Sexual Dysfunction

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The mind and the body must work together for normal sexual function. Thoughts and emotions interact with the nervous, circulatory, and endocrine (hormone) systems of the body to produce a sexual response. The sexual response has four stages:

1. Desire (the wish to engage in sexual activity) is triggered by thought or verbal and visual cues.

2. Arousal (the state of sexual excitement) occurs as blood enters the genital area, leading to an erection in the male.

3. Orgasm (the climax of sexual excitement) occurs at ejaculation (the emission of semen from the penis); muscle tension increases throughout the body.

4. Resolution (a sense of well-being and complete muscle relaxation) follows orgasm.

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Erectile Dysfunction

Psychological problems, neurological problems, abnormalities in blood flow, damage to the genital organs, hormonal imbalance, and the use of drugs or medications—all can interfere with any of the four stages of normal sexual function. Erectile dysfunction occurs when one or more of these factors persistently interfere with the ability to achieve and maintain an erection sufficient to complete sexual intercourse.

Erectile dysfunction is often called impotence. Some experts object to the term "impotence" because of its negative implications and lack of precise meaning. The term "erectile dysfunction" is now used. Erectile dysfunction is defined as the inability to achieve or maintain an erection as part of the overall multifaceted process of sexual function. This definition deemphasizes intercourse as the essential or only aspect of sexual life and gives equal importance to other aspects of male sexual behavior.

At some time in their life, all men experience erectile problems. But for 30 million men in the United States, erectile dysfunction is a chronic, persistent problem. This number includes about 10 percent of the entire male population and 35 percent of men over 60. Fewer than 5 percent of men with erectile dysfunction seek treatment for this condition.

There are different levels of erectile dysfunction:

• a total inability to achieve erection

• the occasional ability to achieve erection

• an inability to maintain erections

• the ability to achieve erection, but inability to control ejaculation

Most cases of erectile dysfunction are treatable and are not the result or inevitable consequence of aging. The response in the penis that results in a normal erection depends on healthy nerves, blood vessels, muscles, and fibrous tissues, as well as on adequate blood levels of certain hormones, such as testosterone. Damage, injury, or malfunction in any of these areas can lead to erectile dysfunction. A number of phys-

The ABCs of Erection

An erection occurs when blood is pumped into the penis. The more blood that fills the penis, the harder the erection. Failure to achieve erection occurs when the penis does not fill or remain filled appropriately.

The penis has three chambers: two chambers called the corpora cavernosa, and one called the corpus spongiosum. The corpora cavernosa run the length of the penis and are filled with spongy tissue that contains smooth muscle, fibrous tissue, open spaces, veins, and arteries. A strong membrane, the tunica albuginea, surrounds the corpora cavernosa. The corpus spongiosum, which contains the urethra, runs along the underside of the corpora cavernosa.

Erection begins when a man receives an erotic sensory or mental stimulus. The brain sends impulses to the nerves around the penis, which cause the many tiny muscles of the spongy corpora cavernosa to relax, allowing blood to flow in and fill the open spaces inside the corpora cavernosa. This blood creates pressure in the corpora cavernosa, which makes the penis expand and compress the veins that normally allow the blood to drain. By helping to trap the blood in the corpora cavernosa, the tunica albuginea sustains the erection. Erection is reversed when the muscles in the penis contract, preventing blood from flowing in and opening the channels that allow blood to flow out.

ical factors such as disease or surgery, as well as psychological factors, can also 147

cause erectile dysfunction. In the past, it was believed that erectile dysfunction Sexuality was largely caused by psychological problems. Today most experts agree that, in 85 percent of cases, erectile dysfunction is the result of physical factors, most of which can be treated.

The following conditions can cause erectile dysfunction:

Diabetes. High levels of blood sugar associated with diabetes can damage small blood vessels and nerves throughout the body, including those in and around the penis. Diabetes can interfere with the nerve impulses and the blood flow necessary to produce an erection. About 60 percent of men with diabetes experience erectile dysfunction.

Heart disease. Atherosclerosis, which causes hardening and narrowing of the arteries, increases with age. Over time it can reduce blood flow to the penis and lead to erectile dysfunction. It accounts for most cases in men over 60 years of age.

