Dr. Aaron Spitz's presentation as Associate Professor at UCI Urology. This presentation covers how couples can work together to improve their sexual health.

1. Sexual Dysfunction, a couple’s
concern
Aaron Spitz MD
Orange County Urology Associates
Associate Professor, UCI Urology

2. Sex :why should we care?
• The WHO said ‘sexual health is the integration of
the somatic, emotional, intellectual and social
aspects of sexual being, in way that are positively
enriching and that enhance personality,
communication and love’

4. Erection: it takes some nerve!
Adapted with permission from Goldstein I and the Working Group for the Study of Central Mechanisms
in Erectile Dysfunction. Sci Am. August 2000:70-75.

5. Its about blood flow
Adapted with permission from Miller TA. Am Fam Physician. 2000;61:95-104, 109-110.

6. Blood flow increases to
cause an erection
Adapted with permission from Miller TA. Am Fam Physician. 2000;61:95-104, 109-110.

7. Adapted with permission from Feldman HA, Goldstein I, Hatzichristou DG et al. Impotence and its medical and psychosocial
correlates: results from the Massachusetts Male Aging Study. J Urol. 1994;151(1):54-61.
Moderate ED
Complete ED
Minimal ED
Age-Adjusted Progression of ED
Major Risk Factors for ED:
Aging
Prevalence
(%)
40
48
57
67

8. Causes of Erectile Dysfunction
• Blood vessel disease
– Smoking
– High blood pressure
– Diabetes
– High Cholesterol

9. Don’t be this guy
• Sedentary
• Poor diet choices
• Cigarrettes and alcohol

10. Causes of Erectile Dysfunction
• Nerve Problems
– Diabetes
– Prostate Surgery
– Multiple Sclerosis
– Parkinsons disease
– ALS
– Spinal Cord Injury

11. Causes of Erectile Dysfunction
• Medications
– High blood pressure medications
• Beta blockers
• Thiazide diuretics
– Prostate medications
• Finasteride, Proscar, Avodart
• Lupron
– Antidepressants
• Prozac, Zoloft

12. Causes of Erectile Dysfunction
• Low testosterone
– Common
– Co-factor along with previously mentioned
causes
– Occurs increasingly with age

13. Production and Regulation
of Testosterone

14. Physiological Effects
of Testosterone

15. *Includes 80 subjects currently treated for hypogonadism
Distribution of
Testosterone Levels*

16. Percentage of Age Group
Hypogonadal by Decade
20-2920-29 30-3930-39 40-4940-49 50-5950-59
00
2020
4040
6060
8080
100100
PercentagePercentage
60-6960-69 70-7970-79
Age group (years)Age group (years)
Free T indexFree T index
Total testosteroneTotal testosterone
Adapted from Harman SM, et al. J Clin Endocrinol Metab. 2001;86:724-731.

17. The “blue” standard: Viagra!

18. The discovery process
• Originally developed as a heart pill
• The clinical trial results for sildenafil in
cardiac patients were lackluster BUT…
• Patients noticed a happy “side effect”
• The same dilatory effects in the
coronary arteries were enhanced in the
vascular spaces of the penis

22. Testosterone Replacement

23. Patient expectations

24. What men think they want
Bigger Harder Faster

25. …and lots of it!

26. What men really want
Sexual Habits
REALITY vs WISHFUL THINKING

28. What men with ED really want
from their treatment
• Enables them to have hard erections
• Works consistently, is dependable
• Enables them to satisfy their
partners and themselves
• Restores their self confidence

29. How do the pills work?
• Effective on up to 70 percent of patients
• Some side effects
– Indigestion, stuffy nose, facial flushing,
headache, visual changes, back pain
• Work better with normal testosterone
• Less effective with severe diabetes
• Less effective after prostate surgery

30. How well does testosterone
work?
• Improves libido in most men quickly
• Has only mild effects on erection in
most men initially
• May have more significant effects on
erection over 6 months of use

31. Salvaging failures
• Proper use of Pills
– Patient education
– Dose titration
– Proper number of attempts

32. Viagra tip
• Take on an empty stomach for faster
onset of action

33. All pills
• Avoid excessive alcohol consumption

34. You gotta make it happen
• Sexual arousal must
be initiated by the
patient
• The brain is the
most important sex
organ

35. Don’t forget to increase
dose from the 50mg or
10mg sample size
Majority respond to
100mg viagra or 20 mg
levitra or 20 mg cialis or
200mg stendra
Dose Titration

36. Other tricks
• Actis constriction band
– Diminishes venous leak
• Avoid sex in female superior positions
– Lying prone accentuates venous leak

37. Proper number of attempts
If at first you don’t succeed…..

38. Don’t beat a dead horse
• Pills don’t work for
everyone
• Testosterone doesn’t
work for many
• Lifestyle changes may
improve erections but
for many, not enough

39. Injectable
Medications

40. Vacuum erection device

42. Treating the penis alone is
not enough!
“Good erection” is a neurovascular reflex event
“Good sex”…
– Is a subjective, cognitive experience
– Involves a complex interplay of emotional,
relational and physiologic factors
– Involves this complex interplay in two people
“Good erection” & “good sex” aren’t the same
thing

43. What is sexual health?
“Sexual health is the experience
of the ongoing process of
physical, psychological, and
socio-cultural well being related
to sexuality”
– PAHO, WHO and WAS, 2000

44. Involve couples in the process of
ED management
• Treatment choice should be guided by
patient and partner preference, and is
affected by...
– Acceptability of treatment modality to patient &
partner
– Appropriateness for the couple’s usual pattern
of lovemaking and social needs
– Attitude of the prescribing specialist
– Reported efficacy, safety and side effects
– Cost implications

45. Other conditions
• Rapid ejaculation
– Up to 50% of men
– May be long standing since youth
– May occur later in life with erectile
dysfunction

46. Rapid ejaculation treatment
• Paxil
– Low dose, daily treatment
– Cannot be used “ on demand”
– Very effective
• Sexual therapy
– Sensate Focus
– Takes both partners
– Very effective

47. Other conditions
• Peyronies disease
– Curvature of the penis
– Sudden or gradual onset
– May cause erectile dysfunction or pain
– May go away spontaneously
– Challenging to treat
– Live with it in many cases

48. Peyronies disease

49. Penile traction device

50. Other conditions
• Peyronies disease: treatments
– Penile surgery
• Shorten other side
• Excise scar tissue
• Penile implant
– Injection therapy
• Ziaflex
• verapamit

51. Other conditions
• Inhibited ejaculation/orgasm
– Common
– Thought to be psychological
– May be longstanding from youth
– May occur with change of
partners/widowers
– Challenging to treat

52. Don’t forget to involve
other experts
• Couples counseling to address issues
of desire and intimacy
• Gynecology referral to address issues
of female pelvic pain, prolapse,
incontinence
• Female sexual dysfunction specialty
support

53. Conclusions
• Nothing is certain but death, taxes and
erections if you want them
• Pills have helped many men but not all.
• Penile injections and pumps offer
efficacy when pills fail
• Penile implant offers a good long term
solution
• Sexual health is a couple’s concern.
Ultimately its about intimacy