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MALE SEXUAL HEALTH PROBLEMS
Sexual problems in men are common. Epidemiological studies show that more than one third of men will complain of problems with penile erection: either not hard enough to penetrate or difficult to maintain once penetration has occurred. In addition, men may have problems with lack of interest in sexual activity, premature ejaculation, delayed ejaculation, inability to ejaculate, poor quality or reduced intensity orgasm, curvature of the penis, painful erections, or other sexual problems. Each sexual health problem listed below includes an overview of the problem, its associated symptoms and risk factors, as well as the diagnostic procedures and treatment options.
Erectile Dysfunction (ED) / Impotence
Desire problems / HSDD
Androgen insufficiency / hypogonadism / low testosterone
Diabetes / metabolic syndrome
Anti-depressants / SSRIs
Dihydrotestosterone (high/low levels)
Estrogen (high levels)
Female Partner's Sexual Dysfunction
Penile curvature / Peyronie's disease
Prolactin (high levels)
Pelvic / Perineal trauma
SHBG (high levels)
Androgens, primarily testosterone, affect sexual desire, erectile function, bone density, muscle mass and strength, adipose tissue distribution, mood, energy and psychological well-being. The mechanism by which androgens affect these physiologic and psychologic systems is through the synthesis of vital proteins. It is primarily testosterone unbound to circulating proteins that directs the synthesis and thus the physiologic activity. Unbound testosterone represents approximately 3% of total testosterone. The remaining 97% is bound to the proteins sex hormone binding globulin (SHBG) (67%) and albumin (33%).
There is a well-documented age-related gradual decline in total testosterone in healthy adult men. Testosterone levels start to decrease at age 40 and continue to decrease linearly at a rate of 1.5% per year, while SHBG levels increase exponentially after age 40. A widely used strategy to determine the unbound portion of testosterone is to measure blood values of total testosterone, SHBG, and if necessary, albumin, and plug these values into the free testosterone calculator in order to determine the “calculated free testosterone.” It is possible to have a normal total testosterone and low “calculated free testosterone” because of a high SHBG value. This can occur associated with obesity, type 2 diabetes and metabolic syndrome. “Calculated free testosterone” values less than 5 ng/dl are considered abnormal.
Symptoms which may be associated with decreased “calculated free testosterone” in the aging male include decrease in sexual activity, loss of libido, erectile dysfunction, decrease in volume of ejaculation, decreased orgasmic intensity, irritability, nervousness, generalized weakness, osteoporosis, decrease of body hair and abdominal obesity. If the “calculated free testosterone” levels are low and these symptoms are exhibited, the diagnosis is testosterone deficiency syndrome. Since blood test values are only one piece of the process involved in protein synthesis and may not represent what is actually happening inside the tissues, it is possible to have normal blood test values of “calculated free testosterone” and still have symptoms associated with testosterone deficiency.
While testosterone is a clinically relevant androgen, there are other androgens including DHEA, DHEA-S (sulfate), androstenedione and dihydrotestosterone (DHT) that can be measured in the blood. Studies have shown that these androgens also fall with increasing age. Although blood levels of free testosterone, percent free testosterone and bioavailable free testosterone may also be measured, studies have shown “calculated free testosterone’ to be more accurate in recording free testosterone.
ANTI-DEPRESSANTS AND SSRIS
The class of medications known as selective serotonin reuptake inhibitors or SSRIs raised the concentration of serotonin in the brain tissue. While elevated serotonin levels may be useful for the treatment of depression, serotonin itself is a potent inhibitor of the sexual response. It lowers or reduces sexual interest, can diminish the ability to achieve an erection, delay ejaculation and diminish the capacity for orgasm. In fact, one of the more common reasons to discontinue SSRI medications despite their positive action in treating depression is the adverse effect on sexual health. If a patient has a sexual side effect following use of an SSRI anti-depressant, several strategies can be employed to reduce these side effects. In conjunction with your physician, the dose of the SSRI may be decreased, an alternative form of anti-depressant such as a dopamine agonist may be prescribed instead of the SSRI, or it may be prescribed in conjunction with the SSRI.
There are two kinds of arterial insufficiency. The most common is when the arterial insufficiency is associated with a history of high cholesterol, diabetes, hypertension, cigarette smoking, obesity, family history and aging. Such arterial insufficiency may be considered to be generalized atherosclerosis. When hardening of the artery plaques form in the arteries delivering blood to the penis, the perfusion pressure to the erection chambers of the penis on the other side of the blockage will be reduced, resulting in a slow-filling, less rigid erection.
