VIMAX Pills can enlarge your penis size up to 3-4 Inches in length and up to 25% in girth !

penis enlargment semenax vig rx

VIMAX Pills is a powerful natural herbal male enhancement formula that increases penis length and girth, sexual desire, sexual health and helps to achieve stronger erections. Combining the formulations of the type of herbs found in many parts of the world that have been proven to work for many years, you can now enjoy the full benefits of our product. Some of the same type of herbs found in Polynesia where the men of the Mangaian tribe have sex on the average of 3 times a night, every night. While this is not what you may wish, it is nice to know your sexual performance can improve substantially.

After many years of medical Research and Development, our company is pleased to offer you a 100% Natural and Safe Product that can safely and permanently enlarge your penis size up to 3-4 Inches in length and up to 25% in girth. Discover what our "proven to work" formula can do for you by ordering today. Many men were skeptical at first but after they gave our pills a try their sex life and self esteem changed for the better.Our pills will improve your overall sexual health, make you feel younger and you will have more pleasurable orgasms. You can take one pill 2 times per day to keep the effects of VIMAX PILLS in your system and to promote virility enhancement.

100% Safe and Natural Herbal Ingredients

Epunedum Sagitum or Horny Goat Weed - Known in China as Yin Yang Huo. Chinese top medical doctors report that horny goat weed boosts libido and improves erectile function. Used to restore sexual fire and allay fatigue.

Saw Palmetto - Known to stimulate a low libido in males and to increase sexual energy. A compound in saw palmetto has aphrodisiac effects.

Ginkgo - Medicinal use of ginkgo can be traced back 5,000 years in Chinese herbal medicine.The herb also increases blood flow to the genitals which improves sexual function. In one study 78% of a group of men with impotence reported significant improvement without side effects.

Other Ingredients: Muira Puama (balsam), Velvet, Damiana (leaf), Cayenne (fruit), Oats (entire plant), Avena sativa, Ginseng (root), Panax Ginseng, Caltrop (fruit) Tribulus terrestris.

penis elargement video natural penis enlargement pills

VIMAX Pills helps you gain:

  • Stronger and more intense orgasms
  • Substantially increase your sexual desire and stamina
  • The appearance of your penis will arouse your sex partners.
  • You will have bigger erections. Because of increased blood flow your erections grow harder.
  • Erections when you want them. Rock hard erections every time. No more problems because you can't get it up and keep it up. VIMAX PILLS will keep the blood flowing to your penis so you will always get hard and stay hard.

Do VIMAX Pills really work?

We get many emails from our customers that say our pills helped them regain their sexual ego. It's up to you when to stop taking our pills since they are 100% safe and made from natural products. We had one customer write to us that he decided to stop the pills after he no longer felt embarrassed when making love. His penis used to be below average, 5 inches to be exact, now he is 7 inches and is fully satisfied. He wrote us saying that now his woman receives an orgasm 95% of the time they make love, before she could barely get excited.

"I'm very grateful to Pillsexpert for bringing such miraculous changes to my life. Having gained 2.5 inches from the 4 months supply and became more passionate and sexually attractive I was even able to fix the relationship with my wife (we were on the verge of the divorce) by simply having great sex with her. I feel more confident now and …I'm just happy!!! You know how they say it: ”Miracles don't just happen, they are firstly very well prepared.” No doubt that your company put a lot of time and effort to start helping people. Thank you so much and good luck to you." Mark Andrew, FL

truth about penis enhancement penis enlagement pill magna rx

Why are we #1 on the market?

Consider the difference between a 7, 8 or 9 inch penis that is thicker and a penis that is 4 to 6 inches and narrower. With a larger penis you penetrate more sensitive areas of the woman. Your longer penis probes deeper searching those special nerve endings. The added width to your penis fills and presses her from side to side to give your partner the most exhilarating sensations. The results are permanent. You control the growth because once you reach your optimum size you could stop taking VIMAX PILLS. We say you could stop taking VIMAX PILLS because it is not necessary to be larger then 9 inches. Most women can only comfortably accommodate a 9 inch penis. Anything larger than that may be too large for most women. Nine inches or more then 9 inches, the choice is yours.

