Treating Erectile Dysfunction

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The Sexual Response Cycle

There are four phases in the sexual response cycle I. excitation, II. plateau, III. orgasm, and IV. resolution (Masters, Johnson, &Kolodny, 1994). In men, phase I (excitation) is characterized by erection of the penis. Phase I takes place more slowly in women and is characterized by the production of lubricating fluid in the vagina, an increase in the diameter of the clitoris, and increased congestion of the labia with blood. For both sexes, phase II (plateau) is marked by a rise in the blood congestion of the pelvis and a strong feeling of sexual tension. A sex flush colors the forehead, neck, and chest, sometimes extending to the abdominal area. Phase III (orgasm) occurs in two stages in men a preejaculatory contraction of the muscles involved in ejaculation, and actual ejaculation. The same muscles are involved in the orgasms of women as those of men. During phase IV (resolution), which is usually completed more quickly in men than in women, the congestion of the blood vessels that...

Sensitization of sexual responses

Regarding sensitization in the human, we are in a most unusual situation. The only experimental studies I know of were performed in women The purpose was not at all to study sensitization of sexual responses, but instead to determine the effects of activation of the sympathetic nervous system or the influence of anxiety on sexual arousal. The stimuli or actions employed for generating sympathetic activation and or anxiety were completely irrelevant as far as sex is concerned. Yet they were found to enhance responses to sexually relevant stimuli. This coincides perfectly with the definition of sensitization given earlier in this chapter. Thus, although the scientists performing the studies I soon will mention did not interpret their results in terms of learning, I will use their data as evidence in favor of sensi-tization of sexual responses. As it turns out, the role of sympathetic activation in sexual arousal in women has been evaluated more directly in a series of well-designed...

Sexual function and dysfunction

Dysfunction can be regarded as an opposite to or an absence of function. The easiest way to define dysfunctional sexual behaviors would then be to maintain that 'all sexual behaviors that are not functional are dysfunctional'. A disadvantage with this kind of extensional definition is that it tells us nothing about sexual dysfunction. It tells us what it is not but not what it is. An intentional definition could be 'the inability to obtain sexual reward through genital stimulation'. That definition would include many of the conditions classified as sexual dysfunctions in the diagnostic manuals. Others, like impotence, might be difficult to include under this definition. It is not impossible to obtain sexual reward without erection, but it is impossible to obtain it through penile-vaginal or penile-anal intercourse. Now, since these are only two of several motor patterns leading to sexual reward through genital stimulation, it is not obvious that the absence of these motor patterns...

Erectile dysfunction

Failure of normal erections occurs with advancing age and it is estimated that around 20 of men between 50 and 70 years of age have moderate or severe ED. The cause of this impotence may be psychogenic, but organic causes (such as diabetes, smoking and peripheral vascular disease) are more likely with increasing age. The mainstays of treatment are the phosphodiesterase type 5 (PDE 5) inhibitors, such as sildenafil, vardenafil and tadalafil. These drugs inhibit breakdown of cyclic guanosine monophosphate (cGMP), thereby enhancing the normal erectile response. They are effective in psychogenic and organic ED. Other modalities of treatment are occasionally necessary including intracaver-nosal prostaglandin E1 and intraurethral vasoactive drug therapy, and vacuum constriction devices. An uncommon side effect of drug therapy for ED is a prolonged erection lasting several hours (priapism), which may lead to ischaemic injury to the erectile tissue in the corporeal bodies. If priapism does...

Sexual Functioning

Of all the psychosocial domains affected by testicu-lar cancer and its treatment, sexual function, for understandable reasons, has been among the most frequently studied. Although findings generally indicate that sexual functioning is altered among survivors, careful consideration of this outcome is warranted. The reasons for altered sexual functioning among survivors are varied. Factors such as the physical sequelae of testicular cancer itself, treatment-related side effects, or psychological distress following treatment can affect sexual functioning.38 For example, retroperitoneal lymph node dissection (RPLND), a surgical procedure commonly used in the treatment of testicular cancer, involves the resection of retroperitoneal sympathetic nerves involved in semen emission.38 A common side effect of RPLND is dry ejaculation, which can negatively impact sexual functioning and satisfaction. Nondis-ease-related variables, such as age, physical or psychological comorbidity, and marital...

The Molecular Pathogenesis of Human Prostate Cancer

Prostate cancer (PCA) has become the most commonly diagnosed cancer among men in the USA, with an estimated 189,000 cases diagnosed in 2002 (1). Encouragingly, over the past several years, increased use of serum prostate-specific antigen (PSA) screening has increased the fraction of men diagnosed with PCA confined to the prostate gland, leading to more effective use of surgery and radiation therapy for treatment, and to a decline in PCA mortality (2, 3). Despite these improvements, some 30,200 men will likely died of progressive metastatic cancer in 2002 (1). Furthermore, even though men with early PCA can be cured using surgery or radiation therapy, the side effects of treatment frequently include erectile dysfunction, urinary incontinence, or rectal irritation (4-6). New insights into the etiology of PCA are needed so that new strategies for its prevention can be developed.

Reasons for Measuring Sexual Behavior

Sexual expression is a fundamental aspect of human relationships. While most research has focused on the problems, risks, and dangers of sex, there are a number of physiological and psychological benefits of sexual expression (Whipple, 2006). For example, frequent sexual activity increases fertility (Cutler et al, 1985), the probability of conception (Wilcox et al, 1995), and improves sexual functioning and satisfaction (Laumann et al, 2006 Parish et al, 2007). Benefits aside, consequences related to sexual activity (e.g., sexual coercion, HIV) may threaten an individual's ability to have satisfying sexual experiences. Accurate, reliable, and valid self-reports of sexual behavior provide essential information to assist researchers and interventionists in developing efficacious programs to improve sexual health.

Frequency Of Autonomic Dysfunction In Parkinsons Disease

Although the focus of routine follow-up visits between PD patients and neurologists is typically on motor symptoms of the disease, autonomic problems are frequently present and can be identified if patients are specifically asked. In one study of 48 men with PD, 89 had at least one autonomic symptom compared with 43 of elderly control subjects (2). Autonomic symptoms seen in these men with PD included erectile dysfunction (60 ), urinary urgency (46 ), constipation (44 ), dysphagia (23 ), and orthostatism (22 ), and each of these symptoms was more common in PD patients than controls. Siddiqui et al. (3) performed a comprehensive symptom survey of autonomic symptoms in 44 patients with PD, comparing the frequency and severity of these symptoms with 24 aged-matched controls. Using a five point scale to rate symptom severity, the authors tabulated the severity of symptoms in each of five areas GI, urinary, sexual dysfunction, cardiovascular, and thermoregulatory. They found that PD...

What should be clarified beforehand

Interactions are important in the choice of combination regimens. Whereas interactions between antiretroviral drugs are well known, interactions with other concomitant medications are often less well characterized (see Interactions ). The urgent need for more research was demonstrated in a study investigating the interactions between HAART and statins. In healthy volunteers, the measurement of plasma levels showed that levels of simvastatin were elevated by 3.059 after concurrent dosing with ritonavir or saquinavir (Fichtenbaum 2002). One fatal rhab-domyolysis on simvastatin and nelfinavir has been described (Hare 2002). Many drugs should not be combined with particular antiretroviral drugs, as incalculable interactions may occur. These include certain contraceptives. Even drugs that seem unproblematic at first glance can have unfavorable effects for example, the plasma levels of saquinavir can be reduced by half due to concurrent administration of garlic capsules (Piscitelli 2002)....

Enhanced genital blood flow

During the discussion of non-human sexual incentives, I mentioned an example of a visceral reaction provoked by an incentive, penile erection in the rat and monkey. We learned that rats enhance the frequency of spontaneous erection in response to odors from a distant female. However, this visceral reaction is not a constant response to an incentive stimulus, because we also learned that during actual cop-ulatory activity, erection in rats is not continuous but associated with mounting. The female odor, however, can be expected to be present with almost constant intensity throughout the copulatory interaction. Female odor cannot, therefore, be the stimulus controlling erection during copulatory encounters. Furthermore, the visceral response of erection does not occur in anticipation of a mount, for example during pursuit of the female, but during the initial stages of mounting when physical contact with the female has already been established. It appears, then, that erection in...

