Alternative Medicine Guide » sexual

Sex is a central part of the human experience

admin — Wed, 18 Mar 2009 00:27:43 +0000

Sex is a central part of the human experience and to deny this is to deny our humanity. Whilst some people make a choice to remain celibate and clearly enjoy wholly fulfilling lives, for the vast majority sex remains important to them throughout their adult lives.
Traditionally, ED has been the almostexclusive preserve of the urologist and psychiatrist. In the past 20 years, a new discipline of sexual medicine has evolved, as our scientific understanding of human sexuality has evolved. Urologists still play an important leadership role in this field and many are amongst the increasing ranks of ‘Sexual Physicians’, offering holistic care to men and women with sexual concerns. They use biomedical and psychotherapeutic techniques and have skills in psychology, different disciplines of internal medicine, and gynecology, as well as urology.
Treating ED effectively and well is a tremendously satisfying professional experience. Almost every individual and couple will benefit from the support, education and therapeutic interventions offered. Even if they are unable to fulfil their expectations of treatment, the therapeutic experience will have informed them and will often have enabled them to better adapt to their situation.
Physicians who treat ED and other sexual problems are not just in the business of helping people have sex. They promote relationships; they help people to communicate more effectively and to share intimacy. They don’t just treat men’s penises, they help couples and families. There are demonstrable social benefits from treating ED and sexual problems; the few reports of adverse social outcomes are far outweighed by the positive social benefits to millions of people worldwide.

Treatment of ED after radical prostatectomy

admin — Wed, 18 Mar 2009 00:23:42 +0000

The majority of men who have had a radical prostatectomy will have ED for at least a limited period, and some will have permanent problems that are resistant to oral therapies. They present a particularly challenging group to treat, and management strategies are still evolving.
The likelihood of a man experiencing post-radical prostatectomy ED is influenced by his pre-operative potency, his age (ED is more likely if over 65), and the achievement of intra-operative nerve preservation (ED is more likely if one or both cavernous nerves are sacrificed), Pre-operative counseling about sexual and erectile function should be included in the routine care of men facing radical prostatectomy, and it is preferable to involve their partners too. The type of post-operative treatment regiments offered should be discussed. If possible, they should have pre-operative treatment for any pre-existing ED; this will not only allow them to enjoy sexual intimacy but also give the physician an idea of ‘baseline’ erectile function.
Traditionally, men w i t h ED after radical prostatectomy would be offered the same treatment regiment as men with ED resulting from other causes (i.e. on-demand use of PDE5 inhibitors introduced at a time of the patient’s choosing after surgery). Pioneering research by Montorsi and colleagues in the late 1990s suggested that men who were restored to potency by the early post’operative introduction of intracavernosal injection therapy had a better chance of recovering normal erectile function, without medication. This suggested that an ‘erection rehabilitation program’ after radical prostatectomy might offer men a better chance of recovering normal erectile function. Further work by Mulhall and colleagues has shown that the early introduction of oral therapy may confer a similar benefit in men able to achieve at least a partial erection response to sildenafil 100 mg. Responsive patients were instructed to use sildenafil to obtain an erection three times a week. Non-responders were offered intracavernous injections as an alternative but were rC’challenged with sildenafil every 4 months after surgery. Subsequent responders were offered transfer to the oral therapy regime. There was a statistically significant difference (p<0.001) in the percentage of patients who could obtain a functional erection without medication at 18 months after surgery between those who had participated in the rehabilitation program (52%) and those \vho had not (19%). Although there are methodological flaws in this study, which were acknowledged by the authors, this striking difference has resulted in many centers offering similar rehabilitation programs to their patients.
It has been speculated that the mechanism by which this apparent benefit is achieved is through maintaining intermittent cavernous re-perfusion and oxygenation, resulting in a reduction in smooth muscle apoptosis. This prevents disruption of the veno occlusive mechanism of erection until cavernous nerve function has recovered adequately for normal erections to resume. Further research is necessary to confirm these interesting findings and to identify the optimal rehabilitation treatment regiment. Three erections a week was an arbitrary choice of convenience; normally potent men will have far more frequent nocturnal and stimulated erections. There is also the issue of cost, inconvenience to the patient, and the possibility of treatment-related adverse effects with oral therapy or, more likely, injection therapy In any event, it seems that rehabilitation programs may offer the hope of better recovery of erections in this difficult to-treat group of patients.

