Tuesday, November 18, 2008

Aggression Helps Men Fight Off Illness

The big bullies of the world may have more than a muscle advantage over the 90-pound weaklings. Research now suggests they have stronger immune systems, too.

The reason may have to do with an evolutionary process in which hunters and warriors needed greater protection from disease, researchers report in the August issue of Psychosomatic Medicine.

In a study of more than 4,400 men who had served in the US Army, Dr. Douglas A. Granger and his colleagues found that those with a history of fisticuffs, run-ins with the law, and behavioral problems in school had immune systems that were equally aggressive. Specifically, the aggressive men had a greater number of white blood cells known as B cells and helper T cells, both key in the immune system's response to foreign invaders.

Granger, a professor of behavioral health at Pennsylvania State University in University Park, told Reuters Health that the link between aggression and immunity was strongest for men who were "moderately aggressive." For example, men who reported committing two aggressive acts in their lives were 70% more likely than passive men to be in the group with the most helper T cells. But the trend toward higher helper T cells leveled off once men had committed six or more aggressive acts.

"I don't think we'd want to encourage people to start being aggressive to strengthen their immune systems," Granger said. However, he added, unlike some research that has linked aggression to poorer health, these study findings suggest "it's not always bad."

Besides looking at aggressive behavior, Granger's team considered other factors that influence immunity, such as overall health and risky behaviors such as smoking, drinking excessively, and having many sex partners. The investigators also measured the men's testosterone levels because some research has linked the hormone to weakened immunity. Even when they accounted for these factors, though, aggression remained tied to stronger immune function.

The reason for the connection is unclear, but Granger speculated that it may have to do with evolution. "We're throwing out the hypothesis that this (connection) has been with us for a long time," he said.

Throughout history, Granger noted, men who were more aggressive may have been more likely to "be out" foraging, hunting, fighting, and otherwise exposing themselves to a high risk of injuries and infection. A strong immune response would have been an asset to these men.

Although the current study focused on men who engaged in bad behavior, Granger said that since stronger immunity was linked to moderate aggression, the findings may extend to men who merely have more aggressive personalities.

Sunday, November 2, 2008

Experience With Injectable Caverject

"Dec 19th

Hi to all,

Well I know that all are wondering what happened at my appointment
at 4 p.m. Monday (Yesterday)

I arrived and checked in at the window, and they checked and had
received the questionnaires that I had mailed back. They made a
photo-copy of my BC/BS card for my file. I then had a seat and
waited to be "called shortly" ... I waited and waited and waited.
I finally was called at 5 p.m. because they had really gotten
behind. They did have a nice 400 gallon aquarium with six fish
and a starfish inside. There was the big yellow one the big gray
one, the stripped black and white one, the spotted one, the blue
one and the little one... I KNOW.

When I went back I was asked about my drug allergies by the gal,
and then she left. The doctor soon came in and I told him about
my impotence and my diabetes. I mentioned the forum and that I had
recently received such positive messages about Papaverine that I
wanted to try it. I also told the doctor that I had heard of Caverject
too, but I thought it was a little more expensive. The doctor
was good, and explained that Caverject is "made" for this problem of
impotence and that Papaverine is not really for this, though it does
work. He went on to explain that Papaverine is not really FDA approved
for this use. He mentioned also that Papaverine is difficult to get
here for impotence but that Caverject goes through the pharmacy programs
and insurance coverage programs much more easily and there is a whole
lot less hassle with getting it at your drug store and a lot less hassle
with your health insurance company. My Doctor went on to tell me about
caverject and how you use it. Told me the benefits and also about
priapism (prolonged erection > 6 hrs) which sometimes can occur.
He then asked me if I wanted to try this medicine and we do a test injection
today. I answered sure !!!! Well at 5:35 p.m. I had received the info
about where the shot goes and so I held it out while the male nurse gave me
my first shot near the back end about 3 o'clock on the side. I thought
it would hurt, but it only hurts slightly as it goes through the skin.
After the needle is through the skin it really does not hurt any deeper,
though they put the needle in all the way. The nurse then put in one
C C in. The doctor and nurse came back in ten minutes at 5:45 and I was
some larger. I was then shown how the Caverject kit goes back together
with the supplies used up and the lid is put on the kit and it is
"locked" by putting a special piece of plastic key that locks this up
from any further use and you can throw this one away. I was then told
to come back on Thursday and **I** do my shot of Caverject in front of
them, and then they will get me a prescription and I will be on my
way. I stopped and got the appointment set up for Thursday, and left.

On the way home I picked up some divider sheets at a store for [wife].
I "felt" much larger than I have ever been since 1987 so I walked up to the
counter to pay,,, sorta covering up the action in my pants with the divider
sheets so no one will notice. (I can hear you all laughing already !!!)

Anyway I get home and it is just me and my wife. We go to a bedroom
together and by this time the medicine had **really** worked. It was about
35 minutes after the shot by now... She was a sweetheart.

I have a couple of questions for the Thursday appointment, BUT this
Caverject is going to work fine for me !!!! So this is what happened
Monday...




[ I will answer here the question you are all going to ask. Yes
we found one way (position) that we could have vaginal sex
in spite of impotence, and used this way almost every week. ]





Dec 22st
Subj : Thursday appointment
F m : [Somebody]
T o : All in 22

Hi to All,

Well I thought I would let everyone here know how the Thursday
appointment went. My appointment was at 4:00 p.m. and they
were behind again.. I watched the fish until 4:45 p.m. before
going back to a room. I found out that a starfish that I thought
was a decoration on the back of the aquarium was ALIVE. So add
one more starfish to the list...

I got back to a room and waited for quite a while. Finally the
doctor and a student doctor came back and we talked. They asked
what happened after I left the clinic. All of that info is listed
in my Monday Appointment message here. I then asked if Caverject
can be stored in a drawer or if it has to be in a refrigerator.
It can be stored in a drawer. I then asked about the strength
of the dose. There are two kinds. One has 10 Micrograms and
one has 20 micrograms. This is actually a dry powder that is
inside a bottle very similar to an insulin bottle. There is
a syringe in this kit that is prefilled with a liquid solution.
You give the bottle a shot and inject the solution in
the syringe on the dry powder in the bottle. You then mix this
up until all powder is dissolved. You can roll this like an insulin
bottle or shake it. Anyway after all is dissolved then you draw *all*
the solution out of the bottle back into the syringe. Now your
shot is ready. You then inject on the three o'clock side or
the nine o'clock side of your penis near the back, putting the
needle all the way in. You try to draw a little blood into the
syringe and as soon as you do, then go ahead and inject all the
contents of the syringe into the penis. Then you remove (pull out)
the needle and cover for a few moments with and alcohol pad.
I am truly surprised but this doesn't hurt. Really ...

You should keep track and inject on the opposite side of the
previous shot. I then replaced all the stuff back into the
Caverject plastic case where everything snaps into its storage
area. Then I replaced the 2 inch by 6 inch lid on the bottom part
and locked it on with a special plastic button key. Now a person
can simply throw this away this way, because you cant get inside
it anymore.

