Mental Impotence Holistic Treatments
A man's ability to have a normal erection depends upon a good supply of blood via the arteries to the penis, and on an intact nerve supply to constrict the veins leading from it. Blood enters the penis through the arteries, but cannot leave because the veins are constricted, thus producing an erection. Diabetes can affect both the blood supply and the nervous control needed to maintain an erection. It is important to remember, however, that sexual dysfunction can have psychological as well as physical causes, whether you have diabetes or not, so it is very important to discuss any sexual problems openly and frankly with your diabetes care team. There are treatments available for all forms of sexual dysfunction in men.
A 60-year-old married man presented with sudden onset of erectile failure about 1 month previously. This occurred in the absence of critical life changes, psychological stress, or known intercurrent illness. Initially, the patient was seen by a general practitioner and treated with sildenafil in incremental doses up to 150 mg. This had only a minor effect ejaculation was maintained but erections remained insufficient for penetration.
In spite of advances in anatomical understanding and surgical technique, bilateral nerve-sparing radical prostatectomy does not assure normal erectile function for all patients. Age, preoperative sexual function, and nerve sparing independently influence the eventual outcome. Sexual inactivity, particularly in the early postoperative period, also may influence the course of functional recovery. Although the return of erectile function may be delayed up to 2 years following surgery, some studies suggest that it may be possible to identify those men unlikely to regain natural erections before that time by nocturnal penile tumescence studies 36 . Tumor stage, race, and patient education have also been implicated 37 . Operative technique, however, is particularly important where other factors are favorable. Rehabilitation using prostaglandin injections and phosphodiesterase type 5 inhibitors may improve outcomes. A role for sural nerve grafting in late recovery of erectile function, in...
The optimum management of patients with localized prostate cancer remains controversial. Three major treatment options are available radical prostatectomy, radical radiotherapy (external beam radiotherapy EBRT or brachy therapy), and active surveillance (also known as active monitoring and watchful waiting). Each treatment involves its own risk. Radical treatments can cause harmful side effects including incontinence, erectile dysfunction, and even death, whereas watchful waiting causes anxiety relating to the presence of cancer and carries a risk of disease progression. However, outcomes in terms of overall survival appear similar with each of the three modalities. patients are significantly more likely than radiotherapy patients to experience urinary incontinence (39 to 49 vs. 6 to 7 ) and erectile dysfunction (80 to 91 vs. 41 to 55 ), whereas radiotherapy patients are more likely to experience bowel urgency (30 to 35 vs. 6 to 7 ) 6 . Late side effects are generally more dose-...
Parasites were thought to be beneficial to humans during the seventeenth and eighteenth centuries. For example, many people believed that lice protected children from disease and leeches were used extensively for blood letting as a cure. For a time, intestinal parasites were thought to help in cleaning the tract of excess food and waste and until recently, the Chinese believed that powdered Ascaris was helpful for medicinal treatment of impotency. In France, the heads of tapeworms (scolices) were once used as weight control measures.
Until recently, there was a significant lack of first-degree evidence through large randomized controlled trials that aggressive treatment of localized prostate cancer improves survival or quality of life. Outcomes for different treatment options in men with localized prostate cancer are difficult to interpret, because many of the published studies are observational, contain too small numbers, and are otherwise insufficiently robust. For example, men treated by watchful waiting may have been selected because they are older, with lower grade tumors, whereas those treated by radiotherapy may have been more likely to have more advanced tumors. Therefore, only data from well-conducted large randomized controlled trials can confidently be used to compare treatment options. Such a trial has been performed in Scandinavia, the results of which were published recently 25,26 . The trial randomized 695 men with early prostate cancer to either watchful waiting or radical prostatectomy, with a...
Among the most important quality of life issues for patients with prostate cancer is the loss of sexual function with treatment. For this reason many men delay treatment or take treatment intermittently. There is no evidence whatsoever that intermittent treatment is less successful than continuous therapy. Indeed, if one examines the effects of hormonal treatment on prostate cancer cells growing in culture, then a single exposure to antiandrogen therapy is seen
As time has progressed, the GnRH agonists have also been shown to have side effects. These include memory loss, parkinsonism, anemia, and osteoporosis, in addition to the hot flushes and impotence that were obvious from their first use. The most important of the side effects phys
Access health care, be it alternative or allopathic, through a variety of informal networks (Chrisman and Kleinman 1983 Pescosolido 1998) or pathways (Wellman 1995), using lay consultation and professional referral systems. While both are part of the overall health care system, there is an important difference between how people access allopathic, and how they access alternative, forms of care. To illustrate, gaining access to alternative therapies can be easy (Campion 1993 Murray and Shepherd 1993). In fact, it can be easier than trying to access an allopathic specialist without a referral from a general practitioner, or than acquiring a family doctor in many parts of Canada today. Further, while the right to diagnose, prescribe, and dispense is controlled by doctors, pharmacists, and other health care professionals (Torrance 1998), lay people are able to prescribe and administer alternative remedies on their own authority. As Richard tells us, I tried things. You can always go out...
Anatomically, the bulk of the striated sphincter is anteromedial, while the neurovascular bundles are lateral to the membranous urethra. Incisions at the three and nine o'clock endoscopic positions are associated with injury to the neurovascular bundles of the corporal bodies and reduced potency. The 12 o'clock sphincterotomy, described by Madersbacher et al. (87), and Yalla et al. (91) is the method of choice, because incision at this site decreases the risk of significant arterial hemorrhage and erectile dysfunction. Hemorrhage associated with the 12 o'clock incision usually emanates from venous structures, and abates spontaneously with catheter placement. fusion in 5-23 , and erectile dysfunction in from 2.8 to 64 of patients (88,90,92,93). Several minimally invasive surgical alternatives to traditional sphincterotomy have been recently developed - laser sphincterotomy and sphincter stent placement.