The other form of arterial insufficiency associated erectile dysfunction is seen in younger men who sustain an episode of blunt perinea trauma. In such cases the artery gets sandwiched between the blunt traumatic force and a portion of the pelvic bone. The lining of the artery, the endothelial surface, gets injured in this particular location. The result of the injury to the endothelium is a localized artery blockage that acts to reduce the perfusion pressure to the erection chamber.
For either form of arterial insufficiency, specialized blood flow tests are used to confirm low blood flow during erection. Most people including physicians are not aware that young, otherwise healthy men could have a form of arterial insufficiency erectile dysfunction.
Cardiovascular exercise such as jogging, racket ball, running, swimming and tennis has been associated with decreased prevalence of erectile dysfunction. While bicycle riding is a form of cardiovascular exercise, bicycle riding is associated with an increased prevalence of erectile dysfunction. The primary problem with bicycle riding is the bicycle saddle. While the rider is bearing his weight on the narrow bicycle saddle or its protruding nose, the compressive forces push the contents of Alcock’s canal against the bony surface of the pelvic bone, stopping blood flow to the genital organs and causing numbness and tingling in the penis and scrotum.
As it concerns the artery, chronic compressive forces can cause focal endothelial dysfunction leading to focal atherosclerosis and narrowing of the artery. The reduction in perfusion pressure in this artery leads to erectile dysfunction. In addition, bicycles designed for males often have a bicycle bar or top tube onto which boys and men can crush their perineum.
The relationship between erectile dysfunction and bicycling was demonstrated in the Massachusetts Male Aging Study (MMAS), a cross-sectional survey of 1709 men in their 40’s to 70’s. The random sample is representative of a similar population of men and includes a variety of cyclists, such as recreational and occasional riders, stationary bikers, and serious sport cyclists. A key finding of the MMAS was the relationship between moderate cycling (< 3 hours per week) or sport cycling (=3 hours per week) and the development of ED. Analysis of the data showed that individuals who cycle at least 3 hours per week have an odds ratio for developing moderate or complete ED of 1.72. (Odds ratios < 1.5 are defined as health risks.) That is, at least 3 hours of cycling per week was more likely to caused artery blockage and long-term damage.Ultimately, men must make their own decisions about the risks and benefits of bicycle riding. Before they begin to ride, however, they should be aware of the need for a properly fitting bicycle and comfortable saddle as well as the potential risks to sexual health presented by long-distance cycling. Finally, supervising children and providing them with properly fitting bicycles and seats, just as we do with protective helmets, is also essential to avoid injury and preserve sexual functioning.CANCER TREATMENTThere are many cancers, such as prostate, colon and testicular cancer, associated with effective therapies such as radiation, surgery, chemotherapy and hormonal ablation therapy that result in long-term survival. As such, quality of life after cancer treatment can be an important issue for some men and their partners. Men treated for various cancers are likely to experience side-effects consistent with reduced sexual interest, reduced erection, absent or reduced ejaculation, absent or muted orgasm, penile shortening, penile curvature or occasional sexual/perineal pain. While the oncologist focuses on eliminating the cancer, there may be limited attention paid to restoring sexual function.A thorough sexual/medical/psychosocial history, physical examination, psychologic assessment and laboratory tests are required to ascertain the basis for the sexual problem and the contribution of psychologic and biologic factors.For example, bladder and colon cancers may involve wearing a collection bag, such that the patient and his partner must adapt both physically and psychologically to these changes.
In prostate cancer, excision or radiation (external beam or seeds) of the prostate gland eliminates or decreases ejaculation respectively. In both cases, however, orgasm is possible, even with a poor quality erection, however the intensity of the orgasm is often reduced. In men whose nerves surrounding the prostate are injured during surgical excision, there is a loss of morning erections and the ability for erection based on sexual arousal. After prostate cancer surgery there is often shortening of penile length. Strategies such as stretching with a prescribed vacuum erection device can help preserve penile length.In an ideal situation discussion of the sexual consequences of cancer treatment occurs before the treatment.
If the patient has choices of treatment, the knowledge may either influence his choice or help prepare him for the consequences of the treatment. Furthermore, there is growing interest in the process of penile rehabilitation, or erectile function preservation. In such situations the patient is provided with strategies to help maintain and restore erectile function immediately after cancer treatment. Penile rehabilitation has been shown to successfully increase the chances of preserving erectile function after cancer treatment. Some cancers, such as prostate cancer, have hormonal dependency therefore hormone therapy, often indicated for hypogonadism may be contraindicated. Management of sexual dysfunction after cancer treatment is best performed with the patient working with both his sexual medicine physician and oncologist.