Sexual incentive properties of odors

Would chose the scented chair more than the others, particularly since their sexual arousal previously had been enhanced by the fantasies. The data revealed that the androstenone chair was not chosen more than the other chairs regardless of whether the subjects were sexually aroused or not (Pause, 2004). Again, the conclusion must be that the steroid does not have any sexual incentive properties. Most humans are able to smell androstenol and androstenone (Gower and Ruparelia, 1993), so the failure to find an effect cannot be due to sensory incapacity. There are many additional curious studies of the influence of chemicals on human behavior and even on sexual functions, but none of them is of any relevance to the problem of olfactory sexual incentives, or the role of pheromones for human sexuality. Nevertheless, I will mention one of these studies as a kind of entertainment. The scientists spent five weeks observing the choice of stalls in a rest-room for men and in another for women....

Nitric Oxide and Carbon Monoxide as Neurotransmitters

In the PNS, nitric oxide is released by some neurons that innervate the gastrointestinal tract, penis, respiratory passages, and cerebral blood vessels. These are autonomic neurons that cause smooth muscle relaxation in their target organs. This can produce, for example, the engorgement of the spongy tissue of the penis with blood. In fact, scientists now believe that erection of the penis results from the action of nitric oxide, and indeed the drug Viagra works by increasing this action of nitric oxide (as described in chapter 20 see fig. 20.23). Nitric oxide is also released as a neurotransmitter in the brain, and has been implicated in the processes of learning and memory. This will be discussed in more detail later in this chapter.

The role of aromatization in men

Although the total number of men having participated in the studies outlined in the preceding paragraphs is rather small, the consistent results inspire some confidence. It does not seem too adventurous to propose that aromatization, and hence estrogen receptors, are not of any crucial importance for human male sexual behavior. In that way, humans may be different from rats and some strains of mice. At the same time, there is a curious report describing a man who had been castrated bilaterally because of severe post-vasectomy orchialgia. He maintained an adequate sexual functioning with a combined treatment of estrogens + progesterone. In fact, this regimen seemed more effective than treatment with testosterone enanthate (Davidson et al., 1983). The significance of this single individual should not be overestimated, but some additional data suggest that estradiol may contribute to the maintenance of sexual functioning in men who have been castrated because of prostate cancer (Ellis...

Studies on men with spontaneous gene deletions

There is one report of a man lacking a functional estrogen receptor because of a premature stop codon in exon 2 of the estrogen receptor gene (Smith et al., 1994). This man showed no response to administration of estradiol despite a large increase in blood estradiol concentration. The patient had normal male genitalia with bilateral descended testes, each with a volume of 20-25 ml, and a normal-sized prostate gland. Semen analysis showed a reduced sperm motility (viability of 18 against around 50 in normal men) with a normal sperm count of 25 million per millilitre. He indicated strong heterosexual interests and reported normal sexual functioning, including presence of morning erections and nocturnal emissions. From the clinical data reported, it is quite evident that the man lacked the estrogen receptor a. Although data from a single case study are far from sufficient for any firm conclusion, the evident lack of alterations of sexual behaviors in this man is remarkably different from...

Products Available

There are also available fresh, freeze-dried, and liquid alcoholic extracts, which come in a variety of forms including tablets, capsules, lozenges, liquids, teas, and salves. A good number of these products are combined with other herbs such as ginseng, goldenseal, and various other supplements to enhance the efficacy of Echinacea.

Reduced Representation Sequencing

The sequencing of BAC ends within the context of genome survey has been described for at least ginseng (Hong et al. 2004), soybean (Marek et al. 2001) and maize (Gardiner et al. 2004). The deep sequencing of BAC ends only really becomes appropriate once a whole genome sequencing strategy has been adopted, but nevertheless there remain significant Genome Survey Sequence (GSS) resources in the public domain.

Effects of other brain lesions on male sexual behavior

Nucleus of the hypothalamus and the main olfactory bulb, as we have already seen. Some are effective only in animals without sexual experience, some affect one aspect of sexual function but not others, some are significant in one study but not in another, and so on. Results from these kinds of studies show that male sexual behavior is sensitive to events in the brain, but they do not provide any solid fundament for useful hypotheses concerning the central nervous control of sex behavior. If someone should be interested in the huge lesion literature, there is a very extensive review that I can recommend (Hull et al., 2002).

Indirect estimations of nervous activity in association with sexual behavior

We have seen many examples of the usefulness of studying changes in genital blood flow in response to sexual incentives. Instead of that, some researchers have preferred to study changes in blood flow in the brain during exposure to such incentives. Changes in blood flow or in the oxygenation levels of hemoglobin are supposed to depend on altered nervous activity. In the marmoset, exposure to the odor of periovulatory females increased the signal from the preoptic area and the anterior hypothalamus more than exposure to the odor of ovariectomized females did. Furthermore, while the response to the periovulatory female odor outlasted the presence of the odor, the small response to the odor of ovariectomized female disappeared as soon as the odor was withdrawn (Ferris et al., 2001). This study confirms that the preoptic area is activated by sexually relevant stimuli. Data from the human, strangely enough, do not systematically do so. Young men watching a pornographic movie while inside...

Significance to humans

Atelidae are represented in the art and legends of the people they live nearby. Their large body size and social habits have probably always made them a source of prized meat. The large testes of Brachyteles were associated with sexual potency, and made into purses by hunters.

Studies in nonhuman mammals

Despite the notion that sexual acts are aversive to females, the possibility that sexual interaction with a male is reinforcing was evaluated in a quite elegant experiment. A straight runway was used. In the goal box, a sexually active or an inactive male appeared on the female's arrival. Some ovariectomized females were tested when sexually receptive because of hormone treatment and others were not given hormones and were consequently non-receptive. In the goal box, the females were removed either after the first sexual response on part of the male, be it mount, intromission or ejaculation, or after 10 seconds if no sexual interaction occurred. The elegance of this experiment resides in the fact that there was an intertrial interval of 10 minutes. As might be recalled, the aversive consequences of sexual interaction, even of receiving an ejaculation, dissipates spontaneously in a time far less than 10 minutes. Thus, in this experiment the females were never tested during the period...

Materials and Methods

This study was an open-label, historically controlled, single center phase IIa study in which men diagnosed with HG PIN were treated with 60 mg day oftoremifene for 120 days. The study primary objectives were to determine whether toremifene was able to reduce HG PIN in men with HG PIN, to evaluate its effect on other intermediate endpoints including serum total PSA and free PSA, as well as its safety and impact on male hormonal status. The effects of toremifene on quality of life issues, i.e., changes in libido, erectile function, and hot flashes were also assessed. Once informed consent was obtained, subjects were referred to the study if any prostate biopsy within the last 6 mo had HG PIN (at least 6 prostate cores were needed to be included in the study). The prostate pathology was re-evaluated to confirm HG PIN. Subjects who had HG PIN and fulfilled all of the eligibility requirements were enrolled in the study. At study day 120, subjects underwent transrectal...

Primary hyperaldosteronism Conns syndrome

In patients who are on a large dose or who experience side effects of the drug, such as impotence, gynaecomastia, hypotension and weakness due to hypokalaemia, surgery is indicated. Since these tumours are normally unilateral and small, laparoscopic adrenalectomy is the treatment of choice. Total adrenalectomy is normally performed rather than simple extirpation of the tumour from the gland.

