Natural Ways to Treat Mental Impotence

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Combined therapy with testosterone and phosphodiesterase type 5 inhibitors in patients with erectile dysfunction

Oral therapy with inhibitors of the phosphodiesterase type 5, e.g. sildenafil, varde-nafil, and tadalafil, is highly effective for therapy of erectile dysfunction (Shabsigh and Anastasiadis 2003). However, in placebo-controlled phase III clinical trials and post-marketing evaluation approximately 15 to 40 of patients do not respond to this medication. There is some evidence that patients with erectile dysfunction and testosterone deficiency respond poorly to therapy with phosphodiesterase type 5 inhibitors (Guay etal. 2001 Shabsigh 2003). Fig. 11.2 Blood flow parameters of the cavernous arteries assessed by duplex sonography after a standardized pharmacostimulation of erection with 10 g prostaglandin E1. PSV, peak systolic velocity EDV, end diastolic velocity RI, resistance index open bars, baseline values grey bars, placebo plus sildenafil group filled bars, testosterone plus sildenafil group (modified with permission from Aversa etal. 2003, copyright 2003, Blackwell Publishing). Two...

Effects of treatment of erectile dysfunction on testosterone

There is some evidence that not only testosterone is relevant for effective therapy of erectile dysfunction, but conversely that effective therapy of erectile dysfunction can also increase serum concentrations of testosterone. In normal healthy men and patients with erectile dysfunction, serum levels of testosterone increase significantly during the tumescence as well as the rigidity phase of penile erection, and return to baseline in the detumescence phase (Becker etal. 2000 2001). A controlled, non-randomized study demonstrated that effective psychological, medical (prostaglandin E1, yohimbine) or mechanical (vascular surgery, penile prostheses, vacuum devices) therapy of erectile dysfunction leads to a sustained increase of serum testosterone levels (Jannini et al. 1999). This increase could be caused by increased LH bioavailability (Carosa etal. 2002). However, randomized controlled studies are awaited to prove this interesting hypothesis.

What is erectile dysfunction ED and how common is it

The National Institutes of Health (NIH) definition of erectile dysfunction (ED), previously called impotence, is the consistent inability to achieve and or maintain an erection satisfactory for the completion of sexual performance. The definition is subjective, meaning that the individual (and or his partner) is the person who decides that his erections are not satisfactory. This is in comparison to an objective definition, in which an observer or a test makes the decision that the erection is not satisfactory. The definition is not an all-or-nothing one, meaning that different men may experience different degrees of ED. The most severe form of ED would be the complete absence of erections no nocturnal (nighttime) erections, morning erections, or erections noted with stimulation milder forms may be associated with inadequate degree or duration of rigidity. Figure 30 Prevalence of erectile dysfunction. Figure 30 Prevalence of erectile dysfunction. Adapted with permssion from Feldman...

Recovery of Sexual Potency

As for continence, objective evaluation of postoperative erectile dysfunction encounters a number of difficulties 1. Absence of a consensual definition of sexual potency in the studies The definition of sexual potency varies according to the adopted criteria, such as erection without intercourse (i.e., return of erection) or erection firm enough for intercourse. Moreover, the frequency as well as quality of sexual activity has been recorded (66). The most successful tool to evaluate erectile dysfunction proved to be the abridged, five-item version of the International Index of Erectile Function (67). Hara et al. were able to demonstrate its applicability when comparing the quality of life after open and laparoscopic radical prostatectomy. They found a significant impairment of sexual function by surgery with no difference between the laparoscopic or open approach (68). Additionally, the quality of erection should be classified according the international classification (E1-5)...

Erectile Disorders Erectile Dysfunction

Erectile dysfunction (ED) refers to the inability to attain and or maintain penile erection sufficient for satisfactory sexual performance (NIH Consensus Development Panel on Impotence, 1993). Sexual function declines with age, and normal erectile function depends on a number of body systems cardiovascular, endocrine, muscular, nervous, psychological (Lue, 2000). Disorders in any of these can lead to ED, although many factors often are involved. Box 40-6 Erectile Dysfunction Treatment Options Intracavernosal (Caverject, Edex)* Intraurethral (Muse)* Topical Apomorphine (sublingual)* Cognitive-behavioral therapy Ginseng Phosphodiesterase (type 5) inhibitors Sildenafil (Viagra)* Tadalafil (Cialis)* Vardenafil (Levitra)* Yohimbine (Yocon, Yohimex, generic) Penile prosthesis surgery Psychosexual counseling Modified from Tharyan P, Gopalakrishanan G. Erectile dysfunction. Clin Evid 2009 05 1803. Alprostadil (intracavernosal, intraurethral), apomorphine, and phosphodiesterase type 5 (PDE-5)...

Who is a candidate for a penile prosthesis

Penile prostheses are usually placed in men with organic ED. In men with psychogenic erectile dysfunction, extensive counseling should be administered and other treatment options should be exhausted before a penile prosthesis is considered. For all other patients, extensive patient and partner counseling should take place before placement of a prosthesis the expectations, indications, and risks need to be discussed clearly, as well as other currently available and future options. A penile prosthesis is rarely the first-line therapy for ED. In my practice, when I discuss penile prostheses with patients, I equate the procedure for its surgical placement with crossing over a rickety bridge that collapses once the prosthesis is implanted. You cannot go backward once the prosthesis is placed if it is removed because of infection, malfunction, or dissatisfaction, other options of treatment are unlikely to work. Although there have been reports of the vacuum device and injection therapy...

How do I use the penile prosthesis and how is it placed

Placement of a penile prosthesis is a surgical procedure that can be performed under general anesthesia or spinal anesthesia. You will stay in the hospital overnight and are usually able to go home the following morning. Three approaches to placement of the penile prosthesis are used, and the location of the incision varies with In men with ED and prostate cancer who are undergoing a radical prostatectomy for treatment of their prostate cancer, the prosthesis can be placed at the time of surgery. There does not appear to be an increased risk of infection when this route is taken. I had my penile prosthesis placed under general anesthesia. As a part of the initial discussion on the penile prothesis, Dr. Ellsworth discussed the mechanics of the prosthesis with me. As she was explaining the mechanics of the prosthesis, she must have noticed a puzzled look on my part. She said, Do you want to see one Sure, I responded. She returned carrying a rubbery device that has a manually operated...

Prevalence and incidence of disturbances of sexual functioning

In this section I attempt to integrate the available literature on the frequency with which sexual functioning has been compromised as a consequence of traumatic brain injury. Unfortunately, the vast majority of data collected on this topic has centred around the examination of compromise in sexual function in male subjects due to their increased prevalence in head-injured samples and to their more obvious manifestation of sexually aberrant behaviours. Where possible, the available data on alteration in female subjects will also be presented. Dimond (1980) reviewed the older and foreign language literature on the effects of brain injury on sexuality. Impotence has been associated with head injury for many years (Rojas, 1947 Stier, 1938), including boxers with cumulative traumatic encephalopathy (Maudsley & Ferguson, 1963). In examining sexual disturbances in a series of 100 patients with head injuries, Meyer (1955) found that 71 reported a decrease in sexual drive following injury...

H6 Prevalence of testosterone deficiency in patients with erectile dysfunction

Various studies have estimated the prevalence of testosterone deficiency in patients with erectile dysfunction. A systematic multidisciplinary assessment of 256 men with erectile dysfunction showed a prevalence of hypothalamic-pituitary-gonadal axis abnormalities of 17.5 . In only 12.1 did the testosterone deficiency clearly contribute to erectile dysfunction (Nickel et al. 1984). Another routine hormonal screening in 300 men presenting with a primary complaint of erectile dysfunction showed a prevalence of only 1.7 (Maatman and Montague 1986). A similar low prevalence of 2.1 was detected in 330 consecutive patients with erectile dysfunction screened for testosterone deficiency (Johnson and Jarow 1992). More recently, endocrine screening of 1022 men with erectile dysfunction detected serum concentrations of testosterone 3 ng ml in 8.0 of men. However, 40 of these patients had normal serum levels at repeated determination (Buvat and Lemaire 1997). Pituitary tumors were discovered in...

What are the risks ofa penile prosthesis

As with any surgical procedure, there are complications associated with the placement of a penile prosthesis. These risks may be subdivided into intraoperative complications (those occurring during surgery) and postoperative complications (those occurring after surgery). As with all surgical procedures, there are bleeding and anesthetic risks with the implantation of a penile prosthesis. Decreased penile length is actually not a complication of penile implantation, but rather is intrinsic to the surgery. The cylinders are of a fixed length. To obtain penile rigidity, the cylinders increase in width (girth). Very observant patients will note a 1- to 2-cm decrease in penile length after the procedure. One of the most devastating complications of penile prosthesis surgery is infection. Infection rates range from 2-16 in first-time procedures but increase to 8-18 in reoperations. Patients with diabetes and spinal cord injury, in particular, are at increased risk for infection. Patients...