Anyway I did my own shot with the male nurse watching. The
Doctors came back and checked to see that action was taking
place and things were growing. It was. I asked a few questions
about what would happen at the pharmacy. It is such a new drug
to [city] that they are still gathering this information...
I then left to go home. I had supper first and then went to
the pharmacy. [Wife wasn't home.]

I had good news and bad news there.... The
good news is that my pharmacy was open and had SIX in stock.
Bad news is that the computer contacted my health
insurance computer and said CLAIM DENIED ! So I
will have to file a claim with receipts later today. If my insurance
doesn't help pay for these, they will be $20.50 a shot. SO
I better be very romantic when we use these.... I will.
(BTW, my health insurance did honor the claims and paid their
80 % of the total costs.)




On May 20th I was to have my 6 month check-up appointment, however
my doctor was going to be out of town during this week so his
office called me and my appointment was rescheduled for May 9th.

When I arrived for my 6 month check, I waited for quite a while
in the waiting room. The fish inventory is now 2 starfish, 1
black and white spotted fish, 1 black and white stripped fish,
one brownish grey fish, 1 large yellow fish, and one medium
orange fish....

I met with the doctor and he looked over my medical folder, and
asked if I was having any problems with the Caverject kits and
I replied that I was doing fine since we had increased the
strength to the 20 microgram kits. I told him that my time was
a little over an hour with most of them and that my best shot
had lasted 2 hours. My doctor then noticed something in my
records and we proceeded to talk about the financial cost of the
Caverject kits. He told me about a pharmacy on the west coast
and that I could try a liquid medicine called Prostaglandin
or PGE-1 that would be less expensive. I would need a 1 CC
syringe, but that was no problem for me, due to the fact that
I have a prescription for syringes anyway for insulin. He then
told me that this medicine would be cheaper and gave me a
prescription for it and their phone number. Well when I got home
I called them, and I think I must have confused the operator
because she quoted me a price higher than Caverject. I was
frustrated. My wife then called, and asked to speak to the
pharmacist. The pharmacist explained things to us much more
clearly than the operator had, and so we mailed for this prescription.
I received the medicine in just a few days, by overnight delivery
and last weekend we tried the Prostaglandin medicine instead of
the Caverject kit. The medicine worked just fine, in fact better
because it lasted two complete hours. I don't want to advertise
for this pharmacy and advertising is not allowed, but if you need
the address to give to your urologist, you can send an e-mail to
me and ask for it. I check in almost everyday.

Hi to all (Dec 11)
Monday afternoon December 9th I had an appointment with my urology
doctor again. I checked in at the window to let them know that I
was there and then sat down in the waiting room to be called...
The aquarium now has a new scene in back, and different rocks
inside... Fish inventory is now one black and white stripped fish,
one brown spotted fish, one gray fish, one orange fish, and
two starfish... The new rocks have a slight covering of moss
and the water looks cleaner ...
Soon my name was called and I was lead to an examining room. I waited
for about 15 minutes, and then my doctor along with a new doctor
came in. This new doctor was going into family practice, but I think
they have to shadow the regular urology doctors for part of their
training.. My urology doctor then began to ask several questions
inquiring as to how the medicine was working (fine) and how much of
the Prostaglandin I was using. He also asked how long the medicine
was lasting. I told him that I had had two shots that had lasted
4 hours and 5 hours so I had been using less medicine and everything
was fine and that 70 to 80 units was giving me 2 hours of "Fun time"..
For the new doctor's benefit, we switched the conversation to a discussion
about costs of Prostaglandin compared to the cost of Caverject kits.
I have used both in the past year and my our family health insurance
policy covered all both of them so I was able to tell the doctor
of what it was actually costing us out of the household budget.
After talking of this, my urology doctor asked if I needed a new
prescription. I had to tell him that I honestly did not know... He
gave me a new prescription in case I would need it for next year.
I then was checked for scar tissue that might be forming or building
up from shots.. No problem with this at all, I do give myself very
gentle insulin shots, so I am good at being gentle with Prostaglandin
(PGE1) shots too. Again too, I shout from the roof tops here just as
I do in section 22, you won't ever believe it, but truly these shots
DO NOT HURT as much as very firm handshake. At this
point my doctor also said that I could come back in a year. He gave
me a card to take to the window and they arranged an appointment in
December. I then came home. I called the mail order pharmacy
on their 800 number in San Diego California and asked if I should
send in this new prescription. They told me that when I needed to
have my prescription renewed that they simply had the pharmacist there
call my doctor long distance and get a renewal. Very easy.
Again, if you have any questions, you can write to me by email or
send me a (P)rivate message in any section of the forum or ask
me in public messages in section 22 (The Male Room) ... "

-- submitted by Craig 71064,73

Sexual Disorders & Dysfunction

Although the majority of sexual dysfunction probably has a physical basis it is fitting to mention some sexual disorders here because dysfunctions, whether mainly due to physical or psychological causes, can result in distress. For example,
the individual with a sexual disorder may suffer related anxiety and sexual frustration which in turn leads to insomnia, and that insomnia may be the presenting complaint to the GP. The individual's close relationships may suffer and tension may build up in the family as a whole.


According to DSM-IV (the American Psychiatric Association's classification system) there are a dozen or so sexual disorders. All have to cause marked distress or interpersonal difficulty to rate as disorders. A brief overview follows:

1. Hypoactive sexual disorder
A persistently reduced sexual drive or libido, not attributable to depression where there is reduced desire, sexual activity and reduced sexual fantasy.

2. Sexual aversion disorder
An avoidance of or aversion to genital sexual contact

3. Female sexual arousal disorder
A failure of arousal and lubrication/swelling response.

4. Male erectile disorder
Inability to gain an erection or inability to maintain an erection once it has occurred.

5. Female orgasmic disorder
A lengthy delay or absence of orgasm following a satisfactory excitatory phase. The GP must take into account the patient's age, previous sexual experience and adequacy of sexual stimulation.

6. Male orgasmic disorder
A lengthy delay or absence of orgasm following normal excitation, erection and adequate stimulation.


7. Premature ejaculation
Ejaculation occurring with only minimal stimulation, either before penetration or soon afterwards, in either case ceratinly before the patient wishes it. Again the GP must take into account the patient's age, previous sexual experience, extent of sexual stimulation and 'novelty' of the sexual partner.

8. Dyspareunia (not due to general medical condition)
Recurrent pain associated with intercourse, but in women not due to vaginismus, poor lubrication, and in women and men not due to drugs or other physical causes

9. Vaginismus
An involuntary or persistent spasm of the muscles of the outer third of the vagina, again not attributable to physiological effects of physical causes. Vaginismus may be
either lifelong or recent; generalised to all sexual encounters or specific to certain partners or situations.

10. Secondary sexual dysfunction
Dysfunction secondary to illness eg hypothyrodism, mental disorder eg depression, or drugs eg fluoextine.

11. Paraphilias
Exhibitionism (exposure of genitals to strangers). Fetishism (finding nonliving objects erotic eg women's underwear). Paedophilia. Frotteurism (fantasies, urges or behviour centred around rubbing self against non-consenting other). Sexual masochism and sadism. Transvestic festishism (cross-dressing for erotic pleasure). Voyeurism (fantasies, urges or behviour centred around watching non-consenting others undressing, or having sex).