Sexual and relationship therapy

admin — Wed, 18 Mar 2009 00:20:21 +0000

Sexual and relationship therapy is an important clinical discipline, which requires specific training. It is far more than an extension of general counseling. Practices that do not have such a therapist available ‘inhouse’ will have to refer appropriate individuals or couple to an accredited sexual and relationship therapist.
Sexual and relationship therapy may be considered a specialized branch of psychotherapy. It usually involves the use of cognitive behavioral techniques aimed at the relief of the individual’s (or couple’s) sexual dysfunction, involving sex education and the practice of sexual and communication tasks as a part of the treatment process, with regular feedback sessions with the therapist.
It differs from psychoanalytic treatment, which attempts to resolve unconscious conflicts that might be causing dysfunction, and marital therapy, which attempts to improve a couple’s general relationship quality by helping them to resolve unrecognized conflicts. Psychoanalytic and marital therapy techniques may be used by a therapist, but are not at the core of sexual and relationship therapy.
Sexual and relationship therapy is generally considered effective treatment for ED, although this has not been unequivocally demonstrated in trials. A ‘success rate’ of around 60% is commonly quoted, although the size and durability of effect is uncertain. It is likely that older men w i t h complete ED, diabetes and severe vascular disease are less likely to respond than younger men with intermittent or situational ED, and no concomitant medical problems.
Sexual and relationship therapy is effective in the treatment of premature ejaculation, delayed or anorgasmia (for which there is good research evidence), and vaginismus.
It may also be beneficial in desire disorders, although those affected should also have an appropriate endocrine and medical assessment.

