Male Sexual Dysfunction

A Clinical Guide

Suks Minhas, John Mulhall, Suks Minhas, John Mulhall

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781118746547
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Sexual dysfunction affects men of all ages and incidence rates are expected to double by 2025 resulting in a major health burden. Though normal sexual function is an important aspect of health and well-being, sadly, this common condition still carries an associated stigma. As a result, affected men are often reluctant to approach their doctor and, instead, may live for many years with sexual dysfunction, often to the detriment of their personal lives.

Male Sexual Dysfunction: A Clinical Guide covers all the common problems encountered by the clinician in this rapidly expanding and developing field. With full color throughout, this easy to read guide provides a comprehensive and systematic approach to patient management. Packed with key features, every chapter will contain flow diagrams and algorithms, key points, clinical pearls, what to avoid boxes, and numerous tables, graphs and photographs. This book provides:

• Comprehensive focus on the core clinical areas of physiology/pharmacology, investigation, diagnosis, management and surgical options
• Coverage of all treatment pathways, including psychological, pharmacologic and surgical
• A straightforward, logical approach to clinical management
• An experienced and international editor and contributor team

Expertly-written, this book is the perfect resource for urologists and general practitioners with an interest in this highly topical area, as well as those about to undergo their urology trainee examinations.

CHAPTER 1
Epidemiology of male sexual dysfunction

Raanan Tal

Rambam Healthcare Campus, Haifa, Israel

The broad term of sexual dysfunction includes erectile dysfunction, ejaculatory dysfunction, hypogonadism and low sexual desire, Peyronie’s disease and other penile morphological alterations, and urinary incontinence associated with sexual function. Knowledge of the epidemiology of various sexual dysfunctions is important in designing sexual health programs and allocation of budget and healthcare resources, in patients’ and partners’ education, and in clinical assessment of individual subjects. There are numerous epidemiologic studies in the contemporary medical literature, comprehensively detailing the prevalence of sexual dysfunctions; however, reported epidemiologic data vary greatly. Several factors account for these inconsistent data. The main one is probably the definition used to define a particular sexual dysfunction. For example, in selected high‐quality studies reporting on erectile function outcome in the post radical prostatectomy male population, more than 20 different definitions of favorable erectile function were used. Hence, the reported incidence of adequate erectile function varies, ranging from 25 to 78%.¹ Since the definition of sexual dysfunction is not unified, it is not unreasonable to expect variation in sexual dysfunction epidemiologic data: the higher the threshold for normal sexual function, the greater is the incidence of sexual dysfunction. Moreover, sexual dysfunction is commonly assessed using questionnaires. More objective modalities, such as hemodynamic assessment of the penis by Doppler ultrasound of the erect penis to establish a diagnosis of vasculogenic erectile dysfunction, or stopwatch‐measured intravaginal ejaculatory latency time for establishing a diagnosis of premature ejaculation, are not commonly employed to define a sexual dysfunction. Not surprisingly, the type of questionnaire used in a certain study may also have an impact on epidemiologic findings.² Another issue in sexual function epidemiologic research is the study population, as the prevalence of sexual dysfunction varies greatly according to age, risk factors, demographic population characteristics, and other population‐related factors.^3–8 An important consideration in the epidemiology of sexual dysfunction is the existence of specific risk factors in specific populations. There are many well‐studied risk factors for sexual dysfunction.⁹ Common risk factors include cardiovascular diseases, obesity, hypertension, hyperlipidemia, smoking, lower urinary tract symptoms, radical pelvic surgery and, of course, diabetes.^10–12 Radical pelvic surgery has a multi‐faceted impact on sexual function. For example, radical prostatectomy affects erectile function mainly by disruption of neural pathways, causing un‐ejaculation resulting from removal of anatomic structures – the prostate and seminal vesicles – and increasing the risk of urinary incontinence during sexual activity owing to urinary sphincter weakness and even increasing the risk of penile morphologic changes, penile length loss, and Peyronie’s disease.^13,14 There are also other, less commonly discussed but nonetheless important, factors that may be associated with the epidemiology of sexual dysfunction. It has been suggested that the prevalence of sexual dysfunction may be related to the availability of therapies and interventions for sexual dysfunction.⁴ New therapies may increase patients’ and partners’ awareness and hence increase reporting of sexual dysfunction. In the light of these difficulties in measuring and reporting sexual dysfunction, epidemiologic data should be interpreted cautiously.

