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Sexual Dysfunction in Male College Students

Sexual Dysfunction in Male College Students. David Mellinger, MD Duke University And Steven Kraushaar, PsyD Washington Univ in St. Louis. Objectives. Describe the relevant parts of the history and physical examination in a male with sexual dysfunction

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Sexual Dysfunction in Male College Students

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  1. Sexual Dysfunction in Male College Students David Mellinger, MD Duke University And Steven Kraushaar, PsyD Washington Univ in St. Louis

  2. Objectives • 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

  3. Premature Ejaculation (PE) • Ejaculation that occurs sooner than desired • Loss of control over ejaculation and • Causes distress to either one or both partners

  4. What is too soon? • All agree Intravaginal Ejaculatory Latency Time (IELT) of less than 60 seconds is PE • Most agree that less than 120 seconds is PE • May be dependent on culture and expectation

  5. Perceived Normal Time to Ejaculation Montosori, J Sex Med (2005); 2 (suppl 2): 96-102

  6. Overlap in IELT Distribution Patrick, et. al, J Sex Med (2005); 2: 358-67

  7. Premature Ejaculation • 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

  8. Disconnect Between Diagnosed and Reported Prevalence of PE • Male patients don’t often “spontaneously” offer up this problem as a complaint • Clinicians don’t inquire about this common condition

  9. More on the Disconnect • Global Study of Sexual Attitudes and Behaviors • 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 • 48% of men believe that an MD should routinely ask about sexual health concerns

  10. Why don’t patients report PE • Embarrassment • Do not “medicalize” the problem • Perceive that their provider is not able or willing to address the problem

  11. Why don’t Provider’s Ask about PE • 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 • No FDA approved treatment options

  12. What Causes PE • Exact etiology not fully known • Combination of Physiologic and Psychological Factors • Primary PE – “more” neurophysiologic while acquired PE “more” psychological or related to a medical condition

  13. Behavioral Theories of PE • Learned Behavior Conditioned from Early Sexual Experiences (Masters and Johnson) • Role of Anxiety

  14. PE’s Impact on Men • 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 *Symonds et. al., J Sex Mar Ther (2003); 29: 361-370

  15. Important Aspects of History • 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?

  16. Physical Examination and “Tests” • 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

  17. Treatment for PE • Treat underlying cause (e.g. infection) if found • Pharmacologic Interventions • Behavioral interventions

  18. Pharmacologic Interventions • Topical anesthetics • Tricyclic antidepressants (TCAs) • Selective Serotonin Reuptake Inhibitors (SSRIs) • Phosphodiesterase-5 (PDE-5) inhibitors

  19. Topical anesthetics • 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

  20. TCAs • 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 • Side effects • Doses and regimens not standardized (Not FDA approved)

  21. Daily vs As Needed Clomipramine • 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 *Rowland et. al., Int J Imp Res (2004); 16: 354-357

  22. SSRIs • 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)

  23. Oral Therapies* *From Amer Urol Assn Guideline, J Urolog (2004); 172: 290-294

  24. PDE-5 Inhibitors • Mode of Action: ? • 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 • Limited benefit in many studies • Side effects • Expense

  25. Comparison of Oral Medications • 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

  26. Which Option(s) for Patient • Consider co-morbidities • e.g. atopic dermatitis, anxiety • Side effects • Expense • Ultimately a shared decision between patient and provider

  27. Erectile Dysfunction (ED) • “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

  28. Prevalence of ED • 5-35% of men have moderate to severe ED • Men’s Attitudes to Life Events and Sexuality (MALES) study found prevalence of 16%, 22% in US • In the MALES study 8% of men in their 20s reported ED

  29. Epidemiology of ED • Age dependent disorder • Rate depends on how it is defined • Expect the rates will increase as awareness of the condition improves

  30. What causes ED • 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

  31. Anatomy of an Erection

  32. Causes of Erectile Dysfunction • Physical Causes • Vascular (leading cause) • Cavernosal • Neurologic • Hormonal Causes • Psychological Factors

  33. Evaluation of Patients with ED • Sexual history • Onset of Symptoms • Duration of Symptoms • Circumstances when ED occurs • Problems with having an erection • Problems with maintaining an erection • Libido • Concurrent premature ejaculation

  34. Medical History in Patients with ED • Any comorbidities? • CV disease, Diabetes, Depression, Alcoholism • Smoker? • Pelvic surgery, radiation, or trauma? • Neurologic disease? • Other endocrine problems? • Recreational or prescribed medication use?

  35. Medications Known to Cause ED • Many medications linked to ED • Antihypertensives (thiazide diuretics and beta blockers) • Antidepressants • Hormones

  36. Physical Examination • Blood Pressure Measurement • Testicular Exam • Exam of Penis • Vascular and Neurologic Exam if indicated

  37. Laboratory Exam • 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

  38. Treatment of ED • 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

  39. Treatments • Lifestyle modifications • Weight loss • Increase Exercise • Smoking Cessation

  40. Improvement in ED of Ex-smokers Age Groups, Years ED Grade 30-39 40-49 50-60 Pourmand, et. al. BJU Int (2004), 94: 1310-13

  41. Older Treatments • Intracavernosal Injection • Vacuum Constriction Devices • Intraurethral Alprostadil Suppositories • Inflatable Prosthesis • Vascular Surgery

  42. Oral Drug Therapies • Phosphodiesterase Type 5 (PDE-5) Inhibitors • Sildenafil (Viagra) • Tadalafil (Cialis) • Vardenafil (Levitra) • Yohimbe

  43. Use of PDE-5 Inhibitors • 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

  44. Comparisons of Available Medications* *Moore, et. al. BMC Urol (2005); 5:18

  45. Comparison Of Phosphodiesterase Type 5 (PDE-5) Inhibitors *Based on average price reported

  46. What to tell patients about PDE-5 Inhibitors Use • 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

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