sexual dysfunction
"Gladly I think of the days when all my members were limber, all except one. Those days are certainly gone, now all my members are stiff, all except one" (Goethe)

Virgin Abishag caring for the impotent King David (Bible, Genesis 20;3)


Male Sexual Dysfunctions

Changes of Erection With Age
It is important to understand that wit age the sexual responses undergo changes but it can continue throughout man's life.

In the 20s
The sexual arousal is very quick. Any sexual stimulus visual or imaginary can cause instant erection. The ejaculation is often very fast (Premature ejaculation). He is able to get another erection quickly.

In the 40s
The sexual arousal become slower than before. The ejaculation is more under his control. The second erection takes longer time to start again.

In the 60s
At this age sexual arousal is slow, direct stimulation is needed. In the absence of appropriate stimulation the erection may become soft. It becomes difficult to maintain erection.

In the 80s
At this age sexual arousal is even slower. Poor general health and use of many medications make the erections very poor. However if the man is blessed with good health and has understanding partner who can provide the necessary stimulation and fantasy the sexual life can be enjoyed successfully. Good sex is a gift of nature


Changes in Women with Age
Those women who undergo menopause (change of life) experience considerable changes in their sexuality. After menopause the female hormones are very low, it causes loss of sexual desire, dryness of vagina, thinning of lining of vagina. The intercourse can be very uncomfortable even painful. Therefore many women avoid vaginal penetration. It is important that a female partner must be treated for these conditions so that she can regain her interest in sex and becomes a willing partner.

Types of dysfunctions
Soft / Un-sustained Erection
Premature ejaculation
Ejaculatory Failure
Loss of sexual desire
Bent Penis (Peyronies disease)
bent penis
Blood Supply


penis
Blood Supply
Soft / Un-sustained Erection
Sexual inadequacy in otherwise healthy man provokes great deal of anxiety and concern. Sexual difficulties have been reported to be as high as 50% in healthy men. The understanding of mechanism of erection in men is now fully understood. A brief description is as follows:

Penis consists of two long cylinders called corporeal bodies (corpus cavernosum). These two corporeal bodies are covered with a strong fascia (Tunica albuginea) in the center of each corporeal body is a blood vessel (Cavernosal Artery). During sexual excitation these two blood vessels open up and fill the corporeal bodies (Cylinders) with blood, this causes the cylinders to become long and hard. Please note that the blood in the cylinders is drained out by means of Emisseary Veins. When the spongy tissue in the cylinder gets filled with blood it presses the Emisseary Veins against the Tunica albuginea causing them to be closed, hence blood is contained within the cylinders and prevented from escaping. This is how erection takes place and is maintained.

When sexual intercourse is complete, usually after ejaculation the penis gradually becomes soft. This is called Detumescence. The spongy tissue in the corpus cavernosum (Cylinders) shrinks, this opens up the emisseary veins and the blood in the penis escapes out into the body. This cases the penis become soft and the erection ends.

Causes of Loss of Erection
A. Psychological Causes
B. Physical Causes (Organic)
1. Vascular causes
2. Neurological causes
3. Harmonal causes
4. Penile deformity

A. Psychological Causes
There may be clear-cut psychological problem present. The use of many psychotropic drugs may explain the problems with erection. How ever in many cases it becomes necessary to make sure that there are no physical factors. Depression, Anxiety and Stress are very important factors causing impotence. These are caused by job related problems or financial difficulties. Relationship problems between couples may be the underlying problems.

The following tests can be helpful in determining the true cause:

Nocturnal penile tumescence testing    NPT
In 1970 Dr. Karacan suggested this test. It is based on the fact that every normal potent man gets 4 to 5 cycles of normal erection during sleep. These erections occur during the period when sleep is light (REM sleep). The person is not aware of these erections because these occur during sleep. However if he wakes up during this light sleep as it happens in early morning than he will notice a good erection. Taking advantage of this fact NPT test has been devised. It can be performed the following two ways:
snap guage
Snap Guage tape
Snap-gauge technique
A piece of circular tape like device is applied to the penis before going to sleep. During sleep when erection occurs the expansion of the penis will break this tape. This will confirm that a good erection occurred at night. How ever if this snap gauge does not break, it will mean lack of penile erection during sleep. If the problem is psychological one fines that erection are normal during sleep. If there is physical problem than there will be no erection at night and snap gauge will not break.
Rigiscan
Rigiscan
This device is based on the same idea as mentioned above in the snap gauge technique. How ever this is more elaborate method. Two expandable rings are applied to the penis, one near the head of the penis and the other at the base of the penis. These rings are attached to a small computerized recorder. Patient goes to sleep after applying these rings. During erection these rings get stretched and this is recorded by the computer. The following day the computer will printout the activity of the penis as it occurred at night. If normal cycles of erection are noted it will point towards the psychological factors being the cause of impotence.
 