Physiology of Penile Erection

The penis contains two chambers (the corpora cavernosa), which run the length of the organ, and are surrounded by a membrane (the tunica albuginea). Erection or flaccidity of the penis results from relaxation or contraction, respectively, of smooth muscle cells in the corpora cavernosa. Penile erection is a complex neurovascular process involving relaxation of the corpus cavernosal smooth muscles and vasodila-tion of blood vessels supplying the corpora cavernosa. This is due to both increased arterial inflow into and restricted venous outflow from the penis. Increased blood flow causes physical expansion of sinusoidal spaces, creating a pressure in the corpora cavernosa and making the penis enlarge 1, 2 . Compression of the dilated blood vessels against the semielastic tunica albuginea restricts venous outflow, producing penile rigidity and sustaining erection. Detumescence occurs as a consequence of increased cavernosal smooth muscle tone and contraction of the sinusoids, reducing...

Mechanism of Penile Erection

Shear Stress Erection

The main mediator of penile erection is nitric oxide (NO). NO is synthesized by two enzymes endothelial NO synthase (eNOS NOS3) and neuronal NO synthase (nNOS NOS1). nNOS-containing (nitrergic) nerve fibers course from the major pelvic ganglia (MPG) and terminate in the penis. eNOS localizes to the vascular and sinusoidal endothelium in the penis 4 . Sensory reflexogenic and psychogenic sexual stimulation activates nNOS, which initiates the erectile response. Sexual stimulation also neuronally releases acetyl-choline, which stimulates eNOS in the endothelium. The resulting increase in blood flow activates eNOS and causes sustained endothelial NO release, accounting for the achievement and maintenance of full erection 1 . Upon its synthesis and release from nerve terminals and endothelial cells, NO diffuses to neighboring vascular and trabecular smooth muscle cells in the penis where it activates soluble guanylate cyclase to produce cyclic guanosine monophosphate (cGMP). NO cGMP...

Models of Human Sexual Response

Masters and Johnson first described the physiology of human sexual response cycle in 1966. Based on the physical components of sexual functioning, they described four phases of the sexual response cycle excitement, plateau, orgasm, and resolution (Fig. 43-1). Helen Singer Kaplan subsequently described a more subjective, psychologically oriented sexual responsiveness model with three phases desire, excitement, and orgasm. Recently, however, nonlinear alternative models have been suggested, especially for women's sexual response (Basson and Schultz, 2007) (Fig. 43-2). In certain settings, men may have similar nonlinear sexual responses. Response phases establish a framework to discuss sexual dysfunction.

What is a penile prosthesis

Penile Implants Devices

A penile prosthesis is an artificial device that, when placed in the penis, allows a man to have an erection. The development and use of penile prostheses began in the 1970s. Since then, numerous revisions and modifications in the prostheses have improved the satisfaction rate and mechanical durability of these devices. Figure 36 Three-piece penile prosthesis. Drawing of AMS 700CX CKM Penile Prosthesis courtesy of American Medical Systems, Inc., Minnetonka, MN ( Figure 36 Three-piece penile prosthesis. Drawing of AMS 700CX CKM Penile Prosthesis courtesy of American Medical Systems, Inc., Minnetonka, MN ( Figure 37 One piece, semi-rigid penile prosthesis. Figure 37 One piece, semi-rigid penile prosthesis. Placement of a penile prosthesis requires extensive patient and partner discussion. It is not considered a first-line therapy in most cases of ED, but is an appropriate therapy for well-counseled individuals who have not responded to other therapies...

Coronary Artery Disease and Viagra

As male patients get older, the chance of developing coronary disease increases. The incidence of erectile dysfunction or impotence also increases with aging. Recently, a new medication called Viagra has become available to treat erectile dysfunction. Although effective, it should not be used with certain heart medications. Those of us who specialize in heart disease receive many questions regarding Viagra and sometimes questions on other treatment options for impotence from patients who shouldn't take Viagra. I have therefore asked my colleague, Dr. Chipriya B. Dhabuwala, who specializes in impotence and is a professor of urology at Wayne State University, to discuss Viagra as it relates to heart medication and to also discuss other treatment options available for erectile dysfunction.

Causes of Erectile Dysfunction

The incidence of erectile dysfunction increases with age. Hardening of the arteries and blockage within the arteries is the most common cause of erection problems. Very often, blockage of the arteries of the penis occurs with blockage of the coro Erectile Dysfunction Also referred to as impotence. The inability to achieve or maintain an erection for sexual intercourse. Involves blockages of the lower aorta as well as the arteries in the pelvis coming off the aorta, including the iliac arteries. It is characterized by claudication, which is pain, aching, and tiredness of the legs and buttocks. It is associated with erectile dysfunction. nary arteries of the heart. In many individuals, the erection problem is followed a few years later by coronary artery disease and even heart attack. Blockage of the terminal aorta (Leriche's syndrome), internal iliac arteries, or internal pudendal arteries by the atherosclerotic process can also lead to erectile dysfunction. There are many other...

Erectile Dysfunction

Erectile dysfunction (ED), or impotence, is defined as the persistent inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. The typical patient is at least 50 years old, is usually married or in a long-term monogamous relationship, and has had a year or more of gradually progressive ED. Often he is otherwise in good mental and physical health. Because penile erection is a neurovascular phenomenon, however, there are a number of neurologic and vascular conditions that can lead to ED. Vascular disease such as atherosclerotic stenosis or occlusion of the cavernosal arteries, or vascular problems secondary to smoking, can cause ED. Antihypertensives, antidepressants, antiandrogens, histamine type 2 (H2) receptor blockers, and recreational drugs are commonly associated with ED. Diabetes, hypertension, hyperlipidemia, and alcohol use are risk factors in ED. ED frequently provides insight into the patient's emotional problems. ''If you were to...

Sexual Function

Erectile function and seminal ejaculation can be aided by many techniques. Sildenafil and newer orally taken drugs enable an erection that permits penetration for 80 of pa-tients.224 Intracavernous injections of papaver-ine and other substances work for some, but priapism is a more common adverse reaction in the person with SCI. Vacuum techniques are often useful for maintaining an erection. Implanted, semirigid penile prostheses benefitted 52 of 63 veterans with sexual dysfunction, some of whom had skin lacerations from external appliances, but they carried an initial 33 complication rate.225 Infections occurred in 7 and skin erosions evolved in 11 after 6 months. Penile vibration, subcutaneous physostigmine with masturbation, and surgical vasal-epididymal sperm retrieval elicit semen for insemination. Infertility may be related to the poor quality of semen. Some causes are treatable.226 In addition to the technique of anterior sacral root stimulation, erectile function and...

What is a radical prostatectomyAre there different types

Laparoscopic radical prostatectomy is a procedure that has the advantages of the retropubic approach but, because there are several small abdominal incisions as opposed to the longer midline incision, the discomfort is less and the recovery is quicker with this approach. The disadvantage of this procedure is that it is relatively new and requires a urologist with advanced skills in laparoscopy. It may take longer to perform than an open radical retropubic prostatectomy. The outcomes of laparoscopic prostatectomy, such as urinary incontinence, erectile function, and positive margin rates are similar to open surgery. Robotic-assisted radical prostatectomy has surpassed laparoscopic radical prostatectomy in terms of the number of procedures being performed. Form of radical prostatectomy whereby an attempt is made to spare the nerves involved in erectile function. The nerves responsible for erectile function run along each side of the prostate and along each side of the urethra before...

What types of laser therapy are available

The procedure can be repeated in different areas of the prostate. The procedure takes about 30 to 60 minutes to perform. After the procedure is performed an indwelling foley catheter is placed which is usually removed in a few days. It is not uncommon to see some blood in the urine after the procedure, which usually clears in a week. Rarely, erectile dysfunction, retrograde ejaculation, and incontinence can occur.

How do erections normally occur

In order to understand how an erection occurs, one must first learn a little about the anatomy of the penis. The penis may look like one simple tube, but it is actually comprised of three cylinders. There are two on the top of the penis called the corpora cavernosa (a Latin phrase meaning, roughly, bodies composed of hollows or caves ) and one on the underside of the penis, the corpus spongiosum ( sponge-like body ) (Figure 28). The tip of the penis, called the glans, is part of the corpus spongiosum. The corpora cavernosa are surrounded by a fibroelastic layer of tissue, the tunica albuginea (literally, white coat, referring to fact that the tunica albuginea is a thick white membrane wrapped around the You might be surprised to learn that erections aren't simply something that happens in the penis. For an erection to occur, there must be proper functioning of many physical structures and systems the brain, certain nerves in the pelvis, and the arteries and veins that supply the...

Is ED a normal process of aging Is ED preventableIs it curable

Older men often note that it takes longer to achieve an erection. In fact, men older than 50 years can take 2 to 3 times longer to develop an erection than younger men. The erection may not be as rigid as in younger years, and arousal alone may not lead to full rigidity without tactile (touch) stimulation. It may also take longer to climax. Ejaculation (the release of semen through the penis during orgasm) may not occur, or it may occur with less force. The recovery period after ejaculation increases with age, and many men older than 55 years are not able to have another erection for 12 to 24 hours after ejaculating. These normal changes related to aging should not be confused with sexual dysfunction or ED failure to understand these normal changes and to adapt to them may cause stress and anxiety and may complicate erectile function. In ED, the erections are either inadequate for penetration or do not last long enough for completion of sexual performance. In short, the incidence of...

