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Penis Enlargement; Types, Technique, Treatment

Penis Enlargement or male enhancement is any technique aimed to increase the size of a human penis. Some methods aim to increase total length, others the shaft’s girth, and yet others the glans size. Techniques include surgery, supplements, ointments, patches, and physical methods like pumping, jelqing, and traction.

Inflatable penile prosthetic (IPP) devices have been available and used for more than four decades. Often times, medical conditions causing erectile dysfunction also cause penis shortening, causing the decreased patient quality of life. To identify and review all available penis lengthening procedures that can be performed at the time of IPP insertion. An extensive, systematic literature review was performed using PubMed searching for key terms penis lengthening, inflatable penis prosthesis, penile girth, clitoroplasty, glans augmentation, and penis enhancement; all articles with subjective or objective penis length outcomes were reviewed.

Anatomy of Penis Enlargement

Lateral cross-section of the penis.

Male Reproductive System Labeled and Label Male Reproductive System Reproductive System Of The Human Male – Human Diagram Chart

Parts

  • The root of the penis (radix): It is the attached part, consisting of the bulb of the penis in the middle and the crus of the penis, one on either side of the bulb. It lies within the superficial perineal pouch.
  • Body of the penis (corpus): It has two surfaces: dorsal (posterosuperior in the erect penis), and ventral or urethral (facing downwards and backward in the flaccid penis). The ventral surface is marked by a groove in a lateral direction.
  • Epithelium of the penis consists of the shaft skin, the foreskin, and the preputial mucosa on the inside of the foreskin and covering the glans penis. The epithelium is not attached to the underlying shaft so it is free to glide to and fro.[rx]

Structure

The human penis is made up of three columns of tissue –  two corpora cavernosa lie next to each other on the dorsal side and one corpus spongiosum lies between them on the ventral side.[rx]

The enlarged and bulbous-shaped end of the corpus spongiosum forms the glans penis with two specific types of sinusoids, which supports the foreskin, or prepuce, a loose fold of skin that in adults can retract to expose the glans.[rx] The area on the underside of the penis, where the foreskin is attached, is called the frenum, or frenulum. The rounded base of the glans is called the corona. The perineal raphe is the noticeable line along the underside of the penis.

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Comparison of mean body weight, mean testicular weight, mean plasma testosterone and mean IGF-1 among experimental groups.

C MP G Testosterone GT
Bodyweight (g, s.d.) 588 (34) 579 (28) 575 (39) 552 (44) 567 (45)
Testis volume (mL, s.d.) 1.36 (0.11) 0.97 (0.05)b 1.26 (0.08)a 0.83 (0.06)ab 1.10 (0.09)a,b
Tibial length (mm) 38.4 (2.6) 36.6 (3.1) 39.1 (2.2) 35.5 (3.3) 36.8 (2.9)
Plasma testosterone (ng/mL, s.d.) 3.72 (1.91)a 0.44 (0.05)b 2.08 (0.51)a 27.5a,b 29.2a,b
Plasma IGF-1 (ng/mL, s.d.) 1445 (155) 1432 (232) 1704 (116)a,b 628 (206)a,b 1197 (126)a,b

denotes statistical significance (P < 0.05) compared to MP; denotes statistical significance (P < 0.05) compared to C.

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Disorders of Penis Enlargement