APOMORPHINE

admin — Wed, 18 Mar 2009 00:18:06 +0000

Mode of action: Apomorphine is a centrally acting drug for the treatment of ED; it is not approved in the United States, although it is available in Europe. CNS control of sexual function is thought to be maintained through a balance of inhibitory and excitatory systems, influenced by androgens and by erectogenic stimuli from centers of the brain concerned with sight, sound, smell, touch, and cognition. A variety of neurotransmitters are involved but, simplistically, the primary neurotransmitter of central sexual inhibition is serotonin, and of central sexual excitation, dopamine. Apomorphine activates dopamine D2 receptors in the hypothalamus and has the potential to both initiate an erection and enhance responsiveness to erectogenic stimuli.
Use in practice: Proper counseling about the use of any therapy is vital to a successful outcome, but particularly so with ED therapy. Apomorphine is taken sublingually and it is essential that the patient be told to pop it under the tongue, and to allow it to dissolve slowly rather than suck or swallow it. If it is swallowed, it will probably be ineffective, because of the very high proportion of drug metabolized on the first pass through the liver. The 2’mg tablet is pentagonal, and the 3’mg, triangular.
The response rate to apomorphine is significantly less than for the PDE5 inhibitors. A randomized, placebo’controlled, crossover study comparing apomorphine 3 mg with sildenafil 50 mg in the treatment of ED of mixed etiology and severity reported attempts resulting in erections firm enough for intercourse in 44% of men taking apomorphine and 85% of men taking sildenafil [51]. One of the proposed advantages of apomorphine is its relatively rapid onset of action. Clinical trial evidence shows that 71% of responders will achieve an erection within 20 minutes of putting the tablet in their mouths. Apomorphine can be taken once every 8 hours. All men should start with one dose of the 2’mg presentation. They should increase this to 3 mg if the starting dose is well tolerated. Only 15% of men will respond to 2 mg, but dose titration will reduce the risk of users suddenly experiencing unwanted side effects. It is important not to label men ‘nonresponders’ because they do not respond to the first few doses of apomorphine. Some men will give up after just one or two unsuccessful attempts with oral therapy. It should be explained that there is often considerable general and performance anxiety surrounding the use of a new ED medication, which will tend to inhibit erectile responsiveness.
In addition, if men are paying for apomorphine themselves, they may not understand why it is necessary to keep taking a drug that doesn’t work first time. They should be advised to take at least eight doses of 3 mg, in an appropriate environment and with adequate sexual stimulation, before deciding whether or not it is effective for them.
As with PDE5 inhibitors, nonresponders should be closely questioned about how they took the drug, how many doses they had taken, and under what circumstances. Genuine non responders should be offered appropriate alternative therapies. Adverse effects: Because of its relative selectivity for the dopamine D2 receptor, apomorphine is reasonably well’tolerated and there is a low incidence of dopaminergic side effects, such as nausea, vomiting (probably D3 receptors), and hypotension (probably D5 receptors).
In trials of 2’mg and S-mg tablets, 6.8% of men reported nausea, 6.7% reported headaches, 4.4% reported dizziness and 0.2% reported syncope. The reported nausea was usually mild and tended to disappear with repeated use. More than 90% of those men who reported syncope experienced premonitory vasovagal symptoms. Men should be warned not to drive for 2 hours after taking apomorphine, although this is unlikely to be a significant disadvantage for the majority of users. It is sensible to advise users to avoid all potentially dangerous activities, such as climbing ladders or operating machinery, for the same period.
Use in cardiovascular disease: All ED therapies, including apomorphine, are contraindicated in men with severe unstable angina, recent MI (within 4 weeks), severe heart failure or hypotension, and other conditions where sexual activity is inadvisable.
It should be used with caution in men with a history of uncontrolled hypertension, known hypotension, postural hypotension, or those with compromised renal or hepatic function. Apomorphine can be used with caution in men taking anti’hypertensives or nitric oxide donor medications, such as nitrates and nicorandil.
There are published authoritative guidelines on the use of ED therapy in men with cardiovascular disease. Drug interactions: Special care must be taken in prescribing apomorphine to men taking other drugs that act on dopamine receptors, such as antipsychotics and antiemetics, Apomorphine is a dopamine D2 receptor agonist and most antipsychotics are dopamine D2 receptor antagonists. It seems sensible that if a combination is prescribed, then the patient should be foUowed up more carefully for the first weeks of treatment. There is no evidence that the sublingual presentation of apomorphine has any effect on antipsychotic therapy but there may be theoretical risk of precipitating a relapse of psychotic illness. It should not be used in combination with sildenafil or other ED therapies.

Providing a quality service

admin — Wed, 18 Mar 2009 00:09:57 +0000

Continuing professional development: In order to be able to provide a high’quality service to men and couples affected by ED, it is essential to maintain the appropriate knowledge and skills. This task should be approached in a holistic manner; to provide high’quality care, the physician needs to have a wide range of resources in sexology, urology, gynecology, and internal medicine.
While factual knowledge can be obtained from reading and personal study, skill acquisition is more difficult. Many doctors will find talking about sexual issues uncomfortable and struggle for appropriate language that is intelligible to clients without being too simplistic or too crude. Videos have been produced that illustrate the difficulties, but these are no substitute for practical experience. If you are unable to find a suitable skill acquisition course to attend, t ry working in pairs or threes with partners or local colleagues, using case vignettes.
To begin with, discuss the case together, first exploring the clinical issues (which most people will feel more comfortable with) and then the communication issues. Draw up a list of words and expressions used to describe body parts and sexual behavior. What words might be used instead of penis, vagina, sexual drive and desire, erection, lubrication, masturbation, oral sex, intercourse, orgasm, and ejaculation?
Next, when you feel more comfortable, try role-playing the consultation. Take it in turns to act as patient and physician (and observer, if you work in threes). Focus on the communication issues to begin with. The person playing the patient should decide on what language to use and then use it consistently. The person playing the doctor should ensure that they understand the language used by repeating and seeking clarification. For example, if the patient says “I’m having trouble with my arousal”, the doctor might ask “arousal?” or “can you explain to me what you mean by arousal?”, or “by ‘arousal’, do you mean erection?” Involving the extended healthcare team: Other members of your extended healthcare team may have the interest, knowledge and skills to contribute to the assessment and management of men with ED. In many countries, specialist nurses make a major contribution to ED and sexual healthcare; they are often seen by men as more approachable than doctors.
Practice administrative staff may feel uncomfortable about discussing sexual issues, and even find it uncomfortable to pass on information or make appointments for men with ED. Care should be taken to provide them with appropriate information, training, and support, so that they are able to deal with such matters in an open-minded and non-judgemental manner, respecting the confidentiality of affected individuals at all times.

