Male sexual dysfunction

1. Male sexual dysfunction Joseph Breuner, MD 10/21/02

2. Take home points • .get the facts. Most residents precept sexuality complaints with inadequate information. Find out frequency of failure, arousal/libido , erections, pain, loss of erection, which partner is more bothered. • .viagra : not a controlled substance, but it’s not for everyone • context matters for male sexual function: erectile dysfunction much more common when patient is anxious, conflicted about relationship, or feeling obligated by partner desire.

3. definition • — A man is considered to be impotent when he cannot acquire or sustain an erection of sufficient rigidity for sexual intercourse. Any man may, at one time or another during his life, experience periodic or isolated sexual failures. The term "impotent" is reserved for those men who experience erectile failure during attempted intercourse more than 75 percent of the time.

5. Etiology of erectile dysfunction • 25% each are due to: • drug side effects • endocrine abnormalities • psychogenic • diabetes/neurologic/urologic disease combined

6. evaluation

7. Sexual history takingGeneral physical exam • Are you having sexual relations currently? If so, with men or women or both? If not, when did you last have sexual intercourse? Are you satisfied with the frequency and quality of your sexual experience? Do you have more than one sexual partner?

8. Sexual history takingsexual complaint • Assess libido/arousal: do you have sexual thoughts? How often do you want to have sex with your partner • Assess erectile function: how often do you get an erection when you want to have sex with your partner? Do you get nighttime erections? • Assess ejaculatory function:do you ejaculate too early, or is it difficult to ejaculate?

9. Causes of libido decline • Libido declines with androgen deficiency [1], depression [2], and in association with the use of prescription and recreational drugs.

10. Causes of erectile dysfunction1. Drug side effects • Spironolactone • Sympathetic blockers such as clonidine, guanethidine, or methyldopa • Thiazide diuretics[9,10] • Most antidepressants (not wellbutrin)

11. Causes of erectile dysfunction1. Drug side effects • Ketoconazole • Cimetidine, but apparently not ranitidine or famotidine • Popular nonprescription chemicals such as alcohol, methadone, heroin and cocaine[11]

12. Causes of erectile dysfunction2.endocrine abnormalities • Hypogonadism • hypo or hyperthyroidism • hyperprolactinemia

13. Causes of erectile dysfunction3. psychogenic • Was onset of ED instantaneous (one time, and then ever since) except for post surgical nerve damage, this is always psychogenic • common in first-time encounters, conflicted relationships, when patient feels obligated to have intercourse but does not want to.

14. Causes of erectile dysfunction4. Diabetes/neurologic/urologic • Diabetes: rarely a presenting symptom, if your patient doesn’t have diabetes and is without symptoms, not a concern • neurologic: abdominal surgery, stroke, spinal cord abnormality • urologic: will have associated urinary or bowel difficulties due to prostatic cancer or hypertrophy

15. Causes of delayed ejaculation • SSRI’s • trazodone/serzone • prostate surgery (retrograde ejaculation)

16. Other important history • Rapidity of onset — Sexually competent men who had no sexual problems until "one night when they could not perform" and thereafter become impotent invariably have psychogenic impotence. This problem may be caused by performance anxiety, disaffection with the current sexual partner, or some other emotional problem; psychologic counseling is the preferred therapy in this setting. Only radical prostatectomy or other overt genital tract trauma causes a sudden loss of male sexual function [4]. In comparison, men suffering from impotence of any other cause complain that sexual function failed sporadically at first, then more consistently.

17. Other important history • Erectile reserve — In men presenting with a complaint of inability to develop erections, the presence or absence of spontaneous erections is an important clue to diagnosis. Most men experience spontaneous erections during REM sleep, and often wake up with an erection, attesting to the integrity of neurogenic reflexes and corpora cavernosae blood flow. Information regarding nocturnal or early morning erections can be elicited by history from patient and/or partner, but proof may require nocturnal penile tumescence testing. Complete loss of nocturnal erections is present in men with neurologic or vascular disease.

18. Other important history • Nonsustained erection with detumescence after penetration is most commonly due to anxiety or the vascular steal syndrome. • With anxiety, a conscious or subconscious concern about maintaining erectile rigidity activates an adrenergic hormone release, which is inimical to maintaining erectile turgor and rigidity. Sensate focus exercises are effective in restoring erectile confidence and competence in this setting. • In the vascular steal syndrome, blood is diverted from the engorged corpora cavernosae to accommodate the oxygen requirements of the thrusting pelvis . Vascular surgery to ensure equitable genital and pelvic arterial inflow is obligatory

19. Physical exam • A careful assessment of femoral and peripheral pulses as a clue to the presence of vasculogenic impotence. If pulses are normal, the presence of femoral bruits implies possible pelvic blood occlusion. • A search for visual field defects, present in hypogonadal men with pituitary tumors. • A breast examination to detect gynecomastia, often present in Klinefelter's syndrome

20. Physical exam • A search for penile strictures indicative of Peyronie's disease. • Examination of the testicles looking for atrophy, asymmetry or masses. • Evaluation of the cremasteric reflex, an index of the integrity of the thoracolumbar erection center. This is elicited by stroking the inner thighs and observing ipsilateral contraction of the scrotum.