12. Gender identity disorder
Strong and persistent identification of the self with another gender. Persistent dissatisfaction with own sex. Desire to participate in stereotyped games and pastimes of opposite sex. Preference for cross-dressing. May insist that they are
wrong sex. May occur in children, adolescents and adults, (Green, 1985). Not concurrent with physical intersex condition.

Table One: Physical Causes of Male Erectile Disorder

Illness and disease

* Alcoholism (neuropathy)
* Diabetes mellitus
* Arterial disease eg Leriche syndrome
* Renal failure
* Carcinomatosis
* Neurosyphilis
* Hypothalamo-pituitary dysfunction
* Liver failure
* Multiple sclerosis
* and many others


Drugs


* Beta-blockers
* Thiazide diuretics
* Tricyclic antidepressants
* Phenothiazines
* Spironolactone
* Cimetidine
* Cannabis
* Anti-epileptics


Table Two: Physical causes of dyspareunia that would need to be excluded


Female


* Failure of vaginal lubrication
* Failure of vasocongestion
* Failure of uterine elevation and vaginal ballooning during
arousal
* Oestrogen deficiency leading to atrophic vaginitis
* Radiotherapy for malignancy
* Vaginal infection e.g. Trichomonas or herpes
* Vaginal irritation e.g. sensitivity to creams or deodorants
* Abnormal tone of pelvic floor muscles
* Scarring after episiotomy or surgery
* Bartholin's gland cysts/abscess
* Rigid hymen, small introitus


Male


* Painful retraction of the foreskin
* Herpetic and other infections
* Asymmetrical erection due to fibrosis or Peyronie's disease
* Hypersensitivity of the glans penis


How common are sexual disorders?

The majority of adults can recall times in their lives when they were troubled with low desire or problems with orgasms. Arousal difficulties increase with age. Sexual dysfunction may arise in the most well-adjusted and satisfied of couples. In 100 educated young couples Frank et al (1978) found that 50% of men had difficulties with erection, ejaculation or orgasm sometimes and 75% of women had problems with arousal or orgasm sometimes.


Table Three: Estimated lifetime prevalence of sexual problems in young adults (at some time).


Women


* Reduced libido 40%
* Arousal difficulties 60%
* Reach orgasm too soon 10%
* Unable to have orgasm 35%
* Dyspareunia 15%


Men


* Reduced libido 30%
* Arousal difficulties 50%
* Reach orgasm too soon 15%
* Unable to have orgasm 2%
* Dyspareunia 5%
(Source: Haas & Haas, (1993) Understanding Human
Sexuality)


What can be done?

Given that these disorders are relatively common and that they can cause such distress it is a matter of concern that patients often feel they cannot talk to their doctors about such matters.

Treatments break down into two main kinds: behavioural psychotherapy and physical. The former is largely derived from the pioneering work of people like Masters &
Johnson. Masters & Johnson type therapy addresses the sexual problem itself directly using the couple as a co-operative unit in the here-and-now rather than delving into an individual's unconscious for details of their past life. Masters & Johnson sessions may involve a male and female co- therapists who
sit with the couple and discuss the couple's sexual education and involve a medical examination by separate medical staff. If the problem is thought to be primarily medical then physicians usually take over the treatment. Within further sessions the couple is given guidance, instruction, and 'homework' - sexually orientated activities which the couple practice in their own bedroom alone.


Masters & Johnson Techniques:

Giving and Receiving Partners take turns in giving and then receiving touch and massage, i.e. giving pleasure, without at first touching breast or genital areas. This giving and receiving exercise is called sensate focus.

The early prohibitions on touching and orgasm hopefully reduce the couple's anxiety level and re-educate them that mutual pleasure can be derived from simple touching. Some authors have written about how it is possible to prescribe sensate focus without prohibiting sexual intercourse,(Lipsius, 1987). In the sensate focus process
each partner may use the hand over technique where the others' hand is guided. The receiver puts his/her hand over the giver's to show where touch should be and what that touch should be like. This further improves communication and teaches the couple what they can achieve rather than what they can't achieve. Masturbation, either alone or together may form part of the programme as may also the squeeze
technique which is sometimes used to prevent premature ejaculation - in this the partner places their thumb just below the coroanl cleft of the glans and places her other fingers opposite. Gentle, firm pressure for about five seconds usually stops the ejaculatory urge. After a rest of a few minutes sexual activity can begin again. The squeeze technique can be repeated several times during lovemaking.


Accurate information, to dispel false ideas, can often be enough to resolve problems. Indeed such a simple, straightforward strategy will obviate the need for specialist input in many cases. Jack Anon's PLISSIT approach is a pragmatic example (1976). Anon, acknowledging that all couples are different and require tailored solutions described a four stage model. Some couples/individuals are seeking Permission from their doctor/therapist i.e. reassurance about their activities. Others will respond to Limited Information or Specific Suggestions and a few may
require Intensive Therapy. This four level approach advances with the patient(s) as necessary.


Low sexual interest has ben found to respond to the encouragement of sexual fantasy. Orgasm and arousal difficulties often respond to the sensate focus approach described above. Dyspareunia and vaginismus may also respond to senate focus, although is some cases of generalised vaginismus treatment may involve teaching the woman to insert her own fingers into her vagina, and after practice, when the
woman is comfortable she may use the hand- over technique to introduce her partner's fingers into her vagina, whilst relaxing. Ultimately progression to penile insertion is encouraged.

Physical treatments are much more in vogue than they were. Useful though they were seemed in the seventies and eighties, Masters & Johnson type therapy has been re-eavluated. Like many treatments and drugs the initial enthusiasm has
been tempered with time. Initially a success rate of 80% was quoted for their techniques, but further evaluation suggest that in the medium term such techniques bring benefit to about 50% of patients. The current opinion suggests that a
high proportion of sexuxal dysfunction is attributable to psychophysical causes rather than purely psychological ones. In other words a man may complain that he is impotent, but there are several aspects to his problem - there is the tension caused in his relationship with his partner because they can't have a certain kind of sex - there is anxiety about performing which reduces his ability to begin to have an erection and there is an underlying transient or permanent physiological difficulty with erection. Once the latter is treated and the man is able to see that he can have
intercourse again after all some of the secondary anxieties (which were also affecting performance) begin to be dispelled as well.


Possible physical treatments:
o Premature ejaculation fluoxetine / clomipramine
o Erectile difficulties intrapenile injections of papaverine
and prostaglandin, inflatable prosthetic penile implants, suction
devices, cockrings

Audit Points

As a doctor, estimate how often people come to see you with their sexual problems? Do you think that the majority of people who come tosee you about their sexual difficulties can talk to you? What can you do to make it easier for people to
talk to you about these issues? What local resources are there to help doctors treat sexual disorders? If the resources seem scarce or have exceedingly long waiting times is there anything that can be done about this?