• Leaking veins. When veins in the penis are not compressed during an erection, a vein can leak, leading to erectile dysfunction. A leak can be the result of injury, disease, or damage to the veins in the penis.

• Neurological injuries or disorders. Spinal cord and brain injuries, including paraplegia and stroke, can cause erectile dysfunction when they interrupt the transfer of nerve impulses from the brain to the penis. Other nerve disorders, such as multiple sclerosis, Parkinson's disease, and Alzheimer's disease, may also result in erectile dysfunction.

• Drugs. More than 200 prescription medications may directly cause or contribute to erectile dysfunction. Among these are drugs for high blood pressure, antidepressants, tranquilizers, sedatives, and a number of over-the-counter medications. Long-term, excessive consumption of alcohol and use of illegal drugs such as heroin and cocaine also can cause erectile dysfunction.

• Hormonal imbalances. Hormonal disorders account for fewer than 5 percent of cases of erectile dysfunction. Testosterone deficiency, which is rare, can result in the loss of libido (sexual desire). An excess of the hormone prolactin, produced by tumors in the pituitary gland, reduces levels of testosterone. Kidney and liver disease also may lead to hormonal imbalances that contribute to erectile dysfunction.

• Peyronie's disease. This is a relatively rare inflammatory condition that causes scarring of the erectile tissue in the penis. The scarring produces a curvature in the penis that can interfere with sexual function. In addition, it may cause erections to be painful.

• Pelvic surgery. With surgery of the colon, prostate, or bladder, the nerves that control the flow of blood into and out of the penis may be cut or removed. These nerves can be permanently damaged in men who have undergone radiation therapy for prostate or bladder cancer. Although these nerves do not control sensation in the penis and, therefore, are not responsible for orgasms, they influence the firmness of the penis during erection.

Some surgeons may try to spare nerve function during these procedures, with the hope that any sexual function problem will be temporary. Usually it takes 6 to 18 months for erections to return. Partial erections may return sooner. If they do, it could be a sign that complete erectile function will eventually return.

Pelvic injury. A minor injury to the pelvic area, including a fall or blow to the hip while playing sports, or a very long bike ride, can sometimes numb the nerves around the penis and block their normal functioning. A day of rest is usually enough time for the nerves to recuperate.

Psychological causes. Even though most cases of erectile dysfunction are the result of physical factors, psychological factors should not be overlooked. The most common psychological cause of erectile dysfunction is performance anxiety, a man's fear that he will not be able to perform sexually. Anxiety may lead to an initial failure, which increases the anxiety, resulting in a cycle that leads to future failures to achieve an erection.

Stress, tension, depression, worry, guilt, and anger can also inhibit sexual performance. These psychological factors may occur secondary to and possibly as a result of the physical causes. They may magnify the impact of erectile dysfunction resulting from physical causes.

Problems Associated with Erectile Dysfunction

Many cases of sexual dissatisfaction are related to problems in the control of ejaculation or in the loss of sexual desire unrelated to achieving or maintaining an erection.

Premature ejaculation is ejaculation that occurs too early, usually before, upon, or shortly after penetration. This condition, also called rapid ejaculation, is the most common sexual dysfunction. As many as 30 to 40 percent of men may have this problem. Even when rapid ejaculation is not defined by a man as a problem, it limits the sexual satisfaction of his partner.

Premature ejaculation is common among adolescent boys who fear being caught having intercourse or making their partner pregnant, or who have anxiety about their sexual performance. Some boys may find the excitement of seeing a nude body or touching a female to be so overwhelming and so stimulating that they may ejaculate even before they get their pants unzipped. In most men, ejac-ulatory control increases with sexual experience.

When premature ejaculation persists into adulthood, it often signals a problem in the relationship. One consequence of premature ejaculation is that the man begins to feel inadequate in meeting his partner's sexual needs since he may not maintain an erection long enough for his partner to achieve orgasm. He often

Reproductive System tries to distract himself mentally during the sexual experience or reduce his 149

thrusting in an effort to slow ejaculation. Some men may concentrate so heavily Sexuality on not ejaculating that they lose all sense of pleasure in sexual intercourse.

