Male Sexual Dysfunction 1 Hypoactive Sexual Desire Disorder • Affects 15% of men • Typically associated with a medical condition, mental health issues, or medication side effects – hypogonadal – depression – antidepressant induced 2 Male Erectile Disorder • DSM-IV – Inability to attain or maintain adequate erection – problem persistent or recurrent – caused by psychogenic or combined factors • common reason for seeking treatment • highly distressing to men • prevalence 3 Male Erectile Disorder (ED) 4 Male Erectile Disorder • Medical causes: – vascular diseases (most common cause), e.g., hardening of arteries, long term cigarette use – diseases affecting the nervous system, e.g., multiple sclerosis, alcoholism – diseases affecting vascular and nervous system, e.g., diabetes, hypothyroidism – anything impairing penile vascular and/or nervous system: • surgical or accidental injury • old age • pharmaceuticals 5 Drugs Associated with ED • Alcohol ß-blockers Estrogens Psychotropics Antiandrogens Cigarettes H2 receptor blockers Cocaine Anticholinergics Spironolactone Ketoconazole Lipid-lowering agents Antidepressants NSAIDs Marijuana Cytotoxic drugs Antihypertensives Diuretics Narcotics 6 Male Erectile Disorder (ED) • Psychological Causes: – occasional episode normal (e.g., stress) – men with ED focus on anxiety/worries rather than sexual cues --> negative feedback loop – normally functioning men focus on erotic cues --> positive feedback loop (Barlow, 1986) 7 Male Erectile Disorder (ED) 8 Male Erectile Disorder (ED) • Treatment: – Viagra (sildenafil), also, Cialis (tadalafil), Levitra (vardenafil) – injection of vasodilating drugs (e.g., alprostadil) – vascular surgery – vacuum pumps and constrictive devices – penile prosthesis or implants 9 Male Erectile Disorder (ED) • Sildenafil: Mechanism of Action – Nitric oxide acts through a second messenger, cGMP, in the normal development of erections – cGMP relaxes corpus cavernosal smooth muscle cells, promoting blood flow into cavernosal spaces – cGMP broken down by PDE - the predominant enzyme of this type in the corpus cavemosum is PDE type V – Sildenafil is a selective and potent inhibitor of PDE type V 10 Vacuum Pumps and Constrictive Devices 11 Male Erectile Disorder (ED) • Penile Implants Two types: semirigid and multicomponent inflatable Patient satisfaction: 81% to 97% Average functional life: 7 to 10 years 12 Inflatable Penile Implant 13 Malleable Penile Implant 14 Male Orgasmic Disorder • DSM-IV: Inability to reach orgasm after sufficient stimulation • often require manual/oral simulation - “hard work” • rare disorder – 1.5/1000 general population – 13% of those presenting for therapy • Physiological causes – SSRI – dopmanine agonists – spinal reflex abnormalities • Psychological causes – frustration/anxiety from previous incidents – childhood sexual abuse 15 Premature Ejaculation • Ejaculatory inevitability • Premature Ejaculation – ejaculation with minimal stimulation – before, upon, or shortly after penetration – taking into account: • age • novelty of partner – problem is persistent and recurrent 16 Premature Ejaculation • Prevalence • Causes: – Physiological • neurotransmitters (dopamine, serotonin) • touch sensation (Roland; Fanciullacci et al., 1988) • detecting ejaculatory inevitability (Kaplan, 1974) – Psychological • anxiety (only in acquired types; Cooper et al., 1993) • hostility 17 Premature Ejaculation • Treatment – Pharmaceutical • SSRIs • anti-anxiety • lidocaine – Psychological • pause-and-squeeze (Semens, 1956; Masters & Johnson) • mental imagery 18