B. Physical Causes (Organic)
Important physical problems causing damage to blood Vessels are: High Cholesterol, Hardening of the blood vessels (Artereosclerosis), smoking and radiation to the pelvic organs. (Prostate, Rectum, Bladder).

The following tests are helpful in determining the true cause:

1. Vascular Evaluation

Penile Plethysmography (Pulse Volume)
A small cuff is applied to the flaccid penis. The cuff is inflated above the systolic pressure and then gradually released. The tracings are obtained at various levels. This study is of limited value because it is perform during flaccid state.

Penile Injection Test
10 ug of prostaglandin E1 is injected in to the corpus cavernosum. It open the blood vessels in the penis resulting in erection. This technique is often combine with audio visual sexual stimulation. In 15 minutes normal erection should develop. If there is poor erection than further tests with duplex ultrasonography are needed.

Duplex ultrasonography
A baseline study of the flaccid penis is carried out. It is followed by penile injection of 10 ug of prostaglandin E1. 5 minutes after the injection the arterial pulsations are recorded. The diameter of the cavernous arteries is measured. As these blood vessels open up the velocity of blood flow increases, it should exceed 25cm/sec. Within 5 minutes of injection. It usually reaches 35 cm/sec. in a normal person. The diameter of the cavernous artery during flaccid state is 0.3 mm. After injection it opens up to 0.7 mm.

Arteriography
Angiography is the most accurate test for the penile blood vessels. It is an invasive radiographic test. After injecting 10 ug of prostaglandin E1, a catheter is passed into the internal pudendal artery and contrast solution is injected and X-ray films are taken. Any abnormality of the blood vessels can be clearly seen.

Cavernosometry and Cavernosography
When the penis is erect the pressure inside the corpora Cavernosa (cylinders) is 110cm H2O indicating that he emissary veins are properly closed as they should during normal erection. It is called normal veno-occlusive mechanism. If this mechanism is defective indicating that veins are open and blood is escaping from the penis, it results in soft erection and lower pressure. A contrast medium can be injected and X-ray pictures can be taken at the same time. In this way the veins which are open can be clearly seen. This venous leek phenomenon is generally present more than 1 site.

2. Neurological TEST
The erection may be affected if the nerves going to the penis or involved in a disease e.g. Spinal cord injury due to accidents or tumors, Peripheral neuropathy (Diabetes, M.S.), prostate surgery resulting in nerve damage to the penis.

BIOTHESIOMETRY
This test measures the sensations in the penis. Vibratory stimulation is applied to the penis and to the index finger. However recently it has been found that the vibration receptors in the glance penis are very scanty. There for this test is unreliable for testing penile nerves.

SACRAL EVOKED RESPONSE
Stimulation is applied to the penile skin it takes 30-40 millisecond to reach the bulbocavernosus muscle. This test is particularly useful for the diagnosis of the neuropathy. e.g. diabetic patients.

GENITOCEREBRAL EVOKED POTENTIAL
The skin of the penis is stimulated and the response is measured over the cerebral cortex. This is a purely sensory evaluation. Its not a useful routine test.

3. Hormonal causes
It is estimated that 12 % of cases of impotence show hormonal abnormalities e.g. increased Prolactin, hypothyroidism and Hypogonadism.

FREE BIOLOGICALLY ACTIVE TESTOSTERON (300-1000 ng/dl)

LH and FSH 1-15 ml U/ml

PROLACTIN >22 ng /ml

4. Penile deformity

Peyronie’s Disease
The penis become bent or constricted and distorted during erection. This is due to the scar tissue developing in the Tunica Albuginea. This may be due to injury to the penis during sexual intercourse. During vigorous intercourse if the penis suddenly bends causing pain and swelling (Penile fracture) it results in scar tissue and eventually bending of the penis. Some time this can happen without any apparent cause. This condition was first noted in 1743 by a French physician De La Peyronie.

Vitamin E 1000 iu can stabilized the disease. Hydrocortisone has also been used with some benefit. Potaba has been used with beneficial results. The surgical correction is only considered if the patient cannot have sexual intercourse due to the savior bending of the penis. The scar tissue can be removed and penis can be straightened.

