Type 1 Diabetes Clinical Trial Aims to Retrain Immune System

Type 1 diabetes (T1D) is a chronic condition in which your immune system mistakenly attacks healthy insulin-producing cells in the pancreas and destroys them. This results in the pancreas making little or no insulin. Insulin allows blood sugar to enter cells around your body to be used for energy, but a lack of it can cause your blood sugar to rise to dangerous levels. 

While a cure for T1D remains undiscovered, researchers at Benaroya Research Institute at Virginia Mason (BRI) are working on innovative therapies to treat this disease. BRI is now starting the TOPPLE Study, a clinical trial to test a new potential therapy designed to teach the immune system to stop attacking cells in the pancreas.

TOPPLE is a Phase 1 trial, which means this therapy is being tested in people to assess its safety, look for side effects and determine the appropriate dosage. As of now, this study is actively recruiting participants to help researchers uncover more information and move them closer to better treatment options for this debilitating disease.

Eligible participants include those between the ages of 18-45 who have been diagnosed with type 1 diabetes in the last four years.

You can learn more about the TOPPLE Study on BRI’s website here. If you’re interested in getting involved with this study, please contact BRI at 800-888-4187 or Diabetes@BenaroyaResearch.org.

Q&A: Living with ADHD as an Adult

**Q&A with Jason Law, MSN, ARNP**

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopment disorder that can lead to problems focusing, difficulty with organization, hyperactivity and impulsiveness. While most commonly perceived as a childhood disorder, a recent study showed about 4% of adults in the U.S. over the age of 18 also live their lives managing ADHD.

If you’re included in the aforementioned 4%, you unfortunately might know that resources for adults are not as widely available as they are for children. I’ve answered some common questions associated with ADHD in adults below in hopes that you can find some solace and learn how to work with your brain, rather than against it.

Q. What causes ADHD and what are some common symptoms?

A. Your brain contains neurotransmitter chemicals called dopamine and norepinephrine that help you pay attention to and focus on your daily activities. At its core, ADHD is the result of an imbalance of these two chemicals.

When your brain experiences a lack of these neurotransmitters, you may find yourself having a difficult time focusing or remaining organized. On the other hand, when your brain experiences heightened levels of these neurotransmitters, you might find yourself becoming too engrained in whatever it is you’re working on, which is known as hyper fixation.

While lack of focus and disorganization are frustrating to deal with, hyper fixation can be an exceptionally grueling symptom, as it doesn’t always translate to the immediate task at hand you’d like to accomplish.

Q. How does ADHD in adults differ from children?

A. As you age, the core symptoms of ADHD will still be there, but they may present themselves differently. Children typically have more structured processes provided for them, such as school, sports and other extracurriculars, so their ADHD symptoms translate more closely to hyperactivity and academic struggles. However, it is important to note that not all children with ADHD struggle in school.

Alternatively, adults have less structure provided for them and must find ways to build these daily living processes themselves. Symptoms in adults tend to lean more toward forgetfulness, lack of punctuality, frequently losing items, impulsiveness and quick to anger.

Q. What are some common myths/misconceptions associated with ADHD?

A. First and foremost, the most glaring ADHD misconception is that it has something to do with a person’s intelligence, which could not be further from the truth. In fact, there are many adults that are not diagnosed with ADHD until later in life because they performed well throughout their years of schooling. ADHD is an issue of focus, disorganization, hyperactivity and impulsivity, not one of intelligence.

The name ADHD itself can also be misleading because it’s not solely an attention deficit, it can also be directing too much attention toward something. Additionally, lack of focus and hyper fixation are not mutually exclusive – it is possible to experience both of these at once. For example, you might be working hard to accomplish a work task but keep finding yourself gravitating toward and becoming engrained in a different task that brings you more excitement.

Q. What advice or resources would you provide for adults with ADHD?

As I mentioned above, learning to work with your brain rather than against it will work wonders for adults struggling with ADHD. The first step is to identify the symptoms affecting you most, which can be done by creating a “problem behavior list” to figure out what’s currently happening that you don’t want to happen. Are there certain tasks or activities that trigger your symptoms more than others? Make note of these and when it comes time to complete them, try dividing them up into smaller, more manageable actions, while incorporating small breaks for things you do enjoy.

ADHD coaching has become quite popular and involves teaching different organizational skills, time management and impulse control, to name a few. The Hallowell Todaro ADHD Center here in Seattle has some amazing coaches who will work with you to address your specific needs and help you reach your personal goals. CHADD is another great resource that has a wealth of up-to-date information on the topic and can help you seek the answers you’re looking for or find the help you need.

Treating or managing ADHD varies from person to person. Always work with your doctor to determine a solution that works best for you. If you’d like to speak with a Virginia Mason Franciscan Health provider, visit our website here.

Finding Calm in a Crisis: Changing What We Tell Ourselves

**By Bethany Davis, LSWAIC**

“I’m feeling too much all at once.”

