planus is more difficult to treat and typically lasts longer than skin lichen planus. The most cases of lichen planus of the mouth cause minimal problems. Oral lichen planus typically appears as patches of fine white lines and dots. These changes usually do not cause symptoms.

• You may consult a skin specialist and follow his advice. Though the recurrence can not be avoided, they can be treated.

17. M.S. . Dubai

* One of my friends in his 50's has a habit of sniffing snuff regularly. Is it harmful and will it have any adverse effect on his health. I tried to stop him from this habit but he argues that it is not harmful at all.

**Many terms are used to describe smokeless tobacco products, such as oral, chewing, snuff, spit and spitless tobacco. All forms of oral tobacco contain known carcinogens (cancer-causing agents). They can cause cancer of the oro-pharynx mouth and pancreas and many other health problems. Smokeless tobacco is less lethal than cigarettes, but all forms of tobacco pose significant health risks. Smokeless tobacco may also play a role in heart disease and high blood pressure. Men who switched from cigarettes to snuff or chewing tobacco had higher death rates from heart disease, stroke, cancer of the mouth and lung, and all causes of death combined than former smokers who stopped using all tobacco products. The snuff and chewing tobacco products most widely used contain very high levels of tobacco-specific causing nitrosamines. These carcinogens (cancer-causing agents) cause lung cancer in animals, even when injected.

18. R. J., Mangalore

* I am 28 years of age. I got married in December 2015. Since then we have not done any family plan but my wife did not conceive. Last month I went to a gynecologist and as per her advice semen analysis was done. The report: spermatozoa count : 10.0 millions/cc total sperms in ejaculate: 20.0 millions. Grade of motility : on liquefaction 60% , after 1/2 hours 60% , after 2 hours 50% , abnormal forms : micro sperms 2% , cellular elements/others pus cells 2-3 /hpf. Doctor suggested me to take certain tablets (name given) for 3 months and she also told me that my wife is normal even though my wife has only 2 days flow in during her periods. Are we taking the right treatment?

** The report indicates that you have low sperm count. You are advised proper medicines by your doctor. It is better to follow the advice of your doctor and if needed you may be advised to undergo further tests.

19. S.P. Dubai

* I am 35 years of age, with two kids aged 9 and 8. I need advice on two issues: a) my menstruation is only for a day for the past three years since I removed the loop. Is this normal? Do you suggest any medication for this? b) We would like to have another baby. My only concern is I have had two miscarriages before my two healthy kids were born and I had a miscarriage last year

** I presume you have not discussed these issues with your gynecologist. Though the scanty bleeding can be normal it is better you undergo an assessment by your doctor as you have previous history of miscarriage and now you are planning for another child.

20. J. R. Qatar

* I am 30 years of age. I am working in gulf and I go to my native place once in year. We have one child and we do not want any more. We use condom, but both of us are not happy about that and we do not want to use it. As I stay there for about a month every year, what is the other method that can be used instead of condom? We do not want to take any chance of pregnancy. My wife is on gardinal tablets for some other problem.

** Your wife may consult a gynecologist and take oral contraceptives, if you desire to have contraception for a month or two. Oral contraceptives, also known as birth control pills, contain artificially made forms of two hormones produced naturally in the body. These hormones, estrogen and progestin, regulate a woman's menstrual cycle. When taken in the proper amounts, following a specific schedule, oral contraceptives are very effective in preventing pregnancy The doctor will guide her how to start and how long to continue the tablets.