Self- Assessment MCQs

1. In terms of sexual function:

A women taking benzodiazepines may experience delayed orgasm
B men taking fluoxetine may experience delayed ejaculation
C sexual interest can be reduced by benperidol
D chlorpromazine may cause galactorrhoea in women
E libido can be reduced by digoxin therapy


2. Useful treatments for:

A erectile dysfunction include intrapenile injections of dobutamine
B premature ejaculation include the squeeze technique
C homosexuality include electric shock therapy
D vaginismus include the 'stop-start' technique
E premature ejaculation include fluoxetine


Answers


1. All true.
2. A=F, B=T, C=F, D=F, E=T.


Useful Addresses

Institute of Psychosexual Medicine, 11, Chandos Street,
Cavendish Square, London, W1M 9DE. Tel: 0171-580-0631


Relate, Herbert Gray College, Little Church, Rugby, CV21
13AP. (Look in UK telephone directory for local address/telephone
number).


References and further reading.


American Psychiatric Association, (1994). Diagnostic and
Statistical Manual of Mental Disorders. Fourth Edition (DSM-IV).
Washington,
APA.


Bancroft, J. (1989) Human sexuality and its problems. 2nd
Edition. Edinburgh, Churchill Livingstone.


Covington, S. (1991) Awakening your sexuality. San Francisco,
Harper SanFrancisco.


Cranston-Cuebas, M A, Barlow, D H. (1990) Cognitive and
affective contributions to sexual functioning. Annual Review of Sex
Research. 1,119-162.


Fisher, R, & Brown S. (1988) Getting Together. Boston,
Houghton-Mifflin.


Frank, E, Anderson, C & Rubinstein D. (1978) Frequency of
sexual dysfunction in 'normal' couples. The New England Journal of
Medicine, 299, 111-115.


Green, R. (1985) Gender identity in childhood and later
sexual orientation: follow-up of 78 males. American Journal of
Psychiatry. 142, 339-341.


Haas, K & Haas, A, (1993) Understanding Human Sexuality,
St. Louis, Mosby.


Kinsey A C, Pomeroy W B, Martin C E (1948) Sexual behaviour
in the human male. Philadelphia, Saunders.


Kinsey A C, Pomeroy W B, Martin C E, Gebhard P H. (1953)
Sexual behaviour in the human female, Philadelphia, Saunders.


Lipsius, S H. (1987) Prescribing sensate focus without
proscribing intercourse. J-Sex-Marital-Ther. 13(2): 106-16


Masters W H, Johnson V E. (1970) Human sexual inadequacy.
London, Churchill.


Mathers, N, et al. (1994) Assessment of training in
psychosexual medicine. BMJ, 308, 969- 972.


Pollack-MH; Reiter-S; Hammerness-P (1992) Genitourinary and
sexual adverse effects of psychotropic medication.
Int-J-Psychiatry-Med. 1992; 22(4): 305-27


Walbroehl-GS (1987) Sexuality in the handicapped.
Am-Fam-Physician. 36(1): 129-33


Wyatt-GE; Peters-SD; Guthrie-D (1988) Kinsey revisited, Part
I:
Comparisons of the sexual socialization and sexual behavior
of white women over 33 years. Arch-Sex-Behav.17(3): 201-39

Penile Prostheses (Implants)

The concept of the penile prosthesis dates back to early times when it was noticed that several species of animals had what was termed as an os penis or biaculum. This is a cartilaginous support noted to keep the penis erect. The first penile prosthesis was actually a rib graft implanted into the corporal body.

The recent history of penile prosthesis dates back to 1950, when Dr. Scardino implanted the first synthetic material into the penis. Penile implants improved dramatically with subsequent work of many investigators, and penile implant surgery has progressed to a very high level.

The indications and contraindications for penile implant surgery include vascular disease, diabetes, bladder or prostate cancer surgery or for benign prostate disease, Peyronie's disease, neurologic disease, hypogonadism, pelvic fractures and impotence related to many medical diseases including chronic renal disease, alcoholism, multiple sclerosis, genital trauma, Parkinsonism, drug therapy.

Some of the relative contraindications for penile implant include a poorly controlled diabetic, mostly because of the patient's high susceptibility to infection and significant symptoms of bladder outlet obstruction because a prosthesis
can cause a relative increase in the outflow obstruction and, thereby, produce urinary retention.

When choosing a penile prosthesis, it is important to recognize the major categories. These include:

1) rigid, semi-rigid and malleable rods, which produce varying degrees of rigidity and

2) inflatable prostheses which include two types; a) the multi-component inflatable prosthesis, and b) the self contained inflatable prosthesis. The main objective is to leave the patient with a penis that when sexual intercourse is desired it is
achieved with no complications and with a penis that satisfies both him and his partner.

There is no single penile prosthesis that is best for all patients. It is, therefore,
imperative that the urologist sit down and very carefully review the risks, benefits, and drawbacks to each of the different types.

When discussing the semi rigid prosthesis, the balance sheet includes an erection sufficient for penetration. This is termed axial rigidity in the urologic spectrum and means the amount of torque that can be placed on the penis. Most of the rigid prostheses are associated with a low mechanical failure rate because there really are no moving parts and a fairly simplistic implantation is possible. The down side
is that they produce an erection that may be noticeably unsightly, and because these are the most obstructing of the devices can interfere with urination. Also prostate surgery if needed in the future can be very difficult in this situation. The rigid protheses is however good for men with poor hand mobility, who are relatively elderly, or who do not wish to have the increased risk of malfunction because there are more moving parts.

The one-piece inflatable penile prosthesis offers a compromise between the multi-component inflatable and the semi-rigid device. The downside to this device is that it can sometimes be difficult to manipulate. It doesn't get as erect as the rigid and it doesn't deflate as much as the multi-component inflatable. Additionally,
this device is very limited to the "average size penis," and if the patient has an extremely long penis is not an adequate device.

The multi-component inflatable prosthesis is what we term the "Cadillac" device. It gives the best appearance when erect and is the softest when deflated. It is probably the most popular and there are several major manufacturers including
American Medical Systems and Mentor.

Several penile prostheses are no longer in vogue and do not have a place in modern implant surgery.

The small carrying prosthesis introduced in 1973 was available in numerous sizes and lengths was a reasonable device, but really failed to produce the axial rigidity necessary for intercourse and was supplanted by better models.

The Jones Prosthesis was a malleable rod consisting of an outer silicone shell and silver wires and a twisted configuration that allowed some degree of torquing and thus causes some loss of axial rigidity. This was implanted with a trimable version to ensure adequate sizing.

American Medical Systems introduced the malleable prosthesis. This gives a very adequate erection, but one that can be very unsightly. That the normal erection
is a hydraulic event was really the rationale behind the inflatable device. It has three pieces including a reservoir to store the fluid, cylinders, and a pump which is placed in the scrotum. The pump transfers fluid from the reservoir into the cylinders, thus creating erection and when one desires to end the erection this process is reversed with a releaser deflate valve.

Another American Medical Systems product is the controlled expansion inflatable penile prosthesis which increases the actual rigidity. It has reinforced non-kinking tubing, revised pump, and a rear-tip system to allow adequate sizing. Mentor also
has an inflatable prostheses with both a two-piece and three-piece inflatable prostheses.