Depression often contributes to sexual problems and can intensify a dysfunction caused by medical issues. Depression has long been shown to negatively affect sexual performance. It can reduce sexual drive and blunt sexual interest. Depression can reduce energy levels and make it more difficult to achieve optimal physical and sexual functioning. Becoming sexually aroused is difficult if the individual is feeling depressed. Fully enjoying sex may be impossible under these conditions.Depression may be associated with a feeling of sadness, lack of energy and lack of initiative. For this reason many men with complaints of ED are not quick to seek help.
When they do, these men with depression associated erectile dysfunction are a particularly difficult group of patients to treat. Many men with depression are treated with anti-depressives, which may be a problem, as the medication used to treat their psychologic problem is highly associated with an iatrogenic (physician caused) form of erectile dysfunction.During history taking, it is common to note that the erectile dysfunction associated with depression more commonly starts after the treatment for depression has been initiated than after the depression itself. Physical examination should attempt to identify other potential causes of erectile dysfunction, such as Peyronie’s disease, vascular insufficiency or androgen insufficiency,
which has symptoms similar to depression. Men with depression on anti-depressant agents should undergo a full hormonal profile, as there is a high association to androgen insufficiency syndrome in such men. Psychologic assessment is obviously a critical component; the psychological assessment should consider the relationship of the treatment strategies to alterations in erectile function.HYPO ACTIVE SEXUAL DESIRE DISORDER/ LOW SEXUAL INTEREST/ LOWDESIRE The diagnosis of hypoactive sexual desire disorder (HSDD) in men is established primarily by history. Men with HSDD report that they would prefer doing almost anything else to having sexual activity. Physical examination may reveal abnormalities such as diminished sensation in the penis, or even diminished size. Hormonal testing may reveal androgen insufficiency syndrome and low "calculated free testosterone." Some medications lower blood androgen levels. Men who are overweight or who have high serum estradiol values can have high SHBG that lowers "calculated free testosterone." Other hormonal abnormalities may include hypothyroidism and elevated TSH. Low sexual drive may also occur in men with elevated prolactin. Neurologic testing may identify low sensation. Psychologic evaluation may reveal low self-esteem and self-confidence issues as well as relationship concerns. It is common for erectile dysfunction to be a cause of low interest, as that becomes a way to avoid sexual activity.DIHYDROTESTOSTERONE (HIGH / LOW LEVELS)Dihydrotestosterone (dht) is the final and most potent androgen in the androgen synthetic metabolic pathway starting with dhea. The enzyme 5a reductase is involved in the synthesis of dht from testosterone. Dht levels can be artificially lowered in men who take 5a reductase inhibitors either for the treatment of hair loss or lower urinary tract symptoms. Some patients even take finasteride for prevention of prostate cancer, although that prophylactic treatment is controversial.Men with low levels of dht can complain of various sexual dysfunctions, including low sexual drive, reduced erectile functions, reduced ejaculation/orgasm, and increased prevalence of peyronie's disease.
Histologic studies of penises of animals given 5a reductase inhibitor showed abnormal penile tissue with scarring. Men can have high levels of dht while taking testosterone treatment. With such treatment the testosterone may increase the dht to excessive levels and symptoms such as acne and hair loss may ensue.Ejaculatory disordersPremature ejaculation (pe)The most common of all sexual dysfunctions in men is premature ejaculation. The diagnosis of premature ejaculation is established by patient history. Efforts to distinguish premature ejaculation from erectile dysfunction need to be made.