What is sexual dysfunction

The term sexual dysfunction broadly encompasses trouble with any component of the sexual response cycle. The sexual response cycle in men consists of sexual desire interest (libido), sexual arousal (erection), orgasm (including emission involuntary discharge of semen from the ejaculatory duct into the urethra and ejaculation), and detumescence (return of the penis to the flaccid, nonerect state). An abnormality in one component of the sexual response cycle may not affect the remainder of the components of the cycle. For example, one may still be able to climax and ejaculate without achieving a rigid erection. Common sexual dysfunctions include problems with libido, ejaculation, and orgasm. Sexual arousal requires input from nerves and arteries. To achieve an adequate erection, there must be at least six times as much blood flow into the corpora cavernosa. Changes in nerves, arteries, and veins may lead to trouble with erections. The Massachusetts male aging study demonstrated that...

What is anorgasmia and how is it treated

Anorgasmia, the inability to achieve an orgasm, may be congenital or acquired. It is estimated that about 90 of anorgasmia problems are related to psychological issues. Surveys point to performance anxiety as a common psychological problem. There is a relationship between anorgasmia and childhood or adult sexual abuse or rape. Marital strife, boredom with a relationship, coupled with a monotonous sex life are other contributing factors. Some drugs, such as alcohol and the selective serotonin reuptake inhibitors may impair orgasmic response. Certain medical conditions such as spinal cord injury, multiple sclerosis, hormone conditions and diabetes have been implicated. Treatment of anorgasmia

What is priapism and what causes it

High-flow priapism may occur after there has been an injury to the penis that causes damage to an artery that results in unregulated blood flow into the penis. Because there is an increase in arterial blood (which carries oxygen) into the penis, high-flow priapism does not cause pain. In high-flow priapism, there is venous drainage out of the penis, so the erection does not tend to be as rigid as in a full erection. Low-flow priapism occurs more in men with sickle cell disease trait a condition in which the red blood cells take on an abnormal (sickle) shape in response to decreased oxygenation, dehydration, and acidosis and cancers of the blood, such as leukemia. It may also occur with injection therapy for erectile dysfunction and with certain psychiatric medications, such as trazodone. It has also been seen in men taking illicit drugs such as cocaine and marijuana. Because the problem consists of a problem with drainage of blood from the penis, which has little oxygen in it, this...

What are oral therapies for ED specifically the phosphodiesterase type 5 PDE5 inhibitors

Currently, three oral therapies are available for the treatment of ED. The first therapy to become available was sildenafil (Pfizer's Viagra), which was approved by the FDA in 1998. Vardenafil (Bayer's Levitra) and tadalafil (Lily Icos's Cialis) were approved for use years later. All three of these oral therapies are phosphodi-esterase type 5 (PDE-5) inhibitors. Critical to the success of all of the PDE-5 inhibitors is the need for sexual arousal (sexual stimulation) after taking the medication. That is, these medications will not cause an erection to occur without sexual stimulation. It is okay to have a glass of wine, a beer, or a mixed drink when using these therapies such limited alcohol consumption should not interfere with their effectiveness. Too much alcohol, however, may have a negative effect on erectile function, so a man should limit his alcohol intake when taking any of these medications. Figure 32 Neurologic mechanism of erectile function. Sexual stimulation leads to...

What is the vacuum device

The vacuum device is a safe, reliable, reversible, noninvasive method of achieving an erection. The vacuum device consists of a plastic cylinder, a pump that is either battery or hand operated, and one or more constrictive bands (Figure 35). The cylinder is wide enough and long enough to accommodate the erect penis. It is closed at the tip and open at the base. The constrictive bands are preloaded onto the base of the cylinder before its use. The time taken to achieve an erection with the vacuum device varies but may be as short as 2-3 minutes. The band may be left on the penis for 30 minutes only. Most men are able to quickly learn how to use the device and become comfortable with using it within four practice sessions. I have tried the vacuum device but never had much satisfaction with it. For me, the preparation and the mechanics of achieving and sustaining an erection with the device were too much. I was dubious right from the onset, when the vacuum device's manufacturer's...

Who is a candidate for the vacuum device

Erect penis may not fit in the cylinder. In such cases, corrective surgery to straighten the penis may be performed before the use of the vacuum device, or the man can try using the device and generating a less rigid erection. An uncooperative partner precludes the successful use of the device.

What are the success and satisfaction rates for the vacuum device

The initial report on the vacuum device, which was published in 1985, reported a 90 success rate for this device in achieving an erection that was adequate for sexual performance. Since then, published success rates with the vacuum device have ranged from 84-95 , and overall satisfaction rates reported for this device have ranged from 72-94 . Notably, the vacuum device has been shown to be effective in treating men with erectile dysfunction of many different causes. In patients with spinal cord injuries, the success rate is reported to be 92 . In those with psychogenic erectile dysfunction, this device also yields good results. In men who have erectile dysfunction caused by arterial disease or after radical prostatectomy, the success rate ranges from 90-100 . Furthermore, the vacuum device is successful in some men who were impotent after the removal of a penile prosthesis. Several studies have compared the vacuum device with other forms of treatment for ED. In a study of men who were...

Is there a role for sex therapy in the treatment of ED

Sex therapy is very effective in helping people understand both the physiologic and the psychological aspects of ED. It also helps people identify and deal with unrealistic expectations and negative self-images, understand their partner's sexual needs and requirements, and dispel any myths about sexuality and sexual function that the patient and his partner may have. It also allows for help with relationship issues, such as intimacy conflicts, power and control struggles, and trust issues, which may be just as important as treatment of the ED in the restoration of a healthy sexual relationship. International Index of Erectile Function (IIEF)

Over the Past 6 Months

How do you rate your confidence that you could get and keep an erection 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner) 3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner 4. During sexual intercourse, how difficult was it to maintain your erection after you had penetrated (entered) your partner

Who is a candidate for oral therapy with a PDE5 inhibitor

Source Ellsworth, P. 100 Questions and Answers About Erectile Dysfunction, 2e. Jones and Bartlett Publishers, LLC, 2008. Source Ellsworth, P. 100 Questions and Answers About Erectile Dysfunction, 2e. Jones and Bartlett Publishers, LLC, 2008. Use of PDE-5 inhibitors is on demand, meaning that in most cases, each time you want to have intercourse, you need to take a pill. These pills facilitate your body's response, rather than causing an erection on their own, so they require sexual stimulation or foreplay to work. Other medications that increase PDE-5 inhibitor levels include erythromycin (E-mycin), clarithromycin (Biaxin), ketoconazole (Nizoral), itraconazole (Sporanox), and cimetidine (Tagamet). Men taking protease inhibitors, such as indinavir (Crixivan), nelfinavir (Viracept), ritonavir (Norvir), or saquinavir (Fortovase), should start at a lower dose and take the PDE-5 inhibitor less frequently because the protease inhibitors (generally prescribed for HIV infection and AIDS)...

Are there different types of problems with ejaculation What causes them and how are they treated

What is premature ejaculation and what causes it Premature ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetration, that causes distress to one or both partners. This condition tends to occur more frequently in younger men. Premature ejaculation is the most common form of sexual dysfunction, occurring in 21 of men ages 18 to 59 years in the United States. The condition may be lifelong (primary) or acquired (secondary). Despite its prevalence, men rarely seek help. Some men with ED may develop secondary premature ejaculation, possibly caused by either the need for intense stimulation to attain and maintain an erection or because of anxiety associated with difficulty in attaining and maintaining an erection. In these patients, treating the erectile dysfunction may lead to resolution of the premature ejaculation.

What is the success rate for PDE5 inhibitors

Overall, the PDE-5 inhibitors have a similar success rate. Success rates range from 48 to 81 with the various therapies, depending on the etiology of the ED. Individuals who have failed to respond to one of these medications may, however, respond to a different PDE-5 inhibitor. In one study, vardenafil was shown to be helpful in patients who had previously failed to respond to sildenafil therapy. However, studies have also demonstrated that patients who have failed an initial trial of sildenafil, when educated regarding proper use and rechallenged with sildenafil, have an increased likelihood of responding. Similarly, if you experience bothersome side effects with one medication, let your doctor know and your doctor may recommend trying a different PDE-5 inhibitor. In men who have External-Beam Radiation Therapy-related erectile dysfunction, response rates range from 48 to 90 . erectile status prior to the surgery and nerve-sparing status. The success rates of sildenafil for men who...

Who is a candidate for penile injection

The dose required to achieve a successful erection varies greatly with the cause of the erectile dysfunction. Young men with spinal cord injury may require only 1 ig of Caverject or Edex, whereas older men with vascular disease and diabetes may require 40 ig of these medications.

