Sexual Dysfunction
DSM-IV
Hypoactive Sexual Desire
Arousal Disorder
Inhibited Orgasm
Sexual Aversion
Premature Ejaculation
Sexual Pain
Sexual Disorder Not Otherwise Specified
Erectile Dysfunction
Four Etiologies
(1) Pure Psychogenic - seen in young people, "too nervous", "too anxious", "too sad", or "too angry". These men are capable of having erections (morning, mastabatory) but not in the context that they’re coming to you for.
(2) Organic - a physical problem, spinal cord injuries, peripheral vascular disease, DM, medications, surgery, Ischemic heart disease. ED has the same risk factors as Coronary artery disease (smoking, HTN, etc)
(3) Mixed - the most common in older men. (30% of men >60 y/o have unreliable penises, 60% of men >70 y/o)
(4) Idiopathic - "sorry dude, I have no idea why you can’t get it up"
Psychogenic ED and Viagara
primary (lifelong) - a problem in personal development, patients are usually young men (virgins or close to it), a therapeutic challenge (needs psychotherapy)
- Common causes
: wish to be a woman, homosexuality (often repressed), paraphilic, severe mental illness (OCD, schizophrenia), sexual trauma (unresolved), Misfortune in early life (problems with attachment), and religious guilt.
secondary (acquired) - "had it then lost it", seen at any age, a host of psychological situations that create negative feelings, medical and/or psychological therapies help most of the time
- Common causes
: anger, partner alienation, separation/divorce, guilt-affairs, widower, illness of self or partner (don’t exactly want to hop on a demented person even if she is your wife), Job failure or disappointment with oneself.
Two-horse race between Excitement and Fear - especially with new sexual partners, fear can win the race if excitement is weakened or fear is heightened. The response to the first sexual experience colors future events.
Mechanisms of psychogenic ED
(1) insufficient arousal (too anxious, too guilty, etc)
(2) limited motivation (hate your partner) Þ both present with "performance anxiety".
Viagra: March 27th 1998 the day the FDA approved Viagra (Sildenifil citrate) and forever changed the approach to ED
- an emotional arousal causes erections - arousal is enhanced by Sensuality, sensual preoccupation alters conscious, diminishes cognition, and loosens time sense
- Arousal generates NO in endothelial tissues of corpora cavernosa, NO causes guanylate cyclase to produce cGMP, cGMP causes relaxation of smooth muscles resulting in vasodilation. No AROUSAL = No NO = No ERECTION
- viagra
works by inhibiting phosphodiesterase-5 (located in corpora cavernosa) thereby Ý [cGMP] that is already around
- the side effects of Viagra have to do with inhibition of phosphodiesterase elsewhere in the body (e.g. blue vision because of cGMP in the retina (PDE-6), facial flushing due to vasodilation of the face, tylenol responsive headaches due to vasodilation).
- VIAGRA is CONTRAINDICATED in patients taking Organic Nitrates (nitroglycerine or amyl nitrate "poppers") because of catastrophic decreases in BP (
ß 30-60 mmHg resulting in sudden death)
- DOSE: 25 mg (63% response), 50mg (75% response), 100 mg (82% response) more side effects with higher dosages
6 Other (non-Viagara) Effective Treatments for ED
Intracavernosal injections of vasodilators - works well but requires injection
Intraurethral suppository of aprostadil MUSE - good idea, doesn’t work too well in real life
Vacumn pump - pump it up then rubber band it off to keep the blood in there. Good for a 20 min "erection"
Penile prosthesis - 10 yr lifespan currently; implanted surgically in patients who can’t have erections
Individual psychotherapy - works well in many instances of psychogenic ED
Conjoint psychotherapy - often ignored by medical folks but works well
How to help YOUNG men with ED
Remind them, "the penis is connected to the heart"
A limp penis can be a friend (remember it’s limp for a reason, maybe the context isn’t right)
Cultural attitudes determine "meaning", there is no word for ED in Polynesia
In newly divorced men, are they trying to be a rooster in a henhouse?
How to help OLD men with ED
Remind them it’s not just common it’s expected with advancing age
Most older people don’t have as much desire as they used to
Let’s consider your partner’s attitude about this (Dr.’s should also bear in mind the receptive partner’s sexual health, e.g. you don’t want 60 year old man to be too rough on his 60 year old wife’s atrophic, dry, menopausal vagina)
MOST IMPORTANTLY - "THERE IS HOPE FOR RECOVERY!"