Range of biomarkers used to investigate health benefits

There are presently available a number of validated tools for measuring health status (Nottingham Health Profile, Hunt et al., 1985), activities of daily living Physical Self Perception Profile (Fox and Corbin, 1989 Fox, 1990) , and quality of life (QOL) MOS General Health Status Questionnaire 36-SF (Ware and Sherbourne, 1992) . Quality of life incorporates the individual's perceptions of health and functional status and is reflective of the perception of his or her health. Its measurement incorporates psychosocial (e.g., daily function, recreation, sexual function, etc.) (see below) as well as physiological (e.g., blood pressure, weight) factors. It is important to point out that the validation of the measure rests with the individual. Several standardized instruments to measure QOL are available including single-item global measures or multi-item health measures generic measures or condition specific measures. Other clinical measures might also be useful although they do not...

The concept of homosexual behavior a source of much confusion

Preference for having sex with partners of one's own sex is called homosexuality in contemporary society. It becomes immediately urgent to differentiate this preference from a strange concept frequently used in both the scientific and the lay literature, namely the concept of homosexual behavior. If we look at the behaviors in humans preferring to have sex with their own sex, so to say, we find that many of these behaviors are exactly the same as those displayed in sexual activities with the opposite sex. For example, many men have anal intercourse with their female partners (20-50 of 'heterosexuals' according to surveys such as those conducted by Kinsey et al. (1948, 1953) and by Laumann et al. (1994)), while others have it with their male partners, and some with both. Independently of the partner's sex, the behavior consisting of insertion of the erect penis into the rectum through the anus is always the same. We cannot call this behavior homosexual. It is simply sexual. be...

Adverse Effects and Toxicity

Clinical studies have reported very few adverse effects that are of a mild nature (usually gastric distress or headache) following saw palmetto administration at normal doses. One randomized, double-blind study of finasteride, tamsulosin, and saw palmetto for 3 months observed no differences among the three treatments in terms of the effectiveness measures and no change in sexual function in those individuals receiving saw palmetto, though ejaculation disorders were noted as the most common side effect in those individuals receiving either tamsulosin or finasteride (26).

Information from Human Studies

Due to the powerful multisystem effects linked to oxytocin and vasopressin in regard to social phenomena, intervention research examining effects of increases in oxytocin in humans has recently burgeoned, including studies linking oxytocin to increased interpersonal trust, greater recognition of faces and decreased fear (Meyer-Lindenberg, 2008). For example, Ditzen and colleagues (2009) compared effects of intranasal oxytocin versus placebo in couples during conflict discussion, finding that oxytocin reduced cortisol and increased positive communication. Zak and colleagues observed that intranasal oxytocin increased experimentally assessed trust, reciprocity, and generosity behaviors (assessed by monetary transfer to strangers), and they also found that exposure to either deep massage or empathy-evoking film clips likewise increased both circulating oxytocin levels and such reciprocating or generous money sharing (Barrazza and Zak, 2009 Morhenn et al, 2008 Zak et al, 2007). As...

Conclusions and Future Directions

In summary, the function of physiological systems and behaviors influenced by oxytocin and vasopressin are important to major health outcomes. They are also important to some of the things that we as humans value most attachment to family, friends, and other members of our social groups, desire for physical closeness, childbirth and parenting, and sexual response. We anticipate that in the next few years, there will be accelerating interest in human oxy-tocin and vasopressin research. In particular, we expect that there will be expanded research employing salivary and urinary oxytocin and vasopressin sampling, especially for studies in the home environment where obtaining blood for plasma measures is impractical. Although there is some skepticism about the validity of salivary oxytocin (Horvat-Gordon et al, 2005), a new study indicates that in mothers of infants, salivary and plasma oxytocin measures showed parallel increases and decreases during infant feeding, cuddling, rests, and...

Another confusing concept sexually dimorphic behaviors

A point that must be taken into consideration, even if the only purpose is to reject it, is the fact that popular, and frequently not so popular, beliefs maintain that some sexual behaviors are sexually dimorphic in both the human and other animals. There is, indeed, one sexual behavior that we must accept not only as typical of one sex but also as possible only for one sex. I am referring to a class of behaviors usually called penetrative sex and within that class to the acts of the penetrator. The act of sexual penetration requires an erect penis on the part of the penetrator and only men and other males are properly equipped for displaying that kind of behavior pattern. If we exclude women employing plastic surrogates for penetrating other women or men, we need to conclude that the penetrator, or inserter as some like it, is always a male. However, the human male can easily penetrate other males, so being the penetrated, or the insertee as some like it, is not a

Sources and Chemical Composition

Korean ginseng, Asian ginseng, Oriental ginseng, Chinese ginseng (7), Japanese ginseng, American ginseng (8). Note that the term ginseng can refer to the species of the genus Panax, as well as to Eleutherococcus senticosus (Siberian or Russian ginseng) (8). Unless otherwise noted, the information in this monograph refers specifically to species of the genus Panax. Depending on the particular botanical reference, there are three to six different species of Panax ginseng, and three with purported medicinal benefits P. ginseng (Chinese or Korean ginseng), Panaxpseudoginseng (Japanese ginseng), and Panax quinquefolium (American ginseng) (8). In this chapter, the term Panax ginseng will be used to refer to these species, and Siberian ginseng will be used to refer to E. senticosus. The chemical composition of Siberian ginseng differs from that of P. ginseng (8) thus, the distinction between the two is important in a discussion of therapeutic and adverse effects.

Drug Interactions

A probable interaction between warfarin and apanax ginseng product has been reported (13). A 47-year-old man with a St. Jude-type mechanical aortic valve had been controlled on warfarin with an international normalized ratio (INR) of 3.1 (goal 2.5-3.5). He experienced a subtherapeutic INR of 1.5 following 2 weeks of ginseng administration (Ginsana three times daily). Other medications included 30 mg of diltiazem three times daily, nitroglycerin as needed, and 500 mg of salsalate three times daily as needed. He had been on all of these medications for at least 3 years before the abrupt change in his INR. Discontinuation of ginseng resulted in an increase in INR to 3.3 within 2 weeks. In this regard, a randomized, double-blind, placebo-controlled trial was undertaken to study the effects of ginseng on warfarin and INR (70). Coadministration of ginseng statistically significantly reduced the INR by -0.19 (95 confidence interval, -0.36 to -0.07) as well as reduced the INR area under the...

Longterm Effects Of Cancer Diagnosis And Treatment On Survivors Family Members

The literature on the effect of cancer diagnosis and treatment on family members is sparse.74 Of studies in this area, most have focused on the impact of cancer soon after diagnosis, during recurrence, or at the terminal phase of the disease.75-77 One study shows that partners of men with prostate cancer, generally from small convenience samples, report more distress than their sick partners, but also believe that their partners are more distressed. The only reviewed study of long-term prostate cancer survivors found that couples' health-related QOL was associated with marital satisfaction.61 Distress was inversely related to levels of family support. The men's focus of concern, on their sexual functioning (i.e., impotence), was not shared to an equal degree by their non-sick partners.78,79 The most relevant study included

Reproductive biology

Growls, and staccato whimpering sounds. If courtship ensues, the male vocalizes with a string of whimpering notes that he may segue into singing lasting up to two minutes. As the two approach each other more closely, they touch noses, sniff genitals, and begin an elaborate contact ritual that looks like a combination of dancing and wrestling. The two stand bipedally, grappling, and interlocking their incisors. Courtship moves may include ritual head-tosses and dancing, ending at last with mounting. The male's forelegs tremble as he approaches the female, a common courtship ritual in rodents. Males may also approach bipedally, with an erect penis.

Directions For Future Research

What little research that has been done has focused on the time of the initiation of treatment, at the time of recurrence, or during the terminal phase of the disease.77 All three of the cancer sites reviewed can impact partners of a survivor, but at present there are very few studies on how couples overcome this challenge. In our review, several studies found major changes in sexual functioning even after 5 years after diagnosis. Only few have looked at interventions that can help the couples to deal with this experience.92-94 Men and women treated for Hodgkin's disease as well as younger women treated for breast cancer may have to cope with infertility. More research should be focused on the impact of cancer survivorship on family members. Interventions for family members who are at higher risk for getting cancer should be a priority as well as interventions to improve family resilience for persons at higher risk for poorer outcomes such as families in which...

