Brian Birch - Sexual dysfunction in men
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Brian Birch - Sexual dysfunction in men
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Brian Birch - Sexual dysfunction in men
- 1. MS Malesexualdysfunction Brian Birch MA MB BChir MD (Cantab) FRCS Honorary Associate Professor Urology University Hospital Southampton NHS FT
- 2. MS and male sexual dysfunction
- 3. MS and male sexual dysfunction Schedule • Basic facts • Loss of desire (Libido) • Ejaculatory dysfunction • Infertility issues • Erectile dysfunction • Summary
- 4. MS and male sexual dysfunction It’s common (75-90%) in both ♀ and ♂ Includes one or more of: • Loss of sexual desire (libido) • Sexual aversion and lack of sexual enjoyment • Failure of genital response • ♂ erectile dysfunction • Orgasmic dysfunction • Premature ejaculation
- 5. MS and male sexual dysfunction Types of SD • Primary SD • Due to neurological damage in CNS • ED, ejaculatory disorders, anorgasmia and sensation • Secondary SD • Physical changes indirectly affect sexual responses • Fatigue, muscle tightness, bladder and bowel dysfunction • Tertiary SD • Psycho-social issues • Body image, emotional challenges, cultural influences • Depression, low self-esteem
- 6. MS and male sexual dysfunction International online study (Marck et al, BMC Neurol, 2016) • Self reported data for PwMS • N=2062 PwMS from 54 countries • 81% ♀, 19% ♂ • mean age 45 yrs • most with relapsing-remitting MS
- 7. MS and male sexual dysfunction International online study (Marck et al, BMC Neurol, 2016) • 55% reported SD • Most common: • Lack of sexual interest (42% ♀) • ED (41% ♂) • Associations with • Age • Depression • Anti-depressant use • fatigue
- 8. MS and male sexual dysfunction Lack of sexual Interest
- 9. MS and male sexual dysfunction Lack of sexual Interest (>30-40%) What is sexual desire? Sexual desire or sex drive (libido) is the urge to engage in sexual activity Psychological elements • how you think of yourself • how you think about a partner • previous positive and negative experiences of sex • cultural and religious factors • your mood Physiological factors such as • hormones (testosterone) • nerve activity in the brain
- 10. MS and male sexual dysfunction Lack of sexual Interest What can I do if I have reduced sexual desire? Stay active Stay social It's not all about orgasm • Expressing love, affection, intimacy and sensuality do not depend on penetrative sex and a relentless quest for orgasm • Taking the focus away from sex
- 11. MS and male sexual dysfunction Delayed or absent orgasms and ejaculation (25-50%) Orgasm Causes contractions in the muscles around the genitals, often accompanied by feelings of pleasure or euphoria. Ejaculation The ejecting of semen from the penis in a series of muscular contractions or spurts. • Usually occur at the same time but they are separate processes. • Despite having an erection and sexual desire and stimulation, some men will find that it is difficult or impossible to reach a climax. • Others may find that the intensity of their orgasm has reduced.
- 12. MS and male sexual dysfunction Ejaculation The Brain The Spinal Cord The Periphery
- 13. MS and male sexual dysfunction Ejaculation
- 14. MS and male sexual dysfunction Ejaculation
- 15. MS and male sexual dysfunction Premature ejaculation What can I do if I have premature ejaculation? Management • Psychosexual counselling • Pharmacological treatment • SSRIs • On demand: dapoxetine (30-60mgs 1-3 hrs before SI) • Daily: sertraline (50-200mgs), paroxetine (10-40mgs) • Topical LA (EMLA cream) • PDE5 inhibitors: sildenafil, tadalafil alone or in combination with SSRIs
- 16. MS and male sexual dysfunction Infertility What can I do if I have no ejaculation and want to start a family? Management • Retrograde ejaculation • Ejaculation with obstruction • Anejaculation
- 17. MS and male sexual dysfunction Infertility: Retrograde ejaculation What can I do if I have no ejaculation and want to start a family? Management • Stop alpha blockers like tamsulosin • Drugs • Alpha agonists (pseudo-ephedrine) • Tricyclic anti-depressants (imipramine) • Urinary sperm retrieval • Prostate massage
- 18. MS and male sexual dysfunction Infertility: No ejaculation What can I do if I have no ejaculation and want to start a family? Management • Penile vibratory stimulation • Electro-ejaculation • Prostate massage • Vasal aspiration (surgical sperm retrieval)
- 19. MS and male sexual dysfunction Infertility: No ejaculation What can I do if I have no ejaculation and want to start a family? Management • Penile vibratory stimulation
- 20. MS and male sexual dysfunction Infertility: No ejaculation What can I do if I have no ejaculation and want to start a family? Management • Electro-ejaculation
- 21. MS and male sexual dysfunction Erectile dysfunction