Is this what you think when people ask “how are you” during the COVID-19 crisis? If so, you’re not alone: the impact the pandemic is having on our lives, families and communities makes higher stress a natural response. We want to know when this will end, how to stay protected, what will happen to our loved ones and so much more.

What I see as I work with people is that it’s not the course of the crisis that’s having the most effect, but more what they’re telling themselves about what’s going on. Our self-talk can undermine our sense of how safe we are, as we sort through not only a morass of information, but changes in our work, daily routines and relationships.

Here are four key areas in which redirecting our self-talk – and taking some simple actions – can help us feel more grounded in in a storm of emotions.

Minding the monologue

Does any of this self-talk sound familiar?

  • I am unproductive, I should be doing more.
  • I’m feeling alone.
  • This reminds me of feeling depressed, maybe that’s coming back.
  • This is how it’s going to be forever.

It’s important to know it’s possible to adjust our framework. Think of it like changing a lens on a microscope; seeing things in different focus can break the cycle of thought patterns that tend to feed anxiety and obsessive thinking. Here are examples of how to reframe your self-talk:

  • Staying home during this crisis is not a reflection on my self-worth or work ethic.
  • I can still maintain good relationships and reach out to those I love.
  • It’s normal to feel down when distancing, but it is not permanent.
  • This situation is temporary.

Be aware of “should” during self-talk, as in “I should be handling this better,” or “I should be more grateful.” Should and shouldn’t feed negative self-judgment.

Examining Isolation

dog-comfortTime to change that lens again! What are you telling yourself about being physically alone? Shame, blame or depression are some of the feelings that may come up when we are isolating from others. Switching your mindset can start with considering the difference between being “alone” versus being “lonely.”

Remember that we are temporarily distancing ourselves for health precautions. We are not cut off from relationships, friendships or love. We all count on these connections to check in and feel OK, and we can make still make those connections while distancing. In the meantime, try being curious about what feelings come up about being alone. Don’t see them as good or bad, but as evidence that everyone’s well-being depends on human connection.

Creating Feelings of Control

A good single phrase for self-talk when you feel out of control: “I’m going to be OK.” We’ve all heard the stories of panic buying, which may be an attempt to feel more in control. In moments of being overwhelmed by a perceived need, it can help to physically pause to regain a sense of calm. Try opening your hands while sitting in a posture of acceptance, close your eyes and take deep breaths.

Remember activities that you can control: I can go outside or take a walk. I can FaceTime or call family members or friends. I can listen to music. I can pick up an old project or start a new one. I can write down my thoughts or write a loved one a letter. I can sit in the sun.

Engaging Joy  

So much is happening in our world now, and if we’re being honest, it’s taking a lot of our energy and mental space. Consider giving your brain a break from scrolling through the endless crisis news and social media threads.

Here’s a question: When was the last time you felt happy? What were you doing? For me it was FaceTiming with my niece and nephew, sitting in the sun, calling my grandmother and looking up dog memes online (try it!) If you can remember something you enjoyed last week, try to think of how you felt in the moment. Whatever it was, try to do more of that, more often.

Another pathway to joy is through empathy and compassion for others. Once you’ve recognized the importance of self-talk and showing compassion for yourself, holding it for others becomes possible. Opening our minds to what people outside our circle are facing helps switch off our negative thought patterns and ease resentment about our own situation. We can think of (or maybe we know) people who work in health care, or who’ve lost their job, or even have symptoms and are stressed and self-isolating. Recognizing that we all face different challenges can open our capacity to feel joy again.

If You Need More Help

There will be times when all of us feel more stress than we have the tools to handle ourselves. If you have resources or access to a therapist via an online format, this would be a great time to connect to help you build on a more positive framework. The King County 24-hour crisis line offers immediate help and translation services for over 155 languages: (866) 427-4747.

Feeling anxious – or a variety of other emotions – during this crisis is completely normal. What can help is noticing patterns of thinking that get in the way of experiencing pockets of happiness and calm that can keep us moving forward in difficult times. We may all experience pain, heartache and loss, but soon we will all know the joy that still lies ahead.

Here’s some joy you can pocket to get you started, from the poem “Invictus,” written by William Ernest Henley in 1873, while recovering in an infirmary:

“It matters not how strait the gate,
How charged with punishments the scroll,
I am the master of my fate,
I am the captain of my soul.”

Bethany.DavisBethany Davis, LSWAIC, is an Oncology Social Worker who enjoys writing about mental health. 

Hay Fever in Winter? Yes, But There’s Help

**By David Jeong, MD**

David Jeong, MD

David Jeong, MD

Although many think of spring as the time of year when most people are bothered by allergic rhinitis, or hay fever, the condition can affect folks year round depending on what an individual is allergic to at any given time.

As an allergist, I see and treat children and adults with allergic rhinitis 12 months out of the year.