Homosexual behaviors a lesson from history and some observational data pertinent to the issues of classification and

Most of the toilet visitors stopped by on the way to or from work. According to a strict and silent ritual they demonstrated their willingness to have sex by displaying a full erection while standing at the pissoir. When they had received signals of acceptance from another man, both disappeared into one of the stalls. There fellatio was performed and, immediately afterwards, both men left without a word. Sodomy was exceptional. Many intricate details of the interactions in the toilet are described in the book, but they are not necessary for our present purpose. What is more interesting, though, are the data obtained during the home visits. It turned out that a substantial proportion of the men were married and had children. Some had mistresses. The reason they frequently gave for visiting the toilet and having oral sex there was that they needed an ephemeral distraction or wanted sexual activity in addition to that obtained in their current relationship, without much expense of money...

Therapy for sexual dysfunction General overview

Phosphodiesterase 5 inhibitors (PDE-5 inhibitors sildenafil, vardenafil, tadalafil) have substantially improved the therapy of ED. They are simple to take, effective and, in general, relatively well tolerated. However, with the exception of a few private insurance companies, PDE-5 inhibitors are not covered by insurance plans. and so must be paid for by the patients themselves. With the introduction of PDE-5 inhibitors, intra-cavernous erectile tissue injection or the intra-urethral application of vasoactive prostaglandins has clearly receded into the background. Today, surgical interventions, such as penile vein surgery, revascularization surgery or prosthodon-tics, also no longer play a role. tient. In particular, for patients using a boosted PI regimen PDE-5 inhibitors need to be started at a lower dose. We specifically recommend a mini test dose at the beginning (e.g., 1 4 of a tablet of sildenafil 50 mg) and increase according to the success and side effects. Our experience...

Shrinking Of The World

Physical movement also is restricted as the environment shrinks. Contrary to the dictates of human health requirements, older persons become more sedentary and engage in less exercise. Part of this reduced physical activity results from reduced participation in the environment because of physical or environmental barriers. Environmental barriers can include the structure of the home, its layout, and the presence of stairs. Storage spaces and appliances may be difficult to access or use, thus cutting back on the person's activity. Shrinkage of the environment due to the nature of the environment itself means that there is a lack of fit between the person and the environment. Such a lack of consonance means that the person is less stimulated by the environment and finds it to be more of a frustration. Increasingly, drawing away from the environment and curtailing their ability to manipulate the environment to their own best advantage results in persons losing control of their lives and,...

Spinal cord compression

Neurological dysfunction of the bladder (the neurogenic bladder) is particularly important to recognize. In the early phases, there is failure fully to empty the bladder such that the bladder enlarges, eventually building up back pressure on the ureters and kidneys. Finally, the patient goes into urinary retention which is often painless due the involvement of the sensory pathways. In the male, neurogenic bladder is accompanied by failure of penile erection and ejaculation.

Bladder Bowel and Sexual Disturbances

Sexual symptoms are also common among MS patients. Men most often experience erectile dysfunction, but may also suffer from problems with ejaculation (135,144). These symptoms typically accompany abnormal micturition. Women most typically experience difficulty in achieving orgasm, but may also complain of problems with lubrication (145). Both men and women may also complain of diminished libido. In contrast, a recent case of episodic hyperlibidinism has been reported (146).

Other Special Situations

The second problem with glaucoma medications in younger patients is a greater frequency of, or sensitivity to, psychological and sexual side effects. These can include depression, anxiety, confusion, sleep disturbances, drowsiness, weakness, fatigue, memory loss, disorientation, emotional lability, loss of libido, and impotence. Central nervous system side effects of CAIs have been primarily associated with their systemic use and can be described as a complex consisting of general malaise, fatigue, weight loss, depression, anorexia, and loss of libido. Once again, careful instruction on nasolacrimal occlusion can result in reduced dosages of medications and decreased systemic absorption. This is especially important when topical medications are prescribed for pregnant or lactating women.

Pharmacological treatments Hormones

Effectiveness of this treatment is not surprising. We learned already in Chapter 5 that adequate functioning of the central motive state requires stimulation of androgen receptors in the brain and that this stimulation is insufficient in men with very low blood androgen concentrations, as is the case in hypogonadal men. However, since it is quite likely that most men suffering from hypoactive sexual desire disorder have blood testosterone concentrations within the normal range, it is not evident that they would benefit from treatment with testosterone. Nevertheless, it would be interesting to have empirical data with regard to the effects of supplementary testosterone in such men. It seems that most clinicians regard the possibility of such an effect remote, at least too remote for trying treatments with androgen. There is, to my knowledge, no study of the effects of testosterone treatment in men diagnosed with hypoactive sexual desire disorder. In eugonadal men suffering from...

Clinical features and epidemiology

Cases and are therefore classified as such rather than a ''unipolar mania''). In order to fulfill current criteria for depression (WHO, 1992 American Psychiatric Association, 1994) an episode must last at least two weeks but in practice most episodes last longer. In addition to low mood and low energy levels, other typical symptoms include anhedonia (the inability to enjoy), loss of self esteem, suicidal ideation, guilt and hopelessness. Biological symptoms are common such as disturbances of sleep, appetite, weight and sexual function. In mania the mood by contrast is one of elation (although irritability is also common). This is typically accompanied by racing thoughts, rapid speech, reckless overactivity, social and sexual disinhibition and overspending, sometimes to a ruinous level. There is almost always a reduced need for sleep and there are frequently expansive and grandiose ideas such as being in possession of special powers or abilities or of having become suddenly rich or...

Intracellular RNA Processing and Turnover

Moiseyev et al. (55, 56) have isolated, characterized and sequenced two plant ribonucleases isolated from ginseng calluses. These enzymes, with polypeptide lengths of 150 residues, are homologous with cyto-toxic intracellular pathogenesis-related proteins (IPR or PR-10) from several plants such as parsley (57) and bean (58), and with pollen allergens from tree species such as birch (59) and alder (60). This suggests that the cytotoxic properties of these latter proteins are caused by their ribonuclease activities. However, this hypothesis is still being met with skepticism. In addition, this protein family does not contain any conserved histidine residues, a universal active-site residue in all other investigated ribonuclease families so far investigated.

Triangular Test And Further Work

The triangular test has now been used in a wide variety of clinical studies concerned with many therapeutic areas. Examples include trials of corticosteroids for AIDS-induced pneumonia (41), of enoxaparin for prevention of deep vein thrombosis resulting from hip replacement surgery (42), of isradipine for the acute treatment of stroke (43), and of implanted defibrillators in coronary heart disease (44). In pediatric medicine, the triangular design has been used to study the use of surfactant to alleviate respiratory distress in infants (45) and in a trial concerning gastrointestinal reflux (46). An evaluation of the drug Viagra in the treatment of erectile dysfunction after spinal injury also used the method (47), and it has been implemented in animal studies of medical techniques (48). An interesting combination of the triangular test with the play-the-winner rule was applied in a study of spinal anesthesia during cesarean section (49). Within oncology, besides the renal and lung...

Diagnostic criteria and general description

Most exhibitionists get an erection and some masturbate when exposing themselves. They are said to achieve an intense experience of sexual satisfaction. Others do not show any genital response and have no conscious experience of satisfaction. A particular individual may show the first kind of behavior on some occasions and the second kind on others. A common feature of most, if not all, exhibitionists is that the reaction of the woman or women to whom they expose is crucial. An old study (Ellis, 1933) describes three principal reactions

Male And Female Brains Are Different

Many of the sex differences seen in the brain manifest themselves in a variety of ways, such as sizes of particular regions of the brain, number of nerve cells in specific regions, distribution of neurotransmitters, and even development of behavior (Goldstein et al., 2001 Hutchinson, 1997 Segovia et al., 1999). In humans, for instance, there are region-specific dimorphisms, with some structures larger in females (caudate nucleus, hippocampus, Broca's area, anterior commissure, and right parietal lobe) and some larger in males (hypothalamus, stria terminalis, and amygdala) (Goldstein et al., 2001). In rodents, numerous sexually dimorphic nuclei have been studied, the following two perhaps most extensively. One is the sexually dimorphic nucleus of the preoptic area (SDN-POA), which is larger in males than females, and another is the anteroventral periventricular nucleus (AVPv), which is larger in females than males (Davis et al., 1995 Gorski et al., 1980 Simerly et al., 1988). Sex...