Principles of taking a sexual history

admin — Wed, 18 Mar 2009 00:04:17 +0000

Taking a sexual history presents different challenges to the physician, not least because most physicians have had little or no training or experience in doing so. Many people, both lay and professional, find talking about sex uncomfortable to a greater or lesser degree. Many people, again both lay and professional, have their own beliefs, rooted in the culture and religion of their upbringing, about what is acceptable sexual behavior and what is not. The ability to talk freely about sexual behavior and lifestyles is a skill that must be acquired if the physician is to help people with sexual problems. If, for whatever reason, they find themselves unable to do this, it is better that they acknovsledge the fact and promptly refer people with sexual problems to a colleague. There is no shame in doing this, but it is shameful to withhold treatment or discriminate against people who adopt sexual lifestyles and behaviors that are legally acceptable, but at variance with our own belief system.
In general, the foUowing principles of taking a sexual history should be considered.
• Use appropriate language — for the understanding and comfort of the couple. Keep checking that you all agree what particular words and expressions mean. For example, ‘arousal’ may mean ‘sexual excitement’ to one person, ‘erec’ tion’ to another and ‘orgasm’ to a third.
• Allow adequate time for the consultation. Even relatively straightforward problems will take 20—30 minutes to assess. This may seem like a long time, but is really not much different from the time that is spent in assessing a patient with newly diagnosed asthma or diabetes. It may not be possible to accommodate a consultation of that length in a normal clinic appointment. In this case, a special appoint’ ment or, less desirably, spreading the assessment over more than one consultation might be more appropriate.
Privacy and confidentiality — ensure that complete privacy is possible and that the confidentiality of both partners is maintained.
Consider the cultural and religious beliefs of the couple and how these might affect their sexual behavior, their response to questions of an intimate nature, and the acceptability of physical examination to them.
Beware of recording third-party information in the patient’s notes. You should not record identifiable details of the partner’s sexual behavior or problems other than in their own notes.

