MALE SEXUAL DYSFUNCTION RISK FACTORS

ANDROGEN INSUFFICIENCY

Circulating androgens (male sex steroid hormones) have direct effects on diverse physiological and behavioral systems. Androgens affect sexual desire, bone density, muscle mass and strength, adipose tissue distribution, mood, energy and psychological well-being. There is a well-documented age-related gradual decline in serum testosterone and androgen concentrations in healthy adult men. Levels start to decrease at age 35 and continue to decrease at a rate of 2% per year. Erectile function is partly dependent upon androgens that include substances such as DHEA (dehydroepiandrosterone), androstenedione, testosterone and four other androgens. If your androgen levels are low your diagnosis is androgen insufficiency syndrome.

Symptoms which may be associated with androgen insufficiency syndrome in the aging male include decrease in sexual activity, loss of libido, erectile dysfunction, poor intensity and decrease in volume of ejaculation, irritability, nervousness, generalized weakness, osteoporosis, decrease of body hair and abdominal obesity.


BICYCLE RIDING

Bicycling has become a popular activity for relaxation, exercise, and weight loss. The aerobic exercise required for biking has strong cardiovascular benefits and has also been shown to reduce the risk of diabetes and hypertension. Hippocrates, however, identified horseback riding in the Scythians as a possible cause of male impotence as early as the ninth century BC. In current times the relationship between bicycle riding and ED has become a matter of concern. Numerous case reports have been published of bicyclists with erectile difficulties and/or perineal nerve dysfunction that may resolve with changes in cycling techniques, rest, or use of a softer saddle. Small observational studies have also showed a relatively high prevalence of ED among elite cyclists, who often report penile numbness and changes in sensation after cycling. These effects have been confirmed in pathophysiologic studies that describe compression-related changes in perineal structures, as well as in studies of stationary bicycling, which show a significant decrease in penile blood flow during seated biking and a return to above normal when the rider stands.

Although research all points to a relationship between ED and bicycling, this association has been demonstrated only recently in a population-based random sample of men. Researchers evaluated data from the landmark Massachusetts Male Aging Study (MMAS), a large cross-sectional survey of 1709 free-living men in their 40s to 70s. The random sample is representative of a similar population of men and includes a variety of cyclists, such as recreational and occasional riders, stationary bikers, and serious sport cyclists. This is unique among studies done on ED and bicycling to date, and it allows the findings to be generalized to the entire population of cyclists.

Before we discuss the findings of the MMAS, a brief anatomy review should help explain how bicycling can contribute to or cause sexual dysfunction. When humans sit, they bear their weight on the ischial tuberosities, or what we have come to refer to as the "sit bones." The ischial tuberosities have no organs attached to them and no nerves or arteries; they are surrounded by the fat and muscle of the buttocks. This area is very well vascularized and allows humans to sit comfortably and safely for hours.

Unfortunately, most bicyclists bear their body weight on a bicycle saddle that is not wide enough to support the ischial tuberosities. As a result, they wind up straddling the bike and, in effect, sitting on the internal part of their genitals. The penis (and the female clitoris) is attached deep within the pelvis. It does not end, as it appears to, at the scrotum but rather near the anus. Like the roots of a tree, this internal part of the penis provides stability so that an erection doesn't buckle as the penis penetrates the vagina.

In the straddle position, body weight is supported not by the ischial tuberosities but by the ischiopubic rami, the connector bones that join the ischial tuberosities to the pubic bones. Unlike the ischial tuberosity, which has evolved into the perfect place to bear body weight, the ischiopubic ramus is a working area that contains erectile tissue, nerves, arteries, and the urethra. As a result, the bicycle rider bears his weight directly on an area where the nerves and arteries enter the penis. This area is a tubelike structure called the Alcock canal, which lies along the ischiopubic ramus. Straddling compresses the nerves and arteries running through the Alcock canal against the ischiopubic ramus, which frequently results in complaints of numbness in the penile/scrotal area after cycling. Importantly, straddling may also lead to localized atherosclerosis secondary to a denuding or non-deniding focal endothelial injury of the arteries within Alcock's canal and compromised blood supply to the penis over an unknown time period, resulting in ED.

Traditional atherosclerosis is initiated by endothelial injury, which triggers a series of events that result in inflammation, plaque formation, calcification, and eventual blockage of the artery. Endothelial injury generally occurs in individuals with risk factors such as elevated lipid levels, cigarette smoking, diabetes, or hypertension. Substantial evidence exists that localized blunt trauma to the penile artery can also injure the endothelium. What occurs in a healthy 22-year-old bicycle rider, however, differs from what takes place in a 62-year-old in that the older man will most likely also have atherosclerosis of the coronary, cerebral, and leg arteries in addition to the penile arteries. ED in the older male patient occurs as part of a systemic vasculopathy. In contrast, although the 22-year-old has atherosclerosis of the penile artery, his cerebral, coronary, and leg arteries are likely perfectly healthy. The focal blunt trauma to the endothelium caused by straddling is believed to be the inciting factor for this man's localized atherosclerosis that may take place slowly over time.

