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Disorders of Male Sexual Function
Erectile dysfunction, also called impotence, is the inability toachieve or maintain an erection sufficient to accomplish inter-course. The man may report decreased frequency of erections, inability to achieve a firm erection, or rapid detumescence (sub-siding of erection). Incidence ranges from 25% to 50% in men older than 65 years of age. The physiology of erection and ejacu-lation is complex and involves sympathetic and parasympathetic components. At the time of erection, pelvic nerves carry parasym-pathetic impulses that dilate the smaller blood vessels of the re-gion and increase blood flow to the penis, expanding the corpora cavernosa
Erectile dysfunction has both psychogenic and organic causes. Psychogenic causes include anxiety, fatigue, depression, and pressure to perform sexually. Organic impotence, however, may account for more impotence than previously realized. Organic causes include occlusive vascular disease, endocrine disease (diabetes, pituitary tumors, hypogonadism with testosterone deficiency, hyperthyroidism, and hypothyroidism), cirrhosis, chronic renal failure, genitouri-nary conditions (radical pelvic surgery), hematologic conditions (Hodgkin’s disease, leukemia), neurologic disorders (neuropathies, parkinsonism, spinal cord injury, multiple sclerosis), trauma to the pelvic or genital area, alcohol, medications (Chart 49-1), and drug abuse.
The diagnosis of erectile dysfunction requires a sexual and medical history; an analysis of presenting symptoms; a physical examination, including a neurologic examination; a detailed assessment of all medications, alcohol, and drugs used; and various laboratory studies. Nocturnal penile tumescence tests are conducted in sleep laboratories to monitor changes in penile circumference. In healthy men, nocturnal penile erections closely parallel rapid eye movement (REM) sleep in occurrence and duration. Organically impotent men show inadequate sleeprelated erections that correspond to their waking performance. The nocturnal penile tumescence test can help to determine whether erectile impotence has an organic or psychological cause. Arterial blood flow to the penis is measured using a Doppler probe. In addition, nerve conduction tests and extensive psychological evaluations are carried out. Figure 49-3 describes the evaluation and treatment of men with erectile dysfunction.
Treatment, which depends on the cause, can be medical, surgi-cal, or both (Table 49-2). Nonsurgical therapy includes treating associated conditions, such as alcoholism, and readjusting hyper-tensive agents or other medications. Endocrine therapy may be instituted for erectile dysfunction secondary to hypothalamic-pituitary-gonadal dysfunction and may reverse the condition. In-sufficient penile blood flow may be treated with vascular surgery. Patients with erectile dysfunction from psychogenic causes are re-ferred to a health care provider or therapist specializing in sexual dysfunction. Patients with erectile dysfunction secondary to or-ganic causes may be candidates for penile implants.
Sildenafil (Viagra) is an oral medication for erectile dysfunction (Eid, 2000). When it is taken about 1 hour before sex, an erec-tion can occur with stimulation; the erection can last about 60 to 120 minutes. Despite the effectiveness of this medication, it does have side effects: headache, flushing, and dyspepsia. Sildenafil is contraindicated in patients who take organic nitrates and should be used with caution in patients with retinopathy, especially those with diabetic retinopathy (Chart 49-2).
Other pharmacologic measures to induce erections include in-jecting vasoactive agents, such as alprostadil, papaverine, and phen-tolamine, directly into the penis. Complications include priapism (a persistent abnormal erection) and development of fibrotic plaques at the injection sites. Alprostadil is also formulated in a gel pellet that can be inserted into the urethra to create an erection.
Penile implants are available in two types: the semirigid rod and the inflatable prosthesis. The semirigid rod (eg, the Small-Carrion prosthesis) leaves the man with a permanent semierection. The inflatable prosthesis simulates natural erections and natural flac-cidity. Complications after implantation include infection, erosion of the prosthesis through the skin (more common with the semi-rigid rod than with the inflatable prosthesis), and persistent pain, which may require removal of the implant. Cystoscopic surgery, such as transurethral resection of the prostate (TUR or TURP), is more difficult with a semirigid rod than with the inflatable prosthesis. Factors to consider in choosing a prosthesis are the pa-tient’s activities of daily living and social activities and the expec-tations of the patient and his partner. Ongoing counseling for the patient and his partner is usually necessary to help them in adapt-ing to the prosthesis.
Negative-pressure (vacuum) devices may also be used to induce an erection. A plastic cylinder is placed over the flaccid penis, and negative pressure is applied. When an erection is attained, a con-striction band is placed around the base of the penis to maintain the erection. Although many men find this method satisfactory, others experience premature loss of penile rigidity or pain when applying suction or during intercourse.
Personal satisfaction and the ability to sexually satisfy a partner are common concerns of patients. Men with illnesses and disabilities may need the assistance of a sex therapist to find, implement, and integrate their sexual beliefs and behaviors into a healthy and satisfying lifestyle. The nurse can inform patients that support groups for men with erectile dysfunction and their partners have been es-tablished.
Premature ejaculation occurs when a man cannot control the ejac-ulatory reflex and, once aroused, reaches orgasm before or shortly after intromission. It is the most common dysfunction in men. In-hibited or retarded ejaculation is the involuntary inhibition of the ejaculatory reflex. The spectrum of responses includes occasional ejaculation through intercourse or self-stimulation or the com-plete inability to ejaculate under any circumstances.
Treatment modalities depend on the nature and severity of the ejaculation problem. Behavioral therapies may be indicated for people with premature ejaculation; these therapies often involve the man and his sexual partner. “Homework” assignments are often given to the couple to encourage them to identify their sexual needs and to communicate those needs to each other. In some cases, pharmacologic and behavioral therapy together may be effective.
Neurologic disorders (eg, spinal cord injury, multiple sclero-sis, neuropathy secondary to diabetes), surgery (prostatectomy), and medications are the most common causes of inhibited ejac-ulation. Chemical, vibratory, and electrical stimulation have been used with some success. Treatment is usually multidisciplinary and addresses the physical and psychological factors that are often involved in inhibited ejaculation (Lue, 2000).
For men with retrograde ejaculation, the urine may be col-lected after ejaculation; sperm is then collected from the urine for use in artificial insemination. In men with spinal cord injury, electroejaculation may be used to obtain sperm for artificial in-semination.
The effects of trauma, chronic illness, and physical disability on sexual function can be profound. In addition to psychogenic factors, the physical changes associated with illness and injury can impair sexual function.
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