Lous dissection with the use of optical magnification in the intercrural and rectourethral spaces will also help identify the dorsal penile arteries. An intraoperative Doppler may be an invaluable tool at this point of the procedure to help identify these structures. Unfortunately, the perineal and periprostatic anatomy is so deformed at times that clear distinction and identification of these encased neurovascular and arterial strictures is not always possible. Consequently, patients need to be appropriately counseled that a 3 -5 incidence of impotence may occur after surgery. Furthermore, ventral chordee may also result from the procedure if a long stricture is repaired and aggressive mobilization techniques are utilized.
A4 enzyme system, drugs that are metabolized through this system (Rifampin, barbiturates, carbamazepine, certain statin drugs, amiodarone, benzodiazepines, sildenafil (Viagra), theophylline, and certain selective serotonin reuptake inhibitors) may increase repaglinide metabolism (19). Although in vitro data indicate that repaglinide metabolism may be inhibited by antifungal agents (such as ketoconazole and miconazole) or antibacterial agents (such as clarithromycin), systematically acquired data is not available on increased or decreased plasma levels with other cytochrome P-450 3-A4 inhibitors or inducers.
The goal would be to develop an instrument that contained a generic core battery of HRQOL items supplemented with disease-specific questions for use in the population of women with uterine myomata. The instrument would contain clinical endpoints, symptoms, HRQOL, and satisfaction measures. A number of steps are involved in the development of a standardized instrument 1) item selection, 2) item scaling, 3) item reduction, 4) reliability, 5) validity, and 6) responsiveness. Item generation includes development of an item pool based on items previously published as well as items generated from the expert panel and from patient focus groups. The expert panel identified, as part of their rating process, a number of outcomes that they felt essential and important to measure. These included both disease-specific outcomes (e.g., death, reoperation, vascular disruption due to embolization, menorrhagia) as well as HRQOL outcomes (e.g., mental health, sexual functioning).
NOTE Testicular cancer is most common in the young male from age 18 to 30. This type of cancer can be fatal if not diagnosed and treated early. Therefore, any lump on the testes should be cause for an immediate medical check. The loss of the testes will cause sterility. However, loss of the testes will not affect the ability to have an erection, ejaculation, or orgasm.
Neurological manifestations include peripheral nervous system abnormalities of impotence, autonomic dysfunction, peripheral neuropathy, and postural hypotension central nervous system disturbances include behavioral changes, memory loss, hallucinations, nightmares, depressions, and insomnia.
Although rare, accounting for less than 1 of all testicular neoplasms, SCTs may arise at any age (most commonly middle age). They may present with a painless testicular swelling or with symptoms of gynecomastia or impotence. Most are sporadic tumors, but there is an increased risk of SCT in patients with Peutz-Jeghers polyposis, and Carney's and androgen insensitivity syndromes 157,158 . Ultrasound examination shows a well-circumscribed, hypoechoic mass, with a variable amount of cystic change 159 . Most cases show no features enabling distinction from other testicular neoplasms, including germ cell tumors. A rare variant, the large cell calcifying SCT, however, commonly presents in young children and adolescents with bilateral tumors containing large calcified areas, and has a characteristic ultrasound pattern of bright echogenicity and posterior acoustic shadowing 160 .
Strictures, erectile dysfunction, and (in some cases) urinary incontinence may be problems with lifelong ramifications for these patients. Attempts to suture both ends of the urethra are challenging - dissection of the periurethral and prostatic tissues can cause additional damage to the neurovascular bundles and the intrinsic urethral sphincter structures. Due to the increased risk of iatrogenic impotency and incontinence, primary anastomotic repair is no longer recommended. Reconstructive procedures should be limited to open surgical placement of the transurethral catheter and suprapu-bic drainage of the bladder. The purpose of the realignment is to reduce the number of secondary urethral strictures, and to decrease the stricture length in comparison to both suprapubic cystostomy and delayed repair. Although the ultimate value of this procedure is still under discussion, there is clear evidence that realignment can significantly decrease the incidence of strictures (Koraitim 1985,...
The continence and potency preservation rate for early realignment and for delayed urethroplasty has been compared in a review of literature by Herschorn the incidence of impotence was 30 and 36 and the incidence of incontinence was 6 and 8 for delayed repair and early realignment, respectively 13 . In an review of 871 cases, Koraitim 1 evaluated the morbidity of different treatment of post-traumatic urethral disruption. For suprapubic cystostomy, overall the incidence of stricture was 97 , the incidence of impotence was 19 incontinence occurred in 4 of cases. For early or immediate surgical realignment, overall the incidence of stricture was 53 , the incidence of impotence was 36 incontinence occurred in 5 . However, caution must be exercised when comparing retrospective series published over more than 40 years. The treatment of disruption is not related to the incidence of impotence and incontinence, which are rather due to trauma itself 14 . Open surgery performed immediately after...
Dhabuwala CB, Hamid S, Katsikas DM, Pierce JM (1990) Impotence following delayed repair of posterior urethral disruption. J Urol 144 677-678 35. Corriere JN Jr, Rudy DC, Benson GS (1994) Voiding and erectile function after delayed one-stage repaire of posterior urethral disruptions in 50 men with a fractured pelvis. J Trauma 37 589-590
Because amputative surgery for penile cancer may lead to major psychosexual dysfunction, various attempts have been made to devise conservative treatment modalities based on careful oncological, anatomical, and technical considerations. Judicious use of conventional or micrographic surgery, laser ablation, or radiotherapy can allow preservation of a functioning phallus in appropriately selected patients with early cancers. However, there are no comparative studies and no consensus regarding the best modality for PCT. The type of cases suitable for a particular PCT modality depends on the size, site, extent of the tumor, and presence or absence of invasive carcinoma. Circumcision has been reported mostly for cancers limited to the prepuce, conven-tional micrographic wide excision for very small superficial invasive carcinoma, laser excision ablation for in situ or very select superficial invasive carcinoma, and radiotherapy for all variants of early penile cancer. In contrast to 97 to...