Penis Enlargement

  • Paraphimosis – is an inability to move the foreskin forward over the glans. It can result from fluid trapped in a foreskin left retracted, perhaps following a medical procedure, or accumulation of fluid in the foreskin because of friction during vigorous sexual activity.
  • In Peyronie’s disease – anomalous scar tissue grows in the soft tissue of the penis, causing curvature. Severe cases can be improved by surgical correction.
  • A thrombosis can occur during periods of frequent and prolonged sexual activity – especially fellatio. It is usually harmless and self-corrects within a few weeks.
  • Infection with the herpes virus can occur after sexual contact with an infected carrier –  this may lead to the development of herpes sores.
  • Pudendal nerve entrapment – is a condition characterized by pain on sitting and the loss of penile sensation and orgasm. Occasionally there is a total loss of sensation and orgasm. The pudendal nerve can be damaged by narrow, hard bicycle seats and accidents. This can also occur in the clitoris of females.
  • Penile fracture – can occur if the erect penis is bent excessively. A popping or cracking sound and pain is normally associated with this event. Emergency medical assistance should be obtained as soon as possible. Prompt medical attention lowers the likelihood of permanent penile curvature.
  • In diabetes – peripheral neuropathy can cause tingling in the penile skin and possibly reduced or completely absent sensation. The reduced sensations can lead to injuries for either partner and their absence can make it impossible to have sexual pleasure through stimulation of the penis. Since the problems are caused by permanent nerve damage, preventive treatment through good control of diabetes is the primary treatment. Some limited recovery may be possible through improved diabetes control.
  • Erectile dysfunction is the inability to develop and maintain an erection sufficiently firm for satisfactory sexual performance. Diabetes is a leading cause, as is natural aging. A variety of treatments exist, most notably including the phosphodiesterase type 5 inhibitor drugs (such as sildenafil citrate, marketed as Viagra), which work by vasodilation.
  • Priapism – is a painful and potentially harmful medical condition in which the erect penis does not return to its flaccid state. Priapism lasting over four hours is a medical emergency. The causative mechanisms are poorly understood but involve complex neurological and vascular factors. Potential complications include ischemia, thrombosis, and impotence. In serious cases, the condition may result in gangrene, which may result in amputation. However, that is usually only the case if the organ is broke out and injured because of it. The condition has been associated with a variety of drugs including prostaglandin. Contrary to common knowledge, sildenafil (Viagra) will not cause it.[rx]
  • Lymphangiosclerosis – is a hardened lymph vessel, although it can feel like a hardened, almost calcified or fibrous, vein. It tends not to share the common blue tint with a vein, however. It can be felt as a hardened lump or “vein” even when the penis is flaccid and is even more prominent during an erection. It is considered a benign physical condition. It is fairly common and can follow a particularly vigorous sexual activity for men, and tends to go away if given rest and more gentle care, for example by use of lubricants.
  • Carcinoma of the penis – is rare with a reported rate of 1 person in 100,000 in developed countries. Some sources state that circumcision can protect against this disease, but this notion remains controversial among medical circles.[rx]

Developmental Disorders

Hypospadias
  • Hypospadias is a developmental disorder where the meatus is positioned wrongly at birth. Hypospadias can also occur iatrogenically by the downward pressure of an indwelling urethral catheter.[rx] It is usually corrected by surgery.
  • A micropenis is a very small penis caused by developmental or congenital problems.
  • Diphallia, or penile duplication (PD), is the condition of having two penises. However, this disorder is extremely rare.

Alleged and observed psychological disorders

  • Penis panic (koro in Malaysian/Indonesian) – delusion of shrinkage of the penis and retraction into the body. This appears to be culturally conditioned and largely limited to Ghana, Sudan, China, Japan, Southeast Asia, and West Africa.
  • In April 2008, the Kinshasa Democratic Republic of Congo, West Africa’s ‘Police arrested 14 suspected victims (of penis snatching) and sorcerers accused of using black magic or witchcraft to steal (make disappear) or shrink men’s penises to extort cash for cure, amid a wave of panic. Arrests were made in an effort to avoid bloodshed seen in Ghana a decade before when 12 penis snatchers were beaten to death by mobs.[rx]
  • Penis envy—the contested Freudian belief of all women inherently envying men for having penises.

The technique of Penis Enlargement


Physical Techniques

  • Physical techniques involve extension devices, hanging weights, and vacuum pressure. There is also significant overlap between techniques intended to enlarge the penis and techniques intended to achieve other, related objectives, such as reversing impotence, extending the duration of erections, or enhancing sexual climax.