Peyronie’s Disease correction (Surgery)
The main reason to perform surgery is impotence or severe deformity. The scar tissue can be removed (Plaque Excision). The operation of Imbrication of convex side is often employed. There can be some shortening of the penis. when extensive removal of scar tissue is necessary the penile erections can suffer there for penile implant is used to straighten the penis as well as overcome the impotence.

Medication
There are many medications which can interfere with sexual drive or quality of erection and ejaculation. Alpha blockers e.g. Flomax can significantly block the ejaculation. Proscar, Zoladex, Lupron and Viadur can profoundly reduce the sexual desire. Medications for High blood pressure e.g. Thiazides, Betablockers, Ace Inhibitors reduce the penile erection. Antidepressant drugs also reduce desire and erection.


TREATMENT OF MALE SEXUAL DYSFUNCTIONS
  1. MEDICAL TREATMENT (Non Surgical)
  2. Surgical Treatment.
Medical Treatment
  1. Lifestyle change
  2. Change of Medication
  3. Psychosexual therapy
  4. Harmonal Therapy
  5. Oral Agents
  6. Intra Urethral drugs
  7. Penile Injections
  8. Vacuum Devices
Surgical Treatment
  • Penile Prostheses
  • Vascular Surgery
Medical Treatment


Lifestyle change
There is no doubt that every day stresses of life take a great toll of our sexual health. Change of life style is fundamental to general health and sexual heath in particular.

Regular exercise, low fat diet, to stop smoking are important issues.

Change of Medication
Medications have profound effect on sexual drive, quality of erection and ejaculation. Drugs like Proscar, Lupron, Zoladex, Viadur decrease sexual desire profoundly. Antihypertensive drugs reduce the erection and drugs like Flomax can block ejaculation. Substitute drugs should be considered.

Psychosexual therapy
Psychotherapy can be extremely useful regardless of the cause of sexual dysfunction. Explanation of the cause and encouragement can go a long way helping the patient with performance anxiety. The interpersonal conflicts can be resolved. However it cannot replace the medical or surgical treatment if the causes organic.

Harmonal Therapy
The diseases of thyroid, Adrenal, Pituitary gland have significant influence on sexual functions. These conditions are best treated by Endocrinologists. The deficiency of testosterone is well known to cause severe sexual dysfunction. It can be given in the form of injections (Deltatestryl) 200 mg i/m every three weeks. It can also be given in the form of a patch (Testoderm). Androgel is a lotion which can be applied after shower. The risk of increasing PSA, enlargement of Prostate and increase in hematocrit must be closely observed.

viagra

Viagra

WARNING: Viagra should not be taken by those individuals who are taking nitrates in any form e.g. Isodril, Sorbitrate, Imdur, Ismo, Monoket. www.viagra.com/newpatient

Levitra

Cialis

Oral Agents
The literature is replete with sexual potions. Here only important references will be made to the agents currently in use.
YOHIMBINE
It is an extract of Yohim tree. It is widely used. Some authorities believe that effect is marginal. While others have shown a good response.

TRAZODONE
It is known to increase the nighttime erections and sexually stimulated erections. A combination of Trazodone and Yohimbine improves the quality of erection. It is best taken at night and sexual activity in the morning.

SILDENEFIL (VIAGRA)
It is a revolutionary drug which has helped millions of men all the world over. It is in fact extremely safe as proven by the recent research. It works by helping the natural mechanism of Nitrous Oxide in the Corpora Cavernosa. Hence blood vessels in the Corpora open up, more blood can come into the penis and erection becomes harder. The timing is critical with Viagra. It must be taken 1 hour before sexual intercourse. The stomach should be empty. One should start with 50 mg of Viagra, it may be increased two 100mg depending upon the response. The common side effects are mild headache, redness of the face, and blush vision.

LEVITRA

 

CIALIS

 

Muse

Muse Flaccid

Muse Inflated
Intra Urethral Drugs

MUSE (Alprostadil) Urethral Suppository
Alprostadil (PGE1) was found to open up the blood vessels in the penis, thereby increasing the blood flow in to the penis. this results in harder erection. This drug is available of the form of small suppository which can be inserted into the urinary canal of the penis. it dissolves and acts on the penis. the most effective dosage is 500 mcg to 1000 mcg. It is used 20 minutes before sexual intercourse. It can be used in addition to Viagra if needed. Some individuals find it unpleasant because it may cause discomfort in the urinary canal of the penis.

Further information 1-888-367-6873

Penile Injections
Many drugs have been used to produce erection by making direct injection into the penis. it was popularized by Giles Brindley in a personal demonstration. Some of the selected drugs are mentioned here.