What is the success rate of MUSE

Constrictor, a constricting band that is placed at the base of the penis, have helped some men. In some men, an erection rigid enough for penetration may occur in the standing position however, when these individuals change to a supine position, the erection may decrease. In these men, changing the position used for intercourse or using the constricting band has proved helpful. It is difficult to predict who will and who will not respond to MUSE. The patient's age and the cause of the erectile dysfunction, for example, are not predictive of response. Nevertheless, MUSE is unlikely to be effective in men who have not responded to intracav-ernous injection therapy.

What happens when hormone therapy fails

Still believed to have organ-confined disease. Individuals in this group include those who have a Gleason score 6, a low pretreatment PSA level ( 10 ng mL), and low clinical stage tumor (T1c or T2a). At the time of the salvage prostatectomy, they should still have a favorable Gleason score, a low clinical stage, and, ideally, a PSA that is 4 ng mL. Salvage prostatectomy is a challenging procedure, and if you are considering this option, you should seek out an urologist who has experience with it because there is an increased risk of urinary incontinence, erectile dysfunction, and rectal injury with this procedure. Rarely, because of extensive scarring, it is necessary to remove the bladder in addition to the prostate, and a urinary diversion would be necessary. A urinary diversion is a procedure that allows urine to be diverted to a segment of bowel that can be made into a storage unit similar to a bladder or allows urine to pass out of an opening in the belly wall into a bag, similar...

Are there different types of hormone therapy Do I need to have my testicles removed

The male hormone or androgen that is produced primarily by the testes and is needed for sexual function and fertility. The advantages of bilateral orchiectomy are that it causes a quick drop in the testosterone level (the testosterone level drops to its lowest level by 3 to 12 hours after the procedure average is 8.6 hours ), it is a one-time procedure, and it is more cost effective than the shots, which require several office visits per year and are more expensive. The disadvantages of orchiectomy are those of any surgical procedure and include bleeding, infection, permanence, and scrotal changes. In men who have undergone bilateral orchiec-tomy and are bothered by an empty scrotum, bilateral testicular prostheses may be placed that are the same size as the adult testes. Most men who undergo bilateral orchiectomy lose their libido and have erectile dysfunction after the testosterone level is lowered. Other long-term side effects of bilateral orchiectomy, related to testosterone...

What are some of the side effects of hormonal therapy and how are they treated

LHRH analogues and antagonists have side effects that may affect your quality of life over the short and long term (Table 9). Some of the side effects related to these medications, such as hot flashes, erectile dysfunction, anemia, and osteoporosis, can be treated. Erectile dysfunction occurs in about 80 of men taking LHRH analogues and antagonists and is associated with decreased libido (sexual desire). The widely prescribed drug silde-nafil (Viagra) as well as the other oral therapies for erectile dysfunction, vardenafil (Levitra) and tadalafil (Cialis) are effective in most of these men if they had normal erectile function before starting hormone therapy. Unfortunately, there is no medication to restore libido.

What are the 5alpha reductase inhibitors

What are the side effects of 5-alpha reductase inhibitors Side effects found in the first year of 5-alpha reductase inhibitor use include decreased sexual drive (libido), increased ejaculatory dysfunction (such as smaller amount of semen ejaculated), difficulty getting an erection, breast tenderness or enlargement. One large study demonstrated that after a year of treatment, finasteride resulted in the same level of decreased sex drive and inability to get an erection as placebo. Ejaculatory dysfunction was higher with finasteride than with placebo. Asymptomatic men with a PSA 3.0 ng ml who are regularly screened with PSA or who are anticipating undergoing annual PSA screening for early detection of prostate cancer may benefit from a discussion of both the benefits of 5-alpha reductase inhibitors for 7 years for the prevention of prostate cancer and the potential risks (2-4 increase in reported erectile dysfunction and gynecomastia (enlarged and or painful breasts), and decrease in...

What if my testosterone level is low What are the risks and benefits of testosterone therapy

Hypogonadism is a condition in which low levels of testosterone are found in association with specific signs and symptoms, including decreased desire (libido) and sense of vitality, erectile dysfunction, decreased muscle mass and bone density, depression, and anemia. When hypogonadism occurs in an older male, it is referred to as andropause, or androgen deficiency of the aging male. Hypogonadism is estimated to affect 2 to 4 million men in the United States, and its incidence increases with age. Only about 5 of affected males are being treated. Table 18 Treatment Options for Erectile Dysfunction 48-81 varies with etiology of erectile dysfunction Concomitant nitrate use, retinitis pigmentosa. When using concomitant alpha-blockers, pt should be on stable dose of alpha-blocker prior to starting sildenafil start with 25 mg dose. Follow Princeton guidelines regarding use in CV pts. Table 18 Treatment Options for Erectile Dysfunction (Continued) Vardenafil Nitrates, retinitis pigmentosa if...

What are externalbeam and conformal externalbeam radiation therapies What are the side effects of EBRT

Ams Artificial Urinary Sphincter

The side effects of EBRT or conformal EBRT can be either acute (occurring within 90 days after EBRT) or late (occurring 90 days after EBRT). The severity of the side effects varies with the total and the daily radiation dose, the type of treatment, the site of treatment, and the individual's tolerance. The most commonly noted side effects include changes in bowel habits, bowel bleeding, skin irritation, edema, fatigue, and urinary symptoms, including dysuria, frequency, hesitancy, and nocturia. Less commonly, swelling of the legs, scrotum, or penis may occur. Late side effects include persistence of bowel dysfunction, persistence of urinary symptoms, urinary bleeding, urethral stricture, and erectile dysfunction. 24. What if I am incontinent after radical prostatectomy or radiation therapy What if I have erectile dysfunction after radical prostatectomy or EBRT or brachytherapy erectile function. Basically, all of the treatment options carry a risk of erectile dysfunction however, they...

What is intraurethral alprostadil MUSE and how do I use it

Muse Alprostadil

Intraurethral alprostadil (Vivus's MUSE) is an intraurethral medication (i.e., a drug that is injected into the urethra) that was approved by the FDA in June 1998. Alprostadil is a synthetic form of a normal body chemical, prostaglandin E1, that causes increased blood flow into the penis. MUSE works differently than sildenafil (Viagra), the oral therapy for ED. That is, the prostaglandin in MUSE stimulates the production of a chemical called cAMP, which, like cGMP, can cause the relaxation of smooth muscle and thus increase blood flow to the penis. MUSE is an on-demand medication, meaning that you must take it each time that you wish to achieve an erection. The suppository of the alprostadil is enclosed in a small applicator (Figure 33). You should void before inserting the tip of the applicator into your penis, because voiding helps lubricate the urethra. Other topical lubricants, such as K-Y Jelly, Vaseline, and mineral oil, cannot be used with MUSE because they interfere with the...

What happens if my sex drive libido is low What causes it can it be treated

Your interest in sex is governed by sex hormones, primarily testosterone, and by psychosocial factors. Low testosterone levels are associated with decreased libido. Stress, depression, or anxiety may also affect your libido. In men with erectile dysfunction, interest in sex may be diminished as a result of their inability to achieve an adequate erection.

What is Peyronies disease and what causes it

Peyronie's disease is a benign condition of the penis that tends to affect middle-aged males. The exact cause of Peyronie's disease is not known. The disease is characterized by the formation of plaques in the tunica albuginea of the penis. These plaques may be felt on penile examination and at times can feel as hard as bone. The plaques are like scar tissue and affect the function of the tunica in that area. Because the plaque is not elastic and stretchy like the rest of the tunica, it pulls the penis to the side of the plaque during an erection and may also cause wasting narrowing at the site of the plaque. There may also be pain associated with an erection. Lastly, because the plaque does not behave like normal tunica, it may also cause erectile troubles. The plaque may occur anywhere along the penile shaft but is more commonly identified on the top (dorsal) surface of the penis. More than one plaque may be palpable. The hallmarks of Peyronie's disease are a palpable plaque (a hard...

What is brachytherapyinterstitialseed therapy Who is a candidate What are the risks

Greek Word Prostate

Erectile Dysfunction This condition may occur in as many as 40 to 60 of men who undergo interstitial seed therapy. Unlike radical prostatectomy, the erectile dysfunction tends to occur a year or more after the procedure and not right away. As with post radical prostatectomy ED, there are a variety of options available to treat it (see Part Three, Erectile Dysfunction).

What are the risks of surgery How are they treated

All surgical procedures have risks, and the common ones are infection, bleeding, pain, and anesthetic complications. Larger surgical procedures, which involve lengthier operative times and decreased postoperative mobility, have the risk of blood clots in the legs (deep venous thrombosis), pulmonary embolus, pneumonia, and stress-related stomach ulcers. Complications of radical prostatectomy include hernia, significant bleeding requiring blood transfusion, infection, anesthetic-related complications, impotence, urinary incontinence, bladder neck contracture, deep venous thrombosis, rectal injury, and death. Impotence Impotence, or erectile dysfUnction, is unfortunately a commonly identified risk of radical prostatectomy. The nerves that supply the penis and that are involved in the erectile process lie along each side of the prostate and the urethra. They may be taken deliberately by the surgeon (non-nerve-sparing radical prostatectomy), or they may be injured permanently or...