What is allergic rhinitis?

Hay fever is the group of uncomfortable symptoms that occur when your body is exposed to a specific allergen. An allergen is a typically harmless substance that causes an allergic reaction.

When your body comes into contact with an allergen, the immune system recognizes it and signals the release of histamine, among other natural chemicals, from the body. Unfortunately, an excess of histamine can cause uncomfortable symptoms.

As a result, it is important to seek treatment since this condition can interfere with your everyday quality of life.

Types of allergens

Common allergens that can cause this condition include:

  • Grasses and weeds
  • Dust mites
  • Animal dander (old skin) and saliva
  • Mold
  • Pollens (Pollens are the biggest allergen culprit during certain seasons – trees during early and mid-spring, grasses during summer and weeds in fall)

Risk factors for allergic rhinitis

Although allergies can affect anyone, they are often genetic. You are more likely to develop allergic rhinitis if your family has a history of allergies.

Other risk factors for developing hay fever include:

  • Being male
  • Born during pollen season
  • Being the firstborn in your family
  • Early use of antibiotics
  • Maternal smoking exposure in the first year of life
  • Exposure to indoor allergens, such as dust mites

Hay fever symptoms

The most common symptoms of allergic rhinitis include:

  • Runny nose
  • Sneezing
  • Itchy nose (also eyes, ears and throat)
  • Stuffy nose
  • Postnasal drip
  • Coughing
  • Dark circles under eyes
  • Eczema-type symptoms (e.g., extremely dry, itchy skin)
  • Excessive fatigue
  • Frequent headaches

Allergic rhinitis is often associated with asthma, eczema (atopic dermatitis), allergic conjunctivitis, repeated sinus infections and chronic ear congestion (Eustachian tube dysfunction).

Diagnosing allergic rhinitis

Minor allergies usually only require a health history and physical exam. However, your primary care provider may refer you to an allergist for allergy testing to identify your triggers and develop an individualized treatment plan.

Skin prick testing is the most reliable and fastest testing method available. During this test, your doctor uses a prick method to introduce individual allergens onto the surface of your skin (usually the arms and/or back) and watches for a skin reaction at the test site. A small red bump develops if you are allergic to something.

Another often used allergy test is a blood test, which measures the amount of immunoglobin E antibodies (the allergic antibody) to particular allergens in your blood. This blood test is slightly less accurate than the skin test, but is often used when a skin test cannot be done for certain reasons.

When it is diagnosed, allergic rhinitis may be classified as seasonal and/or perennial (year-round).

Treating hay fever

Allergic rhinitis is treated with one or more of the following items:

  • Antihistamines
  • Decongestants
  • Eye drops
  • Nasal sprays (various types)
  • Antileukotrienes (help block inflammatory response)
  • Immunotherapy (allergy shots)

Antihistamines can effectively treat allergies. They can also help prevent allergic symptoms.  Most antihistamines are available over the counter.

Oral decongestants are used over a short period to help with sinus pressure and stuffy nose. If you have high blood pressure or heart disease, be sure to ask your physician before taking a decongestant.

Nasal corticosteroid sprays are the single most effective therapy in treating allergic rhinitis. Some have moved to over the counter in the last couple of years, but the rest are still only available through a prescription. Nasal antihistamine sprays can also be very helpful. Over-the-counter nasal decongestants (e.g., oxymetazoline, Afrin, Zicam, etc.) can be immediately effective but cause physiologic dependence when used over extended periods. These should not be used long term.

If you have severe allergies, your physician may recommend immunotherapy. This treatment plan, which is usually referred to as allergy shots, is used to desensitize you or decrease your immune response to specific allergens over time.

Deciding which allergy medications and treatments are the most effective and safest can be overwhelming. Make sure to speak with your health care provider and/or allergist to find the most appropriate treatment for you.

Preventing allergies

As the saying goes, “Prevention is the best medicine.” This is especially true when it comes to allergies. The best way to avoid allergy symptoms is to manage allergies before your body has a chance to negatively react to substances.

In fact, the American Academy of Allergy, Asthma and Immunology recommends beginning medications ahead of seasonal allergy attacks. For example, if you are affected by tree pollen in the spring, you might want to start taking your allergy medications just before the season hits and the allergic reaction has a chance of happening.

Another way to prevent hay fever is to avoid allergens that prompt your symptoms. For example, change the clothes you have been wearing outdoors when you come back inside and shower to remove pollen from your skin. In addition, consider implementing proper avoidance precautions for dust mites, pets and molds if you are allergic to any one of these triggers.

Prognosis for people with allergic rhinitis

As with much of medicine, the treatment outcome for hay fever is dependent on a person’s unique condition. Allergic rhinitis has a tendency to be a chronic condition and can significantly disrupt quality of life. The good news is that it can be managed and well-controlled with the right treatment plan.

