Transcript Male Sexual Dysfunction

Sexual Dysfunction in
Male College Students
David Mellinger, MD
Duke University
And
Steven Kraushaar, PsyD
Washington Univ in St. Louis
Objectives
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Describe the relevant parts of the history and
physical examination in a male with sexual
dysfunction
Compare the available medications used in the
treatment of erectile dysfunction in terms of
selection
Discuss various psychological interventions in
treating males with sexual dysfunction
Premature Ejaculation (PE)
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Ejaculation that occurs sooner than desired
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Loss of control over ejaculation
and
Causes distress to either one or both partners
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What is too soon?
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All agree Intravaginal Ejaculatory Latency Time
(IELT) of less than 60 seconds is PE
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Most agree that less than 120 seconds is PE
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May be dependent on culture and expectation
Perceived Normal Time to
Ejaculation
Montosori, J Sex Med (2005); 2 (suppl 2): 96-102
Overlap in IELT Distribution
Patrick, et. al, J Sex Med (2005); 2: 358-67
Premature Ejaculation
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Epidemiology
Most common form of sexual dysfunction
 Prevalence Rates vary from 4-39% ; most general
studies in 21-31% range
 Rates generally not affected by age, marital status,
race, or country of residency
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Disconnect Between Diagnosed and
Reported Prevalence of PE
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Male patients don’t often “spontaneously” offer
up this problem as a complaint
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Clinicians don’t inquire about this common
condition
More on the Disconnect
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Global Study of Sexual Attitudes and Behaviors
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9% of men reported that they had been asked about
their sexual health by an MD during a routine visit in
the last 3 years
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48% of men believe that an MD should routinely ask
about sexual health concerns
Why don’t patients report PE
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Embarrassment
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Do not “medicalize” the problem
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Perceive that their provider is not able or willing
to address the problem
Why don’t Provider’s Ask about PE
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Lack of provider comfort in discussing sexuality
issues
Lack of provider knowledge about PE
Low prioritization by medical system of PE
No physical comorbidities
 Time pressure
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No FDA approved treatment options
What Causes PE
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Exact etiology not fully known
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Combination of Physiologic and Psychological
Factors
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Primary PE – “more” neurophysiologic while
acquired PE “more” psychological or related to
a medical condition
Behavioral Theories of PE
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Learned Behavior Conditioned from Early
Sexual Experiences (Masters and Johnson)
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Role of Anxiety
PE’s Impact on Men
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Symonds et. al study*
68% said their confidence generally or in a sexual
encounter affected – low “self-esteem”
 50% had relationship issues – reluctant to form new
relationships or were distressed not satisfying current
partner
 36% reported being anxious
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*Symonds et. al., J Sex Mar Ther (2003); 29: 361-370
Important Aspects of History
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Age at onset of disorder
Frequency of PE (Consistent or Intermittent)
Circumstance(s) when PE occurs
Estimate of Intravaginal Ejaculatory Latency Time
(IELT)
Any other sexual problems (e.g. ED)?
How has it affected your relationship(s)?
How has it impacted your sense of well-being?
Physical Examination and “Tests”
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Physical exam is not helpful in diagnosing
condition except in some secondary cases where
neurologic conditions or prostatitis are
entertained
No laboratory test available to confirm the
diagnosis
Can consider psychological tests to assess for
anxiety disorder
Treatment for PE
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Treat underlying cause (e.g. infection) if found
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Pharmacologic Interventions
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Behavioral interventions
Pharmacologic Interventions
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Topical anesthetics
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Tricyclic antidepressants (TCAs)
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Selective Serotonin Reuptake Inhibitors (SSRIs)
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Phosphodiesterase-5 (PDE-5) inhibitors
Topical anesthetics
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Mode of Action: Desensitize penis and therefore
increase IELT
Example: Lidocaine/prilocaine cream
How to use: Apply to penis 20-30 minutes prior
to intercourse, wash off before sex
Potential problems
Loss of pleasurable sensation for male and partner
 Contact skin reaction or allergy
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TCAs
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Mode of Action: presumed to act via neurotransmitters
involved to inhibit ejaculation
Example: Clomipramine
How to use: Can take on as needed basis before
intercourse or continuous basis
Potential problems
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Side effects
Doses and regimens not standardized (Not FDA approved)
Daily vs As Needed Clomipramine
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In a study* of on demand (OD) clomipramine
use in men with PE, 3 factors predicted likely
success of OD use
Men with IELTs of greater than 60 seconds
 Men with higher self-reported sexual satisfaction
 Men who ejaculated 2 or more times per week
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*Rowland et. al., Int J Imp Res (2004); 16: 354-357
SSRIs
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Mode of Action: Acts centrally through
serotonin receptors in inhibiting ejaculation
Example: Paroxetine
How to use: Can take OD, on a continuous
basis, or a combination of both
Potential problems
Side effects
 Doses and regimens not standardized (Not FDA
approved)
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Oral Therapies*
Fluoxetine
5- 20 mg/day
Paroxetine
10-40 mg/day or
20 mg 3-4 hrs before
intercourse (BI)
25-200 mg/day or
50 mg 4-8 hrs BI
Sertraline
Clomipramine
25-50 mg/day or
25 mg 4-24 hrs BI
*From Amer Urol Assn Guideline, J Urolog (2004); 172: 290-294
PDE-5 Inhibitors
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Mode of Action: ?