The type of surgery used for the implant is generally left to the surgeon's experience and type of device, but can include:

1) a perineal approach which is under the scrotum;
2) a penoscrotal approach which is at the base of the penis on top of the scrotum,
3) the protheses may be placed in the penile shaft, or
4) an infrapubic incision, which is an incision above the penis.

There are advantages and disadvantages to each device, and the most important part of penile prosthesis includes the proper selection of length and diameter to fit the corpus cavernosum, general dilation of the corporal body to avoid perforation proximally, with meticulous attention to detail to avoid infections, including preoperative preparation, intraoperative antibiotics, and copious irrigation during the procedure.
Complications of the penile implant include infections, which can be disastrous and treating an infected prosthesis actually can exceed the cost of the original prosthetic implant. Attempts to avoid infection include use of a surgical
bubble system to prevent particles and bacteria from getting access to the device.

Other complications include perforation of the corporal body which is the area where the prosthesis is held which can cause migration of the device. Management for this includes creating a Dacron graft to prevent migration. Perforation into the
urethra or glans penis can be disastrous and any perforation to a potentially infected area, such as the urethra, should require termination of the procedure.

Other problems include tubing kinks, fluid leaks, aneurysm, dilatation of the cylinders, breakage of the wire, the Silicone spillage, loss of rigidity to the prosthesis, erosion of the reservoir, spontaneous deflation, spontaneous inflation, penile curvature, which is a variant of Peyronie's disease, pump or pump reservoir
migration, phimosis, paraphimosis, things that go along with circumcisions.
All of these can be tremendous problems during the placement of a penile implant.

Male Sexuality and Impotence: "How's your love life?"

"How's your love life?"

That's a question many of us have heard, often in a casual, off-handed way. But if we're having problems with sex, it's not a joking matter. And the fact is, a lot more of us are having trouble than most people imagine.

The latest statistics suggest that as many as one out of ten adult American males have problems with sexual inadequacy. Among certain groups the percentage is even higher. For example, adult male diabetics may have erection problems up to 50% of the
time. Men with disorders of the arterial system heart disease, hypertension and vascular disease may have an even higher likelihood of being unable to function well sexually.

In some men, the problem is a complete inability to get an erection. The system simply does not work. More often, the problem is a partial one. A man cannot depend on an erection each time he wants one, the erection is not hard enough, or the
erection does not last long enough for mutual satisfaction. In these situations, sexual intercourse can present insurmountable difficulties, and attempts at it can be the source of anxiety and unhappiness. Of course, this affects not only the men, but their partners as well.

What we are talking about here is impotence. Not only is impotence more common than most of us suppose, but nowadays it is much more treatable than ever before. The first step is to take a good look at our own situation. If there's a problem, ignoring it won't help.

In this post we'll examine how men are able to achieve erections, and we'll try to shed some light on why some men cannot function well. We'll discuss what can be done to correct serious problems and then we'll consider some simple ways to make sex more exciting, more satisfying and more enjoyable for both parties.

How does a man have an erection?

In the human body, male or female, there's no other organ that works the way the penis does. When a man is sexually aroused, his penis changes from a limp phase to become longer, wider and heavier. Most importantly, it becomes firm or rigid,
allowing penetration to occur. For both men and women, of course, this process provides a high degree of pleasure.

First, let's take a look at how the penis functions when we are not sexually aroused.
In this state, a small amount of blood trickles into the penis, bathing the spongy tissues in the two erectile chambers of the penis, which are called the corpora cavernosa (literally, "spacious bodies.") There is just enough blood flow to furnish
oxygen and nutrients to the tissues. The blood then readily leaves the corpora through tiny veins, and returns to general circulation. Since there is little pressure in the spongy tissues, the corpora are not filled out, and the penis is limp.

The process by which a man gets an erection depends on increasing the blood flow into the chambers of the penis, and then trapping the blood inside. This fills and expands the spongy tissues and causes the entire penis to become firm.

But what makes more blood flow in? This is the role of sexual stimulation or "arousal." All forms of sexual stimuli work through the nervous system, and they depend to some degree on testosterone, the principal hormone made by the testicles.
Testosterone is necessary for male sexual functioning. Without sufficient quantities of this hormone, men cannot be sexually stimulated, nor can the internal structures of the penis function properly.

So, when testosterone is present in sufficient quantity, a man can be "turned on" by any number of stimuli. For example, the stimuli can be visual, they can be tactile (touch), they can be sheer fantasy or even certain fragrances. The brain sends a
series of nerve signals to the penis and, under ordinary conditions, an erection develops. The proper nerve signals cause the tiny arteries bringing blood to the penis to widen, allowing more blood to enter. These same nerve signals also cause the muscular walls of the spongy tissues to relax. Then, as the spongy tissue fills with more blood under pressure, the tiny thin-walled veins leading blood out of the penis are squeezed shut. The spongy tissue and the corpora cavernose actually beings to trap blood inside itself. To bring about real rigidity, we require one more anatomical component, the muscles located at the base of the penis. When the penis is stimulated during sexual activity, these muscles contract. They squeeze the corpora and raise the pressure inside to the point of rigidness.

What causes erection problems?

Even from that simple overview, you can see that for the penis to do its job, a lot must happen. We need the proper stimulation from the brain and nervous system. Male hormones must be secreted in the right way and in the correct amount. Most importantly, the heart must pump blood through the arteries to the penis and certain muscles and tissues must respond in very precise ways to make certain that blood does not escape too readily.

With all these physical factors at work, it may seem odd that until fairly recently, many doctors believed that impotence was all or mostly "in the mind." A popular home medical guide published in 1973 deals with impotence under "Emotional and Mental Illness" and mentions only "counseling or psychiatric help" as treatment.
Today we have a better understanding of the physiology involved. We find that although psychological factors often come into play, by far the most common causes of impotence are physical parts of our body are not working the way they should
be. Nowadays there are specialists, usually urologists, who can treat many of these conditions. The majority of patients can be restored to sexual potency. The type of treatment, of course, depends on the precise cause of the problem and on the motivation of the patient.

We have seen how an erection depends on the flow of blood. Consequently, it is easy to understand how any problems with the blood flow not enough blood entering the penis or blood flowing out too quickly can seriously affect our ability to achieve and sustain an erection.

Why do diabetics suffer from impotence?

Just one year after Sidney M. found out he was diabetic, he began having difficulties in sexual intercourse. At first, he noticed that his erections were less firm. Soon he could not maintain an erection long enough to satisfy himself or, for that matter, his wife June. Eventually, both husband and wife realized that Sidney had become impotent. At this point, they sought help from a urologist
specializing in sexual dysfunction. When the evaluation was completed, the doctor determined that the cause of Sidney's impotence was his diabetes.

Men with diabetes often have a malfunction of both the nerves and the blood vessels involved in the erection process. Not only may the signals that stimulate the penis not arrive properly, but the blood vessels bringing blood to the male sexual organs may be blocked. In addition, current research shows that the trapping mechanism which keeps the blood from leaving the penis too quickly is very sensitive to blood vessel damage of the type found among diabetics.

What drugs are available to treat impotence?

Papaverine is a medication commonly used by vascular surgeons to prevent spasm in tiny blood vessels. It has also become a common treatment for impotence. Papaverine increases blood flow in the penis and helps to trap blood inside the erection chambers. Self-injection therapy with this drug (and with Prostaglandin-caverject) has revolutionized the treatment of impotence for men with diabetes as well as a variety of other physical disorders.