David Jeong, MD, is board certified in allergy, immunology and pediatrics. He specializes in allergy and asthma and practices at Virginia Mason University Village Medical Center, Virginia Mason Hospital & Seattle Medical Center, Virginia Mason Issaquah Medical Center and Virginia Mason Lynnwood Medical Center.

Remember These Simple Steps for Years of Healthy Skin

**By Catherine Pham, MD**

As a dermatologist, I often hear from patients that they don’t have time for intensive skin care. However, people should still take care of their skin by doing the basics over their lifetimes.

Catherine Pham, MD

Catherine Pham, MD

Good skin care and healthy lifestyle choices can help delay the natural aging process and prevent various skin problems.

Protect yourself from the sun
Planning to escape the winter “blahs” in a sunnier location this year? Don’t forget that one of the most important ways to care for your skin is to protect it from the damaging effects of overexposure to the sun’s harmful ultraviolet (UV) rays. And here’s a timely reminder for skiers and snowboarders: UV rays can be just as damaging on the ski slopes as on the beach.  A lifetime of sun exposure can cause wrinkles, age spots and other problems, like skin cancer.

For the most complete sun protection:
• Use sunscreen – Use a broad-spectrum sunscreen with an SPF of at least 30. Apply it generously and reapply every two hours or immediately after swimming or heavy sweating.

• Time your outdoor activity – Avoid the sun between 10 a.m. and 2 p.m., when the sun’s rays are strongest.

• Wear protective clothing – Cover your skin with tightly woven, long-sleeved shirts, long pants and wide-brimmed hats. Also consider laundry additives, which give clothing an additional layer of UV protection for a certain number of washings. For winter sports, cover your head to protect your scalp and wear wrap-around style sun glasses or goggles with UV protection.

Don’t smoke
Smoking makes skin look older and contributes to wrinkles. It narrows the tiny blood vessels in the outermost layers of skin, which decreases blood flow. This depletes the skin of oxygen and nutrients important to skin health.

Smoking also damages collagen and elastin, the fibers that give skin strength and elasticity. In addition, the repetitive facial expressions people make when smoking can contribute to wrinkles.
If you smoke, the best way to protect your skin is to quit. Ask your doctor for tips or treatments to help you stop.

Daily cleansing and shaving can take a toll
To keep it gentle:
• Limit shower or bath time – Hot water and long showers or baths remove oils from skin. Limit shower or bath time and use warm, not hot, water.

• Avoid strong soaps – Strong soaps can strip oil from skin. Instead, choose mild cleansers.

• Shave carefully – To protect and lubricate skin, apply shaving cream, lotion or gel before shaving. Use a clean, sharp razor. Shave in the direction the hair grows, not against it.

• Pat dry – After washing or bathing, gently pat or blot your skin with a towel so some moisture remains on your skin.

• Moisturize dry skin – If your skin is dry, use a moisturizer that fits your skin type. For daily use, consider a moisturizer with SPF. Ointments and creams are better for dry skin since they are more effective at sealing in moisture. Lotions, which are often in pump bottles, have a high water content that tends to evaporate off of skin.

Anti-wrinkle creams
The effectiveness of anti-wrinkle creams depends, in part, on the active ingredient or ingredients. Common ingredients that may result in slight to modest improvement in the appearance of wrinkles include:

• Retinol – Retinol is a vitamin A compound, the first antioxidant to be widely used in nonprescription wrinkle creams. Antioxidants neutralize free radicals – unstable oxygen molecules – that break down skin cells and cause wrinkles.

• Vitamin C – Vitamin C may help protect skin from sun damage. Before and between uses, wrinkle creams containing vitamin C must be stored to protect them from air and sunlight.

• Hydroxy acids or exfoliants – These substances remove the upper layer of old, dead skin and stimulate growth of smooth, evenly pigmented new skin.

• Coenzyme Q10 – This ingredient may help reduce fine wrinkles around eyes and protect skin from sun damage.

• Tea extracts – Green, black and oolong tea contain compounds with antioxidant and anti-inflammatory properties.

• Grape seed extract – In addition to its antioxidant and anti-inflammatory properties, grape seed extract also promotes wound healing.

• Niacinamide – This substance is related to Vitamin B-3 (niacin). It helps reduce water loss in the skin and may improve skin elasticity.

Healthy diet
A healthy diet can help people look and feel their best. Eat plenty of fruits, vegetables, whole grains and lean proteins. Although the association between diet and acne isn’t clear, some research suggests a diet rich in vitamin C and low in unhealthy fats and processed or refined carbohydrates, might promote clearer skin.

Manage stress
Uncontrolled stress can make your skin more sensitive and trigger skin problems. To encourage healthy skin – and a healthy state of mind – take steps to manage stress. Set reasonable limits, scale back your to-do list and make time for things you enjoy.

