Health Articles

Impotence

emirx — Wed, 25 Jul 2007 10:19:56 +0000

Etiology and Pathogenesis
Impotence increases progressively in frequency with age. About 25% of 65-yr-old men and 50% of 80-yr-old men are impotent. Impotence can be caused by vascular, neurologic, and endocrine disorders and by structural abnormalities of the penis. Drugs also cause impotence in the elderly.
Vascular disorders that can affect sexual function include atherosclerosis and venous leakage. Any occlusion of the arterial supply to the corpora cavernosa—such as from atherosclerosis, a clot (as in Leriche’s syndrome), or vascular surgery (eg, aoitoiliac bypass surgery)—that results in inadequate arterial pressure to the penis can lead to impotence. Venous leakage, in which inadequate compression of the venous drainage of the corpora cavernosa results in excessive venous outflow, occurs in 75% of impotent men with normal neurologic and hormonal function.
Neurologic causes of impotence include trauma, diabetes, multiple sclerosis, and toxins. Trauma to the nerves of the penis can occur from lumbar disk disease and from surgical procedures such as rectal surgery and prostatectomy. Diabetic neuropathy is a particularly common cause of impotence in the elderly. Alcoholism can produce a similar peripheral neuropathy.
Endocrine causes of impotence are relatively rare in the elcierly. However, testicular failure as a result of childhood exposure to mumps, Klinefelter”s syndrome, radiation and chemotherapy, pituitary and adrenal tumors, and other conditions (see TABLE 69-1) can cause extremely low testosterone levels and impotence.
Structural abnormalities of the penis are not common causes of impotence in the elderly. Peyronie’s disease, which is more common in younger men, is characterized by fibrous accumulation in the tunica albuginea, which leads to a deformed erection. Although not technically impotence, the deformed erection may not allow penetration.
Drugs cause an estimated 25% of cases of erectile dysfunction (see TABLE 69-2). Among the most common offenders are some antihypertensives (most notably reserpine, β-blockers, guanethidine, and methyldopa), alcohol, cimetidine, antipsychotics, antidepressants, lithium, sedative-hypnotics, and hormones.
Psychologic causes are less common than organic causes and account for a smaller proportion of impotence cases in the elderly than in younger men. The misperception that prostate surgery will result in impotence may actually cause psychogenic impotence, which may be prevented by thorough explanations both before and after the surgery. Depression can lead to impotence in the elderly, as in younger men, and older men can also experience performance anxiety, especially when having sexual intercourse with a new partner.
Diagnosis
Elderly men today are more likely than past generations to seek help for impotence, and physicians should make them feel comfortable discussing the problem. A comfortable environment can be eslablished by
explaining that impotence is a common problem and by reassuring the patient that treatment is often effective. In private, the patient should be asked if he would like to discuss the matter alone or have his sexual partner present.
History: Before beginning the physical examination, the physician should be relatively certain whether the problem is erectile dysfunction or some other sexual dysfunction. History begins by establishing whether libido is intact and if nocturnal or morning erections occur. A history of changes in secondary sex characteristics or of vascular, pelvic, rectal, or prostate surgery may give clues to the cause. Depression, anxiety, and stress must also be sought, and the physician should learn about changes in sexual partners or problems with relationships. A review of all medication use, including alcohol and over-the-counter and illicit drugs, is essential.
Physical examination: The physical examination is usually less revealing than the history, but it helps detect signs of severe hypogonadism, such as small, soft testes, loss of pubic hair, and gynecomastia.
The bulbocavernous reflex helps establish the normalcy of the peripheral nerves innervating the pelvis. Measuring penile arterial pressure is not generally useful, although measuring pressures in the legs may help establish whether the patient has peripheral arterial disease.
Laboratory evaluation: Laboratory tests generally include obtaining a tree (or total) testosterone level. Other tests for the common diseases that can lead to impotence should be ordered, such as CBC count fasting blood sugar, and thyroid-stimulating hormone (TSH) level. A nocturnal penile tumescence measurement is useful if the occurrence of spontaneous erections cannot be ascertained. The simplest and least expensive test uses a ring of postage stamps placed around the penis at night: if the perforations are broken in the morning, an erection has occurred. More sensitive and reliable measurements can be made at home using a portable computerized unit.