If conservative methods fail, surgical alternatives may be required. Patients are selected for surgical management on the basis of a careful neurourological evaluation, patient compliance, and hand function. A sphincterotomy is indicated in patients with DESD and elevated intravesical storage pressure that can be associated with deterioration of the upper urinary tracts (46). Sphincterotomy should lower the detrusor leak-point pressure to an acceptable level, thus treating the dysfunction primarily as one of emptying. The resultant storage failure can be handled with an external collecting device. For patients who are unable to self-cath, this procedure allows urinary drainage with low pressure, often significantly reducing postvoid residuals (59). In addition, there is evidence that 70-90 of patients show substantial improvement after sphincterotomy with a reduction in vesicoureteral reflux and upper tract deterioration (60). Use of this procedure has waned recently because of both...
The answer is c. (Fauci, 14 e, p 1976. Tierney, 39 e, p 1070.) Patients may use anabolic steroids to improve athletic performance. The risks associated with use of these agents include mood swings, aggressiveness, paranoid delusions, psychosis, gynecomastia, infertility, testicular atrophy, hepatic tumors, peliosis hepatis, hypertension, and decreased HDL cholesterol levels. Patients with prolactinomas (pituitary tumors) generally present with galactorrhea, reduced libido, erectile dysfunction, amenorrhea, infertility, and visual field defects. Chronic cocaine use may
Radical retropubic prostatectomy has become the most predominately performed procedure to treat localized prostate cancer following observations by Walsh and colleagues that have allowed for a more anatomic dissection, resulting in decreased blood loss and preservation of erectile function in a significant number of patients (28). By preserving the cavernous nerves, O'Donnell and Finan reported that improved continence rates are achieved (29). However, Steiner et al. (30) in a larger series reported no difference in continence rates regardless of whether a nerve-sparing approach was used or not. They suggested
Late side effects are generally more dose-limiting than acute effects because they can have a significant impact on quality of life and are often permanent. They may appear between 6 months and 2 years after radiotherapy, although sometimes acute effects do not settle and can continue as late effects. Late urogenital toxicity manifests as chronic cystitis, urinary incontinence (2 to 11 ) and erectile dysfunction (10 to 40 ). Late damage to the rectum results in late radiation proctitis, rectal ulceration, or stricture severe damage occasionally necessitates a defunctioning colostomy (risk
The answer is b. (Seidel, 4 e, pp 665-668. Tierney, 39 e, pp 1141-1142.) Germ cell tumors are the most common tumors in men between 20 and 35 years of age. A man who presents with a testicular mass and an elevated serum a-fetoprotein (AFP) level most likely has non-seminomatous testicular cancer. The elevated AFP implies yolk sac or nonseminomatous elements. Patients with seminomas (more common than nonseminomas) often have elevations in human chorionic gonadotropin (hCG). All germ cell tumors, even if advanced, are curable with chemotherapy. Leydig and Sertoli cell tumors tend to produce estrogen, causing gynecomastia and impotence. Squamous cell carcinoma of the penis presents as a painful, nonhealing ulceration and is often found in uncircumcised men with poor hygiene. Testicular lymphoma is often bilateral. Swellings containing serous fluid transilluminate those containing blood and tissue do not. tion of the glans penis and prepuce). Balanitis is inflammation of the glans...
The answer is a. (Rock, 8 e, pp 375-378.) Partial colpocleisis by the Le Fort procedure is reasonable for elderly patients who are not good candidates for vaginal hysterectomy and A&P (anterior and posterior) repair as treatment for vaginal and uterine prolapse. The technique involves partial denudation of opposing surfaces of the vaginal mucosa followed by surgical apposition, thereby resulting in partial obliteration of the vagina. Patients who are candidates for this procedure must have no evidence of cervical dysplasia or endometrial hyperplasia, have an atrophic endo-metrium, and no longer desire sexual function since the vagina is essentially obliterated and there is no longer access to the cervix or uterus via the vagina. Urinary incontinence can be a side effect of this procedure, so care must be exercised in the denudation of vaginal mucosa near the bladder. In a patient who already has urinary incontinence, the Le Fort operation would be relatively contraindicated. An...
Arousal and plateau aspects of the sexual response cycle (SRC) require an intact vascular system, cyclic guanosine monophosphate (cGMP), and, probably, adequate androgen levels. Because this phase of the SRC includes muscular tension, some degree of muscle tone contributes to the sensation of heightened tension that occurs in this phase. As vaginal lubrication and penile erection are equivalent phases of the SRC, the clinician should be aware of medications, illnesses, and physiological changes that affect men's SRC in order to understand women's arousal difficulties. Changes in women's arousal are not readily noticeable to the woman or her partner until a fairly significant change has occurred penile erectile difficulties are likely noted at a much earlier threshold, since penetrative sex requires a much greater degree of vasocongestion compared with the level of vagocongestion required for receptive vaginal sex. As with increasing erectile difficulties with age alone, there are...