Medical expertise
A dermatologist can help people create a personalized skin care plan by assessing your skin type, evaluating your skin’s condition and recommending products likely to be effective. If you’re looking for more dramatic results, a dermatologist can also recommend medical treatments for wrinkles, including prescription creams, Botox injections or skin-resurfacing techniques.

Catherine Pham, MD, is a board certified dermatologist who practices at Virginia Mason University Village Medical Center .  

Can How You Eat Reduce Your Risk of Breast Cancer? Mediterranean Diet Study Suggests Link

In September study results published in JAMA Internal Medicine got a lot of attention: the almost five year study showed women who followed a version of the Mediterranean diet significantly lowered their risk of developing breast cancer.

Dietitian Cindy Snyder

Dietitian Cindy Snyder

The clinical trial, known as PREDIMED, randomly assigned about 4,200 women to one of three groups: the Mediterranean diet supplemented with extra-virgin olive oil, the diet supplemented with mixed nuts, or a control group following a regular low-fat diet. Compared to the control group, those on the olive oil diet showed a 68 percent reduction in breast cancer risk, after controlling for variables including age, BMI, smoking, family history of cancer, and physical activity.

But before you grab a bottle of olive oil and a straw, consider the study’s limitations: just 35 women were diagnosed with invasive breast cancer – a small number for analysis – and the women recruited were all postmenopausal and at high risk for heart disease. That’s because PREDIMED’s first purpose was to assess cardiovascular benefits of the Mediterranean diet.

So what could be so special about this diet, and olive oil in particular? Most of us have heard of the Mediterranean diet – full of vegetables, fruits, whole grains and olive oil, and low in dairy products and red meat – known from over a decade of study to improve heart health. PREDIMED and earlier studies show the Mediterranean diet has a favorable effect on blood pressure, lipids, artery plaque, insulin sensitivity and inflammation, lowering the risk of heart attack and stroke.

“What extra-virgin olive oil has are polyphenols, a type of phytonutrient known for strong antioxidant activity,” says Cindy Snyder, MPH, RD, CD. “It also has a unique blend of fatty acids which may reduce the inflammation that leads to atherosclerosis, or hardening of the arteries, and cardiovascular disease.”

Seafood, another staple in the Mediterranean diet, may also contribute to the health benefits of this dietary pattern. Fatty acids known as Omega-3’s – like in salmon, tuna and other fish – areiStock_000016218804Small[1] essential for healthy cell function, and the body is inefficient at making them. Phytosterols, a type of natural plant fat that slows the absorption of cholesterol in the body, are found in avocados, nuts, seeds, whole grains and legumes – all of which have a number of other important nutrients.

When considering the known health benefits of the Mediterranean diet alongside very preliminary findings on reducing breast cancer risk, what is the takeaway for women? For starters Cindy advises against focusing on one thing, like olive oil, as a magic bullet.

“For years, researchers have investigated individual food components,” says Cindy. “But, what PREDIMED demonstrates is that a pattern of eating, in which dietary components work together, could improve people’s health.” She points out that the PREDIMED study included specific lifestyle factors associated with the Mediterranean region, requiring participants have at least two meals seated at a table each day, spending a minimum of 20 minutes eating each meal.

In fact, a 2014 multi-study review has linked a “Mediterranean dietary pattern” with a decreased risk of breast cancer. But while the suggestion that a certain diet or oil may help prevent breast cancer is encouraging, more long-term studies specifically targeting breast cancer are needed. Meanwhile, with all the upsides for choosing a Mediterranean diet and virtually no downside, it may just be the diet you’ve been looking for.

A Labor of Love: Creating Hats for Hope

Kailey and John Ryan, MD, a retired Virginia Mason surgeon and longtime family friend.

Kailey and John Ryan, MD, a retired Virginia Mason surgeon and longtime family friend.

Kailey Druffel has visited Virginia Mason a number of times, but not as a patient. Her mother, Shelly, was a surgical technician at Virginia Mason when Kailey was young, before a long battle with breast cancer took Shelly’s life. Now her mom’s former colleagues are like extended family for Kailey, staying in touch with the high school graduate as she plans her own career in medicine.

Last summer, Kailey spent a week learning about orthopedic surgery at Virginia Mason, rounding with a surgeon who had worked with her mom, looking at X-rays and scrubbing in to observe procedures. The experience cemented her desire to become an orthopedic surgeon.

“I’d never been surrounded by so many people who absolutely love what they do,” says Kailey, who plans to study biochemistry at Washington State University this year. “The team at Virginia Mason loves teaching and sharing their passion for what they’re doing. It makes me excited about becoming a doctor.”

Kailey has always looked ahead with optimism despite also losing her father, who died in a boating accident just months before her mother died. Raised by her grandparents in Clarkston, Wash., Kailey grew into a community volunteer, working through her church to serve homeless families and administer other programs, and in her local Salvation Army soup kitchen.