Pumping

  • Water-based vacuum pump commonly called a “penis pump”, a vacuum erection device, or VED, creates negative pressure that expands and thereby draws blood into the penis.[rx][rx] Medically approved VEDs, which treat erectile dysfunction, limit maximum pressure, whereas the pumps commonly bought by consumers seeking penis enlargement can reach dangerous pressure, damaging penis tissue.[rx]
  • To retain tumescence after breaking the device’s airtight seal, one must constrict the penis’ base, but constriction worn over 30 minutes can permanently damage the penis and cause erectile dysfunction.[rx] Although vacuum therapy can treat erectile dysfunction sufficiently to prevent penis deterioration and shrinkage,[rx] clinical trials have not found it effective for penis enlargement.[rx][rx]


Jelqing

  • Performed on the halfway tumescent penis, jelqing is a manual manipulation of simultaneous squeezing and stroking the shaft from base to corona. Also called “milking”,[rx] the technique has ancient Arab origins.[rx] Despite many anecdotal reports of success, medical evidence is absent.[rx]
  • Journalists have dismissed the method as biologically implausible,[rx] or even impossible, albeit unlikely to seriously damage the penis.[rx] Still, if done excessively or harshly, jelqing could conceivably cause ruptures, scarring, disfigurement, and desensitization.[rx][rx]

Traction

  • Traction is a nonsurgical method to lengthen the penis by employing devices that pull at the glans of the penis for extended periods of time. As of 2013, the majority of research investigating the use of penile traction focuses on treating the curvature and shrinkage of the penis as a result of Peyronie’s disease, although some literature exists on the impact on men with short penises.[rx] Scientific evidence supports some elongation by prolonged traction.[rx]

Jelqing exercises

  • Jelqing is an exercise that some people use to try to naturally increase the size of their penis. It involves using a hand-over-hand rolling motion to move blood to the head of your penis and stretch it. It’s sometimes called “milking.”
  • There aren’t enough medical studies to suggest that jelqing can actually increase your penis size. It’s a fairly safe practice, but it may lead to pain, irritation, or scar tissue formation if you do it too often or aggressively.

Clamps and rings

  • Some people use a clamp or ring to try to stretch and elongate their penis. To use one of these devices, you place it around the base of your penis after you’ve developed an erection. It’s meant to prevent blood from flowing out of your penis.
  • Wearing one of these devices may temporarily enlarge your penis. But wearing it for more than 30 minutes can cut off blood flow and cause damage to your penile tissue.

Diet, Exercise, and Lifestyle

  • The sad truth is that in a significant number of cases, erectile dysfunction is a condition we bring upon ourselves. Even when these things aren’t the outright cause of ED, they’re almost certain to be contributing factors that make your condition worse. This is a big, expansive category that covers a lot of ground, but in a nutshell, here’s what you need to know.
  • Eating lots of leafy greens, whole grains, oysters, watermelon, and blueberries (most any fruit will work, really) will help you give your body all that it needs to improve the quality of your erections while cutting out processed foods, cigarettes and alcohol will provide further benefits. Add in a healthy dose of exercise at least three times per week, and you’re well on your way to better sexual health!

References

Penis Enlargement

Are you worried about your panis black colour, small size? Lets go for solution

Are you worried about your panis black colour & small size? Lets go for solution. Treating erectile dysfunction (ED). It may also be used for other conditions as determined by your doctor.

Vardenafil is a phosphodiesterase type 5 (PDE5) inhibitor. It works by helping to increase blood flow into the penis during sexual stimulation. This helps you to achieve and maintain an erection.

Do NOT use vardenafil if

  • you are allergic to any ingredient in vardenafil
  • you have been advised by your doctor to avoid sexual activity because of heart problems
  • you have certain heart problems (eg, severe heart failure, angina), low or high blood pressure, severe liver problems or severe kidney problems that require dialysis
  • you have certain hereditary degenerative eye problems (eg, retinitis pigmentosa)
  • you have had a heart attack, stroke, or life-threatening irregular heartbeat within the past 6 months
  • you have a history of a certain type of irregular heartbeat (eg, congenital QT prolongation) or you take certain antiarrhythmic medicines (eg, quinidine, procainamide, amiodarone, sotalol)
  • you are taking a nitrate (eg, isosorbide, nitroglycerin) in any form (eg, capsule, ointment, patch, tablet), or nitroprusside
  • you use certain recreational drugs called “poppers” (eg, amyl nitrate or nitrite, butyl nitrate or nitrite)
  • you take another PDE5 inhibitor (eg, sildenafil, tadalafil) or another medicine that contains vardenafil

Contact your doctor or health care provider right away if any of these apply to you.