There is no agreement of the effect of menopause on psychiatric disorders, psychological symptoms, and sexual function. The important role of gonadal hormones is suggested by the prevalence of mood disorders such as depression during the reproductive years and the propensity for depressive episodes to occur during times of hormonal change. Lifetime prevalence of depression for women in the USA is consistently twice that of men, and the increased prevalence in women can also be found in other countries.27 Lifetime prevalence depression rates of 21 in women and 13 in men were reported by the National Comorbidity Survey in 1994.28 Decline in coital frequency has been associated with reductions in testosterone levels, and cross-sectional studies have found less evidence of an effect of menopausal status (including specific gonadal hormonal levels) on sexual function, the effects being some reduction in enjoyment of sexual activity and desire.40 Overall, this suggests that reduction of...
These issues, unfortunately, have been entirely neglected in most reports on penile cancer. This is surprising considering the possible major psychosexual impact of a penectomy. There are only a few small, mostly retrospective studies evaluating the quality of life and psychosexual issues (2,88,89). The expected quality of life, particularly sexual functions after treatment, should be specifically discussed with the patient. It is an expansive concept that involves vast and profound evaluation. The Overall Sexual Functioning Questionnaire (OSFQ), first used by Table 24.4. Overall Sexual Functioning Questionnaire (OSFQ) 2,87 Table 24.4. Overall Sexual Functioning Questionnaire (OSFQ) 2,87 Global score of overall sexual function (five categories). I No sexual functioning score, 5-8. II Severely reduced score, 9-14. Global score of overall sexual function (five categories). I No sexual functioning score, 5-8. II Severely reduced score, 9-14. Opjordsmoen et al. 2,87 , is a useful tool and...
With the analyte, therefore it should not affect the chromatographic peak shape of the analyte. However, when the driving force for evaporation of TFA is introduced in the electrospray process, the mass action will make propionic acid a good competitor of TFA for ion pairing with the analyte. It has been shown that by adding propionic acid (0.1 to 0.5 ) propionic acid directly to mobile phases containing either 0.025 or 0.05 TFA, ESI sensitivity improved by 2-5 fold for basic compounds such as sildenafil, fluconazole, nicotine, midazolam, and isoniazid.68 For negative ionization mode LC-ESI-MS assays, it is necessary to use a solvent that creates stable anions. The mixture of halogenated solvents with methanol is a very good system for analysis of oligonucleotides in the negative mode, due to the fact that halogenated solvents can form stable anions through electrochemical reduction processes.67 Examples of these mixtures that have been reported are hexafluoroisopropanol with...
The bulbocavernosus muscle is split down the middle and the urethral bulbus is laid open in the area of the stricture. Although the urethral injury is rarely the main problem of these often multiple and severely traumatized patients, consequences of the urethral trauma such as urethral strictures, erectile dysfunction, and sometimes urinary incontinence are potential problems with lifelong ramifications. The stricture may be localized using a 20-Fr curved metal probe or with a flexible cystoscope (O Fig. 14.5).
Most initial reports suggested that the technique was effective (66,58,64,59,65). Harris reported that 60 of patients developed an acontractile detrusor, but 30 were complicated by vesicovaginal fistula after extravesical subtrigonal injection of 50 ethanol for detrusor instability in 10 patients (67). Subtrigonal injection has fallen out of favor because of recent disappointing outcomes. Mclnerney in a long term follow-up of 97 patients, had only 19 long-term success, 24 short term but unsustained benefit and 57 failure (60). In addition there was a 17 complication rate urinary retention (1 transient, 7 permanent requiring intermittent catheterization, 4 nerve palsies, erectile impotence in 1 of 9 men, and 2 bladder mucosal necrosis). Many of the phenol failures subsequently underwent augmentation cystoplasty as the definite treatment with success.
In their patients, physical changes are not identified as the primary obstacle preventing persons from achieving sexual satisfaction following traumatic brain injury. Rather, the cognitive and emotional sequelae of brain injury seem more important from the professional's perspective.42 A Swedish study43 noted that a high degree of physical independence and maintained sexual ability were the most important predictors for sexual adjustment following brain injury. Preinjury factors predicting successful sexual functioning following traumatic brain injury were not identified. Unfortunately, at this time in the treatment and rehabilitation of brain-injured patients, the causes and effects of sexual functioning after brain injury are very confusing. The medical literature does not clarify this confusion, and one cannot accurately differentiate between primary and secondary sexual problems following traumatic brain injury.44
Prostate brachytherapy involves placement of radioactive sources directly into the parenchyma of the prostate. It is a highly conformal form of therapy, permitting dose escalation to the target volume far exceeding that of other radiation modalities. The surrounding normal tissues are spared because of the rapid dose falloff with distance from the source (inverse square law). The evolution of TRUS imaging, a closed transper-ineal approach, and the increasing sophistication of computerized planning have resulted in a worldwide resurgence of interest in this treatment technique. Its appeal lies in its speed and convenience (it can be done as an outpatient procedure) and the low long-term risk of proctitis impotence is also less likely than after Almost all patients develop urethritis of variable intensity which may last for 3 months. Symptoms may be helped by alpha-blockers and nonsteroidal antiinflammatory drugs. A minority of patients (15 ) develop acute retention either immediately...
In screen-detected cases for any of the major treatments (radical prostatectomy, radical radiotherapy including brachytherapy, and watchful waiting, otherwise known as active monitoring or surveillance) and each can result in damaging iatrogenic complications and outcomes, including various levels of incontinence and impotence for radical interventions and anxiety relating to the presence of cancer in watchful waiting. The problem is compounded because many of the published studies contain flawed analyses and unsubstantiated conclusions. The same evidence has resulted in different approaches to screening on either side of the Atlantic, and even among states in the United States.