Two kinds of injury can actually lead to atherosclerosis in a bicyclist. The first is a chronic compressive injury, which is what occurs among sport cyclists who ride hundreds of miles a day. The other and perhaps more obvious cause of endothelial injury is not chronic compression but an acute crushing injury. A good example of this is a young boy who tries to ride his older brother's bicycle, only to slip and fall on the bar and land on the Alcock canal. A similar injury can also occur in an older boy who falls on the horn of a narrow saddle. Here again, the penile artery gets crushed and the endothelium is injured, initiating the atherosclerotic process in the penile arteries that results in ED.

Despite the potential risks posed by bicycling, this popular form of exercise provides huge benefits. Approximately 131 million Americans bicycle because it is an inexpensive, uncomplicated, and easy-to-learn activity. Bicycling can be learned at an early age and is accessible to people of all ages; it can be done year-round, indoors or outside. Unfortunately, only about 15% of adult Americans engage in regular physical activity (ie, 20 minutes of activity 3 times a week). Sedentary individuals have a 30% to 50% greater risk of developing hypertension, which in turn is associated with chronic heart disease and ED. In contrast, regular exercise improves cardiovascular health, lowers blood pressure, improves lipid levels, and lowers the risk of ED.

A key finding of the MMAS was the relationship between moderate cycling (ձ hours per week) or sport cycling (›=3 hours per week) and the development of ED. The 3-hour period was selected because it reflects a typical amount of exposure for stationary riders going to a gym as well as for commuters who ride about 15 minutes each way to work every day. Analysis of the data showed that individuals who cycle at least 3 hours per week have an odds ratio for developing moderate or complete ED of 1.72. (Odds ratios ؏.5 are defined as health risks.) That is, at least 3 hours of cycling per week was more likely to caused artery blockage and long-term damage. More significant, however, was the finding that men who bicycle less than 3 hours per week or who ride only occasionally have an odds ratio of 0.61 for developing moderate or complete ED. This indicates that moderate exercise in the form of bicycling can, in fact, prevent ED.

As noted earlier, studies have shown that a sedentary lifestyle increases the risk of heart disease and the probability of developing ED. In the MMAS, men who remained physically inactive had the highest risk for ED, whereas those who began exercising or who continued to exercise throughout the study had the lowest levels of ED. This new MMAS analysis further confirms the value of exercise, particularly bicycling. Moderate cyclists were found to be less likely to have moderate or complete ED than men who do not cycle, whereas sport cyclists were more likely to have moderate or complete ED. There was also some suggestion that substituting bicycling for another activity may even protect against ED.

Ultimately, men must make their own decisions about the risks and benefits of bicycle riding. As this recent MMAS analysis has demonstrated, most men can take advantage of the many benefits of moderate bicycle riding without worrying that it will lead to ED. Before they begin to ride, however, they should be aware of the need for a properly fitting bicycle and comfortable saddle as well as the potential risks to sexual health presented by long-distance cycling. Finally, supervising children and providing them with properly fitting bicycles and seats-just as we do with protective helmets-is also essential to avoid injury and preserve sexual functioning.

» READ TIPS FROM A PATIENTS FOR A BETTER BICYLCLE FIT.


DEPRESSION

Although circulatory and hormonal issues are important factors in sexual health, emotional issues also play a large role in the quality of sexual functioning. Specifically, depression often contributes to sexual problems and can intensify a dysfunction caused by medical issues.

Depression has long been shown to negatively affect sexual performance. It can reduce sexual drive and blunt sexual interest. Depression can reduce energy levels and make it more difficult to achieve optimal physical and sexual functioning. Becoming sexually aroused is difficult if the individual is feeling depressed. Fully enjoying sex may be impossible under these conditions.

Further complicating the effects of depression is the fact that many of the newer anti-depressants also have profound side effects that can negatively impact sexual abilities. Commonly used anti-depressants such as Prozac, Zoloft, Paxil and others can influence sexual abilities in a number of ways. This family of medications, known also as SSRI’s, can reduce sexual interest, decrease the ability to achieve erections, reduce vaginal lubrication, prohibit male ejaculation and diminish the capacity for orgasm in both men and women.

When fatigue and depression are present, a number of considerations may be worthwhile. Although it may limit spontaneity, enjoy sexual activities when you are well rested and refreshed. Many doctors, in fact, believe that sexual activities in the morning can be more satisfying. Nighttime oxygenation of the genitals and nocturnal erections often mean better sexual functioning earlier in the day. Later in the day, try a short nap before making love. If making love in the evening, try having sex before eating a heavy meal or before drinking alcohol. Maximize the effects of Viagra by taking it on an empty stomach when well rested.