Unlike other clones, Vimax Pills are made from only high end ingredients available to bring you best results possible. We run a serious business and treat as such, unlike other companies that appear out of nowhere and then disappear with your money without ever sending you a product you paid for.

natural penis enlargement pills penis enlarement surgery

Prices

best enlagement exercise penisbest penis enlarement surgeryfree exercise tip for penile enlargementhomemade pennis enlargementtruth about penis enhancementpenis enlarement technique

40% Order This Deal

Price: $234.95

Price Per Bottle: $39.15

Saving: $124.75

guide to penis enlargementpenile enlargment testimonialsvimax penis enlargement reviewcheapest pennis enlargement pillsvig rx for men

21% Order This Deal

Price: $214.95

Price Per Bottle: $42.99

Saving: $84.80

do penis enlargment pills workfree penis enlagement exercisepenis enlargment secretpennis enlargement result

14% Order This Deal

Price: $189.95

Price Per Bottle: $47.48

Saving: $49.85

natural penile enlargment exercisepenis enlarement before and afterenhancement free penis pills sample

12% Order This Deal

Price: $154.95

Price Per Bottle: $51.65

Saving: $24.90

best penis enargement surgeryhomemade penis enhancement

8% Order This Deal

Price: $109.95

Price Per Bottle: $54.98

Saving: $9.95

prosolution penis enlagement pills

5% Order This Deal

Price: $59.95

Price Per Bottle: $59.95

Saving: $0.00

Most of the orders placed before 1PM Eastern Standard Time are shipped the same day.
Worldemail or IP-PILLSEXPERT will appear on your credit card statement.
All orders are shipped in discreet packaging.

erection penis pills size vimax

There are many products that claim to increase libido and keep your penis healthy, however a healthy penis and strong libido are normally a reflection of overall lifestyle. Many men look for miracle cures, when they should be looking at changes in lifestyle. These changes become even more critical as men pass the age of 40. Lets look at 6 simple liefstyle changes that can help you A healthy penis and overall health The human body is a totally integrated organism, it is virtually impossible to have a healthy penis if there are health problems elsewhere. Al healthy penis means, one without erectile dysfunction (ED). ED is not yet perfectly understood, and most studies are inconclusive if the causes are physiological or psychological, or both factors working together. A healthy penis and testosterone levels As men age, it is proved that the level of testosterone in the blood slowly decreases. This is a main cause of libido drop and if libido can effect erections, it is then a cause of ED. Check yourself, and see if any of the following symptoms apply to you. Do you have sleeping problems, hair loss, become tired quickly, gaining weight, depression, become irritable easily, Sweating and flushing without physical activity? So, if your testosterone is dropping, there is no way to have a healthy penis, and you must resort to the new generation of ED drugs (Viagra, Cialis, and so on) which may work, and may not and have unpleasant side effects. Getting an erection with an ED drug does not mean your penis (or you are healthy) Also, if your state of health has deteriorated, you veins and arteries are not open as they were when you were young, so your ED may be caused by a slowdown / breakdown in your circulatory system. A healthy penis 6 rules for increased libido For both levels of testosterone and your general state of health, you can follow the easy rules below. You will be healthier, and it will show with a healthy penis and a more virile you Rules 1, 2 and 3 are MUSTS! 1.If you smoke, stop now. Smoking damages every part of your body, especially the circulatory system, and introduces dangerous chemicals directly into the blood. 2.You need physical exercise, and every day. It is estimated that you need at least 30 minutes of strenuous exercise daily as a minimum. To get testosterone levels up naturally, put yourself on a good weight lifting program. See your doctor first, and then ask a professional trainer to give you a special program suited to your body type, age, and physical condition. The testosterone levels will rise naturally. This is a proven fact. 3.Diet. If you are overweight, your penis will pay the price, along with your heart and every other critical organ. Eat plenty of fruits (in season only), and vegetables, lots of roughage (in the form of cereals), and meat sparingly. Your weight will drop naturally (without a formal diet) and you will notice your libido returning and your ability to satisfy it as well. The next rules are SHOULDS; so keep as much to them as you can. 4.Moderate your alcoholic intake. Do not over-indulge in drinking. Hard liquor sparingly, and wines and beers with great moderation. 5.Find good vitamin and mineral supplements. It should contain most or all of the following: Vitamins A, B, B complex, C, D, and E. From minerals, look for Chromium, Selenium and Zinc. From protein, L-arginine. From enzymes, DHEA. From natural herbs, look for Damania, Dong quai, Ginger, Ginkgo Biloba, Ginseng, Gotu kola, Horny Goat Weed, Hydrangea root, Pygeum, Sarsaparilla, Saw palmetto, and Wild yam. 6.If you are alone, masturbate. You need to ejaculate often, and through masturbation, the chemicals and reactions required for keeping your penis healthy are put to use. Done properly (as in the technique called jelqing) the result is, if nothing more, an improved circulation to the penis, and use of the prostate gland for more than just continence. A healthy penis final words Remember the state of your penis is a good indication of your own state of health. Follow the rules above, and at any age, you will find increased testosterone in the blood, better circulation, relief from many symptoms that may now plague you, and of course, a healthier penis. penis enlagement pic before and after penile enlargment picture easy enlargement free penis surgery way vimax best penis enlargement pills penile enlargement excercises penis enhancement excersizes penis enlargement excercises plastic surgery penis enargement

