Infertility

Infertility is the inability to conceive or to cause pregnancy. Infertility is a common problem found in as many as 10% of all marriages. A couple is said to be infertile when after 1 year of normal intercourse without the use of contraceptives, pregnancy does not occur. It has been estimated that almost 30% of all infertility is attributable to a male factor. Any patient with a history of infertility should be questioned regarding a history of mumps, testicular injury, venereal disease, history of diabetes, history of a varicocele (see Fig. 18-27), exposure to radiation, or any urologic surgical procedure. Diabetic men may be infertile because of retrograde ejaculation, or ejaculation into the urinary bladder. Determine the frequency of sexual intercourse and any difficulty in achieving or maintaining an erection. Document a careful history of general work habits, medications taken, alcohol consumption, and sleeping habits.

Impact of Erectile Dysfunction on the Patient

ED is the inability of a man to achieve or maintain an erection sufficient to accomplish coitus. ED may be either erectile or ejaculatory. This inability may also be partial or complete. Men may complain of difficulty in achieving or maintaining an erection or of premature ejaculation. The prevalence of some degree of ED ranges from 20% to 30% of the married population. As a man ages, there is a natural loss of both libido and potency. In general, this does not occur before 50 years of age. Some men remain sexually vigorous well into old age. If a patient suffering from ED has occasional erections or can achieve orgasm during masturbation, he may have a primarily emotional problem. In almost 90% of patients complaining of ED, the inadequacy is found to be caused by emotional rather than anatomic factors.

Hearing about a friend's sexual activities, especially if they are exaggerated, can deflate a patient's ego and heighten his sense of inadequacy. The cultural environment of the patient must set the standard for adequacy. It is almost impossible to compare Western and Eastern cultural patterns. In 1948, Alfred Kinsey and his colleagues obtained factual data on Anglo-American sexual patterns. The frequency of sexual intercourse varied from one to four times per week. The period of maximum sexual activity was from 20 to 30 years of age. It was shown that there were marked variations among individuals as well as among socioeconomic groups. The lower the socioeconomic group was, the more frequent were the sexual encounters.

Boredom, anxiety, peer pressure, aging, deterioration of the stereotypical male role, and female ''aggressiveness'' are factors contributing to psychogenic ED. Diabetes mellitus is one of the more common causes of organic ED. Patients with multiple sclerosis, spinal cord tumors, degenerative diseases of the spinal cord, and local injuries suffer from a gradual loss of potency. Certain medications can cause ED: beta blockers, carbonic anhydrase inhibitors, and antihypertensive agents, for example.

Guilt, anxiety, and hypochondriasis are common in men with psychogenic ED. Sexual indifference in a woman may make the man feel more insecure in his own marital adjustment, worsening his ED. The man's self-image may be poor. It is common for a man with marginal difficulties to worry incessantly about his next attempt at coitus. His fear of failure generates enormous anxiety, which reinforces his inadequacy, and a vicious circle is begun. Each failure worsens the next attempt. If the act of coitus is not satisfactory to the patient or his partner, embarrassment and guilt develop.

Some men may be able to maintain erections but have difficulty in ejaculation. They may become physically exhausted and have to stop intercourse before ejaculating. The ejaculatory ducts may become so inflamed or even ulcerated that if ejaculation does occur, blood is present in the semen. This produces further anxiety and emotional upset that aggravate the situation.

Regardless of the cause, ED has vast implications. The man may feel emasculated and develop an inferiority complex. Anger and depression are common. If the patient's ED is associated with an anatomic defect, there may be additional changes in his self-image related to the physical disease. If sexual problems are not resolved, personality changes may develop in the patient. Fear of losing his sexual partner can interfere with his work. Sleep and rest may be disturbed. If sexual maladjustment continues, neurotic complaints may ensue. Without proper guidance, the man may experience complete ED, and suicidal tendencies may develop.

Severe psychiatric disturbances must be treated by a trained psychiatrist or sexual therapist. To a large extent, success depends on the ability of the clinician and the patient's sexual partner to inspire confidence in the patient.

Physical Examination

The only equipment necessary for the examination of the male genitalia is disposable latex gloves. Although the wearing of protective gloves may decrease the examiner's sensitivity, disposable latex gloves should always be worn.

Many students are concerned about the possibility that a patient will have an erection during the examination. Although this is possible, it is rare for a man to become sexually excited because he is usually somewhat uncomfortable under these circumstances. If the examination is performed in an objective manner, it should not be a source of stimulation to the patient.

Examination of the male genitalia is performed with the patient first lying down and then standing. This postural change is important, because hernias or scrotal masses may not be apparent in the lying-down position.

The examination of the male genitalia consists of the following:

Inspection and palpation with the patient lying down Inspection and palpation with the patient standing Hernia examination

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