There is no agreed-upon amount of time that has to pass before an ejaculation is no longer considered premature. Some experts have used the number of thrusts and the partner's achievement of orgasm as criteria. But there is no standard for how long the sex act should last. Some men may feel they are accomplished lovers if they can pull off a "quickie"; others may feel they demonstrate their masculinity by prolonging intercourse to satisfy their partner.

No one is sure what causes premature ejaculation. Some question whether premature ejaculation is abnormal and point out that in the animal kingdom rapid ejaculation is an evolutionary adaptation to ensure procreation of the species. For men, however, most experts think of it as a psychological or learned problem. Although the condition rarely has a physical cause, in some cases inflammation of the prostate gland or a nervous system disorder may be involved.

Three different approaches are used to treat premature ejaculation. Counseling by a psychologist, psychiatrist, or sex therapist may be recommended based on the assumption that the problem is psychological in origin. Success rates of counseling are difficult to evaluate, since therapists use a variety of methods to measure success.

The second approach to treating premature ejaculation is behavior modification. A popular technique is the "stop-start" exercise. The male works with his partner to stop sexual stimulation just short of reaching ejaculation. The erection is allowed to subside. Then stimulation is started over and the procedure is repeated. This gives the man confidence when the deliberately subsided erection returns. The aim is to improve the man's ability to maintain higher levels of sexual excitement without ejaculating.

The third and most recently introduced treatment method is medication. One of two drugs, clomipramine or sertraline, can be used to produce a rapid and dramatic delay in the ejaculation response, which persists only as long as the drug is continued. These drugs have few side effects. While the potential benefits of these medications are significant, there are some concerns that treatment may be offered without first evaluating the man's health history, current health status, and actual need for the medication.

Retarded ejaculation is the opposite of premature ejaculation—the inability to have an orgasm even with prolonged erection. This condition is rare. But as men get older, it normally takes longer to reach orgasm. Often, however, this condition is caused by blood pressure medications, tranquilizers, and antidepressants, as well as by diabetes. Psychological causes include fear of vaginal penetration and fear of ejaculating in the partner's presence. Treatment usually involves undergoing behavioral therapy to reduce anxiety and learning techniques for timing ejaculation.

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150 Retrograde ejaculation is a condition in which semen travels up the urethra

The toward the bladder instead of through the penis. This condition is seen with some spinal cord injuries, after removal of the prostate gland, or after bladder surgery. It does not have any negative effects on the man's health.

Loss of libido (sexual desire) is a decrease in sex drive that occurs in both men and women. Nearly half of those seeking sex therapy have low libido. Most often, this common condition develops after years of normal sexual desire and activity. It may be caused by boredom, stress, depression, conflict with a partner, or changes in hormone levels. Often it is related to the increased use of medications, particularly in middle age.

A loss of libido may occur as a consequence of erectile dysfunction or it may precede erectile dysfunction. There is no "normal" amount of sexual drive or desire. Having less sexual desire than your partner does not indicate that you have a problem, only that there is a difference in how much sex each of you wants. If loss of libido has become a problem in your relationship, it is important to seek a physician's help to rule out medical causes. If psychological factors are involved, sex education, counseling, or behavioral therapy may help you and your partner communicate better and achieve a more intimate sexual relationship.

Decreased orgasmic intensity is another symptom of men who have problems with sexual function. It is not quite the same as loss of libido because the man still has the same level of sexual desire, but he experiences the loss of or diminished sensation of pleasure usually associated with ejaculation. Those who lose the sensation may lose interest in sex altogether. Others may become anxious, which often leads to erectile dysfunction.

The intensity of orgasm depends on many factors, including the setting in which sexual activity occurs, feelings toward the partner, the amount of fantasy and foreplay, the partner's physical response to stimulation, and the amount of time that has passed since the previous orgasm. Men with diabetes or with a neurological condition such as multiple sclerosis often experience decreased orgasmic intensity. With age, some loss of orgasmic intensity is normal.