21. Lab evaluation • Testosterone level (free t4 required only if obese or >65), consider peak 8 am and trough 8 pm when evaluating result, can be 30% difference • prolactin level • TSH

22. NPT testing • Nocturnal penile tumescence testing — NPT testing, once a tedious, laborious and expensive process performed only in a hospital sleep laboratory, has been simplified. Devices such as the Rigi-Scan monitor provide accurate, reproducible information quantifying the number, tumescence and rigidity of erectile episodes a man experiences as he sleeps in the comfort of his own bed [15]. The data generated can be downloaded to provide a graphic index quantifying erectile activity as either normal or impaired . • Impotent men with normal NPT are considered to have psychogenic impotence whereas those with impaired NPT are considered to have "organic" impotence usually due to vascular or neurologic disease. In comparison, testosterone deficient hypogonadal men are still capable of exhibiting some erectile activity during nocturnal penile tumescence studies

23. Treatment:primary carePLISSIT • Permission giving (P) — This first stage can be accomplished by indicating that certain sexual practices (such as oral sex) are normal and practiced by many couples. Individuals may be inhibited by fear that certain desires or practices are abnormal. If the physician is comfortable in normalizing such actions, sexual functioning may be enhanced or restored for couples.

24. Treatment:primary carePLISSIT • Limited information (LI) — This involves helping patients who have limited information about certain aspects of sexual function by explaining normal changes that occur with aging. Some couples and individuals may benefit from an understanding of the importance of foreplay or normal aspects of male and female arousal. The effect of antihistamines in reducing vaginal lubrication is an example of information that may not be widely appreciated.

25. Treatment:primary carePLISSIT • Specific suggestions (SS) — Specific suggestions include advice on subjects such as the use of estrogen, KY jelly, removing a TV from the bedroom, and installing a lock on the bedroom door.

26. Treatment:primary carePLISSIT • Intensive therapy (IT) — Intensive therapy should probably be accomplished by referral to a specialist because of both time and expertise considerations. However, a motivated primary care provider can become knowledgeable in most aspects of intensive therapy if he or she desires.

27. Treatment3 methods • Sildenafil, penile self-injection programs with vasoactive drugs, vacuum erection devices, or penile prostheses • testosterone therapy • psychotherapy

28. Drugs and devices • Sildenafil, penile self-injection programs with vasoactive drugs, vacuum erection devices, or penile prostheses allow many men with vasculogenic, neurogenic, or psychogenic erectile dysfunction to acquire and maintain erections.

29. How to use sildenafil (viagra) • Don’t skip history and physical, also measure hormones • prescribe 25, 50, or 100 mg tab to be taken 30 min to 4 hrs before intercourse. • Contraindicated if patient taking nitrates

30. Sildenafil (cont.) • reduce dose if >65 or impaired liver or kidney function • most common side effects: flushing, headache, dyspepsia. Blue-tinted vision interesting but unusual • caution in men with occult CAD--?worsening infarction/arrhythmia vs. increased exercise stress of sexual fxn

31. ACC consensus statement: besides nitrates, avoid use in • active coronary ischemia (eg, positive exercise test) who are not taking nitrates • heart failure and borderline low blood pressure or low volume status • complicated, multidrug, antihypertensive drug regimen

32. New viagras • Other phosphodiesterase inhibitors — Newer, more selective and more potent phosphodiesterase inhibitors are in development; tadalafil and vardenafil. Both appear to have a more rapid onset of action, and a longer duration of action than sildenafil, allowing for more spontaneity in sexual activity . Neither changes in color vision (blue vision) nor cardiovascular complications have been reported thus far. Both drugs are expected to become available in 2003

33. Books for patients • 1. The new male sexuality, by Bernie Zilbergeld, Ph.D. practical book debunking sex myths, has exercises for ED, losing erections, premature ejaculation. Humorous, useful, good anatomy descriptions. About $10 at amazon.

34. Books for patients • 2. The passionate marriage: love, sex, and intimacy in emotionally committed relationships, David Schnarch, Ph.D. A little higher reading level, better for couples looking to understand sexual politics in their marriage, emphasizes improving sexuality through growth and commitment.

35. Case #1 • 66 yo man requests viagra. When you ask why, he says he recently broke up with his girlfriend in the Philippines. When he had intercourse with prostitutes after that, he had difficulty achieving and maintaining erection. • What else do you want to know?

36. Case #1 continued • Meds: none • prior history of erectile dysfunction: only occasional, never premature ejaculation • has plenty of libido, evidenced by sexual thoughts about attractive women • when he maintained erection, he was able to ejaculate

37. Case #1 (continued) • Surgical history: had bladder resection for bladder cancer 2 years ago. Had unusual nerve sparing abdominal approach in order to maintain erectile function. • Physical exam is unremarkable, except for surgical scars. • What do you do now?

38. Case #2 • 45 year old male requests viagra. He says he doesn’t care very much but his girlfriend told him to bring it up. He gave up methamphetamine, cocaine, and marijuana 6 months ago, along with his girlfriend. • What do you want to know?

39. Case #2 (continued) • Meds: trazodone for sleep • specific trouble: usually has intercourse in the mornings, is frustrated that his early morning erection goes away after urination • drug history: used to rely on cocaine or meth for prolonged erections • libido: present

40. Case #2 • ejaculation: ok when he can maintain erection • who is more bothered?: he says he doesn’t care very much, his girlfriend would like to have IC 2-3x a week but he gets interested only every 7-10 days. • physical exam: noncontributory

41. Case #3 • 38 yo patient on paxil for depression complains that he can’t have sex any more. He began paxil 3 months ago for depression and it’s working well. • What else do you want to know?

42. Case #3 • only gets erections 1/3 as often as he used to, and has to have intercourse or masturbate for 20-30 minutes to achieve ejaculation • denies drug or alcohol use. • Physical exam normal • no surgeries

43. Case #3 • Has 18 year old girlfriend, feels guilty about this.