Endocrine disorders

admin — Tue, 17 Mar 2009 23:54:40 +0000

Endocrine disorders may cause ED and, in some cases, may be one of the few etiologies whose resolution might lead to a ‘cure’. Consequently, such disorders should be routinely sought out in the assessment of men with ED. However, as ED is multifactorial in origin, an endocrine disorder might be only a contributory factor to the problem. Endocrine disorders commonly seen in ED patients include diabetes, thyroid disease, androgen deficiency, and hyperprolactinemia.
Diabetes: Diabetes is the most common endocrine abnormality associated as a risk factor for ED. The prevalence of ED is almost three times higher in diabetic men (28%) than in the nondiabetic population (9.6%). Diabetes is associated w i t h dyslipidemia, neuropathy and smooth muscle dysfunction, all of which are associated with ED. Although there is little evidence that improving glycemic control in diabetics improves their erectile function, there is some evidence that high glycosylated hemoglobin (HbAIC) levels impair smooth muscle function. Thus, there are theoretical grounds for believing that improved diabetic control is advantageous in ED, although this alone will not normally restore erections. Diabetics are a difficult group to treat for ED, as their response rate to drug therapies, such as sildenafil, is lower than in most other groups. Diabetic men also commonly have reduced androgen levels.
Thyroid disease: There is an association between hyper thyroidism and ED. This may be due to a hyperthyroidismrelated increase in sex hormone-binding globulin (SHBG) levels and increased aromatization of testosterone to estrogen. Restoring the euthyroid state may resolve the ED. Androgen deficiency: Androgen deficiency in the adult male becomes more common with increasing age, but its management remains controversial. As well as sexual dysfunction, androgen deficiency is associated with osteoporosis, dyslipidemia, metabolic syndrome and depression. Far from being a benign consequence of aging, it is a significant cause of increased cardiovascular risk. Androgens act at several sites in the sexual response system: within the CNS, peripheral nitrergic nerves, and corpora cavernosa. Androgen deficiency may affect sexual interest, erections, and responsiveness to PDE5 inhibitors.
Identification of androgen deficiency is based upon the identification of its non-specific clinical features and blood testing. Choice of assay is between total, free (unbound to plasma proteins), and bioavailable testosterone (unbound to SHBG). Free testosterone is probably the most reliable assay, as it is not affected by changes in SHBG levels. However, the most reliable direct measure, equilibrium dialysis, is only available in research laboratories; commercial radioimmunoassay are frequently unreliable. Calculated free testosterone is probably the best available surrogate. It can be derived from total testosterone, SHBG and albumin levels; an ou’line calculator can be found at www.issam.ch.
As there is a diurnal variation in testosterone release, samples for testosterone assay should be drawn in the morning, between 08.00 and 11.00. The assay should be repeated after 2 or 3 wrecks, as testosterone is released in a pulsatile manner, as well as with diurnal variation, and the result of a single assay may be misleading.
Men with symptoms of androgen deficiency should be assessed and androgen replacement given on its merits. A screening questionnaire for androgendeficiency symptoms has been published, although it is of low specificity.
There is no evidence that giving testosterone to men with ED and normal androgen levels restores or improves their erectile function. Testosterone should be prescribed under specialist
supervision for men with established hypogonadism. Prior assessment and safety monitoring should be performed accor’ ding to contemporary authoritative guidelines.
Hyperprolactinemia: Hyperprolactinemia is associated with ED, loss of sexual interest and anorgasmia. It is frequently accompanied by androgen deficiency, as high prolactin levels suppress LH production and, consequently, cause hypogonadism.
Hyperprolactinemia should be excluded by blood testing in all men with reduced sexual interest. Moderate elevation of prolactin levels is unlikely to cause ED. Hyperprolactinemia is often due to stress and drugs (notably metoclopramide, chlorpromazine, and several other antipsy’ chotics). Only about one in ten of these men will be found to have a prolactiu’Secreting pituitary tumor, but these must not be missed. Hyperprolactinemia is common in men on dialysis for chronic renal failure. Unless an obvious cause is found and the prolactin levels return to normal, referral to an endocrinologist is advisable.

