Erectile dysfunction

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Slide 1 :

Sexual Desire DisordersSexual Arousal Disorders Mukesh Bhimani Psychiatry Resident AKUH

Slide 2 :

Objectives General overview of sexual dysfunctions Sexual desire disorders Sexual arousal disorders

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Introduction In men sexual dysfunction refers to repeated impairment of normal sexual interest and/or performance In women it refers more often to a repeated unsatisfactory quality to the experience, sexual intercourse can be done, but without enjoyment The essential feature of the sexual dysfunctions is inhibition in one or more of the phases, including disturbance in the subjective sense of pleasure or desire or in the objective performance

Slide 4 :

Common in general population, affecting an estimated 43% women and 31% of men Its prevalence is higher in persons with mental illness Depression=78% Schizophrenics treated with antipsychotics=30-54% With antidepressants=10-50%-----36-65% with SSRI Christopher m. et al; Psychosomatics:48:4, July-August 2007

Slide 5 :

General causes of sexual dysfunction Poor general relationship with partner Low sexual drive Ignorance about sexual technique Anxiety about sexual performance Physical illness Depressive & anxiety disorders Medications Alcohol or drug misuse

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Assessment of patients with sexual dysfunction See both partners Assessment includes:- Define the problem (ask both partners) Origin and course With other partners? Strength of sexual drive Knowledge and fears

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Social relationships Psychiatric disorder Substance misuse Medical illness; medical or surgical treatment Why seek help now?? Physical examination Laboratory tests

Slide 8 :

General approaches to the treatment of sexual dysfunction Before directing treatment to the sexual problem, it is important to consider whether couple therapy is more appropriate because sexual problem is secondary to problem in the relationship. Advise and education Sex therapy---it should be directed to both partners whenever possible The methodology was originated and developed by Masters and Johnson In dual-sex therapy, treatment is based on a concept that the couple must be treated when dysfunctional person is in a relationship Masters WH and Johnson VE (1966) Human sexual response

Slide 9 :

The usual approach has four characteristic features; The partners are treated together; They are helped to communicate better about their sexual relationship; Education stress the physiology of sexual response They take part in a series of ‘graded tasks’. Sensate focus Discourage Spectator role

Slide 10 :

Results of dual-sex therapy Few adequately controlled studies of sex therapy Successful in about a third of cases Worth while improvement in further third Improvement at end of treatment are maintained for months but may not be sustained 3 years after therapy

Slide 11 :

Sexual Desire Disorders Lack or loss of sexual desire Sexual aversion & lack of sexual enjoyment

Slide 12 :

Lack or loss of sexual desire It is characterized by a deficiency or absence of sexual fantasies and desire for sexual activity It is more common among women than among men Reported by 10-15% of women in various countries Lack of sexual desire Loss of sexual desire

Slide 13 :

Global lack of desire suggests a biological determined low level of sexual drive; or homosexual orientation when the complaint relates to heterosexual intercourse Global loss of desire suggests medical or psychiatric cause Situational loss of desire often reflects general problems in the relationship between sexual partners

Slide 14 :

Causes of Low Desire Low testosterone levels (<300 ng/dL), elevated prolactin Age-related (>50) or drug-induced e.g.. SSRIs & others Also associated with: Medical conditions Psychiatric disorders especially depression Substance abuse Interpersonal difficulties and relationship discord

Slide 15 :

Assessment Sexual desire is assessed by asking about: Imagery the frequency and nature of sexual imagery and dreams Desire for and frequency of sexual behavior, with partner or alone Potential causes are assessed by asking about: Relationship problems: loss of affection or anger, etc Sexual orientation, sexual preferences Tiredness, anxiety, depression Past sexual experiences causing fear or disgust Medical/surgical causes:

Slide 16 :

Treatment Treat any primary cause found (physical, psychological, or psychiatric). Testosterone can be helpful especially in those women who are postmenopausal---300ug per day* Daily apomorphine has been reported to benefit premenopausal women with hypoactive sexual disorder (Caruso et al., 2004) Couple therapy, counselling, cognitive therapy may be tried Julia R. Heiman, Ph.D. Treating Low Sexual Desire, N e w Findings f o r Testosterone in Women: N ENGL J MED 359;19 2008

Slide 17 :

Sexual Aversion Disorder It is characterized by an aversion to, and avoidance of, genital sexual contact with sexual partner or by masturbation The causes of the condition are not well understood, they seem to be similar to the psychological causes of hypoactive sexual disorder Assessment and treatment is similar to that for hypoactive sexual disorder

Slide 18 :

Sexual Arousal Disorder Includes Female sexual arousal disorder Male erectile disorder Female sexual arousal disorder, there is failure of genital response, experienced as failure of vaginal lubrication, together with inadequate tumescence of the labia Reduction may be due to Inadequate sexual foreplay by the partner Lack of sexual interest Anxiety about sexual intercourse

Slide 19 :