Combined Androgen Ablation

Trials evaluating the effect of newer non-steroidal antiandrogens, such as biclutamide, in combination with or compared to castration are needed. Biclutamide is better tolerated than flutamide89 and has similar efficacy when combined with castration. A randomized trial of 813 patients with metastatic prostate cancer compared LHRH agonist with either flutamide or biclutamide and found no difference in efficacy or outcome but did not evaluate QOL differences between the two arms.90 Early evidence suggested that standard doses of biclutamide (50 milligrams per day) alone may be less effective than medical or surgical castration. However, high-dose biclutamide (150 milligrams per day) may provide equivalent cancer control with less diminution in QOL particularly with regard to sexual function.45,91-93 In an Italian Prostate Cancer Project study,46 2 20 patients with stage C or D prostate cancer were randomly allocated to receive either biclutamide monotherapy (150 milligrams per day) or...

Diagnostic criteria epidemiology and general description

Some have argued that fetishism should not be considered a disorder at all (Reiersol and Skeid, 2006). The fact of becoming sexually aroused in response to unusual stimuli is a private matter, particularly since fetishism, as defined in the DSM-IV, does not involve any human except the fetishist himself (like exhibitionism, fetishism is most unusual in women). A reason for continuing to consider it a disorder could be that fetishism may cause personal distress and or occupational and other problems, as mentioned in the second criterion. However, there are innumerable private events causing distress and occupational problems lasting more than 6 months for which there is no diagnostic category. My prediction is that fetishism has a rather short life-expectancy as a diagnostic category. It will probably soon follow the category of homosexuality into the history of arbitrary diagnoses.

Side Effects Of Hormonal Therapy Similarities And Differences

Hormonal therapy for prostate cancer eventually produces decreases in libido and potency in virtually all patients regardless of the modality used.34,124 Additional side effects include lethargy, depression, anorexia, breast swelling with or without tenderness, hot flashes, anemia, and osteoporosis with potential for pathological fracture.14,125-130 Most side effects, including impotence and infertility, are slowly reversible with cessation of therapy. However, reduced bone mineral density often does not reverse after prolonged hormonal suppression. There is a consensus that irreversible changes occur more often after suppression of longer than 18-24 months.

Etiology and epidemiology

It seems most unlikely that the causes for the attraction to children or adolescents are to be found in factors unrelated to sexuality. Instead, I suggest that children, for some reason or another, have acquired sexual incentive properties for those expressing pedophilic behavior while they do not have such properties for others. Adult individuals, of the same or of the opposite sex, are also sexual incentives for the pedophile exactly as they are for almost everyone else. This simple suggestion can easily be subjected to experimental test. We could, for example, expose pedophiles to pornographic movies depicting sexual interaction between adults. To these movies, the pedophiles should show exactly the same response as non-pedophiles, that is an erection. Both groups could then be exposed to a pornographic movie depicting sexual interactions between a child and an adult. In this case, we would predict that the pedophile would respond with erection whereas the non-pedophile would not....

Psychosocial Factors and Disease Progression

There is growing evidence suggesting that among cancer patients, psychosocial (e.g., appraisals, coping, social support, depression) and physiological (e.g., neuroendocrine function, immunologic status) factors may mediate relations among distress, QOL, and physical health status following a cancer diagnosis. These psychosocial factors have also been related to adjustment and disease management. For example, greater optimism, active coping styles (e.g., fighting spirit , planning, positive reframing), accurate stressor appraisals, positive growth, and efficacious social networks have been significantly associated with positive adjustment at various stages of the disease (i.e., diagnosis, treatment, and survivorship) in various cancers (e.g., Cruess et al, 2000). In prostate cancer, for example, greater social support from a spouse and family or friends has been associated with higher general and disease-specific QOL (e.g., urinary function), while greater self-efficacy has been...

Psychosocial Interventions Optimizing Health Survival and Improving Quality of Life

In work targeting prostate cancer survivors about 1-year post-treatment, Penedo and colleagues (2006) adapted a CBSM intervention to be delivered among men who had been treated with radical prostatectomy or radiation therapy for localized disease. Men were randomized either into a group-based 10-week CBSM intervention that targeted areas such as coping and communication skills, social support and relaxation training, and provided health information related to prostate cancer and sexual functioning or a 1-day stress management seminar where the techniques covered in the intervention were provided in a classroom format with no group process. Findings showed that relative to men randomized to the 1-day seminar, patients in the CBSM condition showed significant improvements in QOL and benefit finding. Additionally, the acquisition of stress management skills (e.g., mobilizing social networks, ability to cognitively reframe negative stressor appraisals or engage in relaxation training)...

Sexual motivation theoretical framework

Tail Withdrawal Rat

When there is an active central motive state and an appropriate stimulus, behavior is usually activated. As always, behavior is activity in skeletal muscles. This means that the incentive stimulus impinging on the active central motive state in the end must activate motor neurons. The process could be conceived as a kind of automatism where efferent stimulation excites the central motive state which, in turn, excites motor neurons, in the same way as a sensory neuron excites a motor neuron in a reflex arch. In motivated behavior, large amounts of sensory neurons, perhaps from several modalities, vastly distributed in the brain, may connect to large numbers of motor neurons, vastly distributed in the brain. These connections might involve several short interneurons and perhaps also longer projection neurons. Both kinds of neurons may be modulated by the central motive state, making the connection between sensory input and organized motor output either impossible or possible with...

Damon J Vidrine DrPh Ellen R Gritz PhD

Because of the young age at diagnosis and the extremely high survival rates following testicular cancer treatment, survivorship issues become tremendously important. Young men are most frequently diagnosed at or near the prime of life a time during which patients are establishing professional careers and planning families. While mortality may no longer pose the risk it did in earlier years, other important outcomes should be considered. These outcomes include toxicity of treatment, disease-related functioning (eg, body image, sexual functioning, and fertility), and overall quality of life (QOL). A better understanding of these outcomes and how they are influenced by each treatment modality (or combination of modalities) is vital for both physician and patient. Such an understanding will allow for the selection of the most appropriate treatment regimen as well as the early implementation of interventions that have the potential to minimize disease and or treatment-related impairment.

The high cost of the imposed association between sexual behavior and reproduction

Sexual activity among lesbians and gays as well as that of menopausal women becomes illegitimate as a result of the obligatory association between sex and reproduction. A corollary of this principle is that only penile-vaginal penetration is a morally and biologically acceptable sex behavior. Indeed, social learning has convinced most humans that this sexual activity not only is morally superior to other sexual activities, but also that the satisfaction it produces is superior to that offered by any other sexual activity. Both these notions contribute to deprive several human groups besides gays, lesbians and menopausal women of sexuality. One such group is men suffering from impotence. They could easily satisfy their female partners with masturbation or cunnilingus and their male partners with masturbation and fellatio. They could receive sexual satisfaction by being masturbated or fellated. Both activities can easily induce ejaculation orgasm in the absence of erection. In fact,...

A curious observation of some consequence

An ancient study of sexual arousal in men suffering from low desire, impotence, or premature or retarded ejaculation yielded results somewhat different from those mentioned in the preceding paragraph. The penile response to a pornographic audiotape was smaller in the patient group than in healthy controls of about the same age (Heiman and Rowland, 1983). The interest of this observation in the context of disorders of sexual desire is limited, since more than half of the participating men complained of impotence. The responses of the two subjects with low desire probably disappeared among those of the nine impotent men. I mention this study only because it is all we have with regard to men. By doing so I expect to avoid all possible accusations for promoting sexual inequality.