erection penis pills size vimax

Strep throat is inflammation and swelling of the throat, tonsils and lymph nodes. Unlike sore throat, which is caused by infection with viruses, strep throat is caused by infection with bacteria. While most sore throats generate mild symptoms and clear naturally, without the aid of medical treatments, strep throat generally requires a course of antibiotics. Untreated strep throat can lead to serious complications such as otitis, heart problems, renal problems and even rheumatic fever. On the premises of a weak immune system, strep throat can be very severe, in which case doctors recommend prompt medical treatment with antibiotics. Strep throat is caused by infection with group A streptococcus bacterium, a strong and very contagious infectious agent. Strep throat is very widespread in the flu seasons and it can be easily acquired by entering in contact with people who carry the bacteria responsible for causing the illness. Streptococcus bacteria are airborne and they can be contracted simply by breathing the same air with an infected person. Lots of people believe that strep throat only affects children. This idea is unfunded, as strep throat can be acquired by anyone, regardless of age. Although strep throat has the highest incidence in very young children and teenagers, it can also occur in adults. In fact, strep throat is more likely to generate complications when it is acquired by adults. Adults who suffer from strep throat usually have more intense symptoms and they need a longer period of recovery from illness. When it occurs in the elderly, strep throat is more difficult to overcome and the infection with streptococcus bacteria is very likely to become systemic. When suffering from strep throat, it is recommended to pay a visit to your physician as soon as possible. The doctor will perform an overall physical examination, in order to reveal any clinical signs of bacterial infection. Unlike viral forms of the illness, strep throat usually causes enlargement of the tonsils and lymph nodes, symptoms that are very suggestive for infection with bacteria. Fever is also a very revealing sign of strep throat. The presence of these common symptoms of strep throat is usually sufficient for diagnosing the illness. In order to confirm the clinical diagnosis, doctors may also take samples of the inflamed tissues for laboratory analysis. If the cause of illness proves to be infection with group A streptococcus bacteria, the doctor will prescribe you an appropriate treatment with antibiotics. In spite of their side-effects, medical treatments with antibiotics are the most effective means of curing strep throat in present. Doctors strongly recommend a 10-day course of penicillin or amoxicillin to all people affected by strep throat. New generation antibiotics such as cephalosporins can overcome the illness in an even shorter amount of time, curing bacterial infections within 4-5 days of treatment. Prescribed in the incipient stages of the illness, an appropriate medical treatment with antibiotics can provide a quick symptomatic relief for people who suffer from strep throat. Furthermore, antibiotics can prevent the occurrence of serious complications such as rheumatic fever, kidney infections and heart disease. easy enlarement free penis surgery way result review vig rx prosolution penis enargement information herbal penis enlagement penile enlargment without pills enlargment manhattan penile pro solution pills erection penis pills size vimax

