Male Sexual Dysfunction

Male Sexual Dysfunction

Sexual Dysfunction in Male College Students David Mellinger, MD Duke University And Steven Kraushaar, PsyD Washington Univ in St. Louis Objectives

Describe the relevant parts of the history and physical examination in a male with sexual dysfunction Compare the available medications used in the treatment of erectile dysfunction in terms of selection Discuss various psychological interventions in treating males with sexual dysfunction Premature Ejaculation (PE) Ejaculation that occurs sooner than

desired Loss of control over ejaculation and Causes distress to either one or both partners What is too soon? All agree Intravaginal Ejaculatory Latency Time (IELT) of less than 60

seconds is PE Most agree that less than 120 seconds is PE May be dependent on culture and expectation Perceived Normal Time to Ejaculation Montosori, J Sex Med (2005); 2 (suppl 2): 96-102

Overlap in IELT Distribution Patrick, et. al, J Sex Med (2005); 2: 358-67 Premature Ejaculation Epidemiology Most common form of sexual dysfunction Prevalence Rates vary from 4-39% ; most general studies in 21-31% range Rates generally not affected by age, marital status, race, or country of

residency Disconnect Between Diagnosed and Reported Prevalence of PE Male patients dont often spontaneously offer up this problem as a complaint Clinicians dont inquire about this common condition

More on the Disconnect Global Study of Sexual Attitudes and Behaviors 9% of men reported that they had been asked about their sexual health by an MD during a routine visit in the last 3 years 48% of men believe that an MD should routinely ask about sexual health

concerns Why dont patients report PE Embarrassment Do not medicalize the problem Perceive that their provider is not able or willing to address the

problem Why dont Providers Ask about PE Lack of provider comfort in discussing sexuality issues Lack of provider knowledge about PE Low prioritization by medical system of PE No physical comorbidities Time pressure

No FDA approved treatment options What Causes PE Exact etiology not fully known Combination of Physiologic and Psychological Factors

Primary PE more neurophysiologic while acquired PE more psychological or related to a medical condition Behavioral Theories of PE Learned Behavior Conditioned from Early Sexual Experiences (Masters and Johnson)

Role of Anxiety PEs Impact on Men Symonds et. al study* 68% said their confidence generally or in a sexual encounter affected low self-esteem 50% had relationship issues reluctant to form new relationships or were distressed not satisfying current partner 36% reported being anxious *Symonds et. al., J Sex Mar Ther (2003); 29: 361-370

Important Aspects of History Age at onset of disorder Frequency of PE (Consistent or Intermittent) Circumstance(s) when PE occurs Estimate of Intravaginal Ejaculatory Latency

Time (IELT) Any other sexual problems (e.g. ED)? How has it affected your relationship(s)? How has it impacted your sense of wellbeing? Physical Examination and Tests Physical exam is not helpful in diagnosing condition except in some secondary cases where neurologic

conditions or prostatitis are entertained No laboratory test available to confirm the diagnosis Can consider psychological tests to assess for anxiety disorder Treatment for PE Treat underlying cause (e.g. infection) if found Pharmacologic Interventions

Behavioral interventions Pharmacologic Interventions Topical anesthetics Tricyclic antidepressants (TCAs)

Selective Serotonin Reuptake Inhibitors (SSRIs) Phosphodiesterase-5 (PDE-5) inhibitors Topical anesthetics

Mode of Action: Desensitize penis and therefore increase IELT Example: Lidocaine/prilocaine cream How to use: Apply to penis 20-30 minutes prior to intercourse, wash off before sex Potential problems Loss of pleasurable sensation for male and partner Contact skin reaction or allergy TCAs

Mode of Action: presumed to act via neurotransmitters involved to inhibit ejaculation Example: Clomipramine How to use: Can take on as needed basis before intercourse or continuous basis Potential problems Side effects Doses and regimens not standardized (Not FDA

approved) Daily vs As Needed Clomipramine In a study* of on demand (OD) clomipramine use in men with PE, 3 factors predicted likely success of OD use Men with IELTs of greater than 60 seconds Men with higher self-reported sexual satisfaction Men who ejaculated 2 or more times per week

*Rowland et. al., Int J Imp Res (2004); 16: 354-357 SSRIs Mode of Action: Acts centrally through serotonin receptors in inhibiting ejaculation Example: Paroxetine How to use: Can take OD, on a

continuous basis, or a combination of both Potential problems Side effects Doses and regimens not standardized (Not FDA approved) Oral Therapies* Fluoxetine Paroxetine 5- 20 mg/day 10-40 mg/day or 20 mg 3-4 hrs before intercourse (BI)