Copulatory behavior in men and women

Stages Coital

When erection and vaginal lubrication have been obtained, the third stage of sexual interaction, coitus, may begin. This stage starts with the insertion of the penis into the vagina, reaches culmination in the ejaculation of semen and in the orgasm in both partners, and finally ends with penile withdrawal. The 'sexual tension' increases stepwise from the introduction of the penis until orgasm in both the man and the woman. van de Velde illustrates the degree of 'sexual tension' in a series of figures, which 40 years later were employed by Masters and Johnson (1966) in their important book on human sexuality. It was not until the early 1950s that scientists began to observe human copula-tory behavior in a laboratory setting. The groundbreaking work performed at Washington University by William Masters and Virginia Johnson from 1954 until the early 1960s is still unsurpassed in quantity and probably also in quality. In their classical description of human copulatory behavior, Masters...

Risk factors diseases and comorbidities

Other possible risk factors are endocrine disorders, various neurological problems (i.e. disc prolapse) or infectious diseases. Frequent causes of ED in young men are chronic kidney or liver dysfunction (hepatitis, cirrhosis). Psychosocial problems, relationship conflicts and psychiatric illnesses (e.g., depression) are frequently related to sexual dysfunction. As a consequence, HIV patients have an increased risk for erectile dysfunction. Table 1 Substances Substance classes which may cause Erectile Dysfunction

The importance of testicular hormones in men

They were normally offered a penalty rebate if they accepted castration. This practice was considered inhumane in many societies and castration is almost never performed anymore. In Norway, the procedure may still be legally performed after demand by the individual and approval by a committee, but no demand for castration has been presented since 1974. The situation is probably similar in many other countries. During the first half of the last century, though, castration of sexual offenders was regularly performed in Europe and some scientists profited from this to evaluate sexual behavior in these long-term castrates. It should be noted that all these castrations were performed post-pubertally. Thus, we do not know what the effects of prepubertal castration might be. Data from studies of castrated men in several European countries are unequivocal in the way that they all show that the intensity of sexual behaviors, including sexual dreams and fantasies, was much reduced (e.g....

Overall Quality Of Life

Specific dimensions would consider distress that was due to treatment side effects (eg, ototoxicity, nephrotoxicity, and Raynaud's phenomenon), as well as fertility concerns and sexual functioning. Unfortunately, such a measure with good psychometric properties is not yet widely available.

Psychopharmacological treatments

Men A group of men suffering from impotence was treated with the a2-adrenergic antagonist yohimbine for 8 weeks. The drug was given orally in a dose of 30 mg per day. Before and during the treatment period, the men recorded several aspects of sexuality in a diary and at the end of treatment they participated in an interview. Although the main purpose of this double-blind drug trial was to evaluate the effects of yohimbine on erection, data with regard to sexual desire were also obtained. Yohimbine had no effect on desire (Vogt et al., 1997). This study is not particularly relevant to the issue of drug treatment of masculine hypoactive sexual desire disorder, since none of the participants was diagnosed with it. Furthermore, apomorphine or to placebo. Now the pill should be taken once every afternoon regardless of whether they had planned to have sex or not. The results from the first phase showed that apomorphine was ineffective with regard to desire and arousal, while having some...

The relationship between sexual desire motivation and excitation arousal

The most important is that lack of enhanced genital blood flow in some situations is a rather common clinical problem. In men, it leads to erectile dysfunction, a condition called impotence in ordinary language. Impotence has been of much concern to medical practitioners for many years and much basic research concerning the physiological mechanisms of erection has been prompted by this interest. Concepts like motivation do not form part of a physiologist's conceptual framework and is rarely, if ever, mentioned in their analyses of erectile mechanisms. Although motivation is of no concern to the physiologist, she he needs to have some idea of the stimuli that activate the physiological response under scrutiny. The clinicians, for their part, need some reliable diagnostic procedure for determining the severity and or the characteristics of the erectile dysfunction in their patients. A standard procedure is to expose the patients to some kind of erotic stimulus, like a pornographic...

Potential endocrine causes of hypoactive sexual desire disorder

The last few studies mentioned above coincided in reporting reduced androgen concentrations in women with low desire. They also coincided in sloppy descriptions of the diagnostic criteria used for considering a woman as suffering from low sexual desire. All we are told is that their chief complaint was decreased sexual desire. In the Turna et al. (2005) study, we are also told that the women had presented symptoms for at least 6 months. Moreover, all subjects participating in that study answered the Female Sexual Function Index. Results revealed a significant difference between patients and controls, suggesting that there indeed was a difference between patients and controls with regard to sexual desire. Nevertheless, in none of the latter studies mentioned here was the diagnosis based on the criteria given in the DSM-IV or ICD-10. Among other things, we do not know if the patients suffered from acquired or life-long hypoactive sexual desire. This could be of some importance,...

Pharmacological Toxicological Effects 51 Endocrine Effects

P. ginseng may exert hypoglycemic effects possibly by accelerating hepatic lipogenesis and increasing glycogen storage (16-18). In a study of 36 newly diagnosed patients with type II diabetes, ginseng at a dose of 200 mg daily exerted a statistically significant benefit on glycosylated hemoglobin (HbA1c) compared to 100 mg of ginseng daily or placebo after 8 weeks of therapy, and patients receiving 100 mg of ginseng had smaller mean fasting blood glucose levels than patients taking 200 mg of ginseng or placebo (18). The actual difference among the mean HbA1c in the three groups was small the 200-mg ginseng group had a mean glycosylated hemoglobin of 6 vs 6.5 for the 100-mg ginseng and placebo groups. Likewise, the actual difference among mean fasting blood glucose in the three groups was small the mean fasting blood glucose was 7.7 mmol L for the 100-mg ginseng group, 7.4 mmol L for the 200-mg ginseng group, and 8.3 mmol L for the placebo group at the end of the study. The observed...

Visual incentive stimuli

The waist to hip ratio in addition to the traditional breasts and buttocks (Horvath, 1979, 1981 Singh and Young, 1995 Furnham et al., 1998 Maisey et al., 1999). None of these efforts offer any information more useful than what we can extract from the Wiggins studies. However, they illustrate that our knowledge of the sexual incentive properties of stimuli stems entirely from studies of the viscerosomatic responses to them. The stimuli responsible for the initial activation of the desire to engage in sexual activities, the phase preceding excitation or arousal in the human sexual response sexual cycle, remain unknown.

Variations in womens sexual behavior during the menstrual cycle

The four studies of sexual arousal mentioned so far estimated vaginal blood flow by photoplethysmography. An entirely different procedure for estimating vaginal response was used in a Dutch study. The temperature of a labium minus was recorded and it was supposed that an increase in temperature would reflect enhanced blood flow. Pornographic videos were used as sexual incentives. Although the videos turned out to increase temperature in the labia minora, there was no systematic variation in response magnitude during the menstrual cycle (Slob et al., 1991). Thus, this study confirms the majority of those mentioned above despite the use of a different procedure. It cannot be too risky to conclude that as soon as an objective measure of sexual response is employed, the variation during the menstrual cycle is absent or at most marginal. To my critical mind, it must be concluded that any variation in sexual behaviors occurring during the menstrual cycle is of such a small magnitude that it...

On the definition of sexual behavior

These definitions are probably useless in a scientific context. For example, the notion that sexual behavior is any activity that induces sexual arousal has several interesting implications, some of which are counterintuitive. Imagine a woman, comfortably seated on her favorite couch reading an old novel by David Herbert Lawrence. It so happens that she gets sexually aroused by a passage in The Plumed Serpent. Would that mean that reading is sexual behavior I could easily invent dozens of examples equally absurd, but this one should be sufficient to illustrate the point. Likewise, reproductive behavior is said to be any activity directed toward perpetuation of a species. Does this mean that the veterinarian inseminating a cow is displaying reproductive behavior Or the technician who diluted the sperm directly after collection from the bull, did she show reproductive behavior while doing so Yet both the veterinarian and the technician performed activities directed toward perpetuation...