Before using vardenafil

Some medical conditions may interact with vardenafil. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:

  • if you are pregnant, planning to become pregnant, or are breast-feeding
  • if you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplement
  • if you have allergies to medicines, foods, or other substances
  • if you have a deformed penis (eg, cavernosal fibrosis, Peyronie disease), blood cell problems (eg, leukemia, multiple myeloma, sickle cell anemia), or any other condition that may increase the risk of a prolonged erection (priapism)
  • if you have a history of a prolonged (more than 4 hours) or painful erection (priapism)
  • if you have a history of certain eye problems (eg, macular degeneration, optic neuropathy, retinitis pigmentosa, sudden vision loss) or hearing problems (eg, ringing in the ears, decreased hearing, hearing loss)
  • if you have a history of liver or kidney problems, dialysis, high or low blood pressure, ulcers, seizures, lung problems (eg, pulmonary veno-occlusive disease), bleeding problems, blood vessel problems, or heart problems (eg, angina, aortic stenosis, heart failure)
  • if you have a history of heart attack, stroke, a certain type of irregular heartbeat (long QT syndrome), or a family history of long QT syndrome

Some MEDICINES MAY INTERACT with vardenafil. Tell your health care provider if you are taking any other medicines, especially any of the following:

  • Alpha-blockers (eg, doxazosin), medicines for high blood pressure, nitrates (eg, isosorbide, nitroglycerin), or nitroprusside because severe low blood pressure with dizziness, lightheadedness, and fainting may occur
  • Certain antiarrhythmics (eg, amiodarone, procainamide, quinidine, sotalol) because the risk of irregular heartbeat may be increased
  • Azole antifungals (eg, itraconazole), HIV protease inhibitors (eg, indinavir, ritonavir), macrolide antibiotics (eg, erythromycin), or telithromycin because they may increase the risk of vardenafil’s side effects
  • Rifampin because it may decrease vardenafil’s effectiveness

This may not be a complete list of all interactions that may occur. Ask your health care provider if vardenafil may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine.

How to use vardenafil

Use vardenafil as directed by your doctor. Check the label on the medicine for exact dosing instructions.

  • An extra patient leaflet is available with vardenafil. Talk to your pharmacist if you have questions about this information.
  • Take vardenafil by mouth with or without food.
  • Take vardenafil about 1 hour before sexual activity.
  • Do not take vardenafil more often than once daily, or as directed by your doctor.
  • Check with your doctor before you eat grapefruit or drink grapefruit juice while you use vardenafil.
  • If you miss a dose of vardenafil and you still intend to engage in sexual activity, take it as soon as you remember. Continue to take it as directed by your doctor.

Ask your health care provider any questions you may have about how to use vardenafil.

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Important safety information

  • Vardenafil may cause dizziness, drowsiness, fainting, or blurred vision. These effects may be worse if you take it with alcohol or certain medicines. Use vardenafil with caution. Do not drive or perform other possibly unsafe tasks until you know how you react to it.
  • Vardenafil may cause dizziness, lightheadedness, or fainting; alcohol, hot weather, exercise, or fever may increase these effects. To prevent them, sit up or stand slowly, especially in the morning. Sit or lie down at the first sign of any of these effects.
  • Patients with heart problems who take vardenafil may be at increased risk for heart-related side effects, including heart attack or stroke. Symptoms of a heart attack may include chest, shoulder, neck, or jaw pain; numbness of an arm or leg; severe dizziness, headache, nausea, stomach pain, or vomiting; fainting; or vision changes. Symptoms of a stroke may include confusion; vision or speech changes; one-sided weakness; or fainting. Contact your doctor or seek medical attention right away if you experience these symptoms.
  • Vardenafil may rarely cause a prolonged (more than 4 hours) or painful erection. This could happen even when you are not having sex. If this is not treated right away, it could lead to permanent sexual problems such as impotence. Contact your doctor right away if this happens.
  • Vardenafil does not stop the spread of HIV or other sexually transmitted diseases (STDs) to others through sexual contact. Use barrier methods of birth control (eg, condoms) if you have HIV infection or an STD.
  • Vardenafil will not prevent pregnancy. If your partner may become pregnant and you wish to avoid pregnancy, be sure to use an effective form of birth control.
  • Vardenafil may uncommonly cause mild, temporary vision changes (eg, blurred vision, sensitivity to light, blue/green color tint to vision). Contact your doctor if vision changes persist or are severe.
  • Rarely, an eye problem called nonarteritic anterior ischemic optic neuropathy (NAION) has been reported in patients who took vardenafil. This may lead to decreased vision or permanent loss of vision in some cases. If you notice a sudden decrease in vision or loss of vision in one or both eyes, contact your doctor right away.
  • Sudden decreases in hearing and loss of hearing have been reported in some patients who have taken vardenafil. Sometimes they also noticed ringing in the ears or dizziness. If you notice a sudden decrease or loss of hearing, contact your doctor right away.
  • Do not use other medicines or treatments for ED while you are taking vardenafil without first checking with your doctor.
  • Use vardenafil with caution in the ELDERLY; they may be more sensitive to its effects.
  • Vardenafil is not recommended for use in CHILDREN; safety and effectiveness in children have not been confirmed.
  • PREGNANCY and BREAST-FEEDING: Vardenafil is not approved for use in women. If you become pregnant, contact your doctor. You will need to discuss the benefits and risks of using vardenafil while you are pregnant. It is not known if this medicine is found in breast milk. If you are or will be breast-feeding while you use vardenafil, check with your doctor. Discuss any possible risks to your baby.

