Male sexuality

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Male sexuality

• Joseph Breuner, MD
• 5/30/06

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overview

• Whats normal
• History
• Exam
• Meds
• Books
• Special situations

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Sept. 16-17, 2006 Renaissance Hotel Chicago,
Illinois
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Whats normal?

• Masters and Johnson-
• excitementarousalerection
• plateau,
• orgasm,
• resolution

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Whats normal

• Young men-
• Less time from excitement to erection-10-60
  seconds common
• Premature ejaculation common
• Latency period-time after ejaculation til next
  erection-20 minutes to hours
• Up to 3 orgasms per day

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Whats normal

• Middle age 40-60
• 40 have some sexual complaints
• Erections take longer to get
• Dont last as long
• Have to learn to regain-new skill
• Latency periods increase

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Whats normal

• Over 60
• 30-50 report consistent inability to attain or
  maintain erection in this age group
• More diabetes and vascular disease
• More testosterone deficiency

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Causes

• diabetes mellitus
• atherosclerosis
• pituitary tumors
• depression
• chronic renal or cardiac disease
• marital discord

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Red flags

• Diabetes
• Other vascular complaints
• ?testosterone deficiency?
• Depression
• Relationship strife

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The history

• Libido-sexual thoughts and fantasies
• Erections-nighttime and c arousal
• orgasm

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The history

• Have to ask
• How often do they have sex?
• How often do they get and keep an erection?
• How often do they get to orgasm?
• Do they masturbate?
• Does penis ever bend with erection?

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The exam

• Patient standing
• Light behind examiners head
• Normal size testicles-4-7 cm or 1.5 to 3 inches
  in length
• Undescended testicle
• Coronal erosions

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The Creep

• Larry

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labs

• Over 30 or obese-fasting glucose
• No libido-am testosterone
• Endocrine sx-TSH, prolactin
• PHQ for depression

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Meds I Stop

• Thiazides-other anti HTN can cause but rare
• SSRIs PRN-both libido and erection
• Less important
• TCAs
• spironolactone

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Drugs I Stop

• Alcohol
• Meth/cocaine withdrawal

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Books I Use

• New Male Sexuality
• Exercises to
• Regain erection
• Prolong erection
• Prevent premature ejaculation

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Meds I Use

• Viagra
• Cialis
• SSRIs

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viagra

• No nitrates
• No undiagnosed CAD
• Otherwise safe

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Viagra

• 25 or 50 or 100 mg tabs cost 10
• 30 min onset
• 4 hr duration

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Viagra

• Inhibits phosphodiesterase 5
• Promotes nitric-oxide mediated GMP increases

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Viagra

• Erections easier to attain
• Last longer
• Easier to regain

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Cialis

• 24 hr version of viagra
• Effect not quite as strong

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SSRIs

• For premature ejaculation

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The hand on the door

• Usual scenario

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Referral Indications

• Vascular or diabetic dz
• Viagra failure
• Pt. requests other treatments-implants, pumps,
  injections

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Recreational vs therapeutic

• 10 million prescriptions worldwide

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references

• Up to date monographs on
• The sexual history and approach to the patient
  with sexual dysfunction july 2002
• Male sexual dysfunction june 2005
• Zilbergeld, Bernie The New Male Sexuality, 1999.