While several tests are available to assess the penile vascular system, duplex ultrasonography with intracorporeal injections of vasoactive agents is generally the best. A papaverine-phentolamine combination is injected into the corpus cavernosum. Because the drugs are arterial vasodilators, an erection should occur; if erection occurs, such injections could possibly be used therapeutically (see below). Failure to produce an erection indicates venous leakage.
Treatment
Erectile dysfunction can usually be treated successfully, often without surgery. Determining the cause of impotence helps in choosing the initial treatment.
Men whose impotence is the result of psychosocial problems may benefit from psychologic counseling. Even those with primary erectile dysfunction may need psychologic counseling, and it often helps to have the patient’s partner involved. Referral to experts in treating sexual disorders may be helpful when explanations and reassurance are inadequate.
Several drugs may ameliorate impotence, although none is remarkably effective. Yohimbine, an (^-adrenergic blocker taken orally at 5 4 mg tid, appears to help a small proportion of men, especially those with vascular causes. Testosterone replacement therapy benefits only those whose impotence is due to hypogonadism (see above).
Binding and vacuum tumescence devices are often useful for obtaining and maintaining erections, but men who are taking anticoagulants or who have low platelet levels or bleeding disorders should not use these devices. Binding devices, which slow venous outflow at the base of the penis, used alone often help those with mild impotence The devices are made of metal, rubber, or leather with snaps and can be purchased from medical supply houses or pharmacies (see FlG. 69-1)
However, they can also be purchased less expensively at stores selling sexual paraphernalia, where they are known as “cock rings.” The vacuum devices improve on the binder device by increasing arterial engorgement through vacuum assistance (see FIG, 69-2). A plastic cylinder vacuum device is fitted over the unerect penis, and a gentle vacuum is produced by sucking out air with a syringe, pump, or one’s mouth (via tubing). Once an erection occurs, a wide rubber binding band is applied at the base of the penis and the vacuum device is removed. The band retards venous return and helps sustain the erection for up to 30 niin. Binding devices can produce local discomfort and occasional difficulty with ejaculation, especially if too tight, anil vacuum devices can produce petechiae if used excessively. Long-term safety and effectiveness are being evaluated.
Self-injection of vasoactive compounds (intracavernous pharmacotherapy) directly into the corpus cavernosum before sexual activity can help produce an erection (see FIG. 69-3). Self-injection therapy is usually effective when vascular disease is mild to moderate but not when it is severe. Furthermore, self-injection is not acceptable to all patients. A papaverine-phentolamine combination is often used, although the drugs do not have FDA approval. Alprostadil (prostaglandin Ei) is another drug that is used for intracavernous pharmacotherapy. The three agents may be given together, but no advantage of combined therapy over monotherapy has been established. The optimum combination of drugs to maximize effect while minimizing side effects is still being studied.
After injection, the patient should immediately initiate foreplay. He can expect to experience an erection after 5 to 10 min, and under ideal conditions, the erection will last up to 60 min. Problems include priapism, hematomas due to subcutaneous instead of intracavernosal injection, and pain. An injection of dilute epinephrine (20 μg/20 mL saline) or phenylephrine (500 μg/mL saline) usually reverses the priapism.
Permanent penile prostheses or implants may benefit patients with impotence that does not respond to other treatments, especially chronic organic impotence caused by diabetes. A prosthesis produces an erection but cannot correct neurologic deficits that preclude normal sensation. Devices that produce a permanent erection include the Small Carrion semirigid rod prosthesis with a silicone sponge interior and the Flexi-rodII, a hinged modification of the Small Carrion device 1 hat allows the penis to be bent downward more easily when not being used for sexual activity. An inflatable (AMS 700 CX) prosthesis is also available. Contraindications to surgical implants include untreated depression, psychosis, severe personality disorder, and other severe psychiatric problems.
Penile revascularization surgery is still largely experimental. Surgery should be reserved for those with localized, identifiable lesions and performed only by highly skilled surgeons. Ligation of venous drainage is sometimes beneficial for those with impotence caused by venous leakage.