Erectile dysfunction

Erectile dysfunction is the most commonly researched and discussed sexual dysfunction, and the most prevalent sexual dysfunction in older men. The first landmark study that looked at the epidemiology of erectile dysfunction was the Massachusetts Male Aging Study, by Feldman et al. and published in 1994.¹⁵ This was a community‐based observational study, and looked at a random sample of non‐institutionalized men aged 40–70 years in the Boston area. Erectile function was assessed by a self‐administered questionnaire, and the study’s main findings were that the combined prevalence of minimal, moderate, and complete impotence was as high as 52%; subject age was the variable most strongly associated with impotence; and the prevalence of complete impotence tripled from 5 to 15% between subject ages 40 and 70 years.¹⁵ Another pivotal erectile dysfunction epidemiologic study was the Cologne Male Survey by Braun et al., published in 2000.¹⁰ This study looked at a European population, not a random sample but a representative sample of 8000 men, using a validated questionnaire. Results of this study were based on approximately 4500 evaluable questionnaires yielding a response rate of 56%. The prevalence of erectile dysfunction in this study was 19.2%, with a steep age‐related increase (2.3 to 53.4%) and a high rate of conditions comorbid with erectile dysfunction – hypertension, diabetes, pelvic surgery, and lower urinary tract symptoms – corroborating findings of earlier studies of different populations. The most extensively studied risk factors for erectile dysfunction are cardiovascular risk factors, primarily diabetes, and other risk factors, including the metabolic syndrome and its components (abdominal obesity, dyslipidemia, hypertension, and impaired fasting glucose), smoking, ischemic heart disease, and peripheral vascular disease and other cardiovascular risk factors.^7,16,17 Recognition of these important risk factors, especially modifiable cardiovascular risk factors, may improve patient knowledge and awareness, and provide a window for cardiovascular disease diagnosis and early intervention in men with newly diagnosed erectile dysfunction, leading to not only better sexual health but also better overall health.^18–20 The main pathophysiologic link between erectile dysfunction and cardiovascular morbidity is probably endothelial dysfunction.²¹ However, there are risk factors other than cardiovascular ones, both organic and psychological, that are associated with increased risk of erectile dysfunction. Among the significant organic non‐vascular risk factors is Peyronie’s disease, an underdiagnosed condition in men presenting with newly diagnosed erectile dysfunction.²² Peyronie’s disease may contribute to the development of erectile dysfunction probably by altering the elastic properties of the penile tunica albuginea.²³ Another not uncommon risk factor for erectile dysfunction is testosterone deficiency (hypogonadism). It is well established that adequate testosterone levels are required not only for the penile vascular response during erection, but also to preserve penile structural integrity.^24,25 Erectile dysfunction is more prevalent in men with certain non‐organic risk factors, such as emotional, couple related, and socioeconomic factors, creating a complex picture when the epidemiology of erectile dysfunction is discussed in certain specific populations.^8,26 A good example of an emotional risk factor for erectile dysfunction is depression. In a study by Shiri et al. the incidence of erectile dysfunction was 59/1000 person‐years in men with depressive mood and 37/1000 person‐years in those without depression.²⁷ Theses authors also found that the association of depression and erectile dysfunction is bidirectional: not only were men with depression at increased risk for erectile dysfunction, but also men with erectile dysfunction were at increased risk for depression.

In summary, the prevalence of erectile dysfunction is high and age‐dependent, with more than half of men at age of 50 years or older being affected. There are many risk factors for erectile dysfunction, hence epidemiologic data in specific populations should be viewed with careful consideration of the specific characteristics of the population reviewed.