What is cryotherapycryosurgery Who is a candidate What is the success rate What are the risks

Common side effects of cryotherapy include perineal pain, transient urinary retention, penile and or scrotal swelling, and hematuria. Urinary retention occurs in roughly 3 of individuals. Anti-inflammatories seem to help, but individuals may require a catheter or suprapu-bic tube for a few weeks post-treatment. Penile and or scrotal swelling is common in the first or second post-procedure weeks and usually resolves within 2 months of cryotherapy. Penile paraesthesia may occur and usually resolves within 2 to 4 months postprocedure. Long-term complications of cryotherapy include fistula formation, incontinence, erectile dysfunction, and urethral sloughing. The risk of permanent incontinence (i.e., need to wear a pad) is reported to range from 1 to 8 . However, in individuals undergoing salvage cryotherapy after radiation failure, the incidence of urinary incontinence may be as high as 43 . Similarly, with total prostate gland cryotherapy, the ice ball extends beyond the capsule of the...

What causes ED

Many medical conditions and medications (Table 16) can cause ED. Smoking, alcohol abuse, drug abuse, stress, and depression can also cause ED. Considering erectile function as a neurovascular event, we can divide the causes of ED into those that affect the brain and nerves (neurologic) and those that affect the arteries and veins (vascular). prostate cancer. The onset of ED after radiation therapy is usually not immediate it typically occurs 2 or more years after the radiation therapy. Interstitial seed therapy for prostate cancer also affects erectile function in 25 to 60 of men who undergo it. As with external-beam radiation therapy, the effect on erectile function is usually seen a year or more after seed placement. Smoking causes vasospasm, or tightening up of the arteries, but it also may cause atherosclerosis, or hardening of the arteries. Venous leaks or abnormal veins may result from prior trauma and may be identified in Peyronie's disease, a benign condition affecting the...

Patient Instructions

Sexual health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition that affects sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify whether you are experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor.

Multiple Determinants of Behavior

For example, a child may be angry one day because a friend took his favorite game. He may be angry on another day because a girl flirted with him, and he became sexually aroused. He may become angry at another time because he cannot understand the teacher's math instructions. On still another day, he may be angry because his visiting grandparents have gone home. And on yet another day, he may be angry for all those reasons at once. This child may show his anger by throwing chalk at the blackboard on each of these occasions, and his chalk throwing may be the only behavior observed. Yet this single act of anger may be related to one of several different causes or to a combination of any number of them at a given time.

Effectiveness of Early Detection and Intervention

Screening with PSA and DRE can detect prostate cancer in its early stages, but it is not clear whether early detection improves health outcomes. Screening may result in several potential harms, including frequent false-positive results, biopsies, and anxiety. Treatment side effects may include erectile dysfunction, urinary incontinence, and bowel dysfunction. Treatment of all cases detected by screening is likely to result in many interventions for men who would never have experienced symptoms from their cancers (Harris et al., 2001).

Psychogenic Factors that Impair Sexual Ability

1998), consistently promote sexual urges, but many reduce them in ways that are often emotionally troublesome to people. The most widespread problems are associated with the anorgasmia and reductions in sexual motivation that result from the use of antide-pressants, most recently the selective serotonin reuptake inhibitors (SSRIs) (Rosen et al., 1999). However, other agents are not without problems (Gitlin, 1994), and there are some drugs that can facilitate sexual abilities (Crenshaw and Goldberg, 1996). Mammalian sexual energy is dependent heavily on brain dopamine release, so it is not surprising that all antipsychotics tend to diminish sexual urges (Van Furth et al., 1995). There is no simple way around these problems except drug discontinuation. Despite the ability of sexual performance enhancers such as sildenafil (Viagra) to promote sexual capacity, they still need to be evaluated in interaction with the major psychiatric drugs as well as in terms of various psychological...

Influence of testosterone on sexual behaviour in men

The physiological range of testosterone levels (3-12 ng ml) is considerably higher than that necessary to maintain normal sexual functions. Testosterone levels found to be critical for sexual functions in males lie around 3ng ml (Nieschlag 1979), and they show a clear intersubject variation. On the other hand, levels at which a decline of androgen-related sexual behaviour in individual subjects occurs appears to be reproducible (Gooren 1987). As the healthy male produces much higher levels of androgens than necessary to maintain sexual function, lowering serum testosterone levels to the normal low range or increasing them to the high normal range in eugonadal men has no appreciable effect on sexual function (Buena etal. 1993). This led to the conclusion that androgens are only beneficial in those men whose endogenous levels are abnormally low. However, Bancroft (1984) pointed out that we cannot be certain on this point because with increasing levels of endogenous androgen supply it...

Male Sex Act Big Picture

The male sex act begins with sexual stimulation. Somatic sensory nerves relay this information to the central nervous system. Parasympathetic impulses from the S2-S4 levels of the spinal cord cause blood to flow into the erectile tissue of the penis, resulting in penile erection. Sympathetic impulses from the T10-L2 spinal cord levels cause seminal fluids to mix with the sperm in the urethra in a process called emission. Ejaculation is the expulsion of the semen from the penis, which is caused by sympathetic innervation as well.

Impact of Lung Disease on the Patient

Asthma can affect a person's sexual function both physiologically and psychologically. Asthmatic patients may become more dyspneic as a result of the increased physical demands of sexual intercourse. Bronchospasm may occur, owing to excitement, anxiety, or panic. Anxiety about precipitating an asthmatic attack during sexual intercourse worsens the patient's dyspnea and sexual performance another vicious cycle is set into motion. Patients may then tend to avoid sexual intercourse.

Professionalism And Risks

Historically, health professionals, when confronted with infectious disease, have had to fear contagion. Fear (here defined as a sensation or feeling of anxiety caused by the realization, perception, or expectation of impotency in the face of perceived or expected danger or evil) subsumes qualities of dread and awe and further has other emotive and aesthetic elements.32 Counterpoised against such fears are the presumed duties of the profession not only the obligations assumed by moral agents in recognition of the moral law as distilled through the vision of specific social contract by particular societies, but likewise the more specific obligations inherent in being a professional of a particular type. Courage (the disposition to voluntarily act, perhaps fearfully, in dangerous circumstances, its essence being the mastery of fear for the preservation of a perceived good against dangers ) gives the edge to doing what one perceives to be the right thing despite one's fears.33 What...

Effects of testosterone therapy on erection in hypogonadal men

Since the early beginning of testosterone therapy of hypogonadal patients it has been known that testosterone restores normal male sexual behaviour and erectile function (see Chapter 4). A meta-analysis on testosterone therapy for erectile dysfunction in hypogonadal patients confirmed the significant improvement of erections after initiation of testosterone therapy (Jain et al. 2000). It should be noted that most of the clinical trials included only small numbers of patients, in most cases fewer than 20. Pooled data on placebo-controlled studies showed an improvement of erectile function in 36 of 55 men treated with testosterone, whereas significantly fewer men responded to placebo treatment (9 out of 45) (Jain et al. 2000). A recent large study involving 227 hypogonadal men randomly assigned to therapy with non-scrotal testosterone patches (two testosterone patches per day) or testosterone gel (5-10 g testosterone gel per day) demonstrated significant improvement of erectile function...

Psychoanalysis The Middle Years

According to Freud, Leonardo as a child lived with his single mother, felt sexually aroused by her before he could deal effectively with such feelings, and at the same time strongly identified with her. In attempting to manage such complex emotions, Leonardo as an adult became a celibate homosexual, expressing his sexual desires both for his mother and for young boys mainly through his painting. Eventually his superego forced him to steer away from even the indirect artistic expression of these morally and socially unacceptable urges. Leonardo shifted his attention to focus for a while on his scientific research, a less obviously sexual use of his psychological energy. Then, at about the same age that Freud had reached at the time of writing, Leonardo experienced a rearousal of his repressed desires for his mother, stimulated by the woman now known as Mona Lisa. Leonardo thereby regained his artistic creativity in midlife, and maintained that creativity into old age. Freud too...

Public Orientations Modern Voyeurism And Social Allergies

Tent figmental audiences, have no way of offering the person the type of feedback that assists in self-evaluation or future planning. With no means to pacify themselves through normal local social channels, performance anxiety escalates and becomes cued to a variety of social contexts, thus creating the psychic conditions for social phobia.

Effects Of Sexual Assault

In addition, sexual functioning and relationships are altered following sexual violence. Research indicates that the frequency of sexual contact decreases after sexual assault. Up to a year postassault, survivors experience diminished satisfaction and pleasure in sexual activities. Some victims develop sexual problems, such as fear and arousal and desire dysfunction that could persist for years after the assault. Young age, a known assailant, and penetration during the assault were found to have a strong association with sexual problems. Furthermore, emotions such as anger toward self and shame and guilt felt during and immediately after the assault might be predictive of later sexual problems.34

Innovation Characteristics

An example of both characteristics occurred with Pfizer. Chemists were working with a chemical compound (Sildenafil) to treat angina. This treatment proved to be ineffective - thus it was not an innovation. However, it was discovered that this chemical was effective in treating male erectile dysfunction, and very successfully marketed as Viagra. Thus, the unexpected use of the drug lead to it becoming an innovation.