In her junior year of high school, Kailey started the volunteer project that felt closest to her heart: Hats for Hope.

“As a kid I watched my mom go through cancer treatment and her head was always cold,” remembers Kailey. “I wanted to do something in her memory, something she would be proud of.”

So Kailey recruited an eager group of high school students – interestingly all boys – to learn how to crochet beautiful, toasty warm hats intended to comfort cancer patients undergoing treatment. Working during their free “flex time” earned by students doing well in their classes, Kailey and the Hats for Hope team created an impressive collection.

When it was time to find people who needed the hats, Kailey knew where she would go. She recently met with some of her mom’s friends and former colleagues at the Floyd & Delores Jones Cancer Institute at Virginia Mason, bringing along the donations from Hats for Hope.

“I want people to know they don’t have to be cold during treatment,” says Kailey. “There are people thinking about them, like secret angels, who want to help.”

Five Things You May Not Know About the Penis

**By Una Lee, MD**

Una Lee, MD

Una Lee, MD

Since writing the post “Five Things Worth Knowing about the Vagina,”  I’ve been meaning to give equal time to the complex organ belonging to the other team: the penis. As a urologist, I’m committed to demystifying the parts of our bodies that we all wonder about. Knowledge is power, especially when you are the one in the know and your friends are floundering with questions.

1) What you see is not all you get. Here’s something that will change the way you view a penis: Up to half of the length of the erectile organ is actually tucked up inside the body. That’s right, a significant part of the penis is invisible, attached to the pubic bone by a suspension ligament.   Still, that’s little comfort for men who may be feeling “insufficient.”

So when does size matter?  Given the average erect penis size is between 5.1 and 5.7 inches (remembering average means half are smaller, half are larger), only penises less than 3 inches long when erect are considered unusually small. What’s more, there is no consistent relationship between the size of a flaccid penis and an erect one. So don’t assume that a man with a big appearing penis gets much bigger with an erection. Similarly, a flaccid penis that looks small can still, well, rise to the occasion. And when you consider that on average sexual intercourse lasts two to three minutes (not hours), penis size may not be the biggest consideration.

2) Penile curvature is common.  Penises vary in shape and size, and some males are born with penile curvature. While a mild curvature isn’t generally a cause for concern, an excess of scar tissue inside the penis, known as Peyronie’s disease, may cause pain, problems getting an erection or having intercourse.  As long as you are able to have intercourse no treatment is generally needed. If the penis bends more than 30 degrees and interferes with intercourse and/or causes distress and pain, there are treatment options.  Seeing a urologist  who specializes in the condition is important, as treatment may involve medication, surgery and other therapies.

3) Erectile function is a barometer of a man’s health. To get erect, the penis must become engorged with blood. Diseases that impair the arteries and blood vessels, such as diabetes, high blood pressure and cardiovascular disease, can obstruct the blood flow needed to get and keep an erection. Even in seemingly healthy men, studies over the last decade have shown erectile dysfunction (ED) can be an early predictor of their risk of developing heart disease. That’s why it’s a good idea for men over 45 who are experiencing ED to consider lifestyle changes like quitting smoking, a better diet and exercise, along with a plan to visit their doctor. In the meantime, help is definitely available for ED related to blood flow in the form of medications we’ve all seen the ads for (though I’m not sure what a guy does with an erection in a separate bath tub from his partner).

There are also “psychogenic” causes of ED, which encompass psychological factors such as stress, anxiety, depression, relationship problems or other mental health issues. Your brain is also a sex organ, so anything that disrupts normal thoughts and feelings, such as a traumatic life event, can cause ED. Professional counselling can be the key to overcoming this cause of ED.

4) Circumcision rates vary greatly around the world.  According to the World Health Organization, 30 percent of males aged 15 and over are circumcised worldwide. Circumcision is a common practice in the Jewish and Islamic faiths, and traditional in some African communities. Circumcision is much less common in the United Kingdom, where it is not funded by the National Health Service except when medically necessary.

In the U.S. about 60 percent of newborns are circumcised.  While there is some evidence that circumcision may slightly decrease a man’s risk of getting HIV, some sexually transmitted infections and penile cancer, the American Academy of Pediatrics has stated that circumcision is a personal decision best left to the parents of the newborn child.

5) The penis can break, and it’s an emergency.  I saved the hardest to read for last: A penis can break. While there is no penis “bone,” thick tissue that surrounds the erectile tissue can rupture and bleed. Called penile fracture, the injury most commonly occurs during sexual intercourse when the woman is on top. It can also happen if a man is thrusting too hard during sex and forcefully hits his partner’s pubic bone. There is usually a popping sound, an immediate loss of the erection, followed by purplish bruising as the blood escapes.  If it’s a true penile fracture, the tear needs immediate surgical repair (ideally within 24 hours), so seek medical attention right away.