Sertraline 25-200 mg/day or 50 mg 4-8 hrs BI 25-50 mg/day or 25 mg 4-24 hrs BI Clomipramine *From Amer Urol Assn Guideline, J Urolog (2004); 172: 290-294 PDE-5 Inhibitors Mode of Action: ?

having higher cGMP levels might prolong nitrous oxide (NO) effect by delaying ejaculatory emission Prolong erections may reduce performance anxiety since have improved erections Example: Sildenafil How to use: 25-100 mg 1 hour before sex

Potential problems Limited benefit in many studies Side effects Expense Comparison of Oral Medications

Multiple studies proving efficacy in delaying IELT in many SSRIs and TCAs For the SSRIs, paroxetine seems to work the best, with sertraline and fluoxetine close behind Although more efficacious in some studies, almost twice as many adverse effects reported with clomipramine compared with SSRIs The evidence for sildenafil is the weakest, particularly without concurrent erectile dysfunction Which Option(s) for

Patient Consider co-morbidities e.g. atopic dermatitis, anxiety Side effects Expense Ultimately a shared decision between patient and provider

Erectile Dysfunction (ED) the consistent or recurrent inability of a man to attain and/or maintain an erection sufficient for sexual performance* *First International Consultation on Erectile Dysfunction, WHO, 1999 Prevalence of ED

5-35% of men have moderate to severe ED Mens Attitudes to Life Events and Sexuality (MALES) study found prevalence of 16%, 22% in US In the MALES study 8% of men in their 20s reported ED Epidemiology of ED

Age dependent disorder Rate depends on how it is defined Expect the rates will increase as awareness of the condition improves What causes ED

Overall it is a neurovascular phenomenon Sexual stimulation leads to Parasympathetic nervous system enhancement of production of cyclic guanosine monophosphate (cGMP) Smooth muscles relax and blood flows into the penis Filling of the penis, compresses outflow of blood via the veins Anatomy of an Erection Causes of Erectile

Dysfunction Physical Causes Vascular (leading cause) Cavernosal Neurologic Hormonal Causes Psychological Factors Evaluation of Patients with ED

Sexual history Onset of Symptoms Duration of Symptoms Circumstances when ED occurs Problems with having an erection Problems with maintaining an erection Libido Concurrent premature ejaculation

Medical History in Patients with ED Any comorbidities? CV disease, Diabetes, Depression, Alcoholism

Smoker? Pelvic surgery, radiation, or trauma? Neurologic disease? Other endocrine problems? Recreational or prescribed medication use? Medications Known to Cause ED Many medications linked to ED Antihypertensives (thiazide diuretics and beta blockers) Antidepressants Hormones

Physical Examination Blood Pressure Measurement Testicular Exam Exam of Penis Vascular and Neurologic Exam if indicated Laboratory Exam

Consider Testosterone if decreased libido Older patients (or others where indicated) do lipid panel and fasted blood glucose Targeted tests in select patients PSA Prolactin Treatment of ED

Identify and Treat Organic Comorbidities and other risk factors Counsel and Educate the Patient and Partner Identify and Treat any Psychosexual Dysfunctions Medications and Devices

Surgery Treatments Lifestyle modifications Weight loss Increase Exercise Smoking Cessation Improvement in ED of Ex-smokers ED Grade 60 Mild

30-39 10/17 Age Groups, Years 40-49 50- 5/12 2/6 Mild to 4/8

Mod Moderate 5/19 2/6 0/3 2/16 0/7 Severe 0/6 0/8

0/10 Total 19/50 (38%) 9/34 (27%) 2/26 (8%) Pourmand, et. al. BJU Int (2004), 94: 1310-13 Older Treatments

Intracavernosal Injection Vacuum Constriction Devices Intraurethral Alprostadil Suppositories Inflatable Prosthesis

Vascular Surgery Oral Drug Therapies Phosphodiesterase Type 5 (PDE-5) Inhibitors Sildenafil (Viagra) Tadalafil (Cialis) Vardenafil (Levitra)

Yohimbe Use of PDE-5 Inhibitors All three similarly effective 75% of men on medications have satisfactory erection to complete intercourse No large head-to-head trials to compare the 3 available medications