Therapeutic Interventions

Administer to the client psychological instruments designed to objectively assess sexual promiscuity (e.g., Derogatis Interview for Sexual Functioning DISF , Multiphasic Sex Inventory II MSI-II , Sexual Adjustment Inventory SAI ) give the client feedback regarding the results of the assessment.

Antidepressants in the selective serotonin reuptake inhibitor category SSRIs

The oral medications, first introduced in 1997, work by blocking an enzyme (phosphodiesterase type 5) in the penis, thereby allowing the smooth muscles to relax and the penis to fill with blood. They do not produce an erection by themselves, but only when accompanied by erotic stimulation. The effective dose varies among men some men, but not all, get a better response at a higher dose. These medications should never be taken by men who are also taking nitrates for angina or chest pain the drug interaction can be fatal. atrophy of penile tissue. Biopsies of penile tissue were performed at six-month intervals in two groups of men one group took sildenafil every other night for six months and the other did not.20 If additional, longer-term benefits are definitely proven, these medications will be routinely prescribed to preserve penile function in men undergoing treatment for cancer of the prostate. My own experience with erectile dysfunction has been reasonably satisfactory. Like most...

Randomized Data and Current Conclusions

Scores for measures of quality of life and sexual functioning favored EVAR only in the early postoperative period but equalized after 6 months in comparison to open repair, in parallel with a continued need for reinterventions with EVAR. A closer look, however, revealed that many late complications after successful EVAR were of low prognostic impact, such as endoleak type II requiring reintervention in only 17 of 79 cases. Severe complications such as graft rupture (n 9), graft migration (n 12), endoleak type I (n 27), and graft thrombosis (n 12), which required reintervention in 35 of 60 cases, were likely to be attributed to technical or procedural problems with the stent-graft or unsuitable anatomy, again reminding the medical community of the inherently immature nature of an emerging technology. Moreover, at least six different brands of endovascular devices were used by surgeons with different levels of experience.

Allopathic adulterants

The prevalence of allopathic medicines in herbal preparations has been of particular concern in Asian countries with large Chinese populations. The Taiwanese Food and Drugs Administration reported that 30 of the antirheumatic and analgesic herbal products that they sampled contained a wide range of allopathic drugs, including analgesics and steroids (NLFD 1991). Another large-scale study in Taiwan analysed 2609 samples and found that 26 contained at least one adulterant, such as acetaminophen and prednisolone (Huang et al. 1997). In Hong Kong, the government laboratory carried out 65,748 tests on Chinese medicines in 2004 (GovHK 2004). Many of the proprietary Chinese medicines on sale for the treatment of obesity and impotence caused the most concern. They were found to contain sidenafil, tadalafil, sibutramine, and N-nitrosofenfluramine. In Malaysia in 1991, 83 of anti-arthritis preparations seized from Chinese medicine shops contained phenylbutazone. 'Black pills' for arthritis,...

Emergency Department Treatment and Disposition

Mild cases (oxygen saturation in the 90s on low-flow oxygen) at moderate altitudes (below 3500 m, 11,483 ft) may be treated at altitude with bed rest and oxygen. If supplemental oxygen and a reliable person are available, the patient may be discharged with oxygen therapy and bed rest at home or in lodgings. More severe cases should descend immediately and may require admission to a hospital at a lower altitude and, in extreme cases, intubation and mechanical ventilation. Nifedipine is of benefit but is not a substitute for descent. Some experts now use PDE-5 inhibitors such as sildenafil or tadalafil instead of nifedipine. Hyperbaric therapy, especially with a portable hyperbaric chamber (Gamow bag), has an efficacy equal to that of supplemental oxygen and is mainly helpful in prehospital settings where oxygen availability is limited.

Pesticide contaminants

Tagami et al. (2008) detected 56 pesticides in natural medicines. The 2004 Annual Report of the Government Laboratories in Hong Kong reported that about 1 of Chinese herbal medicine samples were found to contain levels of pesticides that were of concern (GovHK 2004). In early 2004, some ginseng powder products imported from Taiwan were found to be contaminated with organochlorine pesticide. Since then, all ginseng powder products imported from Taiwan have been screened for the presence of pesticide residues. Contamination of ginseng was also reported in 2002 on the website. Of the 21 ginseng products tested, two had levels of pesticides 20 times more than allowed levels (Aschwanden 2001).

Effects on morbidity and mortality

Titrated to maintain a serum testosterone concentration of 20 nM (Howell et al. 2001). Testosterone treatment did not alter bone turnover markers, hip, spine or forearm bone mineral density (quantitative computed tomography and DEXA), lean mass or fat mass (DEXA), mood (hospital anxiety and depression scale) or sexual function. However, two out of five components of the multi-dimensional fatigue inventory were improved (activity was increased and physical fatigue was reduced). These inconsistent and minor effects were supported by a case control study showing minimal differences based on lower serum testosterone concentrations in similar men (Howell et al. 2000) suggesting that androgen replacement therapy offers little objective benefit for men with compensated Leydig cell failure post-cytotoxic therapy.

Evolution of the limbic system bringing out the animal in us all

Second are the collections of neurons just in front of the thalamus, (the septal nuclei), the inner part of the cingulate gyrus and the tail end of the hippocampus. This part of the limbic system deals with reproduction and is involved in sexual function and behaviours, encouraging sociability and mating.

Historical Considerations

Phallic reconstruction poses a difficult challenge for the penile cancer surgeon. The main goals of surgery are the creation of a cosmetically acceptable sensate neophal-lus with the incorporation of a neourethra to allow voiding standing up and with enough bulk to allow the insertion of a penile prosthesis in order to allow sexual intercourse.1 Partial or subtotal penectomy for carcinoma of the penis or urethra results in a significant loss in sexual function. Patient satisfaction with their overall sexual life is less than 34 and therefore they represent the ideal candidates for total phallic reconstruction.26-28

Evaluation of the Urinary Tract

The urinary system includes the kidneys, ureters, bladder, and urethra a system history most often focuses on voiding, its primary function. Other issues may include sexual function or areas of overlap with other systems (e.g., abdominal pain). Patients often present with, or are found to have, common concerns specific to the urinary tract (see later discussion). A thorough drug history is critical because many common medications have uro-logic side effects (Thomas et al., 2003) (see eTable 40-1 online).

Who should be considered for treatment

As to the first question, in theory androgen administration to elderly men may be either substitutive to alleviate symptoms and prevent complications of a partial or more complete androgen deficiency, or rather pharmacological administration to elderly men who are not necessarily androgen deficient, but with specific treatment goals such as prevention or treatment of osteoporosis, frailty, or treatment of erectile dysfunction. Clearly, although there have been a few small-scaled studies providing indications of potential treatment benefits (Gruenewald and Matsumoto 2003), for no single indication does the present evidence even approach justifying pharmacological androgen treatment in elderly men. Thus we are left with only substitutive treatment to be considered at this time. There exist a number of questionnaires that are being used in clinical or epi-demiological settings to help describe and semi-quantify symptoms in different areas that are of relevance to elderly men, such as...

Do androgens have physiologic relevance in women

A speculative line of reasoning that androgens are physiologically important hormones in women is that there might be parallels between female and male androgen deficiency. Testosterone deficiency in men, from either surgical or natural hypogonadism, is a well defined state, and the sequelae are outlined extensively in chapter 13. These men are obese, insulin resistant, at risk for heart disease, have decreased muscle mass and strength, are certainly at risk for osteoporosis, and clearly have diminished sexual function. The question is automatically raised is there a similar clinical syndrome in women, albeit subtler We believe what little data does exist in this regard supports this contention.

Possible benefits of androgen replacement in women

17.4.1 Testosterone replacement and sexual function Multiple studies demonstrate clear evidence that testosterone replacement enhances sexual function in hypogonadal men. In women, there is also strong data in this regard. The best-known study demonstrating a beneficial effect of androgen replacement on sexual function in women was published in 1987 (Sherwin and Gelfand 1987). This trial, although non-randomized and unblinded, did demonstrate increased arousal, fantasy, coitus and orgasm in postmenopausal women given monthly intra-muscular testosterone enanthate (150 mg) and 10 mg of E2 valerate. However, mean serum testosterone levels noted in this study were well over 200 ng dl, at least five times the physiological range seen in naturally post-menopausal women. Accordingly, a later study reported that prolonged use of this preparation resulted in virulizing effects in a number of women (Urman et al. 1991). More sexuality data exists with testosterone replacement via subcutaneous...