Assessment follows the same as for sexual dysfunction There are reports of beneficial effects of sildenafil but a control clinical trail (Basson et al., 2002) did not find significant differences from placebo Estrogen and or androgen replacement hormonal therapy may be useful in sexual desire Estrogen therapy is indicated in menopausal women Testosterone treatment is used in combination with estrogen (Estrotest) in menopausal women, for lack of vaginal lubrication

Slide 20 :

There are con?icting reports regarding the bene?t of testosterone for treatment of pre-menopausal women Longitudinal studies of midlife women undergoing natural menopause do not show an association between testosterone levels and libido.* Vivian Lewis, Female sexual dysfunction. BMJ USA VOLUME 5 APRIL 2005 (p101)

Slide 21 :

Male Erectile Disorder It is inability to reach an erection or to sustain it long enough for satisfactory coitus It can be primary or secondary Primary means present from the first attempt at intercourse or it may be secondary in which person develop ED after a period of normal function. In situational male ED, a man is able to have coitus in certain circumstances but not in others More common in older than younger men (in contrast to premature ejaculation)

Slide 22 :

Physiology Of Erection

Slide 23 :

Prevalence & worldwide burden of ED There was very little reliable information in ED available until the very end of twentieth century Prior to about 1985, most information on ED was based on clinical impressions and studies of convenience samples of atypical patients The Massachusetts Male Aging Study (MMAS) was the first major epidemiologic investigation of ED, and is the largest population based study to date with information on the prevalence, incidence and etiology of ED

Slide 24 :

Massachusetts Male Aging Study: Key Prevalence Study of ED Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychological correlates: results of Massachusetts Male Aging Study. J Urol. 1994;151:54-61.

Slide 25 :

ED is Undertreated McKinlay JB. Int J Impot Res. 2000;12 (suppl 4):S6-S11. Based on data from the Massachusetts Male Aging Study (MMAS). Source: AARP. Modern Maturity Magazine, Washington DC, 1999. 90% of US male (>45yrs) never seek care for Sexual problems

Slide 26 :

Erectile dysfunction (48%) in persons taking antipsychotics Erectile dysfunction (21%) Mohammad Younas Khawaja: J Ayub Med Coll Abottabad Jul - Sep 2005;17(3):73-5 Mohammad Younas Khawaja.: J Med Sci Jul 2005;13(2):140-2.

Slide 27 :

Assessment A thorough history (medical, sexual, and psychosocial) Has there been a previous period of normal function? Has the failure occurred with more than one partner? Does erection occur during foreplay? Does erection occur on waking or in response to masturbation? Is there evidence of alcohol or drug abuse (ask the partner as well as the patient) Are there possible effects of any medications

Slide 28 :

Physical examination Investigations includes; Serum Testosterone Serum Prolactin Screening Profile Sugars Lipids Thyroid Functions

Slide 29 :

When etiology in uncertain after history taking, physical exam, and blood tests, several special investigation may be considered, includes Rigiscan Doppler ultrasound may help to identify arterial or venous dysfunction Cavernosography Young men with congenital or traumatic venous leakage Pelvic arteriography Young men with traumatic arterial insufficiency

Slide 30 :

Risk factors for ED Aging Chronic disease conditions Heart disease 1.8* HTN 1.6%* DM 4.1* Peripheral vascular disease 2.6* Smoking (24%) Alcohol use Obesity (22%) Lack of physical activity Depression 1.8* Elevated cholesterol 1.7* *Age-adjusted odds ratio. Martin-Morales A, et al. J Urol. 2001;166:569-575. 2. Braun M, et al. Int J Impot Res. 2000;12:305-311 2. Raymond Rosen, Ph.D., et al; Am J Psychiatry 163:79-87, January 2006

Slide 31 :

Slide 32 :

Causes of ED Psychogenic: Performance anxiety Relationship problems Depression and anxiety disorders Neurogenic: Stroke or Alzheimer’s disease Spinal cord injury Radical pelvic surgery Diabetic neuropathy Pelvic injury

Slide 33 :

Drug-induced: Antihypertensive and antidepressant drugs Antiandrogens Alcohol abuse Cigarette smoking Caused by other systemic diseases and aging: Old age Diabetes mellitus Chronic renal failure Coronary heart disease

Slide 34 :

Hormonal: Hypogonadism Hyperprolactinemia Vasculogenic (arterial or cavernosal): Atherosclerosis Hypertension Diabetes mellitus Trauma

Slide 35 :

Treatment Education about physical and psychological factors that may contribute to erectile failure Any reversible should be treated Psychological causes may respond to appropriate cognitive or psychodynamic therapy Sex therapy Oral medications: Sildenafil --- Phosphodiesterase type 5 inhibitotor Oral phentolamine and apomorphine Yohimbine

Slide 36 :

Intracavernosal injections of papaverine and alprostadil Vacuum devices Surgical treatments

Slide 37 :

Thank You

Slide 38 :

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ERECTILE DYSFUNCTION

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