Patients should be counseled appropriately. Prostatectomy patients are significantly more likely than radiotherapy patients to experience urinary incontinence (39 to 49 vs. 6 to 7 ) and erectile dysfunction (80 to 91 vs. 41 to 55 ), whereas radiotherapy patients are more likely to experience bowel urgency (30 to 35 vs. 6 to 7 ) 6 .
On the other hand, are there problems with immediate treatment The immediate side effects of impotence, hot flushes, and so on have been long recognized. However, just as studies have started to show that clear benefits may result from immediate treatment, so has the possibility emerged that serious harmful effects may result from androgen treatment. Some of these are specific to particular therapies, such as cardiovascular complications of estrogens, and liver toxicity of antiandrogens. However, testosterone deficiency, including androgen deprivation from orchiectomy or LHRH analogues, long considered safe options, is now recognized to cause weight increase, loss of muscle mass, and loss of energy 26 . Anemia may be a particular problem in patients treated with combined androgen blockade 27 . Osteoporosis has been
The potential benefits of androgen deprivation have to be balanced against toxicity. Most patients experience hot flushes, fatigue, and impotence of varying degrees, which can impact significantly on quality of life. Other toxicities include loss of libido, weight gain, muscle wasting, and changes in texture of hair and skin. Longer-term concerns include the development of osteoporosis and the possibility that low testosterone levels may predispose to cardiovascular disease. There is no evidence yet that long-term hormone therapy increases non-prostate cancer mortality, but this is being investigated in the meantime, it is sensible to restrict the use of long-term hormone therapy to patient groups in which it has been shown to have an overall survival benefit.
Radical prostatectomy is generally carried out with the intent of achieving long-term disease-free survival and thereby cure of early-stage prostate cancer 20 . Secondary, but nevertheless important, concerns are the maintenance of quality of life, in particular continence and erectile function. In some countries, interest is growing in a potentially palliative role in patients with more advanced and noncurable disease. Favorable long-term survival in patients with pathologically organ-confined tumors has been recognized since Young's early experience 21 . In spite of early concerns, nerve sparing does not compromise cure rate 22 . Today, alongside the shift of pathological stage toward organ-confined disease at diagnosis, neurovascular bundles are rou
Sildenafil Because the quality of the relationship is pivotal in the sexual response cycle for women, poor or declining quality of relationship can negatively affect desire and subsequently arousal. Clarify the quality of the relationship and the woman's level of attraction to her partner, recommending counseling for less-than-satisfactory relationships. Assess the couple's investment in time and setting the environment conducive to sexual encounters - for example, expecting spontaneous sexual encounters on the night that grandchildren are sleeping over can be unrealistic. Assess medications for potential negative impact. Consider discontinuing, substituting, or reducing the dosage of medications that could be contributing. Selective serotonin reuptake inhibitors (SSRIs) are very successful for treating depression and anxiety, but unfortunately they can negatively affect the sexual response cycle. Drug holidays from SSRIs can be effective, but more so for paroxetine than fluoxetine or...
Recent studies have found that the most important factor is getting the blood pressure controlled, and this is more important than the means. 10 Similarly, most patients will need more than one medication. Several commissions have suggested that the first-line drugs should be low-dose thiazide diuretics or beta-blockers, in the absence of other factors. Beta-blockers, especially the cardioselective types, are good medications for many individuals. Data suggest that use of beta-blockers may reduce the incidence of strokes but not total mortality.11 They are especially good choices in patients with tachycardia, anxiety, migraine headaches, and angina. They should be avoided in asthmatics, patients with bradycardia or atrioventricular blocks, and diabetic patients using insulin who may become hypoglycemic. Beta-blockers can make the individual feel slow, tired, or depressed. Their effects on women's sexual function are not known.
Reduction of anxiety has been associated strongly with an interest in prophylactic oophorectomy in genetic counseling programs, independent of actual risk classification.62 Conflicting information is available regarding the psychological impact of prophylactic oophorectomy. A prospective study of women in a familial cancer clinic compared women who did and did not undergo prophylactic oophorectomy it found significant reduction in ovarian cancer anxiety and a high degree of satisfaction with the decision to undergo the prophylactic procedure.63 Another small study compared utilized responses to the Short-Form (SF)-36 Health Status Questionnaire and the General Health Questionnaire (GHQ) women undergoing oophorectomy for prevention scored poorer functioning on the role-emotional and social functioning subscales, with a trend to report more menopausal symptoms, and reported higher scores on the GHQ. There were no significant differences in the groups with respect to cancer worry or...
Studies have not demonstrated efficacy for evening primrose oil, ginseng, red clover (alone), chasteberry, or dong quai compared with placebo.73,74 Dong quai may act as a photosensitizing agent. It may contain warfarin-like compounds, resulting in a potential for many drug and herbal interactions. Sellers and manufacturers of yams and yam extract have claimed that one component, diosgenin, is a precursor to progestin and DHEA. However, in humans there is no known pathway for bioconversion to these compounds nor is there any known intrinsic biological activity. Mexican yam extract is estrogenic but would require large quantities to produce a therapeutic effect. Efficacy and safety at these higher doses is unknown. Ginseng commercial products, when tested, have frequently contained little or no ginseng and often contained caffeine, pesticide residues, and lead.