- 22. MS and male sexual dysfunction Erectile dysfunction Requires • Intact vascular supply • Intact nerve supply • Intact endocrine system • Intact smooth muscles • Right mood
- 23. MS and male sexual dysfunction Erectile dysfunction
- 24. MS and male sexual dysfunction Erectile dysfunction
- 25. MS and male sexual dysfunction
- 26. • Dipstick urine • Lipid profile • Blood sugar (or glycosylated Hb) • Testosterone (? Only if libido reduced) • PSA in men >50 yrs old? MS and male sexual dysfunction Erectile dysfunction
- 27. Alteration of modifiable risk factors Sexual counselling and education Oral agents Local therapies Surgical therapy MS and male sexual dysfunction Erectile dysfunction
- 28. • Smoking minor difference • Alcohol no difference • Obesity no difference (but see below) • Exercise helpful • Pelvic floor exercises helpful MS and male sexual dysfunction
- 29. Class Individual agents Diuretics Thiazides, Spironolactone Antihypertensives Methyldopa, Clonidine, Beta-blockers, Verapamil Cardiac/circulatory Clofibrate, Gemfibrozil, Digoxin, Disopyramide Tranquilisers Phenothiazines, Butyrophenones Antidepressants Tricyclic antidepressants, MAOIs, Lithium, SSRIs H2antagonists Cimetidine, Ranitidine Hormones Oestrogens/progesterone, Corticosteroids, Cyproterone acetate, 5- Alpha reductase inhibitors, LHRH agonists Cytotoxic agents Cyclophosphamide, Methotraxate, Roferon-A Miscellaneous Anticholinergics, Anticonvulsants Best anti-hypertensives = Angiotensin II inhibitors (-sartans’) MS and male sexual dysfunction
- 30. MS and male sexual dysfunction
- 31. • Compounds that have the main site of action in the CNS to activate neural events that result in coordinated signaling that results in the initiation of a penile erection Apomorphine Initiator Conditioner Central Peripheral MS and male sexual dysfunction
- 32. Spinal cord Erectogenic stimuli erotic imagery audiovisual tactile olfactory Inhibitory stimuli anxiety fear depression Cerebral cortex PVN Apomorphine site of action dopamine receptors in PVN PRO-ERECTILE neural signalling Treatment - Action of apomorphine MS and male sexual dysfunction
- 33. • Compounds whose target is the smooth muscle cell where they initiate the muscle relaxation that results in a penile erection Initiator Conditioner Central Peripheral Prostaglandin E1 PGE1(ICI, TU, TD) Papaverine VIP+Phen (ICI) MS and male sexual dysfunction
- 34. MS and male sexual dysfunction
- 35. MS and male sexual dysfunction
- 36. Initiator Conditioner Central Peripheral Testosterone • Compounds that act mainly to improve the internal milieu of the CNS and the local environment so that penile erection is enabled or enhanced.They do not, on their own, initiate an erection. T MS and male sexual dysfunction
- 37. Initiator Conditioner Central Peripheral • Compounds that act mainly to improve the local or systemic internal milieu so that penile erection is enabled or enhanced Sildenafil Vardenafil Tadalafil MS and male sexual dysfunction
- 38. MS and male sexual dysfunction
- 39. Sildenafil (Viagra) • 1991 • Investigation as drug for angina • AE: tendency to get erections • Inhibits PDE5 (and PDE6) • 1998 and on • FDA approval • Evaluated in >100 trials • Overall erections in 77 - 84% • Used in >15,000,000 men MS and male sexual dysfunction
- 40. Comparison of Currently Available PDE5 Inhibitors Avanafil Sildenafil Vardenafil Tadalafil Onset of action 15-30 minutes 30-60 minutes 30-60 minutes 60-120 minutes Duration of action Up to 6 hours Up to 4 - 12 hours Up to 4 - 10 hours Up to 36 hours Effect of food intake Not affected High-fat meals decrease efficacy High-fat meals decrease efficacy Not affected Unique side effects Vision abnormalities (PDE6) Vision abnormalities (PDE6) Back pain, myalgias (PDE11) Patent expiry 2020 2013 2018 2017 MS and male sexual dysfunction
- 41. • Peripheral action (PDE inhibitors) • Sildenafil (Viagra, Pfizer) • Vardenafil (Levitra, Bayer) • Tadalafil (Cialis, Lilly) • Avanafil (Spedra, Menarini) • All are potent inhibitors of PDE5 • All are effective in a wide range of conditions • All are safe • All have similar side effect profiles • All work as well in the elderly as in the general ED population • All are C/I with nitrates MS and male sexual dysfunction
- 42. • At least 4 – 8 attempts • Try first on your own • Avoid excess alcohol / heavy meal • Sexual stimulation / relaxed surroundings • Try all 3 – ‘failure’ may not be true failure • NB • Contraindicated with active nitrate therapy • Caution with alpha-blockers • use shorter acting • start at lower dose MS and male sexual dysfunction
- 43. MS and male sexual dysfunction
- 44. MS and male sexual dysfunction
- 45. Treatment Ladder • Modify Risk Factors • Proper trial of PDE5 inhibitors • (Psychological input if needed and available) ? REFER • Optimise any hypogonadism if appropriate • Discuss Injections, Vacuum device MS and male sexual dysfunction
- 46. MS and male sexual dysfunction Thank-you for your attention
- 47. MS and male sexual dysfunction