Mid life Crisis is not a disease or an event that one can avoid. It afflicts everyone who lives through their middle years. There is no warning as to when it will hit you, but when it does, it likely will come at the worst possible time, but then again, when is a good time for a meltdown? Most likely your time will differ from that of your friends and others close to you like your Husband or Wife, since our Middle years can begin anytime from our mid thirties through one’s fifties and everyone is different. Don’t even think you can avoid mid life Crisis, because you can’t! No amount of money or influence can get you out of this one. How you endure the transformation and to what degree you suffer or not, will vary as widely as those who experience it. You know the cliché, forewarned is forearmed, so knowing what will happen and how to survive the experience in tact, can go a long way. Right! I may have been exaggerating slightly about how ominous Middle aged Crisis can be, because I wanted to grab your attention. However, we have all heard the jokes about middle aged crisis and know that within all jokes, there does contain a grain of truth. The truth here is that some of you will experience a major shift in your lives, while for others the change may be more gentle. Do not doubt that change is on its way. It is inevitable! You may not have say on if or when it will happen, but you do have a say in how you will deal with it. Each and every one of us is equipped with a silver bullet in our personal arsenal to deploy as we see fit. This is something that you may already be using or something that you have yet to take out. It matters not because you never run out of it. It is the most effective weapon we have and that is Attitude! As a Life Coach, we use our attitude and perspective to help our clients deal with many issues in their lives until their own attitude can take over. In fact, we often say that if we only have one tool to use, Perspective would be it. How you view things, and the attitude you take toward life’s ups and downs, (your perspective), has a dramatic effect on how you cope. Are you a glass is half full or half empty person? Do you laugh in the face of danger or do you run and hide in terror? Are you someone who is afraid of change or do you embrace it like me? Do you see problems or opportunities for improvement? Positive and negative personalities are obviously opposites of each other, with the extremes differing in folks all up and down the spectrum of the pole. I can certainly find folks who exemplify the ends of the pole, those with very strong outlooks, but for those who are fence sitters, you now have an opportunity to change your attitude. Only you know how you experience the world around you, but I know that a positive or negative attitude will affect how you experience what I have coined, The Emergence of our True Self. How would you like to go through life? Seeing opportunities or finding problems everywhere? The choice is yours. Look at this time as an amazing opportunity for you to take a peek behind the veil, the cloak of mystery that is you. Avidly seek out the answers to questions that have plagued mankind since the beginning of time. I know that as a child I lay in bed and many times looked up at the sky and wondered, “Why am I here”? “What is my purpose?” “How can I be more than I am?” These are the questions that will now be answered for you. This is your time to finally solve the mystery. View this time as a positive experience. This is your time and it has been given to you so that you can emerge as your True Self. Feel all of it; embrace the experience, even the tough stuff. Remember the butterfly and its struggle to emerge from it’s cocoon. You may struggle through this time but you will emerge a more content person for it. I am positive about this. Middle Aged Crisis, struck this week and it happened to a man we will call Dan. Let’s see how it begins so we know what to look for. Dan is a slightly paunchy, balding middle-aged man in his late 40’s, whose one attempt of rebellious attitude towards his wife, was to go against her thrifty nature and adorn the front end of his mini van with a ‘bra”! One day, Dan left his ‘bra’ behind and came home wearing a shiny new candy apple red corvette instead. It looks like the van was traded in for this gorgeous sexy rolling piece of penis envy. After the ‘big wow’ fell out of your dropped jaw, was your next thought the same as mine “now there’s a guy whose wife is going to kill him”? Where are the kids going to sit? Is Dan a classic case of a man having a mid life crisis?!” Will his ‘search” for himself end here or will Dan take it a step further? It seems that several of the guys in Dan’s office have traded their wives of 3o years for 30 yr.old wives. We don’t know if Dan knows any 30 yr; old women so we will have to wait and see about that. Dan seems to be the poster boy for Middle Aged Men in crisis but what about woman? Are they immune to mid life angst and do men and woman manifest their symptoms in the same way? Joan Rivers and her G-force facelift might be the perfect example of a woman who is still searching for more in her life but can’t get past her mirror. We often joke about woman and their hot flashes, but do they wake up all sweaty and then head out in the morning to buy sexy cars or is there another measure of being unsatisfied they go for? I have a few lady friends who were the very last women in the world I EVER expected to radically deviate from their MOM role. It seemed at 40 something, they woke up one day and traded their beautifully decorated home, mommy and wifely duties for a basement apartment and freedom. Did it mean they loved their children less? Nope, it just meant that they were compelled to find out who they were after being a mom and wife. Yes, a few became what is commonly referred to today as Cougars, woman who prey on younger men, but for the most part, they seemed to be genuinely seeking themselves. Either this was something that was lost, or something they never had in the first place. So is Mid life Crisis a valid condition or an excuse to be selfish and make up for poor choices along the way? Is it a human condition that we will all experience in varying degrees as we pass through their middle ages, or is it reserved for those who share certain personality traits? Is it possible that it is related to female menopause or male Andropause? Do hormones have anything to do with the ‘stress and distress of those in the eye of this storm? Are these people as out of control as they sometimes seem to be? I am not a doctor and do not know the answer to these questions but I do know as a Life Coach and a woman in her middle years, that there seems to be a great many people in this age category who are seeking and searching for something that will fill a part of them that is missing. They have a great desire for something more in their life, but what that MORE is they don’t know. It is a time of personal reflection and for some breaking out of a mold that has held them for many years. Perhaps you know someone who has quit their executive position or walked out on their 30 year marriage. It doesn’t always make sense, this behaviour, but