Male Sexual Dysfunction

1. Male Sexual Dysfunction

2. Hypoactive Sexual Desire Disorder • Affects 15% of men • Typically associated with a medical condition, mental health issues, or medication side effects • hypogonadal • depression • antidepressant induced

3. Male Erectile Disorder • DSM-IV • Inability to attain or maintain adequate erection • problem persistent or recurrent • caused by psychogenic or combined factors • common reason for seeking treatment • highly distressing to men • prevalence

4. Male Erectile Disorder (ED)

5. Male Erectile Disorder • Medical causes: • vascular diseases (most common cause), e.g., hardening of arteries, long term cigarette use • diseases affecting the nervous system, e.g., multiple sclerosis, alcoholism • diseases affecting vascular and nervous system, e.g., diabetes, hypothyroidism • anything impairing penile vascular and/or nervous system: • surgical or accidental injury • old age • pharmaceuticals

6. Alcohol Estrogens Antiandrogens H2 receptor blockers Anticholinergics Ketoconazole Antidepressants Marijuana Antihypertensives Narcotics ß-blockers Psychotropics Cigarettes Cocaine Spironolactone Lipid-lowering agents NSAIDs Cytotoxic drugs Diuretics Drugs Associated with ED

7. Male Erectile Disorder (ED) • Psychological Causes: • occasional episode normal (e.g., stress) • men with ED focus on anxiety/worries rather than sexual cues --> negative feedback loop • normally functioning men focus on erotic cues --> positive feedback loop (Barlow, 1986)

8. Male Erectile Disorder (ED)

9. Male Erectile Disorder (ED) • Treatment: • Viagra (sildenafil), also, Cialis (tadalafil), Levitra (vardenafil) • injection of vasodilating drugs (e.g., alprostadil) • vascular surgery • vacuum pumps and constrictive devices • penile prosthesis or implants

10. Male Erectile Disorder (ED) • Sildenafil: Mechanism of Action • Nitric oxide acts through a second messenger, cGMP, in the normal development of erections • cGMP relaxes corpus cavernosal smooth muscle cells, promoting blood flow into cavernosal spaces • cGMP broken down by PDE - the predominant enzyme of this type in the corpus cavemosum is PDE type V • Sildenafil is a selective and potent inhibitor of PDE type V

11. Vacuum Pumps and Constrictive Devices

12. Male Erectile Disorder (ED) • PenileImplants • Two types: semirigid and multicomponent inflatable • Patient satisfaction: 81% to 97% • Average functional life: 7 to 10 years

13. Inflatable Penile Implant

14. Malleable Penile Implant

15. Male Orgasmic Disorder • DSM-IV: Inability to reach orgasm after sufficient stimulation • often require manual/oral simulation - “hard work” • rare disorder - • 1.5/1000 general population • 13% of those presenting for therapy • Physiological causes • SSRI • dopmanine agonists • spinal reflex abnormalities • Psychological causes • frustration/anxiety from previous incidents • childhood sexual abuse

16. Premature Ejaculation • Ejaculatory inevitability • Premature Ejaculation • ejaculation with minimal stimulation • before, upon, or shortly after penetration • taking into account: • age • novelty of partner • problem is persistent and recurrent

17. Premature Ejaculation • Prevalence • Causes: • Physiological • neurotransmitters (dopamine, serotonin) • touch sensation (Roland; Fanciullacci et al., 1988) • detecting ejaculatory inevitability (Kaplan, 1974) • Psychological • anxiety (only in acquired types; Cooper et al., 1993) • hostility

18. Premature Ejaculation • Treatment • Pharmaceutical • SSRIs • anti-anxiety • lidocaine • Psychological • pause-and-squeeze (Semens, 1956; Masters & Johnson) • mental imagery