THERAPIES FOR MALE SEXUAL DYSFUNCTION

SEX THERAPY

Many individuals with sexual dysfunction tend to wait months or even years before seeking a proper diagnosis and treatment. The embarrassment often associated with a sexual disorder makes it difficult to discuss sexual issues and to bring them to the attention of professionals working in the field of sexual medicine. In spite of the increasing prevalence of sexual difficulties, there is a often the hope that such problems will resolve themselves without medical attention. Unfortunately, this is seldom the case.

When a sexual difficulty has persisted for a period of months or years it has often taken a significant toll on both individuals in a relationship. For the individual with the difficulty, there may be feelings of embarrassment, shame, inadequacy and even failure. For the partner of a person with a sexual dysfunction, it is not uncommon to also see a variety of feelings and reactions to the problem. These may range from periods of sadness to more intense feelings of frustration and resentment. Other partners feel unattractive and undesirable. In times of such stress, it is not uncommon for communication to be at a minimum or even nonexistent.

Although new diagnostic procedures and medical advances insure a successful resolution to the vast majority of sexual dysfunctions, a resolution of the emotional consequences may be more gradual and difficult to achieve. Feelings of hurt, rejection or resentment may persist even after a medical solution has been achieved. In cases where the emotional stress and relationship issues have been more significant, talking about these areas may be helpful. Reestablishing healthy communication in a relationship is an essential step in regaining emotional closeness and trust.

ANDROGEN THERAPY

Androgen therapy is a simple, inexpensive treatment for relieving both the physical and psychological symptoms of androgen insufficiency. Blood tests will be performed to determine androgen levels, including testosterone (free and total), DHEA, DHEA-S (sulfate), and androstenedione. Symptoms of androgen insufficiency often improve by taking androgen therapy (formerly known as androgen replacement therapy or androgen supplementation). Androgen blood levels must be measured every 3 months until they reach normal physiologic levels, at which time they should be measured every 6 months. Each time androgens are measured a PSA blood test is taken as well. In addition, cholesterol, liver function enzymes, PSA, and BCC will be evaluated to determine any adverse effects of the increase in serum androgens.

The side effects associated with androgen therapy are mainly those attributable to increases in blood androgen levels and include acne, hair loss, on the scalp, hair growth on the face and weight gain. You should not exceed the dose of androgen supplementation recommended by your physician. Recent studies have not demonstrated any significant adverse effect of androgen therapy in prostate enlargement, however, androgens accelerate the growth of an existing prostate cancer. You may choose to live with the sexual dysfunction and low androgens levels without treatment. If you are concerned with any physical changes which might occur after you start androgen therapy, contact your healthcare professionals.

PENILE REVASCULARIZATION SURGERY

Penile revascularization surgery (also known as microvascular arterial bypass surgery for impotence) is similar to a cardiac bypass, but in the penis. It is for healthy men less than 50 years old with no evidence of a venous leak upon testing. The most common causes of erectile dysfunction which can be treated by penile revascularization are blunt trauma to the perineum or bike riding.

Revascdularization is achieved by microsurgical anastomosis of the inferior epigastric artery to the dorsal penile artery. The donor artery is carefully dissected from its origin at the femoral artery to a more distal point near the umblicus where it is transected. The cut artery is then brought through the inguinal ring into the scrotum for microvascular anastomosis to the right or left dorsal artery. This procedure is highly specialized and requires extensive training in microvascular surgery as well as special equipment in the OR. Very few physicians have experience with this procedure. Dr. Goldstein has performed over 1000 revascularization procedures, the largest series anywhere.

The most ideal candidates are young men with a history of perineal or pelvic trauma in whom arteriography reveals a localized common penile artery lesion. Those with generalized vascular pathology are poor candidates for this operation as the same disease will likely affect the revascularized segment in the years following surgery.Adherence to strict patient selection criteria will yield excellent longterm patency and patient satisfaction results. Adherence to strict patient selection criteria will yield excellent longterm patency and patient satisfaction results.