there is common theme. CHANGE! It seems that many are seeking their destiny, and the meaning of life. They want to know what their purpose is and where they fit into the Grand Scheme. They want to know what this thing called LIFE is all about, and they are seeking their soul, their soul mates and questioning long held beliefs. Spirituality is a common theme, and many search for their connection to something larger than the known world and for answers they go to the Unknown world A metamorphosis is taking place and I see it as our third great struggle of life. The first is being born, the second is adolescence and now this time I will coin, The Emergence of Self. The emergence because it is our true self we are seeking. Not the daughter, son, mother, father, doctor, cook or any other label we have put on ourselves, but OUR true SELF , our true soul, the nature of who we really are. It seems this is a time where anything can happen and does. Sometimes those who are most surprised by what happens next are the seekers themselves. As adolescents we go through the change together, it is expected, so resources are in place to help us deal with it. Our families and teachers are there for us, supporting the change. Now in our mid 40’s- 50’s, it seems we face this change alone. No longer are our buddies, families or teachers there to support us. In fact, it may be that those closest to you don’t understand why you are contemplating the things you are. They may argue that you are making a big mistake and you don’t know what you are doing. Even if this is true, and in many cases it is, there doesn’t seem to be anything to do about it except ride it out. Have you ever wondered at the timing of all this? Why is it so important to KNOW right now? Why upset the apple cart at this stage of your life? Perhaps it is so that our time here is not wasted in the larger sense. Many of us as children had a dream or a goal. I think that this first memory may be the truth of who we really are and why we are here. How many of us have stayed true to who we were? I know that there have been many times in my life that duty as a daughter, a mother, and even a wife have taken precedence over who I wanted to be. So maybe this frustration, this time of wanting is really the only way to help us break the chains of ‘good behaviour’ and allows us the time to search for our lost selves or if you believe in the metaphysical then perhaps we are waking up to what brought us here in the first place, our contract or mission. Have you felt that there is a master plan but you haven’t been let in on the details? The there is a great secret, albeit unknown to you, and almost like a cosmic joke, it is at your expense. Why does this transformation take place? Is there a way of escaping it? I think not. It seems to me a natural progression to a higher state of being if we are lucky. It seems we all go through the process, albeit at slightly different ages and degrees of angst. I believe that this is one “Crisis” that is supposed to happen and rather than describe it as a crisis we could rename it as a transformation. We have all have known a “Dan”, a 50 something guy who finally buys his corvette, or his Harley, leaves his wife or leaves his job- any or all of these are fairly common and classic crisis behaviour. As I said earlier, Women are not immune either. We can all envision the Cougar, a woman in her mid to late 40’s who used to be Suzy Homemaker and is now on the prowl for a 2o something guy to make up for her boring life. On the outside, this behaviour seems selfish and I suppose in some ways it is. But remember, this Emergence is about self and change and change never comes easily. There is always a struggle and in this instance, doing what is opposite in nature of what one has always been done may be one of the catalysts to the next step. These folks are in the midst of a chemical and physical transformation. Alchemy is taking place. When all is said and done, they will be different. They are reaching out for their world to make sense and hopefully when all is said and done, they will have found peace. Peace within themselves and peace with their outside world. We know that these folks want more, but and the sexy car, younger mate is not the whole answer because change on the outside does not equate with change on the inside. I feel that this transformation may actually be harder on us than adolescence. When we are young, we have out parents to support us. We walk en mass with our friends to school and we are all going through stuff together. But mid life, we do that one by ourselves and many times, we wreak havoc on the lives of those we love the most. This change, this metamorphosis, cannot likely be stopped, anymore that you can stop breathing, but for some, it comes with great cost. Our bodies change- we don’t child bear anymore. We have wrinkles and grey hairs sprouting from places they aren’t supposed too. Our skin on our hands begin to thin and become translucent, showing the blue of our veins. We fear we are losing our sexuality, our vitality and our ability to be ‘seen’ as one of the players. We fear this invisibility and we fight to be more than we are, because we want to stay in the game. We also know that we are more than we are showing. We wake to an unknown dream or assignment and strive to fulfill our life’s mission, but the guide book is missing. The map is gone and our hands flail in the wind seeking something solid to grip onto. It’s a turbulent time until one day, you wake up and your life begins to make sense again. You start to realize what is important. Who you are and what you are passionate about. You know what you love and whom you love and you have a sense of the greater picture. You know why you are here. You understand your ties to the past and what you bring to the future. The Emergence of Self will happen whether you plan for it or not. At some point in your life mid life, an amazing discovery of self will take place, and I hope that you complete your transformation all the way until you feel at peace within your heart and the world around you. For those of you who are wondering what signs to look for or if you are currently experiencing your transformation, below you can find a list of common features: Typical features of mid-life include: Experiencing healthy dissatisfaction……..yearning for more…..is this it?? What worked before no longer rocks your world. The changing body becomes your guide. You get used to uncertainty You want to give back You become much more than you thought you were. Your values change significantly You are getting a hefty whiff of you own mortality. The emergence of wisdom Mid-life challenges that Coaching can assist with: • Finding your Passion • Removing FEAR from the Change Process • Learning how to acknowledge and accept others • Learning to Communicate at heart level • Reconnect with your SELF • Leaving Guilt Behind • Trusting your instincts • Creating a vision pennis enlargement product free penis enlarement technique vimax cheapest penis enlargement pills penis enargement surgeries guide to penile enlargment penile enlargment testimonials pnis enlargement fact free penis enlagement erection penis pills size vimax