This new form of treatment, Pharmacologic Erection Therapy, was selected by Sidney and his wife in consultation with the urologist. Just before having sex, Sidney injects himself with a dose of the medication directly into the penis. With sexual
stimulation, he is able to achieve a quite normal and satisfying erection, and he becomes capable of having intercourse. Sidney and June are often able to achieve a satisfying climax together because Sidney's erection lasts until the medication's effect wears off, usually up to a half hour. Since he had already learned to use insulin to treat his diabetes, Sidney was easily able to adapt a very similar technique to administering Papaverine. He and June now have intercourse on average once or twice weekly. In his words, "Sex has not been this satisfying for either of us in ten years!"

Sexual dysfunction in men may also be caused by cardiac and peripheral vascular disorders, high blood pressure and its treatment, hormone imbalances and emotional difficulties. These, in turn, may accompany diabetes.

Despite Sidney's success, not every man is a suitable candidate for self-injection therapy. The treatment demands motivation and careful attention to injection technique. There are potential side effects, which include infection, scarring of
the penile chambers, and even a painful prolonged erection. In addition, Pharmacologic Erection Therapy will not work in all cases. There are also many individuals and couples who feel that this technique is not spontaneous enough for their needs and desire a more permanent means of overcoming impotence. Medical
science is constantly exploring new treatments for impotence and your doctor may be aware of some of the medications which can be effective in treating this condition.
The bark of a tropical tree yields a drug called Yohimbine, which can also help certain men by increasing penile blood flow and improving the "venous trapping mechanism". Yohimbine tablets have improved sexual functioning in many men, usually in situations where the loss of sexual function is only partial.

In a few cases, hormone therapy may be advised. If blood tests show elevated levels of prolactin, there is medication to control this erection-inhibiting hormone. For those with low testosterone levels, supplemental injections may be considered.
However, the potential of harmful effects is considerable, so testosterone therapy is only rarely recommended.

Is there an external therapy for impotence?

One of the more recent and popular methods of dealing with an erection problem is with an External Vacuum Device. Quite simply, this is a plastic cylinder with a hand pump attached. The limp penis is placed inside the tube, then air is drawn out
through the pump. Creation of a vacuum outside the penis allows blood to rush in and fill the corpora cavernosa. A tension ring is placed around the base of the penis to maintain rigidity for up to 30 minutes.

Thousands of men have used external vacuum devices, and many with good success. But, they are not suitable for everyone. For example, this technique is not recommended for men who have had injuries to the penis, sickle cell disease, leukemia, pelvic
infections or blood clotting difficulties. Some men as well as their partners object to the limits it may place on foreplay and romance. Still, external vacuum devices are usually safe, relatively inexpensive and simple to use.

Are there permanent solutions to impotence?

Sometimes simple treatments are unsuccessful. At other times, men are dissatisfied with non-surgical solutions. In such cases, the best course is usually a Penile Implant. Also called a penile prosthesis, an implant is surgically placed into the corpora chambers of the penis. It provides enough firmness and substance to the penis so that a man can engage in satisfactory sexual intercourse. In general, the sensations surrounding sexual activity do not change after an implant, nor does
a man's ability to achieve climax and ejaculation. The erection resulting from an implant is very similar to a natural one, and the devices are not visible at all from the outside.

Most penile implant surgery is now done on an outpatient basis, though some may require a day or two in the hospital. The recovery period until a man can resume sexual relations is usually about six weeks. Currently available devices have been
found to be quite safe and reliable. Urologists who specialize in this form of therapy can provide guidance in choosing the type that will be best for a particular individual. More than a dozen different penile prosthetic devices are available, falling into four general types.

Fully Inflatable Implants have an action that most closely mimics normal sexual activity. They provide the best overall results and the greatest degree of patient satisfaction. However, they are slightly more complicated and more difficult to
install.

The surgeon places two balloon cylinders within the penis and a small pumping mechanism inside the scrotum. In addition, a fluid reservoir must be implanted, either in the abdomen or the scrotum, and these units must be connected by tubing.
To achieve an erection, the man squeezes the pump, which sends fluid from the reservoir into the balloon cylinders. The cylinders expand within the corpora, and the penis becomes erect. At the end of sexual activity, the pump is activated again and the fluid returns to the reservoir, returning the penis to its
limp state.

The Self-Contained Inflatable Implant works more or less the same way, except that all the parts are contained in one unit. One device is implanted into each corpora cavernosa. When the pump is squeezed, the unit becomes rigid. Pressing the release
valve returns the fluid to its reservoir and the penis once again becomes flaccid.
Unlike the fully inflatable implant, the self-contained unit will not expand the girth (width) of the penis. However, its rigidity is quite sufficient for effective intercourse. The surgery is slightly less extensive and patient satisfaction is
excellent. Finally, the most simple and least expensive prosthesis is the Semi-Rigid Implant. These devices are non-inflatable and non-expandable, and easiest to implant. They produce a satisfactory erection and most patients are very pleased with the result.

Implant therapy is usually covered by insurance plans and Medicare as long as an underlying physical cause of impotence can be demonstrated. The overall success rate for implants is well over 90 percent, and most men have no change in sensation, orgasm or ejaculation. Men are usually able to resume intercourse four to six weeks after surgery.

A newly developing area for treatment of impotence is Penile Vascular Surgery. In carefully selected individuals, it may be possible to actually increase the amount of blood flowing into the penis, bypassing obstructions in the arteries. In other
cases, the goal of surgery is to decrease the flow of blood leaving the penis by tying off certain veins. These two surgical procedures are the subject of much current research and may hold a good deal of hope for the future.

What can I do to make sex better?

Men who are even slightly impotent want to improve their sexual function. This can lead to fear of failure. Sometimes their partners' expectations create tension or anxiety. Depression, stress and marital problems all can affect our ability to perform sexually. While most impotence is caused by physical factors, psychological factors almost always come into play, sooner or later.

For that reason, whether or not we require medical treatment, we need to examine the way we approach sex and whether our lifestyles should be changed to improve our sex lives. Especially for men and women over 40, these are vital steps to achieving satisfying sex and improved relationships. Cut out smoking. Tobacco constricts blood vessels and the long-term affects of smoking affect all of the tiny blood vessels
in the body. An unusually high percentage of men seeking treatment for impotency are smokers.

Drink less alcohol. Heavy drinking is likely to produce impotence, sterility or loss of sexual desire in men. Alcohol does not improve an erection, it prevents one. With increasing age, it takes smaller amounts to affect us. Look into the prescription and non-prescription drugs you may be taking. Blood pressure medications are particularly prone to reducing our ability to have an erection. Antidepressants,
antihistamines and some ulcer medications also inhibit erections. In most cases, doctors can prescribe alternative medications that will improve your sexual functioning.

Relax and have fun with sex. Take a warm bath, maybe with your partner. Try different positions for sex and you'll find that some lead to better erections. Ask your wife or lover for more stimulation, something that older men naturally require for an erection. Avoid sex when you're tired or tense. Try different times (especially mornings) and places for sex. Get in the mood by combining relaxation and stimulation. Get regular exercise.