The answers are 284-c, 285-a, e. (Fauci, 14 e, pp 287-289.) Nocturnal penile tumescence occurs during REM sleep, and if the man gives a history of rigid erections under any circumstances, the most likely etiology of his ED is psychological (i.e., depression, disinterest, anxiety). In the patient with a history of neuropathy, further studies to evaluate impotence are not necessary. Patients with peripheral vascular disease should be evaluated with a penile brachial index. An index
Also, the fact that only an estimated 10 per cent of pre-clinically tested lead-compounds are likely to ever reach the market must discourage companies from investing into new drug development, in particular for pathologies that are not deemed to constitute a profitable market. Thus, from the point of view of a commercial drug developer, ideal targets are chronic and non-lethal complaints that affect people in the developed world at the prime of their financial viability. In other words, it is 'more economical' to come up with a treatment for obesity, baldness or impotence, rather than to tackle a rare but lethal disease that affects small patient groups or people in underdeveloped regions of the world.
Vegetative symptoms constitute the most biologically rooted clinical features of depressive disorders and are commonly used as reliable indicators of severity (severe depression with somatic symptoms in ICD-10 and melancholia in DSM-IV). They are manifested as profound disturbances in eating (anorexia and weight loss, or the reverse, bulimia and weight gain), in sleep (insomnia and or hypersomnia), in sexual function (decreased sexual desire or in a minority of cases the reverse), loss of vitality, motivation, energy and capacity to respond positively to pleasant events. Additionally, concomitant bodily sensations, usually diffuse pains, and complaints of fatigue and physical discomfort are reported. Disturbances of biorhythms are frequent and are considered as characteristic features of melancholia. They are mainly manifested in sleep patterns, predominantly with early morning awakening.
The morbidity of radical prostatectomy today relates principally to erectile dysfunction, but also urinary incontinence. Uncontrolled or unrecognized hemorrhage can be life threatening and can lead to local or systemic complications.Anastomotic stricture can develop in 2 to 20 of patients, and may contribute to difficulties with voiding and urinary control. Rarely, obliteration or distraction at the site of the anastomosis requires more complex procedures and reconstruction. Other significant complications may include infection, lymphatic leak and rarely rectal injury, deep venous thrombosts, and pulmonary embolism.
Radical prostatectomy when carried out by experienced surgeons in established centers can maintain excellent quality of life, but such claims may not always be representative in wider surgical practice. The impact of surgery is sudden, recovery may be slow and additional therapy may be required. Changes in sexual function other than potency are inevitable, including changes in perception of orgasm, ejaculation, and libido. The effect of these consequences may vary substantially between individuals.
Differences in patients' age, comorbidity, and erectile function 36 . For such reasons,published results based on a surgical series or single centers may not be truly representative of wider outcomes 42-44 . Difficulties in comparing postsurgical morbidity between centers are compounded by the lack of consistency and objectivity in the assessment and definition of continence and potency. Various outcome measures have been used, including physician-reported outcomes, patient-reported outcomes, and neutral data collectors using standardized data collection instruments, which may influence outcome perceptions 43 . Also of concern, factors that determine quality of life and sexual functioning seem to have less than precise relationships with disease and treatment-related morbidity.
Urinary incontinence following radical prostatectomy is far less common than erectile dysfunction, but when present may have significant implications for the patient. Its true incidence varies according to its definition. Many patients will be continent when the catheter is removed, and among the remainder it may take up to 2 years for continence to be re-established. Occasional patients suffer persistent, troublesome or severe incontinence. For these individuals placement of an artificial urinary sphincter can restore urinary control and quality of life.
These three tissue masses are erectile (capable of erection) and contain blood sinuses (channels). When sexually stimulated, the arteries of the penis dilate. Large quantities of blood enter the blood sinuses. Expansion of these spaces compresses the veins, draining the penis and causing most blood entering to be retained. An erection is caused by these vascular changes, the erection being a parasympathetic reflex. When the arteries constrict and the pressure on the veins is relieved, the penis returns to its flaccid (soft, limp) state.
Hysterectomies performed each year for this problem (National Center for Health Statistics, 1998 Lepine, 1997). Hysterectomy is a relatively safe procedure, with a major complication rate of 1-2 and a death rate of 0.1 , and guarantees permanent relief from symptoms of myomata (Bernstein, 1996). It is, however, a major abdominal surgery with a substantial recovery period. Hysterectomy also removes an organ which may play a role in sexual function, guarantees infertility, and has important psychological implications for many women.
There are no data to suggest that women benefit from routine supplementation with testosterone.82 A few early studies suggested that testosterone improved women's sexual function but also caused significant adverse effects, such as acne, excess facial and body hair, and abnormal lipid levels. Testosterone may improve hot flushes in women whose symptoms are resistant to estrogen or estrogen progestin. A combination of estrogen and methyl testosterone is available for the treatment of resistant hot flushes, but it has not been approved for the treatment of sexual dysfunction.
A full urological evaluation is required in all newborns with spinalcord dysraphisms. Initially, the neonatal assessment begins with a detailed physical examination. It is important to document neurologic status with attention to abdominal muscle tone, sphincter tone, function of the sacral reflex arc, and lower extremity function. A urinalysis, urine culture, and serum creatinine should be obtained. Documentation of the renal anatomy can provide baseline information about the radiologic appearance of the upper and lower urinary tracts as well as the condition of the sacral spinal cord and the central nervous system (CNS). These initial studies are important for many reasons. They help identify babies at risk of urinary tract deterioration, help the physician counsel parents about the child's future bladder and sexual function, and can be used to compare with later studies (46).
