According to reports in Drug Topics, the online magazine, Ambien was the thirteenth highest selling brand-name drug in the United States in 2006. So ignoring all the categories of antibiotics, antidepressants and so on (Ambien is the best selling hypnotic sedative used to treat insomnia), only twelve other medications sold more by volume in the US. That makes Ambien one of the most profitable medications on the market and, not surprisingly, other manufacturers would like a slice of Ambien’s pie. But, to do that, the competition has to prove their products are as good (if not better) in direct comparison trials. As Ambien might say, “Bring it on!”

Perhaps even as recently as last year, there was investment money available to develop and bring new medications to the market. Now the credit crunch is starting to bite more fiercely, that money is harder to find. Take as an example, the Neurogen Corp., a biotech company based in Connecticut. It has a medication in development intended to go head-to-head against Ambien. But that is only half the battle. To get past the Food and Drug Administration, it needs clinical data from properly designed trials. This takes time and money. So it all comes down to priorities. Which is more important: current operations or future profits?

Neurogen has just announced it is laying off forty-five of its staff and raising some $30m with private investors to focus on just four prospects. This is a dramatic strategy. Most of the staff were in research and some in administration. So, the company has decided that one of the four prospects - to treat insomnia, anxiety, restless legs syndrome (RLS) and Parkinson’s disease - must succeed for the company to survive. It does not have the capital to maintain the search for future medications. Even the more general administration of the company can be allowed to degrade. The share value fell one third on the announcement, the company having lost almost $58m last year.

But the potential value of even a flea bite in Ambien’s market share would restore Neurogen to profitability. So it has to bet its shirt on its head-to-head competitor in development. If it can produce clear clinical data that it has a safe and effective product and that product is at least as good as Ambien, it will have saved itself. The results of the trial are due at the end of this year.

What price should any company pay to chase the pot of gold at the end of the commercial rainbow? Market dominance such as that enjoyed by Ambien is not necessarily a good thing. In a capitalist society, we should encourage open competition if it benefits consumers by producing excellent products at a good price. But I worry about the forty-five staff who lost their jobs. Who is to say they would not have developed a special new medication next year? Now all they have to look forward to is next month’s red reminders from the credit card companies.

I am not arguing that companies should not compete with Ambien. Competition keeps the established player on form. But I wonder who really benefits if a biotec company like Neurogen does get a good product out there. A few already rich investors get a spectacular return. There is a new product that has to maintain a high price to recover its development costs, i.e. Ambien has no price competition so consumers get no benefit - other than being able to buy Ambien and get some quality sleep, of course. Perhaps that investment money could have been better spent on something more immediately of benefit to the ordinary consumer.

Now turn to many of the forum sites where people discuss their experience with zoloft. The general spirit of these posts is, “I weighed 120lb until I took zoloft. Now I am…”

A simple test rules out thyroid problems, one of the more common physical explanations for sudden weight gains and this leaves us with lack of exercise combined with overeating. . . and a side effect of zoloft. It is a natural association to make. You start taking a medication and immediately you put on five pounds with no obvious change in your diet or level of physical activity. So, let us start off by accepting that some people react to medications by putting on weight. Why? The medication may increase or decrease the basal metabolic rate. If this happens, your weight may fluctuate even though you do not change your caloric intake. In some people, the medication can cause hormonal changes and increase appetite. Increased levels of serotonin are also associated with hunger pangs which encourage you to eat more.

Now we are into the business of balancing the advantages and disadvantages of the particular medication. Let us say that zoloft has made a dramatic improvement in your emotional life. For the first time in months (or years), you do not feel (so) sad. If you have put on a few extra pounds, is that a price worth paying? Or will you get depressed again because your body has become less attractive? As a gentle warning, if your regular doctor asks you whether you want to try a different medication, zoloft causes less weight gain than the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs).

Back to denying the link. After all, the SSRIs were first promoted as anti-obesity medications. Like all decisions on whether to start a medication, you are dealing with unknowables. There is no doubt that some people eat more when they are depressed. Unless you have been keeping a food diary which counts calories, it will difficult to know how your eating habits have changed as the depression increased in intensity. You may already be putting on weight when you start taking the zoloft. Now let us reverse the psychological reaction. When people start feeling less depressed, they eat less and this reduces their weight. In other words, when the depression is cured, you may return to your healthy eating habits. Separating out the effect of the medication from the reality of the number of calories you eat is very difficult. It is easy to confuse coincidence with side effect.