Una Lee, MD, is board certified in Urology and subspecialty certified in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) at Virginia Mason. The Sexual Health Clinic at Virginia Mason in Seattle provides expert consultation and treatment of sexual dysfunction and related problems for both men and women. To schedule an appointment, call (206) 223-6772.

Let’s Talk About Vaginal Prolapse. Don’t Worry, I’ll Start.

Dr. Lee with New Day Northwest host Margaret Larson.

Dr. Lee with New Day Northwest host Margaret Larson.

**By Una Lee, MD

Recently I was lucky enough to have a patient who wanted to help other women, even if it meant talking about something many would find way too personal. Amy joined me on the show New Day Northwest to describe what it’s like when your uterus falls into your vagina, a form of vaginal prolapse, a condition that can feel like a heavy ball is lodged between your legs. Like many women Amy had never heard of vaginal prolapse, but she was well aware of the backache and sore hips that kept her from winning at tennis, or doing anything active without pain.

As a urologist and female pelvic medicine specialist, my most fulfilling role as a doctor is helping women like Amy understand this part of their body and talk openly about it. Pelvic organ prolapse is a condition affecting millions of women, yet many suffer silently, unsure of what’s going on and embarrassed to seek help. Hard to talk about? Well maybe a little, but that didn’t stop Amy from finding expert help, and eventually, a cure. In the pursuit of better health, it’s time for women to get empowered, not embarrassed!

What is pelvic organ prolapse and what causes it?

A woman’s pelvic organs include the bladder, vagina, uterus and bowels. Normally these organs are held in place by a supportive “bowl” in the pelvis made up of muscles, ligaments and connective tissue. This is known as your pelvic floor, or pelvic floor muscles. If part of the support system becomes weak, one of the organs can drop, potentially bulging into (and sometimes out of) the vagina. Where the weakness occurs determines whether it’s the bladder, uterus or bowels that fall, but many women have more than one organ involved.

A common symptom of pelvic organ prolapse is the sensation of a bothersome vaginal bulge. Heaviness or pain in the lower back, like in Amy’s case, can result. Some women also notice painful intercourse, or changes in urinary or bowel function.

So why does this happen? One of the main risk factors for developing pelvic organ prolapse is vaginal childbirth. Childbirth can injure the supportive structures of the pelvic floor, particularly a prolonged labor or difficult birth. A resulting prolapse can happen soon after birth or may take years to fully develop. The good news is that of all women who develop some degree of pelvic prolapse, only about one in nine will ever need surgical intervention. Other risk factors for prolapse include genetics, some diseases that are associated with loose ligaments, increased weight, aging, menopausal changes, and the effects of smoking.

Who can treat pelvic organ prolapse?

If your symptoms are complex, it’s important to seek out a urologist or gynecologist with additional training. Look for those with a subspecialty in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). This indicates a level of expertise specific to the pelvic floor, to help ensure an assessment of your urinary, vaginal, and bowel function and discussion of a full range of treatment options.

Amy gets ready backstage.

Amy and Dr. Lee get ready backstage to appear on New Day Northwest.

What are the options for treating pelvic organ prolapse?

One option is to do nothing – really! It’s a valid approach for women who have minimal symptoms or no symptoms at all. Even women who have evidence of pelvic organ prolapse may not require treatment. When the symptoms of prolapse get in the way of life, the time is right to discuss treatment. The types of symptoms vary greatly among women, depending on what structures are involved and individual anatomy. Some women can have severe prolapse and not be bothered by it, while others who have a mild or moderate case may have a lot of symptoms. Feeling the effects of prolapse also varies a lot based on activity level and even the time of day. Lying down or taking a break from being on your feet can improve prolapse symptoms.

And here’s more good news: There is no harm in having sexual intercourse. The walls of the vagina are designed to be elastic and mobile, and can flex comfortably during sex.

But if pelvic organ prolapse causes bothersome symptoms and is affecting your health and quality of life, it’s time to discuss your options with a specialist. You will undergo a complete medical history and vaginal examina­tion to determine your “stage” (degree of prolapse).

Non-surgical treatment options

  • Pelvic floor exercises (Kegel exercises). Yes, Kegels are key to pelvic floor health, and if done properly, can strengthen weakened muscles enough to improve or prevent the worsening of early stage prolapse. Be sure to get information on the proper technique from your doctor.
  • Pessaries. A pessary is a silicone device inserted in the vagina that provides mechanical support to the prolapsed or­gans, thus relieving symptoms. They may require some trial and error for sizing and fit, but pessaries work well for some women.

Surgical treatment options

Amy, my patient, started with both Kegels and a pessary to relieve her prolapse symptoms, but it was clear she needed more help. She remembers thinking she could have done a million Kegels and it would not have reversed her prolapse. For her the pessary was uncomfortable. Together, we made a surgical plan that would get her back to all her favorite activities.