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having higher cGMP levels might prolong nitrous oxide
(NO) effect by delaying ejaculatory emission
Prolong erections – may reduce performance anxiety since
have improved erections
Example: Sildenafil
How to use: 25-100 mg 1 hour before sex
Potential problems
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Limited benefit in many studies
Side effects
Expense
Comparison of Oral Medications
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Multiple studies proving efficacy in delaying IELT in
many SSRIs and TCAs
For the SSRIs, paroxetine seems to work the best, with
sertraline and fluoxetine close behind
Although more efficacious in some studies, almost
twice as many adverse effects reported with
clomipramine compared with SSRIs
The evidence for sildenafil is the weakest, particularly
without concurrent erectile dysfunction
Which Option(s) for Patient
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Consider co-morbidities
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e.g. atopic dermatitis, anxiety
Side effects
Expense
Ultimately a shared decision between patient and
provider
Erectile Dysfunction (ED)
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“the consistent or recurrent inability of a man to
attain and/or maintain an erection sufficient for
sexual performance”*
*First International Consultation on Erectile Dysfunction, WHO, 1999
Prevalence of ED
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5-35% of men have moderate to severe ED
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Men’s Attitudes to Life Events and Sexuality
(MALES) study found prevalence of 16%, 22%
in US
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In the MALES study 8% of men in their 20s
reported ED
Epidemiology of ED
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Age dependent disorder
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Rate depends on how it is defined
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Expect the rates will increase as awareness of
the condition improves
What causes ED
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Overall it is a neurovascular phenomenon
Sexual stimulation leads to
Parasympathetic nervous system enhancement of
production of cyclic guanosine monophosphate
(cGMP)
 Smooth muscles relax and blood flows into the penis
 Filling of the penis, compresses outflow of blood via
the veins
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Anatomy of an Erection
Causes of Erectile Dysfunction
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Physical Causes
Vascular (leading cause)
 Cavernosal
 Neurologic
 Hormonal Causes
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Psychological Factors
Evaluation of Patients with ED
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Sexual history
Onset of Symptoms
 Duration of Symptoms
 Circumstances when ED occurs
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Problems with having an erection
 Problems with maintaining an erection
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Libido
 Concurrent premature ejaculation
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Medical History in Patients with ED
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Any comorbidities?
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CV disease, Diabetes, Depression, Alcoholism
Smoker?
Pelvic surgery, radiation, or trauma?
Neurologic disease?
Other endocrine problems?
Recreational or prescribed medication use?
Medications Known to Cause ED
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Many medications linked to ED
Antihypertensives (thiazide diuretics and beta
blockers)
 Antidepressants
 Hormones
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Physical Examination
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Blood Pressure Measurement
Testicular Exam
Exam of Penis
Vascular and Neurologic Exam if indicated
Laboratory Exam
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Consider Testosterone if decreased libido
Older patients (or others where indicated) do
lipid panel and fasted blood glucose
Targeted tests in select patients
PSA
 Prolactin
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Treatment of ED
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Identify and Treat Organic Comorbidities and
other risk factors
Counsel and Educate the Patient and Partner
Identify and Treat any Psychosexual
Dysfunctions
Medications and Devices
Surgery
Treatments
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Lifestyle modifications
Weight loss
 Increase Exercise
 Smoking Cessation
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Improvement in ED of Ex-smokers
ED Grade
Mild
Age Groups, Years
30-39
40-49
10/17
50-60
5/12
2/6
Mild to Mod 4/8
2/6
0/3
Moderate
5/19
2/16
0/7
Severe
0/6
0/8
0/10
Total
19/50 (38%) 9/34 (27%)
Pourmand, et. al. BJU Int (2004), 94: 1310-13
2/26 (8%)
Older Treatments
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Intracavernosal Injection
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Vacuum Constriction Devices
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Intraurethral Alprostadil Suppositories
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Inflatable Prosthesis
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Vascular Surgery
Oral Drug Therapies
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Phosphodiesterase Type 5 (PDE-5) Inhibitors
Sildenafil (Viagra)
 Tadalafil (Cialis)
 Vardenafil (Levitra)
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Yohimbe
Use of PDE-5 Inhibitors
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All three similarly effective
75% of men on medications have satisfactory