CAVERJECT Impulse (Alprostadil- Prostaglandin E1)
The patients inject themselves into the penis, 20 minutes before the sexual intercourse. It results in good erection because it opens up the blood vessels in the penis. The erection can last from 1-4 hours. It has proven to be extremely safe. The most frequent side effect is the pain at the site of injection and discoloration of the skin.

PAPAVERINE
It is extracted from Opium Poppy. It also acts by relaxing the Corporal tissue and producing good erection. 15-60 mg has been used. The two major side effects are prolonged erection lasting more than 6 hours and Scar tissue formation after repeated injections. These days it is seldom used alone. It is commonly used as a mixture with Phentolamine and Alprostadil (bi mix or trimix)

PHENTOLAMINE (Regitine)
When injected into the penis it increases the blood flow resulting in good erection. Its side effects are similar to Papaverine.

Most commonly it is used in a mixture form with Papaverine and Alprostadil (bi mix or trimix).

sexual dysfunction
Dr. Giles Brindley

Caverject Kit
Penile Injections
Many drugs have been used to produce erection by making direct injection into the penis. it was popularized by Giles Brindley in a personal demonstration. Some of the selected drugs are mentioned here.

CAVERJECT Impulse (Alprostadil- Prostaglandin E1)
The patients inject themselves into the penis, 20 minutes before the sexual intercourse. It results in good erection because it opens up the blood vessels in the penis. The erection can last from 1-4 hours. It has proven to be extremely safe. The most frequent side effect is the pain at the site of injection and discoloration of the skin.

PAPAVERINE
It is extracted from Opium Poppy. It also acts by relaxing the Corporal tissue and producing good erection. 15-60 mg has been used. The two major side effects are prolonged erection lasting more than 6 hours and Scar tissue formation after repeated injections. These days it is seldom used alone. It is commonly used as a mixture with Phentolamine and Alprostadil (bi mix or trimix)

PHENTOLAMINE (Rregitine)
When injected into the penis it increases the blood flow resulting in good erection. Its side effects are similar to Papaverine.

Most commonly it is used in a mixture form with Papaverine and Alprostadil (bi mix or trimix).


Vacuum Pump

Vacuum with ring


Vacuum Devices
In many patients the vacuum devise produce an erection that is close to normal. It consists of a plastic cylinder with a pump to create vacuum. Penis is placed in the cylinder, vacuum is created. When erection is complete a ring is applied to the penis. After completion of intercourse the ring is removed. Many patients like this system because it is safe and effective. Others find it clumsy and unromantic.

Penial Prothesis 3 Pieces

Penial Prothesis Inflatable

Penial Prothesis Semi-rigid

Penial Prothesis 2 Pieces
Surgical Treatment

Penile Prostheses
There are two categories of penile implant available.

A. Semirigid (Malleable)
B. Inflatable


Semirigid Penile Prostheses.
This device consists of specially constructed silicone rubber rods, which are placed inside the penis (Corpora Cavernosa). A small skin incision is made underneath the penis and one rod is inserted in each cylinder of the penis. it is an Ambulatory out patient procedure. It is particularly useful for the elderly and those with reduced strength of hands because no special manipulation is needed. These are manufactured by American Medical Systems (800)835-4267 and Mentor Corporation (800)235-5731.

Inflatable Penile Prostheses.
The first inflatable penile prostheses was designed and marketed by Scott, Bradley and Timm in 1973. it has undergone many modifications. The most commonly used implants have three pieces. A set of two cylinders which are inserted into the penile cylinders. One control pump to inflate and deflate the cylinders. A reservoir which is in the shape of a small balloon, it holds the fluid which is used to inflate and deflate the cylinders. This device is inserted into the body through a small incision either below the penis or above the penis. After insertion there is a healing period of 8 weeks during which device cannot be used. This device is significantly superior to the Semirigid one, in terms of penile girth and natural looking erection. Those patients who lack manual dexterity are not good candidates for this type of device.

Complications: the most serious complication is the infection, Diabetic patients with poor control are more at risk, because tissue quality is poor due to decreased blood circulation. Most infections occur during the first three months following surgery. The patients with penile prostheses should receive Antibiotics whenever they are going to have dental work or any other surgery. The mechanical reliability is very high. Only 5% have mechanical failure after 10 years of use. The partner satisfaction has been reported from 60% to 80%.

These are manufactured by American Medical Systems (800)835-4267 and Mentor Corporation (800)235-5731.

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