Urologists are all-too-often consulted by patients who feel despondent because they've been unable to have intercourse for years. They've been too embarrassed or afraid to discuss their impotence. But thanks to recent medical progress there are ways to treat almost every erection problem, no matter how long it's been present. With the wide range of treatments available to us now, it's almost a sure bet that a man's sexual function can be restored.

Management of Sexual Dysfunction Associated with Antidepressants: Drug Holidays

KEY POINTS

o · Drug holidays in which the antidepressant is discontinued 2 to 3 days prior to sexual activity is more successful with drugs that have a short half-life.

o · Clinicians should ask specifically about sexual desire, sexual enjoyment, erectile problems, erections unrelated to sexual activity, capacity to reach orgasm, changes in capacity to reach
orgasm, and painful orgasm.

o · Antidepressants also have been used to treat some sexual dysfunctions, such as premature ejaculation.


Tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) have been used in psychiatry and other disciplines for almost 4 decades. Antidepressants were originally reserved for serious cases of depression. Selective serotonin reuptake inhibitors (SSRIs) were introduced into clinical psychiatry about 10 years ago. The use of SSRIs, along with advances in clinical
psychopharmacology research and the decrease in payments for psychotherapy by third-party payers, have to some extent revolutionized the field of clinical psychopharmacology. Since
these times, psychiatrists and primary care doctors have started to treat disorders that were once considered the domain of psychotherapy, such as dysthymia and some anxiety disorders, with antidepressants.

We have been treating patients mostly in the outpatient setting. The results of well-designed, long-term studies have helped to define the duration of treatment of an episode of depression.1,2


We now continue antidepressant treatment for about 6 months following remission, using the dosage that was effective in the acute phase. Clinical psychopharmacologists have also become more aware of various side effects, reasons for noncompliance, and quality-of -life issues during treatment with antidepressants. One such side effect is sexual dysfunction. Changes in sexual
functioning can occur with various mental disorders, such as depression, and can also result from antidepressant therapy (see Table 1).

The effects of psychotropic medication on sexual functioning have been the subject of various excellent reviews.3-6 Drugs used for treating depression have been implicated in sexual dysfunction with increasing frequency, and changes in sexual functioning havebeen reported with almost all the antidepressants (see Table 2). Estimates of the incidence of treatment-emergent sexualdysfunction with antidepressants vary from 1.9% (Physicians Desk Reference, for fluoxetine) to over 90% (see Table 3). This vast range is probably at least partially a reflection of the lack ofattention to sexual side effects in previous studies and the lack of thorough and uniform methodology in current studies focused on sexual dysfunction caused by antidepressant therapy. The majorityof studies have been nonsystematic. For example, some described sexual dysfunctions that were reported spontaneously, some described sexual dysfunction after patients were asked about it in a systematic way, and some studies used questionnaires.

Frequently, changes in sexual desire were not elicited. Serial questioning about sexual dysfunction during the course of pharmacotherapy has also not been used. Our understanding of the biology of normal sexual functioning and of mechanismsof action of antidepressant-induced sexual dysfunction is rather poor. Various neurotransmitter systems (adrenergic, dopaminergic, serotonergic, muscarinic) seem to be involved in the biology of normal sexual response and activity, centrally and peripherally.3,5 None of these systems should be solely implicated, and interactions on central and peripheral levels are likely. Some other neurotransmitters, such as acetylcholine, probably play a mediating role as well.5


Interestingly, a correlation between sexual dysfunction and the anticholinergic effects of antidepressants was not observed in one study.11 Sexual hormones and other substances (eg, vasoactive intestinal peptide) probably have at least a modulating role.

Administration of drugs influencing various neurotransmitter systems, such as antidepressants, could affect sexual functioning in different ways. Various sexual dysfunctions are the most frequently observed effects, but occasional improvement of sexual functioning with antidepressants14 or unusual sexual experiences15 have been reported. Antidepressants also have been used to treat some sexual dysfunctions, such as premature ejaculation.16 Obviously, antidepressants can cause various changes in sexual functioning (see Table 4).

Sexual dysfunction has been a frequently mentioned cause of noncompliance with antidepressant therapy, but this issue has not been systematically studied. Rabkin et al17 reported four cases of discontinuation of monoamine oxidase inhibitors (MAOIs), but only one case was solely due to sexual dysfunction, without any other major side effects. Other reports of noncompliance because of sexual dysfunction are anecdotal. Nevertheless, antidepressant-induced changes in sexual functioning pose a difficult and interesting clinical problem, in part because of the possibility of noncompliance.

Diagnosis of Sexual Dysfunction

The first two steps in the management of sexual dysfunction are (1) recognition or identification of the dysfunction, and (2) patient education. A baseline assessment of sexual functioning is absolutely necessary. Without this there is nothing with which to compare recent sexual functioning, and the clinician is unable to determine accurately if the dysfunction is a new or an old phenomenon.

As shown in Table 1, various factors can contribute to sexual dysfunction; therefore, sexual dysfunction should not always be attributed to medication. It may be a component of depressive
symptomatology (decreased libido); it may be due to concomitant medical illness (impaired erectile capacity may be the first symptom of diabetes mellitus); it may represent primary sexual dysfunction (sexual desire disorders, sexual arousal disorders, orgasmic disorders, sexual pain disorders); or it may be a side effect of medication. Ruling out all other causes before

attributing the dysfunction to medication seems to be a prudent, but not always practiced, approach. Given the multiple possible sources of sexual dysfunction, caution should be used when determining etiology.

Skilled clinicians should ask very specific questions. General questions such as "How is your sex life?" are not enough because they often lead to nonspecific answers such as "All right," "OK,"

"No problem." These answers will not provide adequate baseline information for the assessment of possible future dysfunction.

Clinicians should ask specifically about sexual desire, sexual enjoyment, erectile problems, erections unrelated to sexual activity, capacity to reach orgasm, changes in capacity to reach orgasm, and painful orgasm. It is known that asking about sexual dysfunction elicits twice the incidence found when no questions are asked. A good psychosexual history should be a part of every initial evaluation.

Identification of antidepressant-induced sexual dysfunction can be a diagnostic challenge. Is the problem a true sexual dysfunction or has the patient mislabeled it? What type of dysfunction is involved? Is it a single dysfunction or a combination of dysfunctions? If a combination, which dysfunction is primary? Is the problem generalized or situational? Is it the result of a combination of medications? What is the patient's reaction to the dysfunction? Were comorbid conditions, substance abuse, and relationship problems considered?

Occasionally, other diagnostic procedures, such as physiologic tests of erectile capacity (nocturnal penile tumescence, visual stimulation method), tests of penile vascular competence,neurologic evaluation, and hormonal assessment, must be used.

Patient education about possible sexual dysfunction can be problematic. A good physician-patient relationship plays a significant role. Some clinicians advocate either no discussion of possible sexual dysfunction or a discussion with little emphasis on dysfunctions and their severity, because they do not want to discourage patients. However, some patients may be informed about this topic because of increased attention by the media or because of aggressive marketing strategies used by the pharmaceutical companies. Oc-casionally, pharmacists may discuss various side effects of antidepressants, including sexual dysfunction, with patients, or other patients share their experiences. At least some discussion of these problems is better than no discussion. Clinicians should also mention that various management options for antidepressant-induced sexual dysfunctions are available.