Premature ejaculation

Premature ejaculation is likely the most common sexual dysfunction in men across all age groups and populations, with a worldwide prevalence of approximately 30%.^28,29 For clinical research purposes the accepted definition of premature ejaculation is an intravaginal ejaculatory latency time (IELT) of 1–2 minutes; a prospectively stopwatch‐measured IELT is preferred over self‐ or partner‐reported IELT upon recall. While there is a definition of premature ejaculation for research purposes, in clinical practice there is no agreed definition. Waldinger et al. surveyed a population of 500 couples who were recruited from five countries, aged 18 years or older, had a stable heterosexual relationship for at least 6 months, with regular sexual intercourse. In their study, the median IELT was 5.4 minutes and the range was 0.55 to 41 minutes.³⁰ In their study, the median IELT decreased significantly with age, from 6.5 minutes in the 18–30 years group, to 4.3 minutes in the group older than 51 years, while other studies did not show this age‐related increase in prevalence of premature ejaculation.^31,32 Regardless of whether the prevalence of premature ejaculation is clearly age‐related or not, it is obvious that in younger men who are less likely to have other sexual dysfunctions such as organic erectile dysfunction, premature ejaculation is the most prevalent sexual dysfunction. In the real‐world clinical setting, the use of stopwatch IELT to define premature ejaculation is definitely not a practical approach. Other ways to categorize men as having premature ejaculation are based on men self‐reporting low or absent control over ejaculation irrespective of the duration of the ejaculation time, on the resulted distress for them or their sexual partner ...

Table of contents

• Cover
• Title Page
• Table of Contents
• List of contributors
• Foreword
• CHAPTER 1: Epidemiology of male sexual dysfunction
• CHAPTER 2: Physiology of ejaculation
• CHAPTER 3: Physiology of penile erection
• CHAPTER 4: Anatomy of penile erection
• CHAPTER 5: Endocrinology of male sexual dysfunction
• CHAPTER 6: Pharmacology of drugs used for the treatment of erectile dysfunction
• CHAPTER 7: Pharmacology of drugs used in premature ejaculation
• CHAPTER 8: Cardiovascular risk and erectile dysfunction
• CHAPTER 9: The evaluation of the patient with erectile dysfunction
• CHAPTER 10: Endocrinological investigation of men with erectile dysfunction
• CHAPTER 11: Duplex ultrasonography and its role in the assessment of male sexual dysfunction
• CHAPTER 12: MRI in men with sexual dysfunction
• CHAPTER 13: The metabolic syndrome and ED
• CHAPTER 14: Psychological assessment of patients with ED
• CHAPTER 15: Nocturnal penile tumescence study
• CHAPTER 16: Psychosexual therapy for male sexual dysfunction
• CHAPTER 17: Treatment of premature ejaculation and ejaculatory disorders
• CHAPTER 18: Erectile dysfunction and infertility
• CHAPTER 19: Drug therapy for erectile dysfunction
• CHAPTER 20: Priapism
• CHAPTER 21: Management of erectile dysfunction after pelvic surgery
• CHAPTER 22: Management of erectile dysfunction in men with diabetes
• CHAPTER 23: Management of erectile dysfunction in neurological patients
• CHAPTER 24: Non-surgical therapy for Peyronie’s disease
• CHAPTER 25: Micropenis and penile dysmorphobia: diagnosis, management, outcomes, and future developments in the field
• CHAPTER 26: Surgical treatment of Peyronie’s disease
• CHAPTER 27: Penile implant surgery
• CHAPTER 28: Vascular surgery for erectile dysfunction
• CHAPTER 29: Penile cancer
• CHAPTER 30: Penile reconstruction and trauma
• CHAPTER 31: Disorders of sex development
• CHAPTER 32: Sexual dysfunction and prostate cancer therapy
• CHAPTER 33: Assessment and management of the male to female transgender patient
• Index
• End User License Agreement