Be realistic about your abilities and communicate these to your partner. Even for men, it’s OK not to be in the mood for sex or to realize that you are too tired at the present time. If you are not in the mood for sex don’t try to fake it. Be sensitive, honest and clear about your needs and desires. Communicating these to your partner can reduce performance anxiety and lessen the chance that your sexual encounter will end in disappointment and frustration.

In summary, sexual dysfunction and depression go hand and hand. There is no reason to feel shame or embarrassment if you find yourself depressed. Such feelings are commonplace in today’s society. Untreated, depression however, can be self-defeating and potentially dangerous. Typically, counseling and medications either alone or in combination with one another are the most common and effective treatments of depression. These treatments can significantly improve appetite and sleep, restore energy and ultimately renew sexual interest.


DIABETES MELLITUS
Erectile dysfunction (ED) is a significant medical problem for a large number of men with diabetes mellitus. The prevalence of ED is three times higher in diabetic men (28% versus 9.6%), occurs at an early age and increases with disease duration, being approximately 15% at age 30 rising to 55% at 60 years. ED increases with poor control of diabetes and complications of diabetes, such as vascular and nerve diseases. The prevalence of heart artery blockages (20%) and peripheral artery blockages (5%) in men with diabetes is far higher than in the general population, and both are common risk factors for ED as well.

Diabetes mellitus may cause ED through a number of changes affecting psychological function, central and peripheral nervous system function, male hormone (androgen) function, blood vessel lining (endothelial cell) function and smooth muscle function (necessary for erection). The problem may be due to one or a combination of these possible factors.

This information sheet examines the relationship between diabetes and penile functions such as penile blood flow function, penile nerve function and penile smooth muscle function.

Penile erection depends upon sexual stimulation greatly increasing blood flow into the penis, relaxation of the penile arteries and relaxation of penile smooth muscle. Disturbances of these relaxation mechanisms can be diagnosed by special tests.

Artery blockages are 40 times more prevalent in men with diabetes compared to non-diabetics and are more commonly associated with ED. Men with diabetes show a reduction in the number and rigidity of nighttime erections experienced during sleep. Using an electron microscope, investigators have shown that erection tissue is permanently changed in diabetic men compared with controls, including less smooth muscle content, more scar (connective tissue) deposition and fewer blood vessel lining (endothelial) cells. In comparison to control erectile tissue from potent men, erectile tissue specimen from diabetic men showed impaired ability to relax smooth muscle. This abnormality leads to loss of blood from the erection chambers leading to poor ability to maintain the erection. This is called a "venous leak".

Normal blood vessel lining (endothelial) cells form a biologic layer that regulates the flow of nutrients and the action of various biologic molecules circulating in the blood into the surrounding smooth muscle surrounding the blood vessel. Normal blood vessel lining (endothelial) cells also secrete various molecules that regulate blood flow by changing the tone of the blood vessel smooth muscle.

Abnormal blood vessel lining (endothelial) cells in diabetics occur in approximately 50% of men with diabetes. Elevated blood sugar levels cause injury to the blood vessel lining (endothelial) cells. This has an adverse effect on repair mechanisms, enhancing the progressive damage to the lining cells and ultimately lead to arterial blockage (atherosclerosis). Insulin is thought to enhance endothelial cell function.

Most patients with ED can benefit from treatment today. Treatment options include sexual counseling, drug treatment and mechanical or surgical interventions. However, diabetic men with erectile dysfunction tend to be less responsive to treatment, perhaps because the cause of diabetes-associated erectile dysfunction is likely to be multi-factorial.

Although sex therapy is a wonderful tool for couples, men with diabetes mellitus normally have vascular damage and therefore require medical intervention. Drug treatment comes in different forms. The easiest treatment is by oral phosphodiesterase type 5 (PDE-5) inhibitor. Currently the only PDE-5 inhibitor available in the US is Viagra, which tends to be less effective in the diabetic than in the non-diabetic ED patient. In the future Vardenafil, which has shown very good efficacy and tolerability in the population with diabetes mellitus, and Tadalafil will be available by prescription.

For those patients who do not respond to oral therapy, drugs can be injected directly into the penis. This is a different type of drug which is used which works in a different way. If you take Viagra you still need sexual stimulation. Intracavernosal injection therapy requires no sexual stimulation. We are able to work with you through a series of appointments to find the best mixture to give you an injection and teach you (or your partner) how to inject yourself in order to have sexual relations when you so desire.

If intracavernosal injection therapy does not work for you our patients have success with insertion of a penile prosthesis. Unlike early prostheses that left you with a permanent erection, modern prostheses allow your penis to look flaccid (soft), and then have an erection on demand by activating the internal pump.

If you have a penis, we can help you achieve an erection. There is no reason to suffer, or assume that because you have diabetes mellitus you can no longer have a satisfying sex life.


AGE

CIGARETTE SMOKING

HIGH CHOLESTEROL

HEART DISEASE

FAMILY HISTORY OF VASCULAR DISEASE

HEART ATTACK