Early primary suture repair of the separated urethra has been uniformly abandoned, since the approach is associated with an unacceptable incidence of impotence and incontinence 18 . In a literature review of 871 patients treated from 1953 to 1995 by Koraitin, 37 were treated with primary immediate open reconstruction, resulting in a 21 incidence of incontinence and a 56 incidence of impotence 20 . The high incidences of incontinence and impotence are likely secondary to the gross distortion of tissues secondary to hematoma and edema coupled with release of the tamponade effect, resulting in continued injury to neurovascular and sphincter structures. On the other hand, the low incidence of incontinence after both primary alignment or suprapubic cystotomy with delayed
Partial penectomy is indicated for lesions involving the glans, corona, and distal shaft, where after adequate surgical excision the residual penile stump ensures upright micturition without scrotal soiling and for sexual function. Traditionally, a 2-cm disease-free margin has been advocated. However, Hoffman et al. 49 reported no recurrence in any of their patients with microscopic margins up to 10 mm. Similar findings have also been reported by Agrawal et al. 50 , who feel that a 10-mm margin may be adequate for grade I and II lesions and 15 mm for grade III lesions. This approach would qualify more patients for conservative surgery or partial penectomy rather than total penectomy, and the residual penile length would then be cosmeti-cally and functionally more acceptable. Patients undergoing partial penectomy can be offered penile augmentation or reconstructive surgery at a later date, if they wish to have the normal length of the penis restored.
HPI He was started on hydrochlorothiazide for treatment of hypertension, but it did not control his hypertension, so a-methyldopa was added approximately 2 months ago. On directed questioning, he states that he has been suffering from sexual dysfunction (impotence and inability to ejaculate) for the past several weeks. Discussion Methyldopa is a sympatholytic that produces a false neurotransmitter, a-methyl-norepinephrine, which activates inhibitory a2-receptors in the CNS. It is used as an antihypertensive drug, and its side effects include impotence, Coombs positivity (20 of patients), and, more rarely, hemolytic anemia. It can also cause sedation, drowsiness, severe orthostatic hypotension, and hepatic toxicity.
Antidepressants play a major role in the treatment of major depression. Per Bech has described the developments in antidepressant therapy in a lucid and comprehensive way. The clinician will find this chapter a useful update of differences between older and second generation antidepressants in terms of clinical efficacy, side-effect profile and safety. It is interesting to see that the pendulum swings from broad-spectrum pharmacological profiles to high degrees of selectivity and recently, with the introduction of dual action antide-pressants, back to a broader pharmacological profile with a reduced propensity for disabling side effects such as impotence and toxicity at higher dosages. There is, mainly due to the publication of recent meta-analyses, an ongoing debate concerning the differential efficacy of dual action versus selective monoamine reuptake inhibitors. The recently introduced dual action antide-pressants venlafaxine and mirtazapine in particular have been compared to...
A 58-year-old man with a history of angina for which he occasionally takes isosorbide dinitrate is having erectile dysfunction. He confides in a colleague who suggests that sildenafil might help and gives him three tablets from his own prescription. The potentially lethal combination of these drugs relates to Sildenafil Answer D. Nitrates may be metabolized to nitric oxide (NO) that activates a soluble guanyl cyclase in vascular smooth muscle. The increase in cGMP activates protein kinase G and subsequendy leads to vasodilation. Sildenafil inhibits cGMP phosphodiesterase (PDE), potentiating vasodilation that can lead to shock and sudden death. Although sildenafil has much higher potency for the cGMP PDE isozyme in the corpora cavernosa, it can also inhibit the cGMP PDE in vascular smooth muscle. Nitric oxide synthase (choices A and B) is the physiologic source of nitric oxide in response to vasodilators such as acetylcholine, bradykinin, histamine, and serotonin.
Since its introduction in 1973, visual urethrotomy is the standard therapy for anterior urethral strictures. It is performed in local or general anesthesia. The urethrotome is positioned in the 12 o'clock position to cut the stricture. Some surgeons prefer incisions in the 10 and 12 o'clock positions and others in the 2, 6 and 10 o'clock positions. These varying proceedings have to be seen in relation to the anatomic situation of the erectile nerves to protect the patient from secondary erectile dysfunction due to internal urethrotomy ( Fig. 12.3).
After a thorough assessment of a patient's presenting symptoms, the history should then focus on related areas. There are several aspects of a patient's history that may be intimately related to voiding function. Sexual and bowel dysfunction are often associated with voiding dysfunction. Therefore the review of symptoms should focus on these areas including defecation (constipation, diarrhea, fecal incontinence, changes in bowel movements), sexual function, dysparunia, and pelvic pain. As neurological problems are frequently associated with voiding dysfunction, a thorough neurological history is critical, including known neurologic disease as well as symptoms that could be related to occult neurological disease (back pain, radiculopathy, extremity numbness, tingling, or weakness, headaches, changes in eyesight, and so on). In addition to a focused history regarding LUTS and voiding dysfunction, a thorough urological history is important. This includes a history of hematuria, urinary...
Human sexual response cycle Excitement. This phase is also known as arousal. It is mediated by parasvmvathetic connections to the pelvic organs and results in vascular engorgement. Arousal in women is generally slower, responds more to touch and psychic stimuli, and is manifested by vaginal lubrication. Arousal in men is generally faster, responds more to visual stimuli, and is manifested by penile erection. Each phase of the sexual response cycle can be dysfunctional.
The penis is the male organ of copulation and urination. The shaft of the penis is made up of three cylindrical masses of tissue bound together by fibrous tissue. The two back and side tissue masses are called the corpora cavernosa penis. The smaller third tissue mass is the corpus spongiosum penis located toward the middle of the shaft and containing spongy urethra. These three tissue masses are erectile (capable of erection) and contain blood sinuses (channels). When sexually stimulated, the arteries of the penis dilate. Large quantities of blood enter the blood sinuses. Expansion of these spaces compresses the veins draining the penis, causing most entering blood to be retained. An erection is caused by these vascular changes, the erection being a parasympathetic reflex. When the arteries constrict and the pressure on the veins is relieved, the penis returns to its flaccid (soft, limp) state. See figure 1-8.