SURGERY FOR PEYRONIE'S DISEASE/ PENILE CURVATURE

Indications for surgery for the symptom of penile curvature:

• stable penile curvature x 3 - 6 months
• drawing in chart/photograph home/office
• failed medical Rx
• prevent vaginal penetration or pain in partner or significant emotional concern

Indications for surgery as it concerns pain symptom:

• no - minimal plaque pain/tenderness deep palpation
• no pain in flaccid state
• may have pain in erect state with severe curvature and normal rigidity

Indications for surgery as it concerns erectile dysfunction symptom:

• documented normal erectile function/penile rigidity (OIIT, Duplex, DICC, NPT)
• documented abnormal erectile function/penile rigidity (usually place penile implant)

Contraindications for corrective surgery:

• unstable plaque
• no medical treatment
• curvature not documented by photography
• curvature minimal
• curvature does not result in adverse effects on intercourse/partner/self-image
• curvature associated with pain in the flaccid state or tenderness on palpation
• poor quality erections

PHARMACOLOGIC THERAPY

Pharmacologic therapy includes oral medications, intracavernosal injection therapy, and intraurethral therapy (Muse). Oral medications currently available are Viagra, Levitra and Cialis, all available by prescription. Although these medications are similar, each has its distinctions and individuals may find that one works better than another for that particular person.

VACUUM THERAPY

Sexual arousal causes an increase of blood flow into the penis which, when trapped, creates an erection for sexual activity. For some men, there is not enough natural blood flow for an erection, or the natural trapping mechanism allowing the erection to be maintained does not function properly. When the clear plastic cylinder of the vacuum device is placed over the penis, the attached vacuum pump causes blood to be drawn into the penis, causing an erection. Once the full erection is achieved, a special ring if placed at the base of the penis thus maintaining the erection. The ring must be released after sexual activity. The vacuum device is an FDA approved therapy, and is often favored by older patients not wishing to undergo more invasive therapy.

INTRACAVERNOSAL INJECTION THERAPY (PEP)

Despite the introduction of Viagra a few years ago and the more recent FDA approvals of Levitra and Cialis, self-injection therapy remains a popular and very effective mode of therapy for erectile dysfunction (ED). Popularized in the early 1980's, self-administered penile injections had an instant appeal as an alternative to the only available treatment at the time, the penile prosthesis. Although some men hesitate to think about placing a needle into their penis, and some defer their treatment to "think" about it, most men choosing injection therapy quickly realize that the benefit of the injection far outweighs that little pin prick.

The injectable drug combinations of Papaverine and Regitine (bi-mix) and Papaverine, Regitine and Prostaglandin (tri-mix) have withstood the test of time. Nearly twenty years of patient experience has been gained and much has been learned. Retrospective studies have shown injection therapy to be safe and effective. Liver toxicity, once a concern because of the possible association with papaverine, has become a non-issue. Scar tissue formation as a result of post-injection bleeding can be avoided with proper post-injection compression. Priapism, an unwanted persistent rigid erection lasting for many hours, can be avoided with medically supervised dose-titration office visits. And finally, needle size has been reduced to a user-friendly 31 gauge 5/16th length. With proper instruction and medical supervision, adverse effects are practically non-existent. This treatment has evolved over the past twenty years. Currently, ten different combinations of medications are available for treating all types of vascular and neurologic erectile dysfunctions. For men who have undergone radical prostatectomy and experience discomfort with injections of prostaglandin, a mixture using lower concentrations of prostaglandin has been developed that is effective, yet pain free.

Men finding success with injections and with at least one of the FDA approved oral medications for erectile dysfunction may now have more treatment options. Many men ask about available treatments, including the feasibility of administering an injection simultaneously with the pill. There are no double blind placebo controlled safety studies available for the combined use of a PDE-5 inhibitor and intracavernosal injection therapy as yet. Always check with your physician before changing your medication. While people's results from the three oral therapies may differ, the use of injections should not interfere with the potential effectiveness of the oral agents. Whereas self-injection therapy was once a first line treatment for erectile dysfunction, it is now a safe and effective treatment should oral therapy fail. There is better than an 80% chance that self-injection therapy utilizing vasoactive drugs is an effective treatment.

PENILE PROSTHESIS/ IMPLANT SURGERY

Component Inflatable prostheses consist of a pair of inflatable cylinders, a reservoir, a pump, and tubing to connect these components. The cylinders are implanted within the corpora, the pump within the scrotum, and the reservoir behind the rectus abdominis muscle in the peri-vesical space. Compressing the pump achieves active transfer of fluid from the reservoir into the cylinders. Pressing a release valve on the pump allows passive flow of fluid back to the reservoir and achieves detumescence. Significant design alterations over the years since their first introduction have reduced mechanical failures and improved safety and efficacy of these devices such that they now compare favorably with non-inflatable rod-type devices.

Multi-institutional 2-year follow-up studies have shown an approximately 9% risk of morbidity, 7% risk of revision or explanation, and a 2.5% risk of mechanical failure in one brand of the inflatable three-piece prostheses. Satisfaction rates of 80% or higher in terms of confidence and intercourse ability as well as prosthesis function and rigidity were reported in the same study.