Male Hypogonadism

emirx — Wed, 25 Jul 2007 10:15:11 +0000

Male hypogonadism is not common in the elderly, with surveys suggesting a prevalence of less than 4%. Most cases in elderly men have no ready explanation and are associated with a combination of pituitary and testicular hyporesponsiveness. However, as shown in TABLE 69-1, hypogonadism is also caused by exposure to many drugs and toxins and by a number of illnesses.
Symptoms and Signs
Mild hypogonadism has few or very vague and nonspecific symptoms and no physical findings. Severe and prolonged hypogonadism leads to reduced skeletal muscle mass and the loss of body hair and masculine habitus. Small, soft testes and a loss of scrotal pigmentation and rugae are important clues.
Laboratory Findings
Leydig cell function may be estimated by a morning measurement of bioavailable (free) testosterone; a value < 67 ng/dL signifies hypogonadism. A total testosterone value of < 300 ng/dL is also diagnostic of hypogonadism, but the free fraction is more sensitive because of the increased binding of testosterone to sex hormone-binding globulin in the elderly. The level of luteinizing hormone is normal or low in almost all hypogonadal men. Dynamic testing with gonadotropin-releasing hormone adds little information, because the response is usually proportional to the basal luteinizing hormone level. A normal prolactin level helps exclude a pituitary tumor as the cause of hypogonadism.
Treatment
Hypogonadism is treated with androgen therapy. Long-acting esters of testosterone and 19-nortestosterone (the enanthate and the cyclopen-tylpropionate) are administered IM in a dose of 100 to 200 mg every 1 to 3 wk (usually as 100 mg each week, 200 mg every 2 wk, or 300 mg every 3 wk). Alternatively, oral forms of testosterone derivatives, which have an alkyl group in the 17 position, are usually prescribed as 5 to 50 mg/day of methyltestosterone (10 to 50 mg orally or 5 to 25 mg bucally). The IM formulations are generally preferred because the oral agents may cause hepatotoxicity with reversible elevation of hepatic enzymes, occasional episodes of cholestatic jaundice, and hepatic tumors. Sublingual forms of androgens may be safer than of'il forms.
Testosterone therapy restores muscle strength, bone density, hair pattern, libido, sense of well-being, and mood in severely hypogonadal men. Its effectiveness in the elderly is not usually as clear-cut as in younger men, and a 3-mo trial is recommended to identify benefits before either proposing long-term therapy or terminating treatment because it seems ineffective.
Therapy stimulates erythropoietin secretion, increasing the hematocrit. By enhancing activity of hepatic triglyceride lipase, it also reduces HDL cholesterol levels and increases sensitivity to the anticoagulant action of warfarin derivatives. Some degree of prostate growth and an increase in prostate-specific antigen (PSA) level liay occur, but development or exacerbation of obstructive symptoms is rare. Patients with elevated or borderline values of PSA probably should not be treated with androgens because of persistent, but unpn>Ved, concern that androgens promote the development of prostatic carcinoma. However, for many the benefit may outweigh the risk, so tb^t therapy may still be appropriate after careful consideration.

Male Hypogonadism and Impotence

emirx — Wed, 25 Jul 2007 10:14:19 +0000

Spermatogenesis is remarkably sustained throughout life if testicular androgen synthesis is adequate; however, androgen production does decline with age. The impact of this reduced androgen synthesis on health, well-being, and sexual function has not been determined.
As testosterone secretion diminishes, its diurnal variation is also blunted, resulting in a lower 6 to 8 AM peak. Mean gonadotropin levels rise slowly, but large pulses of luteinizing hormone are less frequent, which impairs pulsatile testicular response. Binding of testosterone to sex hormone-binding globulin increases with age, resulting in substantially less unbound, bioavailable testosterone. Also, metabolism of testosterone is slowed. Evidence suggests that androgens play an important role in libido (sexual appetite) and influence the frequency of nocturnal erections; however, erections produced by erotic stimuli can occur despite low levels of androgens.
Penile erection is accomplished through engorgement of the corpora cavernosa, two paired vascular bundles. Because each corpus caverno-sum is surrounded by a tough, fibrous sheath (the tunica albugineai. engorgement leads to rigidity. Erection occurs when arterial blood flow into the corpora cavernosa exceeds venous outflow. The pudendal artery supplies blood to the corpora, and blood flow is controlled by relaxation and contraction of arterial smooth muscle. Venous drainage occurs through venules just below the tunica albuginea. These venules are easily compressed as the corpora fill. The penis is innervated by the T11-L2 sympathetic nerves and the S2-4 somatic and parasympathetic nerves.