Management

Once the diagnosis of sexual dysfunction induced by an antidepressant is established, the clinician should carefully consider management options (see Table 5) and discuss them with the patient.


Waiting for Spontaneous Remission of Sexual Dysfunction

This might be considered a questionable approach. As with many other side effects of antidepressants, spontaneous remission or decrease in severity to a tolerable level is possible. Cases of spontaneous remission have been reported for some antidepressants, such as sertraline and phenelzine.18 However, spontaneous remission may occur only after several weeks or months, which may be too long for the patient to wait. This approach requires a very good physician-patient relationship. Also, it has not been reported to be effective for tricyclic antidepressant-induced anorgasmia.5


Reduction to the Minimal Effective Dosage

This approach may occasionally help, but it is also risky. Balancing between the minimal effective dose and a subtherapeutic dose can be precarious. The dose at which the dysfunction appears is frequently the lowest that alleviates depression. Some authors 19 have suggested that there is a relationship between sexual dysfunction and the dosage of fluoxetine. They observed an improvement of sexual dysfunction and no recurrence of depression when they decreased the dosage of fluoxetine to 20 mg every other day, and in some cases to 20 mg a week. Sexual dysfunction associated with venlafaxine also showed a dose relation in one study.20 Despite the potential double-blind nature of dose reduction, it has been frequently recommended in erectile dysfunction.

Drug Holidays

A variant of dose reduction, the drug holiday approach requiresthat the antidepressant be discontinued 2 to 3 days prior to sexual activity. The success of this approach depends oncareful planning and a comfortable physician-patient relationship. It is probably more successful with drugs that have a short half-life, such as paroxetine and sertaline, and may be difficult with long half-life drugs, such as fluoxetine. Again, worsening of depressive symptomatology may complicate this practical alternative for management of sexual dysfunction associated with antidepressants.

Switching to Another Antidepressant


Several reports in the literature have described successful substitution of desipramine for imipramine or clomipramine, imipramine for amoxapine, and nortriptyline for imipramine or doxepin. This approach may take a long time and its success may be hindered by relapse of the depressive disorder.

Several studies report no sexual dysfunction with bupropion. In one study,21 24 of 28 patients who reported sexual dysfunction on various antidepressants reported resolution of their sexual dysfunctions when switched to bupropion. Another study reported significant improvement of fluoxetine-associated sexual dysfunction in patients who were switched to bupropion.22

However, caution is needed because one unpublished report has noted sexual dysfunctions in patients treated with the sustained-release form of bupropion.23 With nefazodone, the newest antidepressant available in the United States, there have been no reports of sexual dysfunction to date, and in some clinical trials, the incidence of sexual dysfunctions was found to be equivalent for nefazodone and placebo.

Using Secondary Pharmacologic Agents

Numerous pharmacologic agents have been successfully used in the "treatment" of sexual dysfunctions induced by antidepressants. These include bethanechol (30 mg, 1 to 2 hours before coitus),24 cyproheptadine (4 to 12 mg, 1 to 2 hours before coitus; caution patient that severe sedation or depression may occur),25, 26 yohimbine (5.4 mg tid or prn 2- to 4 hours before coitus; caution patient that yohimbine may induce anxiety),9,27 neostigmine (7.5 to 15 mg, 30 min before coitus), amantadine (100 mg one or twice daily up to 600 mg),28 bupropion (75 mg/day with fluoxetine),29 buspirone (30 mg/day or more with various SSRIs),30 dextroamphetamine (10 to 25 mg/day), and pemoline (18.75 mg/day).31 Other reportedly used agents include methylphenidate, trazodone, and bromocriptine.

Vacuum Erectile Devices

Use of vacuum erectile devices and injection of agents into the corpus cavernosum are specialized procedures that are best handled by urologists.

Matching Therapy to Type of Sexual Dysfunction

There are various treatment strategies for different types of drug-induced sexual dysfunction. In the case of decreased libido, drug holidays, the addition of neostigmine, or the substitutionof another drug such as bupropion or nefazodone may be effective.


For erectile problems, dose reduction, drug holidays, coadministration of bethanechol, or substitution of another drug may be tried. Orgasmic dysfunction may be resolved by waiting for spontaneous remission, or by drug holidays, coadministration of another drug, or substitution of another drug.

Two important additional points are the following:

1. Only tentative conclusions about the efficacy of the above treatments can be drawn because most of the literature in this area consists of case reports or series of cases.6

2. Priapism (abnormal, persistent, usually painful erection unrelated to sexual arousal) constitutes a urologic emergency. Priapism has been reported with trazodone and various other psychotropic drugs.


Positive Effects of Antidepressants on Sexual Function

Antidepressants do not necessarily adversely affect sexual functioning. A few cases of "improved" sexual functioning have been reported. Smith and Levitte reported a return of sexual potency in three elderly men treated with fluoxetine.14 Others32 described an elderly male who developed "orgasmic sensations" on fluoxetine. Orgasms associated with yawning in patients treated with clomipramine and fluoxetine have also been reported.

Trazodone has been used to treat impotence. Lal and colleagues33 described the case of a psychiatrist who successfully treated his own impotence with trazodone, 250 to 350 mg prior to coitus once a week for 4 years. Montorsi and colleagues34 reported that the combination of yohimbine (15 mg/day) and trazodone (50 mg/day) is a safe and effective first-line treatment for psychogenic impotence.

As already noted, one side effect of antidepressants ­p; delayed or inhibited ejaculation ­p; has been used for treatment of primary premature ejaculation. Some case reports have described improvement of premature ejaculation with selective serotonin reuptake inhibitors, such as sertraline35 and fluoxetine.36 Controlled studies have reported greater clinical improvement of premature ejaculation with clomipramine compared with placebo37 (25 or 50 mg/day; the higher dose produced a longer time toejaculation), and paroxetine compared with placebo.16

Conclusion


The effects of antidepressants on human sexuality are complex. The etiologic mechanisms of sexual dysfunctions are unclear and intricate. The diagnosis and management of sexual dysfunction induced by these agents is a challenging clinical issue requiring a good physician-patient relationship, keen and skillful observation, and a certain degree of creativity and patience.


Most effects of antidepressants on human sexuality are adverse, but some effects are beneficial ­p; for example, antidepressants can be used for the treatment of premature ejaculation.



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Glossary



Anorgasmia ­p; Inability to achieve orgasm, absence of orgasm. Drug holidays ­p; Regular periods during which the patient is not given medication.

Impaired erectile capacity ­p; Persistent or recurrent inability to attain or to maintain an adequate erection, until completion of the sexual activity.

Libido ­p; Sexual desire, drive, interest.

Priapism ­p; Persistent penile erection accompanied by severepain.

Primary sexual dysfunction ­p; Disturbance in sexual desire and in the psychophysiological changes that characterize the sexual response cycle causing marked distress. The term primarily refers to etiology.

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