Welcome to my “Free Affiliate Marketing Tips” article, here you will find some free affiliate marketing tips on how to boost your CTR with adwords, what products you should promote, how to pay a few cents per click and more.. 1. Keeping your CTR down In order to keep your CTR down you must be relevant. In order to be relevant, make sure that your ad groups contain only 20 keywords in each and that they all have base keywords as different phrases. For example: Base keyword: Acne Removal Phrases: Buy Acne Removal, Find Acne Removal Products, Removal of Acne Do this for 20 in one ad group, once you have done this, you will need to apply this to all of your ad groups. Make sure that the keyword is in the adcopy of your ad and try to make sure it is in your URL. Either as acne-removal-products.com or mywebsite.com/acne removal. 2. How to keep bid prices down This is severely related to keeping your CTR down. But you also have to find keywords that are very targeted. Don’t use very broad terms as these will be too competitive. It is better to find 100 niche keywords rather than 10 very broad keywords, dominated with competiton. One niche keyword wont get you far, but if you can get a few hundred listed, you can turn that into dollars quite easily. 3. What products should I promote I highly recommend using digital products found on click bank. These are easy to promote as you don’t need to deal with shipping anything and you can just write a review on somebody else’s product and then its their problem. Lucrative markets include gambling, weight loss, giving up smoking, penis enlargement and acne removal. If you would like a list of the best affiliate marketing guides that I personally use everyday, click here Thanks for reading my article, I hope these tips on affiliate marketing will help real pnis enlargement plastic surgery pennis enlargement penile enlargment device herbal natural penis enhancement pennis enlargement product cheap penis enlargment pills penile enlargement picture best penis enlargment surgery erection penis pills size vimax