Radiotherapy as a Treatment of the Primary Tumor 12321 EBRT

2 Gy, and treatment time exceeding 45 days.32 The difference approached prognostic significance (p 0.052). The incidence of complications such as urethral stricture or stenosis has been reported to be 16 -49 . A further two studies have reported on erectile function which is preserved in up to 90 of the patients.33,34

Complications Associated with Radiotherapy

Limited data are available concerning functional and psychosexual outcomes of organ-preservation by radiotherapy. Opsjordsmoen et al. reported on post-therapy sexuality in 30 men.34 Patients underwent a semistructured interview and completed three self-administered questionnaires (psychosocial adjustment to severe illness (PAIS), mental symptoms (GHQ), and quality of life (EORTC QLQ C-30)). A global score of overall sexual functioning was constructed consisting of sexual interest, sexual ability, sexual satisfaction, sexual identity, partner relationship, and frequency of coitus. In 10 of 12 patients treated with radiotherapy the sexual global score was not or only slightly reduced. Eleven out of fourteen patients treated with local surgery, laser beam treatment, or partial penectomy had moderate to severe reduction of global sexual score. All four patients who had undergone total penec-tomy recorded a severely reduced sexual global score. It was remarkable that in the patients...

Benefits of Psychoanalysis Compared with Benefits of Medication

Relaxation and sleepiness, while suppressing all the basic emotional systems and motivations general improvement in mood and decrease in anxiety may promote pleasurable relating to others, though sexual functioning is often diminished. Play is diminished in animals (Panksepp, 1998) and it is not unusual for patients taking SSRI medications to report that they feel emotionally blunted, unable to either laugh or cry (Hoehn-Saric et al., 1991 Garland and Baerg, 2001). Selective serotonergic-noradrenergic reuptake inhibitors (SNRIs) such as venlafaxine, nefazodone, and mirtazapine are designed to overcome this blunting effect by increasing available adrenaline as well as serotonin.

Subcortical structures

The paracentral lobule (Horn & Zasler, 1990). Stimulation of thalamic areas may also result in erection (MacLean, 1975). The medial dorsal and anterior thalamus are sites that may be involved in the production of an erection. In these cases, input probably relays via the efferent tracts from the cingulum and frontal systems. Lesions in the thalamus have been associated with hypersexuality (Miller et al., 1986). The form of hypersexuality noted in the Kluver-Bucy syndrome in man probably represents a failure to discriminate and effectively channel otherwise intact basic drives in the external world (Horn & Zasler, 1990 Mesulam, 1985, 2000a, 2000b). Throughout phylogeny eating, sexual, and aggressive behaviours have been consistently linked to limbic structures (Horn & Zasler, 1990), and direct stimulation of the amygdala often results in aggressive behaviours in primates and other animals (Horn & Zasler, 1990). In humans, complex partial seizures of temporal lobe origin (i.e., temporal...

Patients with impaired mood and wellbeing

Consistent with the effects of DHEA on mood andwellbeing in patients with adrenal insufficiency beneficial effects were also observed in randomizeddouble-blind studies in patients with major depression (Wolkowitz etal. 1999) and midlife dysthymia (Bloch et al. 1999). DHEA also improved scores on an ADL scale in patients with myotonic dystrophy (Sugino et al. 1998). Reiter et al. (1999) have reported an improvement in erectile function, sexual satisfaction and orgasmic function in 4060 year old men suffering from erectile dysfunction and receiving 50 mg DHEA day for six months in a randomized double-blind fashion. To compare the efficacy of DHEA vs. placebo in Alzheimer disease 58 patients were randomized to six months of treatment with DHEA (100 mg day) or placebo. A transient effect on cognitive performance narrowly missed significance (Wolkowitz et al. 2003), possibly because of the small patient sample. Recently Strous et al. (2003) have studied the efficacy of DHEA (100 mg day) in...

Neurohormonal influences

During the first three days following the head injury apparently due to dysfunction of the hypothalamus. The effect on testosterone, which correlated negatively with severity of the injury on admission, persisted at the 3- to 6-month follow-up in 5 out of the 21 patients who were re-tested. The stress of the injury itself can also alter sexual responses by increasing prolactin levels, thus leading to an automatic decrease in testosterone levels (Zasler, 1998). It appears that androgen levels are closely linked to seminal emission and sex drive in the human male, and that there is a requirement for a certain minimal level of androgen to be available for sexual function to take place however, excess amounts of androgen above these levels has minimum effect (Segraves, 1996). In the case of the female subject, current evidence suggests the oestrogen levels are essential to maintain vaginal epithelial integrity and lubrication whereas androgen levels may be related to libido (Segraves,...

Hypoactive Sexual Desire Disorder

Present sexual desire is now absent), acquired (beginning after a period of normal sexual function), or lifelong (persistent no or low sexual desire). The cyclic model of sexual functioning postulates that arousal, not desire, may be the initial trigger for a woman's sexual encounter. Recently, therefore, experts suggest defining HSDD as a recurrent, consistent lack of ability to experience any desire or arousal (Basson et al., 2004). A brief questionnaire can be helpful to screen patients for HSDD (see eTable 43-1 online).

Mechanism of Erection

Erection is a complex process that begins with impulses of sexual arousal at the brain centers of sexual excitement. The impulses travel along nerves from the brain to the penis, where they cause secretion of a substance called nitric oxide. Nitric oxide sends signals that cause dilatation of blood vessels and increase blood flow to the penis. It is estimated that during the early stages of erection, the blood flow in the penis increases 2,000 percent to 4,000 percent. This increase in blood flow, along with the relaxation of the smooth muscles of the penis, causes the penis to increase in length and diameter (engorgement). The veins that normally drain the blood away from the penis are closed during erection. Any disturbance in the whole chain of events can contribute to erectile dysfunction.

Female Sexual Arousal Disorder

Treatment is based on the suspected cause of the sexual arousal disorder. Supplemental water-soluble lubrication may be needed. Off-label use of PDE-5 inhibitors (e.g., sildenafil) may be helpful in restoring the vascular response (Kaplan et al., 1999). The FDA-approved Eros Clitoral Therapy Device uses a silicon cup to apply a vacuum to increase blood flow to the clitoris and surrounding tissue. The device appears effective in women without detectable disease and after radiation treatment for cervical cancer (Munarriz et al., 2003, Schroder et al., 2005), although sample sizes have been small. Herbal supplements and botanical genital massage oil showed some effect in small studies (Ito et al., 2001, Ferguson et al., 2003). Partner issues and situational factors may need to be addressed.

Premature Rapid Ejaculation

The SSRI antidepressants can cause prolongation of the preorgasmic plateau and thus may delay ejaculation. Using SSRIs for premature ejaculation is currently an off-label use, although research is ongoing. In a single-blinded prospective study of paroxetine, fluoxetine, and escitalopram, 100 of men complaining of premature ejaculation experienced an improvement in their symptoms, with no difference detected between the three treatment groups (Arafa and Shamioul, 2007). Dapoxetine is a short-acting SSRI that can be taken as needed, instead of daily as with other SSRIs, but is not yet approved by the FDA for use in the United States. Phase III randomized, double-blind, placebo-controlled trials show dapoxetine, 30 and 60 mg as needed, achieved statistically significant improvements in perceived control over ejaculation (Hellstrom, 2009). PDE-5 inhibitors added to SSRIs may further improve premature ejaculation. Sildenafil with paroxetine or fluoxetine and tadalafil with fluoxetine have

Resuming sexual activity

Stroke can cause physical limitations that influence body positioning and movement during sex which can lead to a reduction in sexual activity, misery and frustration. Other physical changes such as incontinence, drooling, emotional liability may be off-putting to partners and again lead to a reduction in sexual activity. However, this research goes on to report that for those patients who have had a previous myocar-dial infarction then little changed after stroke this may be because pre-existing vascular disorders had already caused erectile difficulties or because the antihypertensive agents commonly given to stroke patients inhibit erections, or because some medications such as beta-blockers also reduce desire. As well as physical difficulties, psychosocial impairments and depression may affect the will to engage in sexual relationships however, these may not be recorded till late after stroke as patients may be unwilling to talk about sexual difficulties....

The evolution of sexual dysfunction following TBI

As with all aspects of behavioural change subsequent to traumatic brain injury, the nature of sexual function following the injury is subject to developmental effects that ensue in the period following the injury. Blackerby (1987) proposes that there are three phases of the development of sexual functioning following TBI. In the acute stage, the severely injured patient tends to be self-stimulating and exhibitionistic,

LUSTSexuality Systems

Perhaps in this Age of Viagra new sexuality-facilitating agents are no longer needed. However, one could argue that beside the mechanical aid offered by such nitric oxide facilitating, erection-sustaining substances, there is still a substantial need for agents that facilitate the psychological side of eroticism. Based on preclinical work in animals, it is to be anticipated that certain neuropeptides and steroids may be harnessed to facilitate such ends. An abundance of neuropeptides and steroids have been identified within the fundamental sexual circuits concentrated in subcortical regions of the mammalian brain (Pfaff, 1999). For some time, it has been evident that testosterone supplementation can strengthen sexual urges in both males and females (Crenshaw and Goldberg, 1996).