The classic history is that a man with premature ejaculation can get a rigid erection, but loses the erection because of inability to control ejaculation. Men with erectile dysfunction typically have a less rigid erection initially, and lose their erection without ejaculating. Men who have erectile dysfunction from venous leakage, however, can have a relatively rigid erection initially and ejaculate without control before losing the erection due to the erectile dysfunction. Thus, in some cases, it is virtually impossible to distinguish the two sexual dysfunctions, and the assumption is that the patient has both erectile dysfunction and premature ejaculation.An objective measure that can be used in the diagnosis of premature ejaculation is intravaginal ejaculatory latency time (ielt). This is the time recorded by stopwatch from when a man penetrates to when he ejaculates. On average for sexual intercourse, the ielt is approximately seven minutes, whereas the ielt of a man with premature ejaculation is one to two minutes. There are also validated questionnaires that may be completed for assessment of premature ejaculation. Normal erectile function test results in a man with symptoms consistent with premature ejaculation will help confirm the premature ejaculation diagnosis.ERECTILE DYSFUNCTION, IMPOTENCE,EDThe first step in the process of diagnosing erectile dysfunction (ED) is the taking of a comprehensive sexual, medical and psychosocial history.In obtaining a sexual history, special attention should be paid to personal or cultural sensitivities. History taking should be aimed at characterizing the severity, onset and duration of the erectile dysfunction (ED), and evaluating the need for specialized testing. Questions should also be asked about other sexual dysfunctions including sexual interest, orgasm and ejaculation, sexual pain and penile curvature.A physical examination and selected laboratory testing should be performed on all patients with complaints of erectile dysfunction (ED). Although not different from a routine physical examination, special emphasis is placed on review of genito-urinary, endocrine, vascular and neurologic systems.
The physical examination may corroborate aspects of the medical history (e.g. poor peripheral circulation), and may occasionally reveal unsuspected physical findings (e.g. Peyronie's plaques, small testes or prostate cancer). The physical examination also provides an opportunity for patient education and reassurance regarding normal genital anatomy. Selective laboratory testing should be considered in all cases. This may include the following blood tests: DHEA-S, androstenedione, total testosterone, dihydrotestosterone, sex hormone binding globulin (SHBG), FSH, LH, prolactin, estradiol, TSH and PSA. Should endothelial dysfunction be considered, the following additional blood tests may be obtained: total cholesterol, HDL, LDL, triglycerides, homocystine, ultrasensitive c-reactive protein, lipoprotein A, and fibrinogen. Specialized diagnostic procedures that may be performed include nocturnal penile tumescence (NPT) testing, vascular procedures such as duplex Doppler ultrasound, dynamic cavernosometry, selective internal pudendal arteriography and flow-mediated brachial artery dilation, and neurologic procedures such as quantitative sensory testing recording vibration, hot, and cold sensation thresholds.Results of the initial evaluation and specialized testing should be carefully reviewed with the patient and patient’s partner, if possible, prior to initiating therapy. Additionally, sexual problems in the partner such as a lack of lubrication, hypoactive sexual desire disorder or dyspareunia (painful intercourse) should be discussed.ESTROGEN (HIGH LEVELS)Estrogens are synthesized from testosterone via the enzyme aromatase.
Men who have hypogonadism and are managed by testosterone therapy, whose testosterone values are elevated can have increased synthesis of estrogen as a consequence. Symptoms include breast tenderness, blood clots, erectile dysfunction, low libido and testicular atrophy.PROLACTIN (HIGH LEVELS)Prolactin is a peptide hormone synthesized and secreted in the anterior pituitary gland. Pituitary prolactin secretion is regulated in part by dopamine, which acts to inhibit prolactin secretion. High prolactin can result from a tumor in the pituitary gland that synthesizes prolactin without any physiologic regulation. Other causes of elevated prolactin include high levels of TSH from hypothyroidism, and a side effect of anti-psychotic medication.Elevated prolactin causes symptoms of low interest and is associated with low levels of testosterone. It is recommended that during an evaluation for a man with a sexual medicine problem, if low levels of testosterone are found, prolactin levels should be measured.PELVIC/PERINEAL TRAUMA ASSOCIATED ERECTILE DYSFUNCTIONIn cases of perineal trauma associate erectile dysfunction (ED), the patient will recall a distinct change in erectile function following an episode of trauma, assuming he was old enough to be aware of his previous function. The perineal trauma could be from forces in an upward direction, such as a karate kick or hockey stick or piece of lumber in the crotch. Forces could also be body weight falling onto an object, such as from skydiving or a fall onto a fence post or bicycle bar. In rare circumstances the episode of trauma might result in blood in the urine or a laceration requiring medical attention.The penis is attached deep within the perineum and does not end, as it appears to, at the scrotum but rather near the anus, so it is vulnerable when sandwiched between the blow and the ischiopubic bone.
