Alternative Medicine Guide

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.

Combination drug therapies

admin — Wed, 18 Mar 2009 00:26:13 +0000

There has been long experience with combinations of different drugs used for intracavernosal injection, although they are unapproved and there is limited evidence for their efficacy and safety. ‘Trimix’ (papverine 30 mg/ml, phentolamine I mg/ml, alprostadil 10 fxg/ml) and ‘bimix’ (papverine 30 mg/mJ, phentolamine I mg/ml) are widely used at varying doses in urological practice in the United States, although less so in Europe. Bimix is offered where the alprostadil component of Trimix causes bothersome penile pain. These combinations have been reported as effective when alprostadil has failed as a single agent. Papaverine was first reported as an effective pharmacotherapy for ED in 1982; with the addition of phentolamine, Bimix has been used since 1983, with Trimix being used rather more recently.

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.

Simple sex education

admin — Wed, 18 Mar 2009 00:14:03 +0000

Basic sex education: This is the vital first step in effective treatment, leading to a successful outcome, in which the indi’ vidual or couple can enjoy ‘a satisfactory sexual experience’, rather than just get erections. Do not underestimate its impor tance and do not omit it.
Many men, including a large number of doctors, have a lamentably poor understanding of their sexuality and sexual function. Personal sex education is frequently delegated by parents to schools and tends to concentrate on reproductive biology, sexually transmitted diseases, and preventing unwanted pregnancy. We are not educated in how to enjoy our own sexual feelings, or in understanding our partner’s sexual needs and how we might best help them to fulfil them. Biology and Personal Development classes would probably be better attended if we did. Good role models are hard to find and, at present, most people learn from experience.
In addition to challenging the sexual myths mentioned earher, helping men to understand the normal changes in sexual responsiveness that occur with aging is important. As men and women get older, changes occur in their attitudes toward, and experience of, sex. These changes should not always be seen as health problems, or ‘getting old’, but part of a natural development of their sexuality that began in childhood and will continue throughout their lives. Older men often find that it takes longer for them to develop an erection. Young men often develop erections at the slightest sexually exciting thought or sight, which can be highly embarrassing for them. Older men, and their partners, often worry that they no longer get an erection when they think about sex or see their partner naked. They are convinced that this is a sign of serious illness or that they are becoming ‘impotent’. This is incorrect. Older men frequently require direct genital stimulation to achieve erection. It may take 5 or 10 minutes to develop, rather than seconds, as in their youth. In addition, they will often try and attempt intercourse before their erection is rigid, which is likely to result in penile buckling, loss of erection, and embarrassment. Drugs will probably deal with this problem, although achieving ‘cure’ through education must be the most desirable approach. Couples should be encouraged to enjoy the changes in sexual responsiveness that come with aging, rather than to simply fight against them. This does not mean that they must inevitably ‘give up’ on sharing sexual intimacy though.
If you feel that you are unable to address all of the necessary issues yourself, offer referral to a sexual and relationship therapist. However, some will refuse this and you may be their only source of appropriate sex education.

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.

The importance of choice for individuals and couples

admin — Wed, 18 Mar 2009 00:07:15 +0000

Individuals and couples will have their own preference for a particular therapy, as it may suit their own sexual lifestyle. The majority of men will select a PDE5 inhibitor as their first treat’ ment of choice. Although the three currently available drugs in this class share a common mode of action, there are subtle pharmacO’ kinetic differences among them that may be of importance to the couple that is unrecognized by the physician. The most obvious difference among them is that tadalafil has a much longer half’ life and duration of effect than sildenafil and vardenafil (about 17 hours, compared with about 4 hours). Preference studies show conflicting results w i t h each of the three drugs being most frequently preferred in different studies. However, it is clear that if men are given a choice of PDE5 inhibitor, they will express a preference for one. Perhaps the best approach is to allow men to t ry more than one and find which suits them best.
Couples will sometimes select other options as first choice: VTD and sex therapy are perfectly reasonable options, as their use is more or less without risk. Couples indicating a first preference for injections, transurethral pellets, or even implants should be carefully counseled about the risks and benefits of each option and encouraged to at least try lower’risk alternatives. Ultimately, the couple should be allowed to make an informed choice regarding their treatment option.

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.

Mental health problems

admin — Tue, 17 Mar 2009 23:58:55 +0000

Depression: Depression and its treatments are strongly associated with ED and other sexual dysfunctions. Sometimes depression causes these problems and sometimes the problems cause depression. Taking a careful history may help clarify the situation. Both problems warrant treatment and should be managed concurrently. There is evidence that treating ED can improve depressive symptoms. However, depression is a serious, potentially lifc’threatening condition and should be treated aggressively.
All antidepressants have the potential to cause sexual dysfunction. Modern tricyclic antidepressants (TCAs) are probably no worse than selective serotonin reuptake inhibitors (SSRIs) in this respect. Older TCAs, with marked sedative and anticholinergic effects, are more likely to cause ED. SSRIs are known to delay orgasm or even cause anorgasmia. They are sometimes used as a treatment for premature ejaculation. They can also cause loss of sexual drive and, less frequently, ED. Newer antidepressant agents, particularly those not working through the serotonin system (e.g. mirtazepine, nefazodone, and reboxetine) may be less prone to cause sexual side effects.
Patients who are depressed or who are receiving treatment for depression should be routinely questioned about sexual function while reviewing the management of their depressive illness. For some, sexual intimacy allows them to escape from the pain of their depressive illness. It is both appropriate and a kindness to offer treatment for ED to affected men w i t h depression. Schizophrenia and other psychoses: Sexual function in men with schizophrenia and other psychotic illness is often neglected while attention is paid to their mental health problems. Most men with relapsing psychotic disorders remain well for most of the time and wish to enjoy sexual relationships. The majority of antipsychotic agents, including several atypical antipsychotics, are centrally acting dopamine antagonists and cause hyperprolactinemia. This can, in turn, cause loss of sexual drive and ED.
The atypical antipsychotic quetiapine seems less prone to cause sexual side effects. Anticholinergics, used to ameliorate other side effects, can add to the problem. Modification of dosage or drug can improve sexual function, but this should only be attempted in collaboration with a psychiatrist.
Men with schizophrenia and other psychotic illness should be routinely asked about sexual function and, where appropriate, treatment should be offered.
Cognitive impairment and dementia: The development of cognitive impairment and dementia often has a devastating effect on a relationship. However, some couples continue to enjoy a satisfactory sexual relationship and, provided that the rights of the cognitively impaired partner are respected and protected, treatment for ED should be offered.