Men's Health
- Erectile dysfunction
Treatment
| TREATMENT Nonsurgical treatment 1-Avoiding risk factors: e.g. smoking, alcohol & drugs. 2-Sex therapy: for psychogenic impotence 3-Medical therapy 4- Intraurethral Alprostadi (PGEl): 45-70% effective, Side effects include pain (30%), burning sensation (12%), & minor urethral bleeding (5%) 4-Intracavernous injections: PGE1, Papaverine, phentolamine. N.B. main complications include prolonged erection & fibrosis. 5-External vacuum & constriction devices: Induction of erection using a vacuum device & maintaining it using a rubber band on the base of the penis. Surgical treatment 1- Vascular surgery 2- Neurologic (experimental): Erection pacemaker (device with a receiving & stimulating electrode implanted on the cavernosal nerves of hemiplegic monkeys; and a transmitter box outside the body to control stimulation of the cavernosal nerves & erections. Drug delivery ports are S.C. ports connected to the corpora cavernosa to deliver small amounts of PGE1. These would also be useful for neurologic impotence. 3- Penile curvature: Nesbit's procedure (removal of a wedge from the longer side of the tunica albuginea to straiten the penis). 4- Priapism: e.g. El Ghorab's procedure (Shunt between the corpus cavernosum & glans penis). 5- Penile implants: Malleable rods or inflatable cylinders are placed in each corpus cavernosum to induce an erection. Artificial erections produced by today's modern devices are both cosmetically and functionally superior to earlier models. Sex therapy Goals 1- Establishing mutual responsibility without blaming either partner. 2- Sex education and correction of myths & misinformation. 3- Ensuring a high level of physical and psychological stimulation through the sensate focus exercises. 4- Eliminating cognitive interference (performance anxiety & negative self-evaluation): Sensate focus exercises & muscle relaxation and systemic desensitization (the pairing of relaxation with sexual images). 5- Eliminating relationship interference due to marital tensions. Strategies for sex therapy (Masters & Johnson) 1- Sensate focus (relaxed sensual massage): Taking turns at giving & receiving stimulation while forbidding genital touching, vaginal penetration & orgasm. 2- Non-demand genital touching: The next step is to allow mutual genital & breast touching but still intercourse & orgasm are not allowed. 3- Vaginal containment (quite vagina): Vaginal penetration is allowed but both partners remain still (no pelvic thrusting). 4- Female superior coitus. 5- Fantasy: Imagining sexually stimulating situations. 6 Squeeze technique & start stop technique (Semans maneuver) to treat premature ejaculation: In the squeeze technique, the wife stimulates the penis then squeezes the glans firmly when the husband signals he is about to ejaculate. In the start stop technique, stimulation is stopped before ejaculation is inevitable & then resumed once more. The cycle is repeated over & over again. Medical therapy 1- Treatment of the cause: e.g. Endocrine disorder: e.g. Testosterone or gonadotrophins for hypogonadism & bromocryptine for hyperprolactinemia. Switching to safe medications: e.g. Captopril & calcium channel blockers are antihypertensives that do not cause impotence; Trazodone is a safe antidepressant. 2- Aphrodisiacs: Drugs that might improve sexual performance nonspecifically; e.g. Yohimbine (presynaptic alpha 2 blocker); & Isoxsupine (beta-adrenergic stimulant). Viagra (Sildenafil) This is currently considered the most effective aphrodisiac. It is a selective penile vasodilator through inhibition of the phosphodiasterase enzyme leading to the accumulation cyclic AMP. It is contraindicated with patients receiving nitrates -coronary vasodilators. Side effects include headache, visual disturbances, dyspepsia. Phentolamine (Vasomax) a1 & a2 Blocker. 30-40% effective in clinical trials. Apomorphine Dopamine receptor agonist. 30-40% effective in clinical trials. Nausea is the main side effect. VASCULAR SURGERY 1- Arterial: Proximal: internal iliac reconstruction; Distal: Penile re-vascularization by anastomosing the inf. epigastric A. to the penile Arteries. Poor success except in young men with a traumatic occlusion. 2- Venous: Ligating the deep dorsal vein & all its tributaries & the cavernosal & crural veins in cases of corporal veno-occlusive dysfunction in young patients with no risk factors for atherosclerosis (DM, hypertension, smoking, hyperlipidemias). Limited long term success (20-40%) 3- Arteriovenous: Arterialisation of the deep dorsal vein using the inferior epigastric artery. PREMATURE EJACULATION DEFINITION (DSM-III) Ejaculation occurring before the patient wishes it, because of recurrent and persistent absence of reasonable control over ejaculation and orgasm during sexual activity. INCIDENCE Premature ejaculation affects one third of all males. It is usually primary. If secondary it suggests significant marital tensions. ETIOLOGY The hypersensitive ejaculatory reflex is almost always psychogenic due to performance anxiety; over concern with pleasing the partner or unresolved marital problems. Rarely it is encountered during initiation of antidepressants, narcotic withdrawal, multiple sclerosis or spinal cord tumor. TREATMENT Start stop & squeeze techniques. Success rate = 95 RETARDED EJACULATION DEFINITION Recurrent & persistent inhibition of male orgasm as manifested by a delay or absence of ejaculation despite an adequate phase of sexual excitement. ETIOLOGY Psychogenic causes · Obsessive compulsive personality. · Repressed hostility · Phobias: Fear of pregnancy, Religious guilt, Fear of soiling the partner with semen, Oedipal fears of retaliation Organic Factors Hypnotic abuse, narcotic & alcohol abuse Neuropathies (e.g. DM) or spinal cord injuries TREATMENT · Reduction of performance anxiety & insuring a high level of stimulation through the sensate focus exercises. · Electrovibratory stimulation could be helpful. · Desensitization by allowing the patient to masturbate up to ejaculation on his own first, then with his wife, then outside the vagina to resolve the fear of ejaculating in the vagina. |
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Copyrights Dr. Hussein Ghanem 1999 All Rights
Reserved
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جميع حقوق الطبع والنشر محفوظة للدكتور حسين
غانم لعام 1999
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Page written & discussion moderated by:
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Professor of Andrology, Cairo University
Formerly: Fellow in Male Reproductive Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA Formerly: Fellow in Male Sexual Function, Reproduction, and Surgery, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA |
| Telephone: +(202) 761 3334 |
| E-mail: ghanem@family-clinics.com |
| Address: 139 (A) Al-Tahrir Street, Dokki, Cairo, Egypt |