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Dear Dr. Roach: I am an 84-year-old man in good health. I have been taking tamsulosin (Flomax) for the past six months for my enlarged prostate, and it works fine for problems with urination. However, it causes reduced libido and reduced ejaculation. Is there an alternate medicine to treat the urinary urgency without this side effect? Or should I forget about sex?

P.S.

Dear P.S.: Sexuality is an important part of life, and there may be a way to improve your symptoms without sexual side effects. Tamsulosin commonly causes decreased ejaculation (in up to 20 percent of men), but decreased libido is less common (2 percent). An often-used alternative treatment, finasteride (Proscar) is about as likely to cause these problems, although its related compound, dutasteride (Avodart), may have fewer side effects.

Also, medicines like tamsulosin start working immediately, while it takes weeks to months for finasteride and dutasteride to reach full effectiveness.

Many men find relief from the herb saw palmetto, despite the fact that trials have not shown consistent benefit for this compound.

Since tamsulosin is mostly eliminated by the body in a day or so, you might consider going without for a day to see if it improves your symptoms.

Dear Dr. Roach: I am a 55-year-old white male who was diagnosed with spinal stenosis this summer. I was given physical therapy, an MRI and an epidural injection in my back. Less than 48 hours before I was scheduled to have surgery, the insurance company denied the surgery because I smoke. The surgeon was aware of this, and felt it was important that I quit smoking AFTER the surgery to let the bones heal. None of his staff or any health care professionals I have talked to since the denial have ever heard about a surgery denied for this reason. The epidural worked for less than a week, and my back went back to hurting as much as before the epidural. Are there any nonsurgical treatments for this? Or do you have any advice on how to get the insurance company to change its mind? I was willing to quit after the surgery, and the surgeon said it would take one to two weeks to heal properly.

K.R.S.

Dear K.R.S.: I also had never heard of a surgery being denied due to smoking, but have read that this is occurring more frequently, especially in Canada, and that it has become policy in some parts of the U.K. for nonurgent operations.

I have consistently argued as passionately as I know how to try to persuade smokers to quit. It is certainly the most important step most people can take to improve their overall health and life expectancy. I have had patients try medication, group classes, acupuncture, hypnosis and electronic coaching programs to try to quit.

There is no doubt that quitting smoking at least four weeks before a procedure enhances wound healing and recovery from surgery. However, denying someone health care for being a smoker is ethically troubling to me.

Physical therapy is the mainstay of nonoperative treatment for spinal stenosis, but there are some people who require surgery to get better. You certainly can appeal to your insurance company, but maybe quitting now would be the fastest way to get treatment.

Email questions to ToYourGoodHealth@med.cornell.edu.

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