Dosage 

Indications

Erectile dysfunction.

Dosage

Adult : PO Initial: 10 mg 60 mins before sexual activity. Adjust dose according to response. Max: 20 mg as a single dose. Max frequency: Once daily.

Dosage Details

Oral
Erectile dysfunction

Adult: Initially, 10 mg taken 60 minutes before sexual activity. Adjust subsequent doses according to response. Max: 20 mg as a single dose. Max frequency: Once daily. Sexual stimulation needed for response to therapy.
Elderly: ≥65 yr: Initially 5 mg 60 minutes before sexual activity, increased to 10 mg then 20 mg if needed.

Special Patient Group

Patients stabilised on α-blocker therapy: max daily dose 5 mg and not to be taken within 6 hr of the α-blocker (except tamsulosin). Patients on erythromycin: Max: 5 mg daily.

Renal Impairment

Haemodialysis: Avoid.

CrCl Dosage
<30 Initial dose 5 mg, increased to 10 mg then 20 mg if needed.

Hepatic Impairment

Child Pugh A-B (mild to moderate) impairment: Initiate with 5 mg. Max dose in moderate impairment: 10 mg. Child-Pugh C (severe impairment): No studies done.

Administration

May be taken with or without food.

Contraindications

Known prolongation of QT interval (congenital or acquired); men for whom sexual intercourse is inadvisable due to CV risk factors; hypotension (systolic <90 mm Hg); hypertension (systolic >170 mm Hg or diastolic >110 mm Hg); recent stroke or MI (within last 6 mth); unstable angina; severe heart failure; end-stage renal disease requiring dialysis; severe hepatic impairment; known degenerative retinal disorders e.g. retinitis pigmentosa. Women, child.

Special Precautions

Anatomical deformation of the penis; predisposition to priapism e.g. sickle cell anaemia, multiple myeloma, or leukaemia; bleeding disorders or active peptic ulceration; left ventricular outflow obstruction; elderly (≥ 65 yr). Discontinue and seek medical advice if there is sudden vision loss or decreased vision in one or both eyes or tinnitus, dizziness or sudden loss or decrease in hearing, while taking vardenafil. May cause dizziness or abnormal vision so avoid driving or operating machinery until effects of vardenafil is known. Seek immediate medical advice if erection last > 4 hr.

Adverse Drug Reactions

Dyspepsia, vomiting, headache, flushing, dizziness, visual disturbances, colour vision changes, raised intra-ocular pressure, nasal congestion, hypersensitivity reactions, nausea, photosensitivity reactions, hypotension, hypertension, priapism, palpitations, myalgia, increased creatinine kinase, sudden decrease or loss of hearing, tinnitus.

Pregnancy Category (US FDA)

Category B: Either animal-reproduction studies have not demonstrated a foetal risk but there are no controlled studies in pregnant women or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the 1st trimester (and there is no evidence of a risk in later trimesters).