Surgery to correct pelvic organ prolapse is as varied as the women who have it: even women with the same type of prolapse may need a different approach. Amy’s procedure was done vaginally (they also may be done through abdominal incisions). I performed a vaginal hysterectomy (removal of the uterus), a vaginal vault suspension (using sutures to restore the deepest part of her vagina to its natural position), and a cystocele (prolapsed bladder) repair.

Once Amy healed from the surgery, she was back to beating her husband at tennis and living her life without discomfort. Remember: Overcoming fear and the stigma of talking about your body (plus finding expert help) can have big rewards for your health.

Dr. Una Lee

Dr. Una Lee

Una Lee, MD, is board certified in Urology and subspecialty certified in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) at Virginia Mason. Other Virginia Mason physicians certified in FPMRS include: Kathleen Kobashi, MD, FACS; Alvaro Lucioni, MD and Blair Washington, MD, MHA.    


Having Both Knees Replaced at the Same Time Has Advantages

**By David Kieras, MD, FAAOS

David Kieras, MD, FAAOS

David Kieras, MD, FAAOS

If someone you know has severe arthritis in both knees that greatly reduces their quality of life, they may be a candidate for bilateral simultaneous knee replacement surgery, where both joints are simultaneously operated on in one surgical procedure.

Although not an option for everyone, this approach is enticing to many people who dread the idea of recovering from two separate surgeries, which delays recovery and a return to normal activities for several months, if not years.

Bilateral ‘staged’ knee replacement – one knee surgery followed by another – is not uncommon.  However, bilateral simultaneous knee replacement is more advanced and uncommon due to the special expertise and team coordination required.

It can be beneficial for people who have limited time off from work for rehabilitation and need to return to a more normal lifestyle as quickly as possible.

Ideal candidates for bilateral knee replacement are reasonably physically fit, in good overall health, have any chronic conditions under good control and are younger than 80 years old. They also need to be motivated to go through aggressive physical therapy and rehabilitation.


The main advantages of a simultaneous procedure are that there is a lower infection rate associated with a single surgical event and it involves receiving only one episode of anesthesia. The surgery typically takes only about 90 minutes, which is advantageous since longer anesthesia times have been shown to be associated with greater risk for infection, blood clots, etc. In addition, patients only experience a single recovery and rehab period, rather than two.

Having both knees done at once may also result in some overall cost savings since patients only have one hospital stay. Medicare and most private insurers cover the simultaneous approach.

Another advantage, at least for people who choose to have it done at Virginia Mason, is that the size and scope of our team allows patients to benefit from the one-stop-shop design of our program, where everything from basic to high-level care is provided by seasoned orthopedic specialists in the community close to where people live.

However, it’s also important to recognize that bilateral simultaneous knee replacement surgery creates additional stress on the body. Your medical condition preoperatively is essential in determining the appropriateness and safety of this approach. A pre-surgery assessment by the surgical team, and any necessary medical specialists, will help patients decide.

Despite the risks and challenges, which are inherent in most surgical procedures, bilateral knee replacement offers a 95 to 98 percent success rate over 15 years.

Rehabilitation: Getting back on your feet

Our goal at Virginia Mason is to get patients up and moving as soon as possible after surgery. We try to control pain aggressively with nerve blocks, special injections around the new knees and oral pain medication. Newer techniques allow the placement of a temporary, indwelling catheter, which allows continuous pain block up to three days after surgery without significant compromise of strength – the ideal time period when pain would otherwise be at its height.

Rehab is somewhat more challenging initially because patients have to recover strength and range of motion on both sides to support them through their gait. But, compared to a knee that is already compromised by arthritis – as in a single knee arthroplasty – each new knee typically responds properly and improves with time – as opposed to gradual worsening in an arthritic knee while the new knee recovers. In fact, the residual arthritis in the opposite knee can permanently hamper recovery due to pain, swelling and dysfunction over time. As a result, transitioning people to walk is initially more challenging. However, after a week or two, bilateral knee patients typically outpace staged knee replacement patients as rehab progresses.

Home team advantage

In our program we want to get people home as soon as possible. As a result, we emphasize the importance of patients establishing a strong support system in advance to help with daily living tasks.

The challenge of recovery from bilateral simultaneous knee replacement takes a team approach. Patients can’t do it by themselves, particularly in the first few weeks, yet most can do far better than they imagine. So, we try to help them assemble their team – typically an interested family member – for a successful recovery.

For more information, visit:
American Academy of Orthopaedic Surgeons
Virginia Mason Orthopedics and Sports Medicine

A version of this story previously appeared in LocalHealthGuide/Seattle.

David Keiras, MD, FAAOS is a board certified orthopedic surgeon practicing at Virginia Mason Federal Way Medical Center.  Virginia Mason is celebrating how everyday people come back from injury with the “Announce Your Comeback” campaign. Join the conversation on Facebook (Facebook.com/vmcares) and follow us on Twitter (@VirginiaMason).