erection to complete intercourse
No large head-to-head trials to compare the 3
available medications
Some patients prefer one over the others
Comparisons of Available Medications*
*Moore, et. al. BMC Urol (2005); 5:18
Comparison Of Phosphodiesterase Type 5
(PDE-5) Inhibitors
Medication
Standard
Dose
When to
Take (h)
Prior to Sex
Duration (h) Cost per
of Action
pill*
Sildenafil
50-100 mg
1.0
<4
$17.30
Tadalafil
10-20 mg
0.5 - 12
36
$18.50
Vardenafil
10-20
0.5-1.0
<5
$16.90
*Based on average price reported
What to tell patients about PDE-5
Inhibitors Use
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Still require sexual stimulation to have erection
Sildenafil’s absorption may be reduced by foods
– especially fatty foods
Expect maximal efficacy in 1 hour (2 hours after
tadalafil)
First few doses may not be successful – try 6-8
times before giving up
Side Effects
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Headache
Indigestion
Flushing
Nasal congestion
Blue hue to vision
Contraindications
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Not to use with nitrates (including amyl nitrate)
Not to use if severe CV disease
Cautious use of vardenafil if has prolonged QT
Care if on alpha blocking agents – may cause
significant hypotension
Follow-up
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Recommended for all patients
Efficacy
 Side Effects
 Any significant change in health status (including
new medications)
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Why Treatment Failures
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Food or Drug interactions
Timing of Dose
?Maximal Dose
Lack of Sexual Stimulation
Heavy Alcohol Use
Relationship Problems
Yohimbine for ED
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Derived from the bark of the yohimbine tree in
Central Africa
Traditionally used to treat all forms of
impotence
Believed to work through the Central Nervous
System
An alpha2 adrenoreceptor blocker
Yohimbine for ED
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Metaanalysis shows yohimbine superior to
placebo (Odds ratio of 3.85)*
Relatively safe medication
Low cost
Amer Urol Assn does not recommend its use at
this time
*Ernst, Pittler; J Urol (1998); 159: 433-436
The Mental Health
Perspective
1.
2.
Premature Ejaculation
Erectile Dysfunction
3. College Health
Sexual History
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In addition to intake process
First awareness of and feelings about anything
he considers related to sex
Childhood curiosity and exploration
Masturbation, including age of first experience,
fantasies
Student’s socialization based on attitudes and
behaviors of family or other significant figures
Sexual History (2)
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Religious teachings about sexual behavior
The Coming Out Process
Dating History – “Losing virginity”
Relationships vs. “hook-ups” or “fuck buddies”
Sexually transmitted infections
Sexual experiences initiated by others/abuse
When specifically sexual difficulties began
PREMATURE EJACULATION
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a.
b.
Conventional Treatments
“Stop-and-start” technique Semans (1955)
“Squeeze Method” Masters and Johnson
(1970)
Limitations
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Some couples don’t want to interrupt sex after
starting.
Some students don’t have partners and some
partners unwilling to squeeze the penis
Techniques viewed as mechanical
The focus is on physiological processes and
neglect psychological dimensions such as
affective communication and sexual pleasure.
Functional-Sexological Treatment
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First Goal of treatment: Keep the man’s sexual
excitement at a level of intensity below that which sets
off ejaculation.
Achieved by modulating sexual excitement, by
monitoring sexual stimulation as well as managing
breathing and the muscular tension deriving from
sexual activity.
(de Carufel, François and Trudel, Gilles (2006)
'Effects of a New Functional-Sexological Treatment for
Premature Ejaculation', Journal of Sex & Marital
Therapy ,32:2,97 — 114)
Hypothetical Case Example
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21 y/o gay Chinese-American (Joe)
Referred by medicine due to difficulty
maintaining an erection
Serious relationship ended 3 months ago, but
they still share a suite
Low self-confidence, career indecision,
interpersonal anxiousness
Mood 6/10 Denies SI or HI
ERECTILE DYSFUNCTION
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Normal to have occasional difficulty achieving
an erection
Men often feel emasculated and ashamed
How could “it” have happened to me?
Solitary or infrequently occurring erection
difficulty does not mean that a man has a sexual
dysfunction.
(Morris, 1998)
Erectile Dysfunction (2)
Cultural expectations
 Fears and Myths
 “Men are taught that their essence is linked to
their penis; it is not enough to just have a penis
but you must have a big one that stands ready at
all times to perform spectacular sexual feats.”
(Morris, 1998)
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Sensate Focus
The cornerstone of sex therapy
 Helping a couple to focus on sensation rather
than performance
 Structured and flexible
 Homework
 Concerns regarding homework discussed in
couples session
Masters and Johnson (1970, 1986)
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College Health
Male reluctance to seek help
 “Sturdy Oak” Manliness = Not needing help
 “The Stud” – “hook-ups”
 Its just a sprain
Brannon (1976)
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Men’s health clinic
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Collaboration, Collaboration, Collaboration
Effective referrals
Men’s slots
QUESTIONS?