The tubelike structure called Alcock’s canal, which lies along the ischiopubic ramus, is where the nerves and arteries enter the penis. The penile artery gets crushed and the endothelium is injured, initiating the atherosclerotic process in the penile arteries. Perineal trauma may lead to localized atherosclerosis secondary to a focal endothelial injury of the arteries within Alcock's canal and compromised blood supply to the penis over an unknown time period resulting in erectile dysfunction. The subsequent change in erectile function can occur immediately after the blunt trauma, but may be delayed up to one year or more after the episode. There may have been pain associated with the blunt trauma that is usually temporary, but in rare cases the injury leads to pudendal nerve damage and chronic pain. The dilemma in blunt trauma is that the artery gets sandwiched between the force and the bone, resulting in immediate artery blockage and inflammation to the lining, slowly leading to the artery blockage.Diagnosis of circulation abnormalities is by sophisticated testing including duplex Doppler ultrasonagraphy, dynamic cavernosometry and internal pudendal selective arteriography. Hormonal and endocrine testing are not necessarily needed but can be performed if issues such as decreased penile sensitivity, low interest or concomitant ejaculation or orgasm problems are identified. Psychologic evaluation is important because of the emotional trauma of being young and healthy with erectile dysfunction, the disruption to normal relationships, and the lack of understanding by the general healthcare community that there could be a physical cause to the erectile difficulties.
Too often the younger man seeking help is dismissed as someone seeking recreational drugs, rather than a patient with a bona fide organic erectile dysfunction.THYROID PROBLEMSGreater appreciation for the role of the thyroid gland on sexual health has been realized in the last several years. As such, most doctors and patients are unaware of the possibility that sexual problems can be the result of abnormal thyroid states and that treatment of the thyroid condition would restore the sexual function without any need for traditional treatments such as PDE5 inhibitorsHYPOTHYROIDISMHypothyroidism occurs when the thyroid does not produce sufficient thyroid hormone. Thyroid hormones are important and act to maintain fat and carbohydrate metabolism, control body temperature, and regulate protein production. Signs and symptoms of low thyroid hormone are varied and include: increased sensitivity to cold, constipation, pale and dry skin, unexplained weight gain, muscle aches, tenderness and stiffness, muscle weakness, and/or depression. Sexual problems can be the result of low thyroid states. Treatment of the thyroid condition could restore sexual function without any need for traditional treatments such as PDE5 inhibitors.Classic symptoms of hypothyroidism include fatigue, weakness, weight gain or increased difficulty losing weight, dry, coarse hair, rough, dry, pale skin, hair loss, intolerance to cold, muscle aches and cramps, constipation, irritability, memory loss, depression and sexual dysfunction. These are all fairly non-specific; it is obvious why the diagnosis of hypothyroidism is often not considered when diagnosing sexual dysfunction.
The sexual complaints in hypothyroidism included not only erectile dysfunction, but lack of sexual interest and muted orgasm, so should be considered as a diagnostic possibility in men who present with multiple kinds of sexual problems.The critical laboratory test at screening is thyroid stimulating hormone (TSH). Should there be consideration for hypothyroidism, more sophisticated tests are indicated. Efforts should be made to understand the cause of the hypothyroidism.HYPERTHYROIDISMHyperthyroidism affects sexual function. Men who have hyperthyroidism associated erectile dysfunction have been shown to restore their sexual function with treatment of the thyroid state, independent of other erectile dysfunction treatment strategies. It is very common that men who have hyperthyroidism and erectile dysfunction also have premature ejaculation and limited quality orgasm.Hyperthyroidism is associated with a constellation of symptoms such as feeling hotter than others around you, losing weight despite eating more, trouble sleeping even though fatigued, trembling hands, heart palpitations, irritability and a tendency to become easily upset. Laboratory testing starts with assessment of thyroid stimulating hormone (TSH). Should this be abnormally low, confirmation with more sophisticated tests are indicated. Efforts should be made to understand the cause of the hyperthyroidism.VENOUS LEAKAGEDuring a penile erection there is relaxation of the muscles of the penis allowing a rapid inflow of arterial blood to the erection chambers. This inflow of blood raises pressure in the erection chambers. In order to maintain this pressure, veins draining out of the erection chambers must be compressed. Anatomically these veins lie on the periphery of the erection chambers in a space just underneath the surrounding wall of the erection chamber called the tunica. As the erection tissue expands against the wall, the veins are compressed.
The result is a firm erection.Venous leak erectile dysfunction occurs when there is failure to adequately compress the draining veins from the erection chamber. The classic history of a man with venous leakage ED is having the ability to obtain an erection without the ability to maintain it. There are two major reasons for venous leak impotence: scarring of the erectile tissue; anxiety and stre