So how should you react if you start zoloft and gain weight? Whatever else you may do, do not stop taking it. First, start counting calories properly. Start exercising. These are most likely to stabilise your weight. Only if you do change your diet and exercise to no effect, should you talk with your doctor. If self-help has failed, see what the professional recommends.

In addition, physical health is promoted by sexual activity. Recent studies have shown that frequency of sexual intercourse is inversely related to death rates in both men and women, but its exact role was different between the sexes. The quantity (frequency) of intercourse was more important for longevity in men, while the quality of the sexual relationship was paramount for women’s longevity.

This health benefit was actually more pronounced in women. If women enjoy intercourse, it has a positive health benefit. If they don’t, but simply go through the motions to meet the frequency needs of a partner, there may be no health benefit. (Therefore, a healthy sexual relationship will attempt to meet the frequency needs of the man, while supplying the quality required for the woman.)

A recent study from Wales published in the British Medical Journal looked at the role of orgasm on health. Men were half as likely to die if they had over one hundred orgasms a year.3 Therefore, even if you don’t feel like it, try your best to have intercourse twice a week. If you have to miss a few reruns to achieve that goal, so be it. Your longevity is worth it.

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The main bulk of the penis is composed of three tubes running lengthwise (see Fig. 1). On top are two side-by-side cylinders, each of which is called a corpus cavernosum (the plural of which is corpora cavernosa*). During erection the corpora cavernosae fill with blood under pressure, kind of like inflating a tire, or maybe an inflatable raft. We often refer to the cavernosae as the corporal bodies. A tough coat called the tunica albuginea surrounds each corpus cavernosum, like the steel belt of the radial tire. Another layer called Buck’s fascia wraps around both corpora cavernosae. (More proof anatomists have a sense of humor, contrary to popular wisdom.)

Immediately below the corpora cavernosae runs the third tube, called the corpus spongiosum.9″ The urethra carries urine and semen through the spongiosum to the tip of the penis. Here, the urethral meatus (the anatomists’ sense of humor at work again) forms a slit-like opening to the outside world. The spongiosum spreads out at the end of the penis to form the helmet-shaped glans penis or “head.” The glans penis holds the nerve fibers that give the penis its sensitivity. The rounded rim of the glans penis is called the corona. (We must wonder what beer anatomists drink.)
A hood of skin (the foreskin) covers the glans penis at birth. Its medical name is the prepuce. This is such a bad name that urologists use it only when writing scientific papers, and try to not say it aloud because few are sure how to pronounce it. Circumcised men have had the prepuce removed. The frenulum is the web of skin on the underside that seems to connect the used for sewing needles or toothpicks. This explains why people in ancient times frequently let things remain stuck between their teeth.

Leonardo da Vinci believed humans had a similar bone: “The origin of the penis is situated upon the pubic bones so that it can resist its active force on coitus. If this bone did not exist the penis, in meeting resistance, would turn backward and would often enter more into the body of the operator than into the body of the operated.”

The penis receives its blood supply from the pudendal arteries and veins. Once inside the penis, the arteries branch out and drain into sinusoids. These sacks can fill with pressure so the tire becomes inflated and rigid.

The penile nerves weren’t fully understood until recently. These tiny strands of tissue are hard to see, so they’re often overlooked by surgeons and anatomists alike. In 1981, Dr. Patrick Walsh was in the Netherlands to address a medical meeting. Since it was Dr. Walsh’s birthday, his hosts reserved a free afternoon for any leisure activity he desired. Most people could think of dozens of things to do for a birthday party in the Netherlands; he chose to spend the afternoon in the anatomic dissection lab on the host university’s campus exploring the exact route the nerves took through the pelvis en route to the penis. His discovery completely changed our understanding of this anatomy. Since we know where the nerves are located, we can now preserve them during urological surgery (see chapter 6). Already one of the preeminent urologists in the world, he thus secured his place in history.

And he didn’t have a headache the next day.

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