Sexual Dysfunction

Though PD patients rarely complain of sexual difficulties, if specifically asked, dysfunction in this area is very common. Bronner et al. (65) performed a comprehensive assessment of sexuality in 75 patients (32 women, 43 men) with PD who did not complain of problems in this area. Using specific sexual function scales, they asked patients to rate their sexuality currently and retrospectively before the onset of their PD. They found that in men, 68 had erectile dysfunction, 65 were dissatisfied with their sexual life, and 40 had difficulty reaching orgasm. In women, the major problems were difficulty getting aroused (88 ), difficulty reaching orgasm (75 ), and decreased sexual desire (47 ). Comparing scores before PD onset to the present, most patients reported a deterioration in sexual functioning with the progression of PD. Using stepwise regression, the authors found that in men, associated disease, medications, and severity of PD predicted sexual dysfunction, whereas in women,...

Genitourinary System

Secretions of both male and female sex hormones decline with age, and sexual activity is reduced. The testes shrink somewhat, the cervix and uterus are reduced in size, and the vaginal mucosa atrophies. The incidence of impotence is higher in old age, but many people continue to enjoy a full sex life well into their seventies and eighties (see Chapter 6).

Endocrine Effects

Administration of GB has also been studied for the treatment of sexual dysfunction. Kang and colleagues evaluated the efficacy of GB administered for 2 months to subjects with antidepressant-induced sexual dysfunction in a placebo-controlled, double-blind design (39). Compared with baseline, both placebo and GB showed improvement in some aspects of sexual function, but there was no difference in effect between placebo and GB treatment. Similarly, Wheatley used a triple-blind, placebo-controlled design to again study the effect of GB on antidepressant-induced sexual dysfunction (40). Again, though some individual subjects experienced improvement, no statistically significant improvement in sexual function was noted.

Pelvic Surgery

Bladder and bowel dysfunction can greatly affect patients' quality of life. The mechanism of injury to these organs from surgery in the pelvis is obvious, however, operations to remove tumors involving the brain and spinal cord can also impact urinary and bowel control. Urinary continence can be affected by any procedure in the pelvis, but prostatectomy and hysterectomy are the most common culprits. Pelvic muscle exercises and medications such as oxybutanin or tolterodine can be helpful, but some patients need further surgical intervention such as the implantation of prosthetic urethral sphincters. Damage to the autonomic nerves, such as during a prostatectomy, can also cause erectile dysfunction which may require pharmacologic or surgical management.

Menopause

The term male menopause is sometimes applied to the structural and functional changes that occur with age-related reductions in the production of testosterone during later life, but there is no scientific justification for this term (Kolodny, Masters, & Johnson, 1979). Changes in the structure and functioning of the sex organs are also typical of older males, but the notion that all men eventually experience a male menopause akin to that in women is inaccurate. Among the changes that occur in older men are a slight shrinkage of the testes, the production of fewer sperm, and an increase in the size of the prostate gland. Older men require longer to achieve an erection, have a softer erection, and lose it more quickly after ejaculation. They experience fewer genital spasms, the force and volume of the ejaculate are less,

Surgical Anatomy

Permanent impotence in men has been reported to be almost universal in some series of abdominoperineal excisions of rectum and occurs in up to half of all men after anterior resection of the rectum for rectal cancer. The incidence of permanent bladder denervation after rectal excisional surgery has been reported to be up to 19 in some series. The presumed mechanism for sexual and urinary dysfunction is damage to the pelvic autonomic parasympathetic and or sympathetic nerves during surgery. The risk of sympathetic nerve damage occurs in the abdomen during ligation of the inferior mesenteric artery pedicle, and high in the pelvis during initial posterior rectal dissection adjacent to the large hypogastric nerves. Lower down, risk to the parasympathetic nerves occurs while dissecting laterally near the pelvic plexus, and during deep dissection of the anterior aspect of the rectum away from the seminal vesicles and prostate near the cavernous nerves. The anterior dissection is thought to...

Sex Therapy

The rapid but effective treatment of sexual inadequacy was pioneered by Masters and Johnson (1970). Many of the patients seen by them and their students were older adults who had stopped having sexual intercourse because of a misunderstanding about the normal biological changes that accompany aging. An illustrative case is described in Report 6-1. After 1 week of therapy, this couple had regained confidence and sexual functioning. The therapy helped them to realize that the increased time to attain an erection and the reduction in seminal fluid by the man, in addition to the decreased vaginal lubrication by the woman, were normal problems of aging with which they could deal. The couple became convinced that, despite these problems, they could continue to enjoy sexual intercourse. Additional procedures for treating sexual dysfunctions are described by Masters et al. (1994). In treating impotence and other problems in older adults, sex therapists may advocate a variety of techniques...

Disease Specific

Reproductive counseling regarding sexual function and fertility is often overlooked given the patient's potentially terminal disease but all patients should be educated regarding sexual and reproductive issues. Many female patients may experience premature menopause, irregular menstrual cycles, and infertility. Infertility can be permanent, particularly in men and women over the age of 40. Patients need to be educated regarding their prognosis so that they can make informed decisions regarding future childbearing. Males may choose to bank sperm prior to undergoing treatment. Females may chose to undergo egg retrieval but this requires considerably more time and expense and therefore the need to initiate therapy as soon as possible may not provide enough time to retrieve viable eggs (8). Patients should be counseled to use reliable contraception and that it is important to avoid pregnancy during chemotherapy and radiation. A waiting period following treatment is recommended for women...

Human studies

There are no rat data concerning classical conditioning of erection or other sexual arousal responses and, likewise, there are none concerning conditioning of copu-latory reflexes like mount with pelvic thrusting. In the absence of useful rodent data on these viscerosomatic responses we have to turn to studies in humans. Classical conditioning of sexual responses is actually one of the few problems in the field of experimental sex research that has been more thoroughly studied in the human than in the rat. In fact, the first studies of conditioning of human sexual arousal (erection) were performed long before similar studies were undertaken in rats or other non-human animals. In one of the early studies, three adult psychologists were employed as subjects rather than the habitual psychology students. They were exposed to pairings of pictures of nude women (unconditioned stimulus) and a pair of black boots (conditioned stimulus). The unconditioned, as well as conditioned response, was...

Qualityof Life

Ferrell (18) uses four domains to define QOL (1) physical well-being, (2) psychological well-being, (3) social well-being, and (4) spiritual strength. Physical well-being includes the ability to maintain functional activities, self care, exercise tolerance, ability to work, appearance, overall physical health, degree of independence, sleep and rest, and symptom control. Psychological well-being provides a sense of control in the face of illness, altered life priorities, and fear ofthe unknown. Diagnosis can causes anxiety, depression, fear, stress, and mood swings. Psychological well-being includes enjoyment of life, intellectual function, adjustment to the disease as well as confidence, acceptance, and satisfaction with treatment. Social well-being includes family issues, adjustment of children, changes in roles and relationships, family stress, patient's social appearance, social isolation, ability to communicate, ability to work, and financial situation. Also included is sexual...

Physical Differences

On the average, girls reach puberty 2 years earlier than boys, and in junior high school some boys may feel like shrimps alongside their female classmates. By the time both sexes have completed adolescence, females have substantially more body fat (70 more) than males but are shorter (5 inches), less muscular (40 less), and have less facial hair (Myers, 1995). These differences persist and others develop in young adulthood. For example, pattern baldness often starts showing in adult males in their late teens or early twenties. And with respect to the biology of sexual behavior, young women are more likely to become sexually aroused soon after experiencing orgasm.

Cabergoline

Clarke and Deane (47) compared cabergoline to bromocriptine in a meta-analysis of five randomized, double-blind, parallel-group studies in 1071 subjects. Cabergoline produced benefits similar to bromocriptine in off-time reduction, motor impairment and disability ratings, and levodopa dose reduction over the first three months of therapy. Dyskinesia and confusion were increased with cabergoline, but otherwise the frequency of adverse events and withdrawals from treatment were similar with the two agonists. Side effects of cabergoline are similar to other dopamine agonists, but also include severe restrictive mitral regurgitation and male sexual dysfunction (48).