Effects of Erectile Dysfunction

Erectile dysfunction, regardless of cause, leads both sexual partners to experience a range of feelings and intense emotions, including a sense of hopelessness and low self-esteem. These feelings can reinforce a man's performance anxiety and create a cycle of repeated failures and increasingly negative feelings. To overcome these feelings, both partners have to acknowledge the problem and communicate openly and honestly with each other. Because sexual performance is linked so strongly to a man's self-esteem, erectile dysfunction can be devastating not only to his sex life but also to his sense of self. Men with erectile dys-

function often develop feelings of inadequacy, embarrassment, or guilt, and may 151

consider themselves unattractive to their partner. These feelings might cause a Sexuality man to avoid intimate situations, isolate himself from the relationship, or withdraw from his partner, which can increase tension in the relationship.

The psychological effects of erectile dysfunction can invade other areas of a man's life as well, such as social interactions and job performance. It is important for a man with erectile dysfunction to overcome the reluctance to talk with his partner and physician to determine effective treatment strategies.

Diagnosing Erectile Dysfunction

Since erectile dysfunction has a number of causes, the underlying problem must be found through diagnostic procedures before treatments can be suggested. A physical examination always includes a medical and sexual history. The doctor asks questions regarding the use of prescription medications, other drugs, and alcohol. He or she also will ask about possible problems at work or at home and about other diseases that may contribute to the dysfunction. In particular, the doctor will ask about your ability to have erections and how frequently you have erection problems. From this information the doctor can determine the severity of the problem.

The doctor will perform a physical examination that includes many of the procedures that are part of a regular checkup. Blood and urine tests can indicate unusual levels of hormones, cholesterol, or blood sugar, and help evaluate liver and kidney function, thyroid activity, and blood counts. The following general diagnostic tests are usually performed for diagnosing erectile dysfunction:

• Urine tests for protein (albumin) and sugar (glucose) can confirm the presence of diabetes and indicate the level of kidney function.

• Blood tests check the levels of several body chemicals that are potential factors in erectile dysfunction. For example, a high blood sugar level indicates diabetes; about 60 percent of men with diabetes experience erectile problems. A high cholesterol level may indicate the presence of atherosclerosis, which might slow the flow of blood into the penis. A lowered blood level of the male hormone testosterone or a high blood level of the hormone prolactin also can cause erectile dysfunction.

• Liver and kidney function tests look for hormonal imbalances that may be present in these organs when they are not properly removing waste from the body.

The following tests are performed less frequently to diagnose erectile dysfunction:

• A thyroid function test measures the levels of thyroid hormones. Thyroid hormones regulate body metabolism and the production of sex hormones.

A complete blood cell count (CBC) measures the number of red blood cells and white blood cells. Too few red blood cells may indicate anemia, which can limit the amount of oxygen the body's cells receive. Increased white blood cell levels can indicate the presence of infection.

The following specialized tests can be used to more directly evaluate erectile function through examination of the blood vessels, nerves, muscles, and other tissues of the penis and surrounding areas:

• An evaluation of blood circulation to the penis is made by taking the pulse of the penis and surrounding pelvic area. This procedure tells the doctor whether the blood supply to the penis is sufficient to produce an erection.

Other approaches to studying penile blood flow include measuring penile blood pressure with the use of a special cuff or with ultrasound. Special types of ultrasound testing, such as duplex ultrasound or Doppler ultrasound, provide motion pictures of penile blood flow while an erection is induced by injection of a drug.

• An assessment of secondary sex characteristics such as breast enlargement in a man (gynecomastia) may indicate testosterone deficiency or an excess of the female hormone estrogen, either of which can decrease erectile function.

• Penile nerve function tests can determine if there is sufficient sensation in the penis and surrounding area. In one such test, called the bulbocavernous reflex, the physician squeezes the glans (head) of the penis, which causes the anus to contract if nerve function is normal.