Effects of Drugs on Sexuality

emirx — Wed, 25 Jul 2007 09:53:22 +0000

Many drugs adversely affect sexuality (see TABLES 68—1 and 68-2). Some interfere with the autonomic nervous system, which is involved in the sexual response. Others affect mood and alertness or change the production or action of sex hormones. Assessing the effects of drugs on sexuality is more difficult in women than in men, since potency problems in men are more obvious. However, drugs that affect men may also affect women, and further studies in women are warranted.
A patient who suspects that medications are the cause of sexual problems may be tempted to discontinue the drugs or decrease the doses without informing the physician. The possibility of adverse drug effects on sexual function should be discussed openly with patients, who should be encouraged to report any side effects.
Although the effects of specific drugs on sexuality are outlined in TABLES 68-1 and 68-2, some drugs deserve special mention. Antipsychotics, such as thioridazine and other phenothiazines, may inhibit erection or ejaculation, even though the capacity for erection remains. Tranquilizers can depress the sexual responses of women and men, and some antidepressants can inhibit sexual desire.
Antihypertensive drugs are the most common pharmacologic cause of impaired erection. Cardiac drugs that are often implicated in erectile dysfunction include those with peripheral or central actions of sympatholytic or β-adrenergic blocking activity. Those that have less of an effect on sexual function include calcium channel blockers, angiotensin converting enzyme inhibitors, and peripheral vasodilators. Methyldopa reduces blood flow to the pelvic area, thereby inhibiting erection. When certain antiarrhythmic drugs and β-blockers cannot be avoided and sexual dysfunction results, patients may benefit from encouragement to explore other forms of intimacy and physical pleasure.
The excessive use of alcohol is a common yet seldom considered factor in sexual problems; although it may stimulate desire, alcohol inhibits performance. Up to 80% of men who drink heavily experience such effects as impotence, sterility, and loss of sexual desire. Alcohol with its depressant action can also affect a woman’s sexual desire. Many of the effects of moderate to heavy drinking are reversible if the drinking is stopped in time. Since alcohol tolerance decreases with age, smaller and smaller amounts may produce negative effects. People who choose to drink regularly should avoid drinking for several hours before sexual activity and should limit themselves to 1,5 oz of hard liquor, 6 oz of wine, or 16 oz of beer in any 24-h period.

Effects of Surgery on Sexuality

emirx — Wed, 25 Jul 2007 09:52:16 +0000

Rate of recovery and return to sexual activity after surgery varies. Thorough explanation of surgical procedures, together with practical advice and emotional support before and after surgery, can enhance recovery and the return to previous levels of sexual activity (see also Heart Disease under EFFECTS OF MEDICAL PROBLEMS ON SEXUALITY, above).
Hysterectomy
Refraining from sexual activity for 6 to 8 wk after hysterectomy is usually advised to allow the surgical wounds to heal. Feelings of depression after hysterectomy are common and usually last from 2 to 10 days, although some women report them for 6 mo or longer. Hysterectomy without oophorectomy does not usually impair sexual function. However, women who are highly sensitive to cervical and uterine sensations during orgasm are aware of the loss. Although oophorectomy decreases testosterone and other androgen levels fas well as estrogen and progesterone levels), the effects on sexuality have not been well studied.
Mastectomy
The loss of one or both breasts can make a woman feel sexually mutilated, and the psychologic effects may be severe. Sexual desire may be lost because of embarrassment, inability to accept the loss of the breast, or fear of being less attractive to a partner. Periodic depression is common and should be expected during the first year or two after mastectomy.
Rehabilitation programs, such as the American Cancer Society’s Reach to Recovery program, help women and their spouses deal with the physical, psychologic, and cosmetic concerns of breast surgery. Couples should share feelings openly and support each other emotionally.
Prostatectomy
Potency is rarely affected by the most common form of prostatectomy, transurethral resection of the prostate, although retrograde ejaculation is common. Healing usually takes up to 6 wk, after which sexual activity can be resumed. Men often assume incorrectly that sexual impairment is inevitable because of the physical proximity of the prostate to the penis. Factual information from physicians can alleviate fears. About 10% of men lose some ability to achieve an erection, although most men return to their presurgery level of sexual functioning. Most impotence after transurethral resection of the prostate is psychologic: about 3% to 5% of men develop nonpsychologic impotence. Suprapubic or retropubic prostate surgery may result in impotence.
Orchiectomy
The psychologic impact of this procedure can be devastating. Emotional preparation before and counseling after surgery are essential. Physiologic impotence does occur, but some men are able to have normal erections. When testosterone can be given soon after orchiectomy, potency may be retained. However, replacement testosterone therapy is usually contraindicated because in the elderly, orchiectomy is usually performed to treat prostate cancer.
Colostomy and Ileostomy
Patients who are sexually active before surgery usually can continue to be so afterward, although the adjustment can be complex. Couples should be given medical guidance and offered psychologic counseling. Some 250 ostomy support groups throughout the USA provide information and help.
Rectal Cancer Surgery
In men, removal of the rectum and anus with a permanent colostomy may result in total impotence. The proximity of male genital organs to the lower rectum leaves essential nerve fibers vulnerable to damage. In women who undergo this procedure, capacity for sexual arousal and orgasm is usually retained, since essential nerves are further from the surgical site.