Histrionic Personality Disorder Conversion or Somatic Symptoms

Patients with histrionic personality disorder have an emotionally expressive style, seek excessive attention, are often dramatic, and may present with a conversion disorder. Physicians may feel flattered, captivated, seduced, or sexually aroused by these patients. Alternatively, the physician may feel overwhelmed by the patient's exaggerated or excessive emotions, embarrassed by the sexual overtures, depleted, or confounded by unexplained physical symptoms, such as pseudoseizures, paralysis, and mutism. These patients may unconsciously use their symptoms to elicit attention or support from the physician (Bornstein and Gold, 2008). They may also use their sexuality to recruit others to satisfy their needs to be taken care of or romantically pursued. They fear that they are not desired and will lose the care or admiration of others.

Role of Oxidative Stress in ED Unraveling the Molecular Mechanism

Abstract Many advances in the understanding of erection physiology and pathophysiology have been made in recent years. These advances have revealed the importance of oxidative stress and a complex interaction between oxidative stress and regulatory pathways in the penis in the development and progression of erectile dysfunction (ED) associated with various disease states. In this chapter, we present current knowledge of the pathophysiology of ED pertaining to the mechanisms of reactive oxygen species (ROS) production, the interaction between ROS-generating sources and the main regulatory pathways in the penis, the status of the antioxidant systems that reduce ROS bioavailability, and cellular targets for ROS action in vasculogenic and neurogenic ED. We further discuss a therapeutic strategy to improve erectile function in disease states by targeting specific ROS mechanisms in the penis. Keywords Oxidative stress Erectile dysfunction Molecular mechanism Penis

Oxidative Stress in Hypertension Associated ED

Angiotensin II is a potent vasoconstrictor implicated in the development and maintenance of hypertension. Within the vascular wall, angiotensin II acting through the angiotensin I (AT1) receptor stimulates the production of ROS by activation of NADPH oxidase 67 . The corpus cavernosum of hypertensive rats exhibits increased lipid peroxidation 68-70 . Protein expressions of NADPH oxidase sub-units p47phox 71 and gp91phox 70 are upregulated in hypertensive rat penis in parallel with increased oxidative stress and ED. Furthermore, apocynin, an inhibitor of NADPH oxidase, reduces oxidative stress and improves erectile function in hypertensive rats 71 implying a major role for NADPH oxidase in ROS production.

Oxidative Stress in Hypercholesterolemia Associated ED

Increased oxidative stress has been postulated to be major molecular factors contributing to hypercholesterolemia-induced vasculogenic ED 72-74 . Corpus caver-nosal tissue of cholesterol-fed animals exhibits increased production of ROS 75-79 . In the mouse penis, hypercholesterolemia increases protein expressions of NADPH oxidase subunits p67p hox, p47phox. and gp91p hox 76 , while inhibition of NADPH oxidase by diphenyleneiodonium chloride and apocynin inhibits ROS production and preserves erectile function 76, 77 . These findings indicate a crucial role for NADPH oxidase as a ROS-producing enzyme in ED associated with hyper-cholesterolemia. In addition to NADPH oxidase, eNOS uncoupling 75, 76 , but not xanthine oxidase 77 , also serves as a source of ROS in the penis of experimental hypercholesterolemic animals.

Oxidative Stress in ED Associated with Cigarette Smoking

Cigarette smoking, both active and passive, is a risk factor for ED 84, 85 . Increasing evidence provided by basic science studies supports the concept that smoking-related ED is associated with reduced bioavailability of NO due to increased oxidative stress. Chronic cigarette smoke exposure impairs neuroregula-tory control of penile erection and impairs NO bioavailability 86 . Many of the vascular effects of chronic smoking are attributed to nicotine. In rabbit cavernosal smooth muscle cells, nicotine increases superoxide formation apparently by inducing NADPH oxidase 87 .

Relevant pharmacology

Pharmacological induction of erection in impotent men can be brought about by intracavernosal injection of the potent smooth muscle-relaxing drug papaverine, or by mixtures of papaverine and the a-receptor blocker phentolamine, or by injection of prostaglandin El, which is also a powerful relaxant of the erectile smooth muscle. The use of phenoxybenzamine (another a-receptor blocker) has been largely discontinued, since although it can produce long-lasting erections, these are often painful and damaging. More recently oral ingestion of a specific phosphodiesterase-5 inhibitor (Viagra) has gained popularity by enhancing erections to psychogenic stimuli. This drug works by reducing breakdown of cGmP, the second messenger mediating the relaxant effects of NO.

Side effects and acceptability

Possible side effects of hormonal male contraception might be caused by too high or too low testosterone levels or by additional substances. Decreased testicular volumes reflecting suppression of spermatogenesis is inherent to all hormonal methods, but is not considered a serious effect by the volunteers as long as sexual function remains unaltered. Weight gain is most likely an anabolic effect of testosterone. Due to the high peak serum testosterone levels caused by testosterone enanthate in the earlier studies, acne and mild gynecomastia could be observed in individual cases. Except for local skin reactions, side effects of GnRH analogues are mainly attributable to decreased testosterone levels, not sufficiently compensated for by testosterone supplementation. Sweating and in particular, nocturnal sweating is a feature of some added progestins (see Table 23.2). Libido sexual function

Therapeutic Strategies to Decrease ROS Production in the Penis

Continued research in the area of improving erectile function in disease states is pointing to the greater importance of targeting ROS formation, rather than ROS scavenging, for the development of an effective therapeutic strategy to reduce oxi-dative damage in the penis and ED. Several pharmacological agents have been suggested to inhibit ROS production and improve erectile function through mechanisms different and beyond their primary therapeutic actions, such as PDE5 inhibitors, angiotensin-converting enzyme (ACE) inhibitors and ATj receptor antagonists, statins, and BH4. This type of therapeutic strategy falls within the first line of recommended treatment of ED. This line of intervention involves preventable lifestyle modifications (such as discontinuation of cigarette smoking, exercise and weight control, Mediterranean-style diet, and a reduction in caloric intake) and treatable noninvasive pharmacologic therapies. The following sections summarize recent findings regarding...

Other common problems

Partnership and sexual functioning partnership is in many cases affected by the post-stroke condition, owing to altered physical and psychological conditions with their implications for everyday life and communication. Couple psychotherapy can be initiated and also improvements to assistance in the various fields can indirectly help relieve the often serious problems. Summarized in a review 127 , observational studies suggest that the frequency and range of sexual disorders after stroke are high and a noticeable decline in sexuality occurs in both genders after stroke furthermore partner dissatisfaction is high. In addition to the direct consequences of stroke, psychosocial issues and depression are likely to contribute to the problem. Pre-existing vascular disorders may also cause erectile difficulties as well as antihypertensive agents and other drugs. As the problems are often complex, treatment suggestions have to be comprehensive. Erectile dysfunctioning can be treated with...

Lesion location and mechanism of sexual dysfunction

Despite the issues raised concerning the site of lesions in TBI and their effect on sexual functioning, there has been surprisingly little support for specificity of localisation in the literature evaluating individuals subsequent to injury. This issue is necessarily confounded by the relatively diffuse nature of traumatic brain injury in its effect on the brain, and in the poor ability for older forms of imaging technology including CT, SPECT, and the earlier generation positron emission tomography (PET) scans to localise specific lesion sites. Griffith, Cole, and Cole (1990) propose that diffuse frontal injury with the involvement of the neural and endocrine systems is responsible for diminished sex drive. Garden (1991) proposes that medial temporal lesions account for hypersexuality whereas bilateral temporal lesions with lesions of the limbic system cause hypo-sexuality. Zasler (1998) contends that the frontal temporal areas, adjacent to the limbic structures of the right...

From the Sushruta Samhita ca 3000 bce

Penis Sup Dorsal Vein Cut Problems

Erectile dysfunction (ED) is an extremely common problem. It has been estimated that more than 30 million American men have some degree of ED and that nearly a million new cases can be expected to develop annually. Studies have shown that ED affects not only a man's physical and sexual satisfaction but also his general quality of life, with especially strong links to depression. In the Massachusetts Male Aging Study, 52 of men from 40 to 70 years of age had some degree of ED. Seventeen percent reported minimal dysfunction, 25 reported moderate dysfunction, and 10 reported complete dysfunction. This study also revealed the progressive nature of ED with increasing age. At 40 years of age, 5 of the American male population has complete ED, and at 70 years of age, 15 of the population has complete ED. Sixty-seven percent of men 70 years of age have some degree of ED. As the population continues to age, clinicians will treat more and more male patients for ED in the future. Erection is a...

History of Present Illness and Debilitating Symptoms

The effect of pain on the quality of life is important to understand. Untreated or undertreated pain impairs physical and psychological health, functional status, and quality of life. In particular, pain may produce unnecessary suffering decrease physical activity, sleep, and appetite, which further weakens the patient may increase fear and anxiety that the end is near may cause the patient to reject further treatment may diminish the ability to work productively may diminish concentration may decrease sexual function may alter appearance and may diminish the enjoyment of recreation and social relationships. In addition, pain has been associated with increased medical complications, increased use of health-care resources, decreased patient satisfaction, and unnecessary suffering. In the United States, the economic costs of undertreated pain approach 80 billion per year in treatment, compensation, and lost wages.

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