Complications

Counts below the reference value, prior to treatment.21 With a hockey stick port, the remaining testicle receives 3 to 5 of the tumor dose. Added shielding against the direct beam and a testicular clamshell to reduce scatter from the thighs can reduce the contralateral testicular dose to less than 1 . This 1 represents internal scatter and can be diminished only by distance or by decreasing the tumor dose. The use of only a para-aortic field supplies this distance. With the hockey stick port, reversible azoospermia is induced in all men whose contralateral testicle is exposed to 1 to 6 Gy, but this recovery takes 1 to 5 years, depending on the dose.22 The para-aortic field stopping at L5 allows less than 0.01 Gy to the contralateral testicle. In my opinion, loss of libido and sexual potency is underrated in men who have undergone post-orchiectomy irradiation.

Timothy S Tracy

Ginseng is commonly used for a variety of conditions where it is purported to have positive effects on mental, physical, and sexual performance. There are some data to suggest it may have some small positive effects on mental and sexual activities, but the data remain conflicting. Ginseng also can reduce glycemic concentrations after glucose challenge. It should be used with caution in patients receiving anticoagulants as reports have suggested it may reduce the effect of warfarin.

Testosterone Decline

The decline in testosterone with age puts a greater number of elderly men at risk for developing hypo-gonadism. Rhoden and Morgentaler estimated that between two and four million men in the United States alone suffer from hypogonadism (defined as serum total testosterone levels lower than 325 ng per deciliter) (Rhoden et al., 2004). More alarmingly though, the same study reported that only 5 of these men are getting treatment for their symptoms, which include decreased libido and erectile dysfunction, loss of muscle mass and strength, weight gain, and declining cognitive function. Hypogonadism is also associated with type II diabetes, musculoskeletal frailty, cardiovascular disease, and the metabolic syndrome.

Pharmacokinetics

The structures and nomenclature of the chemical constituents of Panax ginseng have been discussed elsewhere (78) (see also Section 9). P-Sitosterol is a steroid sapogenin that has been isolated from ginseng. Approximately 50-60 of a dose of P -sitosterol is absorbed from the gastrointestinal tract in rats (79). After oral administration of radiolabeled ginsenoside Rg1, blood radioactivity peaked at 2.1 hours. Bioavailability was 49 (80). have characterized the biotransformation of ginsenoside 20(S)-Rg2, one of the main constituents of ginseng roots and leaves. Its metabolism is complex and involves multiple hydrolysis reactions in the gastrointestinal tract. Metabolites of 20(S)-Rg2 include 20(S)-Rh1 and 20(S)-protopanaxatriol. Details of the biotransformation of 20(S)-Rg2 and chemical structures of the ginsenosides are available in the cited reference (80). Corroborating two rat studies (81,82) suggesting that only trace amounts of ginsenosides are excreted in the urine, low levels...

Cancer

And its capsule at open operation (radical prostatectomy). This technically demanding procedure can be performed via a standard open lower abdominal approach, a perineal approach or laparoscopically. It requires the urethra and bladder neck to be joined together when the gland has been removed. Side effects are significant and include erectile dysfunction (ED), urinary incontinence, bladder neck stric-turing and damage to the rectum.

Definitions

Erectile dysfunction or Impotentia coeundi is defined as the constant or repeated appearance of an inability to attain or maintain an erection sufficient for satisfactory sexual intercourse, (NIH 1993). The diagnosis requires a minimum of 6 months of ongoing problems with 70 or more of the attempts for sexual intercourse unsuccessful.

Medications

Many drugs have a negative impact on sexual function, mainly on libido and the arousability. Table 1 lists an overview of relevant drug classes in this context. Antiretroviral medications are also associated with SD and both duration and combination of therapies have an accelerating effect. In a standardized survey on 78 HIV-infected men who have sex with men (MSM), conducted by Cove in London in 2004, 69 reported on at least one occasion dysfunction and 38 indicated ED. All antiretroviral drugs can decrease sexual function. Some studies (Colson 2002, Schrooten 2001, Martinez 1999) mention Protease Inhibitors (PI's) to be the main culprit, but this was unble to be confirmed by Lallemand, 2002. Furthermore, our own studies suggest that combinations of NRTIs and PIs may cause this problem equally.

Diagnostic criteria

The 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV American Psychiatric Association, 1995) describes human sexual interaction in the same way as van de Velde (1965) did 70 years ago (I remind the reader that van de Velde's book was originally published in 1926), although the terminology has been modified. Instead of talking about sexual interaction as consisting of a series of phases as van de Velde did, the more fancy denomination 'sexual response cycle' is used. Moreover, rather than calling the first phase of sexual interaction prelude, it is now called the desire phase. It is defined in this way 'this phase consists of fantasies about sexual activity and the desire to have sexual activity' (American Psychiatric Association, 1995, p. 505). 1 Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual...

Epidemiology

The epidemiological data show that low sexual desire is the most common of all sexual dysfunctions in women. It is frequently followed by orgasmic disorder and sexual arousal disorder (deficient vaginal lubrication). In men, erectile dysfunction is less common than desire disorders when young, while the reverse is true in old men. Premature ejaculation is the most common dysfunction in young men and almost certainly followed by low sexual desire. The prevalence of premature ejaculation declines with increasing age and, at the time impotence is common, premature ejaculation is rare in those still potent. Nevertheless, while low sexual desire appears to be the major sexual dysfunction in women, it does not appear to be so in men of any age. These epidemiological data justify the fact that female hypoactive sexual desire disorder has received far more attention than the corresponding state in men.

Antiandrogens

In the setting of metastatic prostate cancer, peripheral androgen blockers as monotherapy are traditionally considered inferior to estrogens,43 castration, or CAB.44 However, such monother-apy may be associated with early preservation of sexual function compared to CAB (see below, Combined Androgen Ablation).45,46

Etiology

The very elegant experiment described in the preceding paragraph suggests that conditioning can account for continued sexual responses to an inanimate object. Also the human fetishist frequently obtains reward when exposing himself A role for social learning in the development of fetishism cannot be excluded. By direct observation or through verbal descriptions of other individuals getting sexually aroused by arbitrary objects, we may produce mental representations of those objects as sexually arousing. Perhaps mental representations of an object as sexually arousing are not sufficient for turning it into a fetish, but they may direct our attention to similar objects in situations where sexual reward is obtained, for example through solitary masturbation. Social learning could explain the cultural differences with regard to the most popular fetishes.

Nutraceuticals

Herbals not only have a pharmacological effect on the patient during pain management, but also may require scrutiny when preparing a patient for invasive procedures. Herbals such as St. John's wort can inhibit cytochrome P450 2D6 and 4AC and therefore alter analgesic metabolism (97). This metabolic step is essential in converting hydrocodone to the more active metabolite hydromorphone and codeine to morphine. It is less important in the metabolic conversion of oxycodone to oxymorphone because oxycodone is intrinsically active. Nutraceuticals containing ginkgo, ginseng, and garlic oils have platelet-inhibitory effects and therefore can cause bleeding when used with analgesics such as NSAIDs that also have platelet-inhibitory effects (98). Ginseng (Panax) American, Korean (red), and Chinese

Chest Radiation

Pelvic radiation can damage the autonomic nerves responsible for erection. As a result, erectile dysfunction is common after radiation for prostate, rectal, and anal cancers.43 Improvement often occurs over the first year after treatment but then stabilizes. As important as evaluating the degree of erectile dysfunction is evaluating how much this bothers the patient some patients are untroubled by complete loss of function while others are extremely distressed by even relatively subtle changes in sexual function such as retrograde ejaculation. Erectile dysfunction can be managed with oral agents like sildenafil, tadalafil, and vardenafil, but sometimes requires external suction devices, penile injection therapy, or implantation ofpenile prostheses. Referral to a urologist specializing in male sexual health can be very helpful.

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