There is no safe level of 2,3,7,8-TCDD, which is lethal for some animal species at five parts per billion, i.e. as little as 60 g can kill a mouse. It is a potential carcinogen. Agent Orange itself may increase the incidence of non-Hodgkin's lymphoma and soft tissue sarcoma. Other toxic effects include chloracne, neurological disorders, muscle dysfunction, impotence, birth defects and mutations. Industrial accidents since the 1970s have been associated with extensive loss of nearby animal life and the forced evacuation sometimes permanently of whole communities.
Hysterectomy can generate an emotional crisis for women and their partners, based onhowtheyviewtheir sexuality and their definition ofwomanhood in relationship to their uterus and ovaries.25 Worries about changes of sexual response, pain with sexual intercourse, or body image changes can lead to sexual difficulties for the couple. However, for women who have undergone hysterectomy because of abnormal bleeding or pain, sexual desire, enjoyment, and activity increase post-hysterectomy.27
The Midlife Women's Health Survey, examining the beliefs of 280 mostly white, married, highly educated, mid-life women, found that women whose sexual response had changed in the past year (40 ) reported more decrements than increases in sexual response. When asked how they accounted for these changes, women referred most often to the physical and emotional changes of menopause and to life circumstances, and less often to their relationships with their partners. Most of the decrements were explained by physical events related to menopause, whereas most of the increases were explained by life circumstances.12 The Massachusetts Women's Health Study II was a study of 200 women transitioning through the menopause who were not hormone replacement therapy (HRT) users, who had not had a surgical menopause, and who had partners. It examined associations among menopause status, various aspects of sexual functioning, and the relative contributions of menopause status and other variables to...
Genitourinary abnormalities, including cystopathy, neurogenic bladder, defective vaginal lubrication, retrograde ejaculation, and erectile dysfunction. Often, erectile dysfunction may be the first manifestation of a developing autonomic neuropathy, followed by episodes of diminished ejaculation, loss of ejaculatory effort, or retrograde ejaculation. Poor glycemic control has shown to be the chief risk factor for autonomic neuropathy, although, in the Pittsburgh Epidemiology Study, increased low-density lipoproteins and hypertension were also contributing factors. Other data has implied associations between neuropathies and systolic and diastolic blood pressure or lipid disturbances (31). Metoclopramide (Reglan) is perhaps the best-studied drug and 10-40 mg is usually given in divided doses before meals and at bedtime. Although metoclopramide is generally well-tolerated, side effects can result in galactorrhea, irregular menses, or erectile dysfunction, and metoclopramide may...
Recurrent strictures following primary alignment range in incidence from 45 to 60 22 . A contemporary meta analysis of 203 open and endoscopic primary alignments by Moudouni et al. revealed a urethral stricture incidence of 49 , an incidence of impotence of 22 , and incontinence of 4 1 . These patients were a selected series where periurethral manipulation, primary suturing of the urethra and Foley balloon catheter traction were avoided. This experience convincingly demonstrates that
ID CC A 30-year-old male complains of persistent inability to maintain an erection during intercourse. Discussion Almost 90 of male erectile dysfunction is believed to be of psychogenic origin. Medication- and acute illness-induced erectile dysfunction can also occur. Substances known to cause erectile dysfunction include some tricyclic antidepressants, MAO inhibitors, anticholinergics, ethanol, and amphetamines. Disorders of the hypothalamic-pituitarv axis, thyroid, and kidneys must be ruled out.
B. and Voda, A. M. Midlife women's attributions for their sexual response changes. Health Care Women Int. 2000 21 543-59. 13 Avis, N., Stellato, R., Crawford, S., Johannes, C. and Longcope, C. Is there an association between menopause status and sexual functioning J. Am. Geriatr. Soc. 1972 20 151-8. 15 Bancroft, J. Endocrinology of sexual function. Clin. Obstet. Gynaecol. 1980 7 25381. 26 Rhodes, J., Kjerluff, K., Laugenberg, P. and Guzinski, G. Hysterectomy and sexual functioning. J. Am. Med. Assoc. 1999 282 1934-41. 32 Nurnberg, H., Lauriello, J., Hensley, P. L., Parker, L. M. and Keith, S. J. Sildenafil for sexual dysfunction in women taking antidepressants. Am. J. Psychiatry 1999 156 1664. 33 Caruso, S., Intelisano, G., Lupo, L. and Agnello, C. Premenopausal women affected by sexual arousal disorder traeted with sildenafil a double blind, crossover, placebo-controlled study. Br. J. Obstet. Gynaecol. 2001 108 623-8. 34 Andersson, K. E. and Wagner, G....
The dose of chlorambucil is titrated according to the therapeutic response and the leucocyte count, which should be maintained above 3,000-3,500 cells ml. The maximal dose should not exceed 12-18 mg day (0.1-0.2 mg kg daily). Haematologic toxicity is the most prominent side effect. Myelosuppression is dose dependent and may be profound at doses above 10 mg day and, although reversible, may persist for months after discontinuation of chlorambucil. Haema-tologic and liver function tests should be performed regularly. Higher doses (10-30 mg day) significantly increase the incidence of gonadal dysfunction like amenorrhoea, azoospermia, testicular atrophy and erectile dysfunction 23 . Malignancies seem to occur only at higher doses given for extended periods.
It is importnat to note that transgenic lines used for these studies were developed and are propagated by mating hemizygous GH-transgenic males with normal females, thus automatically selecting against male infertility. Therefore, results obtained in GH-transgenic males from established lines may underestimate the impact of lifelong excess of GH secretion on male reproductive functioning. Patients with acromegaly often experience reduced libido and impotence (53).
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