One of the most confusing things about being diagnosed with early stage prostate cancer is choosing if and how to treat it. Unlike other cancers that have one or two standard treatment options, acceptable approaches for prostate cancer are more numerous. Each has different pros and cons and the decision about how to proceed needs to be customized to each man, depending on his age, his general health, and the severity of his early prostate cancer. Treatment options · Radical prostatectomy is the surgical procedure that removes the prostate gland. The operation is traditionally performed through a vertical incision made in the pelvis. The man needs to be admitted to the hospital and recover for several days. The most worrisome potential long term side effects are urinary incontinence and impotence. A new technology is available: robotic laparoscopic prostatectomy. This method entails making five small incisions instead of one larger one. The recovery is expected to be faster and easier than with the traditional procedure. · Radiation therapy has a cure rate comparable to that of surgery. The two forms of radiation therapy are external beam and brachytherapy, pronounced bray-kee-ther-uh-pee. o External Beam Radiation Therapy entails the use of a radiation treatment machine, most commonly, a linear accelerator. Using sophisticated treatment planning computers and devices built into the linear accelerator, the radiation beams deliver a very precise dose of radiation to the intended area while sparing the normal surrounding structures, such as the rectum and bladder. By using 3-D conformal radiation therapy, the radiation beams conform to, or match the shape of the tumor. Intensity modulated radiation therapy, also known as IMRT, is a refinement of 3-D conformal radiation therapy. It uses multiple, tiny beamlets, instead of a single radiation beam. IMRT beamlets can be understood by visualizing it as multiple, tiny mosaic tiles of different hues of blue; the tumor receives the dark blue beamlets, whereas the tissue near the rectum and bladder receives the beamlets of the palest shade of blue. This way, the intensity of each tiny beamlet is modulated. IMRT has enabled radiation oncologists to deliver much higher doses of radiation therapy to the prostate with fewer complications to the rectum, resulting in higher cure rates. Temporary and early side effects include the need to urinate frequently, diarrhea, abdominal cramping, and fatigue, which is usually not severe. Side effects that can develop months to years later include urinary incontinence and erectile dysfunction, albeit a significantly lower incidence than with surgery. With the advent of IMRT, the risk of rectal injury that can cause rectal bleeding is uncommon. o Prostate Seed Implants introduce multiple radioactive pellets smaller than grains of rice into the prostate gland. The prostate gland then receives a substantial dose of radiation, but the surrounding tissues receive virtually none. This option is very attractive to men who are concerned about maintaining potency. Also, for men who do not have a significant risk of the cancer penetrating through the capsule that envelopes the prostate, a prostate seed implant can serve as the only form of therapy. However, men whose tumors fall into a higher risk category cannot be treated solely with a prostate seed implant, and need to supplement it with external beam radiation therapy, albeit a briefer course of treatment than in men who receive only external beam radiation therapy. The disadvantages of brachytherapy include the fact that the radioactive seeds take several weeks to decay to the level of background radiation; during this time, men need to refrain from getting close to pregnant women and small children. Also, there is a low risk of rectal irritation in the short and long run. Infrequently, the need to urinate frequently can persist. Incontinence and impotence are relatively rare. The risk of a channel forming between the urinary tract and the rectum, also known as a rectal fistula, can cause urine to leak through the rectum. This complication is rare, fortunately, and can be repaired surgically. · Cryosurgery involves freezing the prostate tissue with liquid nitrogen. Via the guidance of an ultrasound probe inserted in the rectum, needles are guided into the prostate, by piercing the skin between the scrotum and the anus. Short term side effects include blood in the urine for several days, soreness of the surgical area, swelling of the penis and scrotum, urinary burning, and frequency of urine and bowel movements. Late complications include nerve damage that can result in impotence and rarely, the formation of a fistula. Also, the long-term success rate is not well known. · Hormone Therapy is also known as androgen deprivation therapy (ADT). Prostate cancer thrives on testosterone. By depleting testosterone, prostate cancer cells die. ADT has never been demonstrated to be a curative modality, but it is useful in holding the disease at bay for some time. Its other role is in shrinking the prostate prior to surgery or radiation therapy. Side effects are those of “male menopause”, such as hot flashes, weight gain, decreased mental acuity and depression. Other potential adverse effects include osteoporosis, anemia, breast enlargement, fatigue, diminished good cholesterol and loss of muscle mass. · Watchful waiting is a reasonable choice for men who have a short life expectancy, as well as for those men who have very slowly growing prostate cancer and will most likely not die from prostate cancer but rather, from some other more life threatening problem. The down side of watchful waiting is the psychological implication that the man’s mortality is looming ahead of him. Although no active treatment is given, men are still followed with digital rectal exams, PSA levels and possibly, transrectal ultrasounds of the prostate. However, with low risk prostate cancer in an elderly man, this might be a fine option. Apparently the spectrum of treatment options is vast, and ranges from doing nothing to undergoing radical surgery. To make the best decision for himself, a man should know his treatment options based on his individual situation and lifestyle. Then, he will be empowered by knowledge as he embarks on his journey into the world of medical opinions. Finally, he should choose an experienced specialist to ultimately treat and follow him. For more information about radiation therapy, check out http://www.ASTRO.org, the official website of ASTRO, The American Society for Therapeutic Radiology and Oncology. Copyright 2006 by Carol L. Kornmehl. All rights reserved.