Drug Interactions

Increased risk of hypotension with α-blockers. Increased risk of priapism with alprostadil. Increased serum levels of vardenafil when used with erythromycin.
Potentially Fatal: Increased risk of hypotension with nitrates, nitrites, and nitric oxide donors, either regularly or intermittently (avoid combination). Increased risk of ventricular arrhythmias with drugs that prolong QT interval e.g. Class IA or Class III antiarrhythmics (avoid combination). Increased vardenafil concentrations with potent CYP 3A4 inhibitors e.g. ketoconazole, itraconazole, HIV-protease inhibitors such as indinavir and ritonavir (avoid combination).

Food Interaction

Increased vardenafil concentration levels with grapefruit juice.

Mechanism of Action

Description: Vardenafil is a phosphodiesterase type-5 inhibitor. It manages erectile dysfunction by increasing the amounts of cyclic guanosine monophosphate (cGMP).
Pharmacokinetics: 
Absorption: Rapidly absorbed from GI tract with 15% bioavailability. Peak plasma concentration: 30-120 minutes. Rate of absorption decreased with high fat meal.
Distribution: Widely distributed. Protein binding: 95%.
Metabolism: Metabolised in the liver primarily by cytochrome P450 isoenzymes CYP3A4 (the major route), CYP3A5 and CYP2C. Major metabolite has some activity.
Excretion: Excreted as metabolites mainly in faeces (91-95%), and some in urine (2-6%). Terminal half life: 4-5 hr.

Storage

Store between 59-86°F (15-30°C).

MIMS Class

Drugs for Erectile Dysfunction & Ejaculatory Disorders

Major Side Effects

If any of the following side effects occur while taking vardenafil, check with your doctor immediately:

Less common:

  • Arm, back, or jaw pain
  • blindness
  • blurred vision
  • chest pain or discomfort
  • chest tightness or heaviness
  • chills
  • cold sweats
  • confusion
  • decreased vision
  • difficult or labored breathing
  • difficulty with swallowing
  • dizziness
  • dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position
  • eye pain
  • fainting
  • fast, irregular, pounding, or racing heartbeat or pulse
  • headache
  • hives, itching, or skin rash
  • nausea
  • nervousness
  • pain or discomfort in the arms, jaw, back, or neck
  • pounding in the ears
  • puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue
  • slow or fast heartbeat
  • sweating
  • tearing
  • tightness in the chest
  • unusual tiredness or weakness
  • vomiting

Incidence not known:

  • Hearing loss

Minor Side Effects

Some vardenafil side effects may not need any medical attention. As your body gets used to the medicine these side effects may disappear. Your health care professional may be able to help you prevent or reduce these side effects, but do check with them if any of the following side effects continue, or if you are concerned about them:

More common:

  • Feeling of warmth and redness of the face, neck, arms, and occasionally, upper chest
  • sneezing
  • stuffy nose

Less common:

  • Abnormal ejaculation
  • abdominal or stomach pain
  • abnormal vision
  • acid or sour stomach
  • back pain
  • belching
  • bloody nose
  • body aches or pain
  • burning feeling in the chest or stomach
  • burning, crawling, itching, numbness, prickling, “pins and needles”, or tingling feelings
  • changes in color vision
  • changes in vision
  • congestion
  • cough
  • diarrhea
  • difficulty seeing at night
  • difficulty with moving
  • difficulty with swallowing
  • dim vision
  • dry mouth
  • dryness or soreness of the throat
  • excessive muscle tone
  • eye pain
  • face swelling
  • fast heartbeat
  • feeling of constant movement of self or surroundings
  • fever
  • general feeling of discomfort or illness
  • heartburn
  • hoarseness
  • increased redness of the eye
  • increased sensitivity of the eyes to sunlight
  • indigestion
  • joint pain
  • lack or loss of strength
  • loss of appetite
  • muscle aches and pains
  • muscle cramping
  • muscle stiffness
  • muscle tension or tightness
  • neck pain
  • pain or burning in the throat
  • runny nose
  • sensation of spinning
  • shivering
  • sleepiness or unusual drowsiness
  • sore throat
  • sores, ulcers, or white spots on the lips or tongue or inside the mouth
  • stomach discomfort, upset, or pain
  • swollen joints
  • tender, swollen glands in the neck
  • tenderness in the stomach area
  • trouble with sleeping
  • trouble with swallowing
  • voice changes
  • watery eyes

References

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