Cardiovascular disease

admin — Tue, 17 Mar 2009 23:50:03 +0000

Hypertension, coronary heart disease and ED frequently coexist.
Around 4 0% or more of ED patients may have some type of cardiovascular disease. Apart from representing a potential causative factor, the presence of underlying cardio’ vascular disease should be taken into consideration in patient management [10].
Hypertension: There is a strong association between hyperteu’ sion and ED. Around 17% of men with mitreated hypertension and 2 4% of men with treated hypertension have ED. It is not only antihypertensive therapy that causes ED, but hypertension itself. There is little evidence that treating hypertension will improve erectile function, although theoretically, the vascular remodeling and improvements in smooth muscle function might enhance erectile response. Hypertension kills people, through stroke, heart failure, and coronary heart disease. The development of ED can be an obstacle to patient compliance with antihypertensive therapy. Treating ED should not compromise achieving good blood pressure control using contemporary treatment guidelines [1,2]. Most men with welLcontroUed hypertension can be safely and effectively treated for ED; uncontrolled hypertension should be brought under control before ED therapy is initiated [18]. Men on such treatment should be routinely asked about their sexual and erectile function, regardless of age. There is no good evidence that changing antihypertensive agents improves erec’ tile function. Unless there is a strong temporal relationship between the introduction of a new drug and the onset of ED, it is unlikely that withdrawing a drug will be of benefit. There are theoretical grounds for suggesting that alphablockers, such as doxazosin, are less likely to cause ED than other agents. However, there is a potential interaction between alphablockers and PDE5 inhibitors that may result in significant hypotension in some patients. Caution should be exercised before co-prescribing these drugs, making reference to manufacturers’ recom’ mendations. Angiotensinconverting enzyme (ACE) inhibitors, angiotensin II (ATII) type I receptor blockers, and calcium channel blockers seem to have a fairly neutral effect on erections.
Modern beta-blockers, particidarly atenolol, are often blamed for causing ED, although the evidence for this is relatively poor. Propranolol and the older, centrally acting antihypertensives (e.g. clonidine) are more likely to cause ED. The evidence for thiazide diuretics causing ED is mixed but several long-term studies show a negative impact on erectile function.
Coronary heart disease: Coronary heart disease is associated with many of the same risk factors as ED, including dyslipidemia, hypertension, diabetes, smoking, and sedentary lifestyle.
Arterial disease in the heart is just one site in a generalized arteriopathy, which is likely to affect the ileal, pelvic, pudendal. and penile arteries, too. Urologists have been known to refer to ED as ‘atherosclerosis of the penis’ .
Research has shown that 4 4% of men who have had a myocardial infarction also have ED. This is probably due to more gener alized vascular disease, rather than impaired cardiac function. Psychosexual issues may also affect erection in men with coronary heart disease. They, and their partners, may be afraid that the exertion and excitement of intercourse could precipitate a further coronary episode.
The vast majority of men with coronary heart disease can safely resume sexual activity and use ED therapies. Education and appropriate counseling about sex should be given to all men with coronary heart disease so that the majority can continue to enjoy this important aspect of their relationship.
Men with unstable heart disease, a history of recent myocardial infarction, poorly compensated heart failure or unstable dysrhythmia are exceptions. Men taking nitric oxide-donor drugs must not take PDE5 inhibitors because of associated hypotension. ACE inhibitors, modern beta-blockers and calcium channel blockers, in normal doses, are unlikely to be a major contributory factor to the development of ED. Much the same can be said of nitrates and nicorandil. However, their use will absolutely preclude the use of PDE5 inhibitors as an ED treatment option. Unlike ACE inhibitors and beta-blockers, they convey no prognostic benefit with regard to the development of further coronary episodes. As such, one can consider their replacement with other anti-anginal agents. Some men may have been given a supply of glyceryl trinitrate
tablets or spray upon their discharge from hospital foUowing a coronary event, even though they do not have angina. They will often have been told to carry it with them at all times
and will have dutifully obeyed these instructions for many years, regularly refilling their prescription from their family physician, even though they never use the drug. Men who never use this medication should be reviewed by their cardiologist or family physician and, if appropriate, be advised that they do not need to carry nitrate therapy, thus enabling them to have PDE5 inhibitors as an ED treatment option.