Some patients prefer one over the others Comparisons of Available Medications* *Moore, et. al. BMC Urol (2005); 5:18 Comparison Of Phosphodiesterase Type 5 Medication(PDE-5) Standard When to Duration (h) Inhibitors Dose

Take (h) of Action Cost per pill* Sildenafil 50-100 mg 1.0 <4 $17.30

Tadalafil 10-20 mg 0.5 - 12 36 $18.50 Vardenafil 10-20 0.5-1.0

<5 $16.90 Prior to Sex *Based on average price reported What to tell patients about PDE-5 Inhibitors Use

Still require sexual stimulation to have erection Sildenafils absorption may be reduced by foods especially fatty foods Expect maximal efficacy in 1 hour (2 hours after tadalafil) First few doses may not be successful try 6-8 times before giving up Side Effects

Headache Indigestion Flushing Nasal congestion Blue hue to vision Contraindications

Not to use with nitrates (including amyl nitrate) Not to use if severe CV disease Cautious use of vardenafil if has prolonged QT Care if on alpha blocking agents may cause significant hypotension Follow-up Recommended for all patients Efficacy Side Effects Any significant change in health status (including new medications)

Why Treatment Failures Food or Drug interactions Timing of Dose ?Maximal Dose Lack of Sexual Stimulation Heavy Alcohol Use Relationship Problems

Yohimbine for ED Derived from the bark of the yohimbine tree in Central Africa Traditionally used to treat all forms of impotence Believed to work through the Central Nervous System

An alpha2 adrenoreceptor blocker Yohimbine for ED Metaanalysis shows yohimbine superior to placebo (Odds ratio of 3.85)* Relatively safe medication Low cost Amer Urol Assn does not recommend its use at this time

*Ernst, Pittler; J Urol (1998); 159: 433-436 The Mental Health Perspective 1. 2. Premature Ejaculation Erectile Dysfunction 3. College Health Sexual History

In addition to intake process First awareness of and feelings about anything he considers related to sex Childhood curiosity and exploration Masturbation, including age of first experience, fantasies Students socialization based on attitudes and behaviors of family or other significant figures

Sexual History (2) Religious teachings about sexual behavior The Coming Out Process Dating History Losing virginity Relationships vs. hook-ups or fuck

buddies Sexually transmitted infections Sexual experiences initiated by others/abuse When specifically sexual difficulties began PREMATURE EJACULATION a. b. Conventional Treatments Stop-and-start technique Semans (1955)

Squeeze Method Masters and Johnson (1970) Limitations Some couples dont want to interrupt sex after starting. Some students dont have partners and some partners unwilling to squeeze the penis

Techniques viewed as mechanical The focus is on physiological processes and neglect psychological dimensions such as affective communication and sexual pleasure. Functional-Sexological Treatment First Goal of treatment: Keep the mans sexual excitement at a level of intensity below

that which sets off ejaculation. Achieved by modulating sexual excitement, by monitoring sexual stimulation as well as managing breathing and the muscular tension deriving from sexual activity. (de Carufel, Franois and Trudel, Gilles (2006) 'Effects of a New FunctionalSexological Treatment for Premature Ejaculation', Journal of Sex & Marital Therapy ,32:2,97 114) Hypothetical Case Example

21 y/o gay Chinese-American (Joe) Referred by medicine due to difficulty maintaining an erection Serious relationship ended 3 months ago, but they still share a suite Low self-confidence, career indecision, interpersonal anxiousness Mood 6/10 Denies SI or HI ERECTILE DYSFUNCTION

Normal to have occasional difficulty achieving an erection Men often feel emasculated and ashamed How could it have happened to me? Solitary or infrequently occurring erection difficulty does not mean that a man has a sexual dysfunction. (Morris, 1998) Erectile Dysfunction (2)

Cultural expectations Fears and Myths Men are taught that their essence is linked to their penis; it is not enough to just have a penis but you must have a big one that stands ready at all times to perform spectacular sexual feats. (Morris, 1998) Sensate Focus The cornerstone of sex therapy Helping a couple to focus on sensation rather than performance Structured and flexible Homework

Concerns regarding homework discussed in couples session Masters and Johnson (1970, 1986) College Health Male reluctance to seek help Sturdy Oak Manliness = Not needing help The Stud hook-ups Its just a sprain Brannon (1976) Mens health clinic

Collaboration, Collaboration, Collaboration Effective referrals Mens slots QUESTIONS?

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