Sexual dysfunction in male college students
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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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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

  • 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


Premature Ejaculation (PE)

  • Ejaculation that occurs sooner than desired

  • Loss of control over ejaculation and

  • Causes distress to either one or both partners


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


Perceived Normal Time to Ejaculation

Montosori, J Sex Med (2005); 2 (suppl 2): 96-102


Overlap in IELT Distribution

Patrick, et. al, J Sex Med (2005); 2: 358-67


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


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


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


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


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


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


Behavioral Theories of PE

  • Learned Behavior Conditioned from Early Sexual Experiences (Masters and Johnson)

  • Role of Anxiety


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


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?


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


Treatment for PE

  • Treat underlying cause (e.g. infection) if found

  • Pharmacologic Interventions

  • Behavioral interventions


Pharmacologic Interventions

  • Topical anesthetics

  • Tricyclic antidepressants (TCAs)

  • Selective Serotonin Reuptake Inhibitors (SSRIs)

  • Phosphodiesterase-5 (PDE-5) inhibitors


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


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)


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


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)


Oral Therapies*

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


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


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


Which Option(s) for Patient

  • Consider co-morbidities

    • e.g. atopic dermatitis, anxiety

  • Side effects

  • Expense

  • Ultimately a shared decision between patient and provider


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


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


Epidemiology of ED

  • Age dependent disorder

  • Rate depends on how it is defined

  • Expect the rates will increase as awareness of the condition improves


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


Anatomy of an Erection


Causes of Erectile Dysfunction

  • Physical Causes

    • Vascular (leading cause)

    • Cavernosal

    • Neurologic

    • Hormonal Causes

  • Psychological Factors


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


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?


Medications Known to Cause ED

  • Many medications linked to ED

    • Antihypertensives (thiazide diuretics and beta blockers)

    • Antidepressants

    • Hormones


Physical Examination

  • Blood Pressure Measurement

  • Testicular Exam

  • Exam of Penis

  • Vascular and Neurologic Exam if indicated


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


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


Treatments

  • Lifestyle modifications

    • Weight loss

    • Increase Exercise

    • Smoking Cessation


Improvement in ED of Ex-smokers

Age Groups, Years

ED Grade 30-3940-4950-60

Pourmand, et. al. BJU Int (2004), 94: 1310-13


Older Treatments

  • Intracavernosal Injection

  • Vacuum Constriction Devices

  • Intraurethral Alprostadil Suppositories

  • Inflatable Prosthesis

  • Vascular Surgery


Oral Drug Therapies

  • Phosphodiesterase Type 5 (PDE-5) Inhibitors

    • Sildenafil (Viagra)

    • Tadalafil (Cialis)

    • Vardenafil (Levitra)

  • Yohimbe


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


Comparisons of Available Medications*

*Moore, et. al. BMC Urol (2005); 5:18


Comparison Of Phosphodiesterase Type 5 (PDE-5) Inhibitors

*Based on average price reported


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


Side Effects

  • Headache

  • Indigestion

  • Flushing

  • Nasal congestion

  • Blue hue to vision


Contraindications

  • Not to use with nitrates (including amyl nitrate)

  • Not to use if severe CV disease

  • Cautious use of vardenafil if has prolonged QT

  • Care if on alpha blocking agents – may cause significant hypotension


Follow-up

  • Recommended for all patients

    • Efficacy

    • Side Effects

    • Any significant change in health status (including new medications)


Why Treatment Failures

  • Food or Drug interactions

  • Timing of Dose

  • ?Maximal Dose

  • Lack of Sexual Stimulation

  • Heavy Alcohol Use

  • Relationship Problems


Yohimbine for ED

  • Derived from the bark of the yohimbine tree in Central Africa

  • Traditionally used to treat all forms of impotence

  • Believed to work through the Central Nervous System

  • An alpha2 adrenoreceptor blocker


Metaanalysis shows yohimbine superior to placebo (Odds ratio of 3.85)*

Relatively safe medication

Low cost

Amer Urol Assn does not recommend its use at this time

Yohimbine for ED

*Ernst, Pittler; J Urol (1998); 159: 433-436


The Mental Health Perspective

Premature Ejaculation

Erectile Dysfunction

College Health


Sexual History

  • In addition to intake process

  • First awareness of and feelings about anything he considers related to sex

  • Childhood curiosity and exploration

  • Masturbation, including age of first experience, fantasies

  • Student’s socialization based on attitudes and behaviors of family or other significant figures


Sexual History (2)

  • Religious teachings about sexual behavior

  • The Coming Out Process

  • Dating History – “Losing virginity”

  • Relationships vs. “hook-ups” or “fuck buddies”

  • Sexually transmitted infections

  • Sexual experiences initiated by others/abuse

  • When specifically sexual difficulties began


PREMATURE EJACULATION

  • Conventional Treatments

  • “Stop-and-start” technique Semans (1955)

  • “Squeeze Method” Masters and Johnson (1970)


Limitations

  • Some couples don’t want to interrupt sex after starting.

  • Some students don’t have partners and some partners unwilling to squeeze the penis

  • Techniques viewed as mechanical

  • The focus is on physiological processes and neglect psychological dimensions such as affective communication and sexual pleasure.


Functional-Sexological Treatment

  • First Goal of treatment: Keep the man’s sexual excitement at a level of intensity below that which sets off ejaculation.

  • Achieved by modulating sexual excitement, by monitoring sexual stimulation as well as managing breathing and the muscular tension deriving from sexual activity.

  • (de Carufel, François and Trudel, Gilles (2006) 'Effects of a New Functional-Sexological Treatment for Premature Ejaculation', Journal of Sex & Marital Therapy ,32:2,97 — 114)


Hypothetical Case Example

  • 21 y/o gay Chinese-American (Joe)

  • Referred by medicine due to difficulty maintaining an erection

  • Serious relationship ended 3 months ago, but they still share a suite

  • Low self-confidence, career indecision, interpersonal anxiousness

  • Mood 6/10 Denies SI or HI


ERECTILE DYSFUNCTION

  • Normal to have occasional difficulty achieving an erection

  • Men often feel emasculated and ashamed

  • How could “it” have happened to me?

  • Solitary or infrequently occurring erection difficulty does not mean that a man has a sexual dysfunction.

    (Morris, 1998)


Erectile Dysfunction (2)

  • Cultural expectations

  • Fears and Myths

  • “Men are taught that their essence is linked to their penis; it is not enough to just have a penis but you must have a big one that stands ready at all times to perform spectacular sexual feats.”

    (Morris, 1998)


Sensate Focus

  • The cornerstone of sex therapy

  • Helping a couple to focus on sensation rather than performance

  • Structured and flexible

  • Homework

  • Concerns regarding homework discussed in couples session

    Masters and Johnson (1970, 1986)


College Health

  • Male reluctance to seek help

  • “Sturdy Oak” Manliness = Not needing help

  • “The Stud” – “hook-ups”

  • Its just a sprain

    Brannon (1976)


Men’s health clinic

  • Collaboration, Collaboration, Collaboration

  • Effective referrals

  • Men’s slots


QUESTIONS?


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