• An evaluation of nocturnal penile tumescence is made. A man normally has five to six erections during sleep, especially during rapid eye movement (REM) stages, which occur during the dream segments of sleep. Nocturnal erections occur about every 90 minutes and last for about 30 minutes each. Failure to have nocturnal erections may indicate a problem with nerve function or blood supply to the penis. Nocturnal erections can be measured at home using either of two methods:

1. A snap gauge is a band that contains three plastic strips that are wrapped around the penis. These strips snap when they are stretched. Each of the strips has a different strength so that a rough measure of penile rigidity and the change in its circumference can be assessed during a nocturnal erection.

2. A strain gauge is a circular device that measures the change in circumference at the base and at the tip of the penis during an erection.

• Biothesiometry uses vibration to measure the perception of sensation. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to erectile dysfunction.

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• Injection of a vasoactive substance (a substance that affects the width of the 153 blood vessels) into the penis may be used to cause an erection by dilating Sexuality (widening) the blood vessels and erectile tissues. These erections may last about 20 minutes, during which time penile pressure is measured and X-ray films may be taken of the penile blood vessels using a special dye.

• Specific nerve tests are used for patients with suspected nerve damage as a result of diabetes or a history of nerve disease, or when a physical examination reveals a nervous system abnormality, suggesting neurological causes of erectile dysfunction.

Treatment

At least half of all men between 40 and 72 have at least occasional problems either getting or keeping an erection. Because it is often believed to be "all in your head" or due to aging, many men think that their case is hopeless and simply stop having sex. Men and women should recognize that sexual intercourse is just one form of sexual relations, albeit an important one; various types of sexual play, including oral sex, can keep a couple close.

About 95 percent of cases of erectile dysfunction are treatable. During the 1990s, the variety of treatment options expanded. A urologist (a physician who specializes in treating disorders of the urinary tract) can describe what methods are most appropriate for you. Regardless of the method you ultimately choose, consider the following important factors:

• Motivation. Honestly evaluate what is motivating you to seek treatment and try to understand your expectations about treatment. Unrealistic expectations may undermine the success of treatment. Be committed to the treatment you choose and do what is necessary to make the course of treatment successful.

• Willingness to adapt. All treatments for erectile dysfunction require active participation by the patient. Be willing to change your habits, learn new sexual techniques, and adapt to unanticipated events or circumstances to make the treatment work.

• Partner's attitude. Erectile dysfunction is often called a couple's problem for a variety of reasons. If a couple is having difficulty getting along, this may result in sexual problems. Also, some treatments for erectile dysfunction may require a man's partner to participate or administer medication. Since partners often experience similar emotional responses to the problem, some couples find that counseling can help them adjust to the treatment and reestablish a mutually satisfying sexual relationship. Either way, a partner's involvement in and commitment to treatment definitely help a man recover. Although the man might be reluctant or embarrassed to have his partner involved, most partners of men with erectile dysfunction want to be involved in the treatment process, because they both will benefit.

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154 Sildenafil Sildenafil is an oral medication for treatment of erectile dysfunction

The that has been available since 1998. Sildenafil does not produce erections, but it improves erections already produced by sexual stimulation. Foreplay is an essential component for the erection. Sildenafil works by inhibiting the enzyme responsible for relaxing an erection by breaking down a chemical called cyclic guanosine monophosphate (cGMP). The action of sildenafil in the body increases the levels of cGMP, relaxing the smooth muscles in the penis and increasing blood flow into the penis.

Sildenafil is absorbed and processed rapidly by the body. It must be taken a half hour to an hour before sexual intercourse and should not be used more than once a day.

Warning: Sildenafil must not be taken by men who are using nitrates, which are medications taken for chest pain and high blood pressure. Men who are using nitrates who then take sildenafil risk dangerously low blood pressure and stroke.

Overall, studies have shown that sildenafil is effective for about 50 to 75 percent of men being treated for erectile dysfunction. Effectiveness rates vary depending on the cause of the problem, but the drug has produced positive results for a range of men under treatment, including those with diabetes (57 percent) and spinal cord injuries (83 percent), as well as men who have had a radical prostatectomy (43 percent).

Sildenafil has few major side effects, but minor side effects include headaches, flushing, indigestion, and blue-green color vision deficiency. Sildenafil is available only with a doctor's prescription.

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