ERECTILE DYSFUNCTION – ETIOLOGY AND RISK FACTORS

admin — Tue, 17 Mar 2009 23:40:00 +0000

ED is frequently described by its presumed etiology; for example, ‘vasculogenic’, ‘diabetogenic’, and’psychogenic’. Thesedescrip’ tions can be very misleading and it is better always to think of ED as a health problem with multifactorial etiology. This is illustrated in the following two examples.
Originally, psychological factors were considered to be the most common cause of ED. However, it is now apparent that psychological factors alone account for a minority of cases of ED, particularly in older men. It is far more common for psychological and organic factors to co-exist.
Psychosexual factors exist in every man affected by sexual dysfunction, although the patient might protest that they do not. The ability to achieve erection and fulfil one’s sexual role is central to the concept of ‘maleness’, even in the most self-aware and well-adjusted individual.
The presence of psychosexual factors should always be considered and sought out because, if they are not addressed, they may lead to ED treatment failure. Inadequate sexual knowledge: Sex education often focuses on reproductive biology, and the prevention of sexually transmitted infection and unviranted pregnancy. Sexual behavior is not usually addressed in any detail. This has led to the acceptance of many ’sexual myths’, which lead men to mistakenly believe that they have ED.
Some sexual myths:
• A man should aWays be interested in sex
• A man should always be able to get an erection in a sexually exciting situation
• A man should always be able to ‘give’ his partner a ‘good’ orgasm
• Good sex always involves having a simultaneous orgasm with your partner
• A man should always be in control during sexual intercourse
• A man should always be able to delay his orgasm during intercourse
• Erection problems are always a sign of cancer or other serious illness These myths are further propagated by the portrayal of sex in the media. Films often show two young, slim, heterosexual and attractive people having prolonged intercourse, the woman enjoying multiple orgasms with the man confidently in control,
until they both collapse with an earth’shattering simultaneous orgasm. Alas, sex is not normally like that. On average, intercourse lasts about 9 minutes (although it may be much briefer), is often enjoyable but rarely tumultuous, and we are not all young, slim and attractive. Performance anxiety: Performance anxiety can be a cause of ED at any age. Anxiety, whatever its cause, leads to an increase in catecholamine production and sympathetic vasomotor tone, opposing and, potentially, suppressing erection. General anxiety related to other life events may cause this problem, but performance anxiety is specifically related to erection and intercourse. Typically, the affected man is able to get an erection in response to sexual thoughts and daydreams, and with masturbation (although often not in the presence of his partner). He will usually continue to experience nocturnal and early morning erections. When with his sexual partner, he will experience anxiety that he will not be able to attain or maintain an erection during intercourse. If this has happened in the past, he will remember the embarrassment that this caused him, particularly if his partner made a critical comment about it. He may be able to get an erection during the early stages of the
sexual encounter, only to lose it when he attempts penetration, or even during intercourse. There are effective therapies for this problem, psychological and pharmacological, but some men will deny the problem, or conceal it. Relationship problems: ED may be the presenting feature of general relationship problems that extend beyond just the sexual relationship. Where ED is the consequence of a relationship problem, the affected man will often still have an erection with imaginative, visual or masturbatory stimuli,
and will usually continue to experience nocturnal and early morning erections. It is only when he is with his sexual partner that he is not able to attain or maintain an erection adequate for intercourse. Occasionally men will complain of ED, even though they can still achieve erections rigid enough for intercourse. The real
problem might be that his partner will not allow intercourse and having ED or failing to respond to ED treatment might be less damaging to his feeling of selfworth. Taking a careful sexual and relationship history will usually clarify the situation.
Relationship counseling and couple therapy are often essential parts of the management program. Simply providing the man with a means to achieve penile rigidity will not help the couple achieve a satisfactory sexual experience and may put the partner at risk of sexual abuse or violence. Concerns over sexual orientation and gender identity: Although relatively uncommon, concerns over sexual orientation and gender identity do occasionally present with ED. Gay men, who have been raised in an environment where homosexuality is unacceptable, often for cultural or religious reasons, may decide to abstain from sexual behavior altogether or to adopt an unwanted heterosexual lifestyle. They may experience sexual and relationship problems later in life, when they are no longer able to deny their true sexuality. Men with gender identity disorders have a firm conviction, usually held since childhood, that they are trapped in a body of the wrong gender (transsexualism), which can cause them varying degrees of distress (gender dysphoria). Some will adapt to their unwanted ‘maleness’ and lead a ‘normal’ life, perhaps with some adaptations to reduce their dysphoria. Others suffer profound and disabling gender dysphoria. This is characterized by a total disgust with all aspects of their born gender and an allencompassing desire to change their bodies, by hormones and sometimes by surgery, to the female gender. Transsexuals have no sexual motivation for their desire for gender change; where this is present, transvestism or fetishistic crossdressing are more likely diagnoses.

Pathophysiology

admin — Tue, 17 Mar 2009 23:29:53 +0000

As normal erectile function depends on the delicate balance between vasorelaxation and vasoconstriction of the corporal smooth muscle, disruption of this equilibrium can result in
ED. If this critical level of smooth muscle relaxation is not achieved, there vvill be incomplete resistance to the venous outflow of blood from the corpora and full penile tumescence will be compromised. This is described as veno’occlusive dysfunction and can result from deficiency of the various systems that support the normal integrated response for penile erection. Vascular factors: Probably the most frequent causes of organic ED are endothelial dysfunction and disturbance of smooth muscle responsiveness within the corporal tissue of the penis.
Decreased arterial flow and perfusion pressure to the lacunar spaces can result from atherosclerosis, or traumatic arterial occlusive disease, of the hypogastric’Cavernous arterial bed and may also be a contributory factor. Excessive outflow through the subtunical venules may result in incomplete tumescence despite sufficient arterial inflow. This can be caused by insufficient relaxation of the trabecular smooth muscle, which may occur in anxious patients with excessive adrenergic’constrictor tone, through damage to the parasympathetic dilator nerves, or by corporal smooth muscle dysfunction.
Neurological factors: Disorders affecting the sacral spinal cord or the peripheral efferent autonomic fibers to the penis can result in incomplete relaxation of the trabecular smooth
muscle. Also, disruption of the somatic fibers from the penis that transmit sensory stimuli to the thalamus and sensory cortex (via the pudendal nerve) may also result in ED.
Such neurogenic ED can arise from spinal cord injury, multiple sclerosis, peripheral neuropathies (secondary to diabetes), alcoholism, surgical procedures such as radical prostatectomy, or pelvic radiation therapy. Endocrinological factors: Androgens are necessary for normal sexual development but also influence sexual motivation and behavior. Androgens have been shown to influence the activity of nitric oxide synthase (NOS) and smooth muscle relaxation in the corpus cavernosum. Low levels of bioavailable testosterone may result from a wide range of causes, including changes in the sensitivity of the hypothalamic—pituitary—gonadal axis due to aging, primary hypogonadism, hyperprolactinemia, and the use of leutinizing hormonereleasing hormone (LHRH) agonists.
Diabetes is the most common endocrine abnormality associated as a risk factor for ED. ED may eventually develop in 60% of men with diabetes mellitus. The main causes of the associated ED are thouglit to arise from tiie vasculoeenic and neurological sequelae of the diabetes. In particular, endothelial and smooth muscle dysfunction and neurological damage to C fibers have been implicated. As many as 40% of diabetic men are also hypogonadal. ED is also associated with hyperthyroidism. Psychogenic factors: The brain is the most important source of proerectile signaling in response to sexual stimulation. Unpleasant tactile, visual, auditory, and olfactory stimuli will tend to inhibit erection. Unpleasant sexual fantasies, perhaps envisaging embarrassment and rejection due to loss of erection with a partner, and memory of poor past sexual experience or relationship dysfunction, will have a similar effect. If these unpleasant, erectolytic stimuli predominate, there may be inadequate central pro-erectile signaling to provide the degree of sustained cavernosal smooth muscle relaxation required for erection. Penile factors: Peyronie’s disease is associated with ED, although it may coexist with other causal factors. In a recent study, nearly a third of men Avith untreated Peyronie’s disease were found to have ED. Changes in the integrity of the fibroelastic components of the trabeculae may result in reduced compression of the subtunical venules. This may be the result of aging, increased cross’linkage of collagen fibers (induced by non-enzymatic glycosylation and hypoxia), altered collagen synthesis associated with hypercholesterolemia, or by trauma to the penis.