Male Sexual Dysfunction: How to work up and manage- by Dr Shahjada Selim

1. Male Sexual Dysfunction:
Workup and Management
Dr Shahjada Selim
Associate Professor, Department of Endocrinology, BSMMU
Faculty in Endocrinology, Texila American University, USA
& EC Member, International Society of Sexual Medicine

2. Male
Hypoactive
Sexual
Desire
Disorder
Premature
(Early)
Ejaculation
Erectile
Disorder
Delayed
Ejaculation
Types of Sexual Dysfunction in Male

3. Hypoactive Sexual Desire Disorder
(HSDD) in Men

4. Krakowsky et al 2016 Management of Sexual Dysfunction in Men and Women:DOI 10.1007/978-1-4939-3100-2

5. There are two possible approaches to the
treatment of male hypoactive sexual desire
disorder:
a.psychotherapeutic approaches and
a.Pharmacological approaches
Treatment of MHSDD
Clayton et al. Burden of phase-specifi c sexual dysfunction with SSRIs. J Affect Disord. 2006;91:27–32.

6. Regarding pharmacological approaches, there are
no effective symptomatic treatments as there are for
other sexual dysfunctions.
Bupropion, has been studied and has shown a
modest effect on women [1].
Flibanserin, an agonist/antagonist of serotonin
receptors, the potential for possible benefit (current
experience is only in research)
….Treatment of Male Hypoactive Sexual Desire Disorder
1. Segraves et al. Bupropion sustained release (SR) for the treatment of hypoactive exual desire disorder (HSDD) in non-depressed
women. J Sex Marital Ther. 2001;27:303–16.

7. Premature Ejaculation (PE)

8. Premature Ejaculation
 It is the most common male sexual dysfunction
 The clinical determination is based on client self
report
 About 30% of men report chronic premature
ejaculation
 There is a current trend to medicalize ED
 Medication should be used in addition to
therapy

9. Important Aspects of History
 Age at onset of disorder
 Frequency of PE (Consistent or Intermittent)
 Circumstance(s) when PE occurs
 Estimate of Intravaginal Ejaculatory Latency
Time (IELT)
 Any other sexual problems (e.g. ED)?
 How has it affected the relationship(s)?
 How has it impacted the sense of well-being?

10. Physical Examination and
“Tests”
 Physical exam is not helpful in diagnosing
condition except in some secondary cases
where neurologic conditions or prostatitis
are entertained
 No laboratory test available to confirm the
diagnosis
 Can consider psychological tests to assess
for anxiety disorder

11. Treatment for PE
 Treat underlying cause (e.g. infection)
if found
 Behavioral interventions
 Pharmacologic Interventions

12. Treatment of premature
ejaculation
Behavioral interventions:
 Treating sex as novelty.
 Fear & performance anxiety.
 Remind the pt about 3 C’s:
 Confidence
 Calmness
 Clear minded.

13. Exercises to cure premature
ejaculation
1. Stop start method
with a squeeze
2.Pelvic floor muscles.
Stop the flow of urine (several
times) while you are peeing
intentionally

14. Exercises to cure premature
ejaculation (cont.)
3.Squeeze
technique
4.Condom

15. Kegel Exercises

16. Pharmacologic Interventions
 Topical anesthetics
 Tricyclic antidepressants (TCAs)
 Selective Serotonin Reuptake Inhibitors
(SSRIs)
 Phosphodiesterase-5 inhibitors (PDE5Is)

17. Topical anesthetics
 Mode of Action: Desensitize penis and
therefore increase IELT
 Example: Lidocaine/prilocaine cream
 How to use: Apply to penis 20-30 minutes
prior to intercourse, wash off before sex
 Potential problems
 Loss of pleasurable sensation for male and
partner
 Contact skin reaction or allergy

18. Lidocaine cream

19. Desensitization cream
 @Marathon cream
 @Enhance male
performance
 @7.5 % benzocaine
 @For climax control
 @Durex play gel

20. Tricyclic antidepressants
(TCAs)
 Mode of Action: presumed to act via
neurotransmitters involved to inhibit ejaculation
 Example: Clomipramine
 How to use: Can take on as needed basis before
intercourse or continuous basis
 Potential problems
 Side effects
 Doses and regimens not standardized (Not FDA
approved)

21. Daily vs As Needed Clomipramine
 In a study* of on demand (OD) clomipramine
use in men with PE, 3 factors predicted likely
success of OD use
 Men with IELTs of greater than 60 seconds
 Men with higher self-reported sexual
satisfaction
 Men who ejaculated 2 or more times per week
*Rowland et. al., Int J Imp Res (2004); 16: 354-357

22. Selective Serotonin Reuptake
Inhibitors (SSRIs)
 Mode of Action: Acts centrally through
serotonin receptors in inhibiting ejaculation
 Example: Paroxetine
 How to use: Can take OD, on a continuous
basis, or a combination of both
 Potential problems
 Side effects
 Doses and regimens not standardized (Not FDA
approved)

23. Oral Therapies- Doses*
Fluoxetine 5- 20 mg/day
Paroxetine 10-40 mg/day or
20 mg 3-4 hrs before
intercourse (BI)
Sertraline 25-200 mg/day or
50 mg 4-8 hrs BI
Clomipramine 25-50 mg/day or
25 mg 4-24 hrs BI
*From Amer Urol Assn Guideline, J Urolog (2004); 172: 290-294

24. Phosphodiesterase-5 inhibitors
(PDE5Is)
 Mode of Action: ?
 having higher cGMP levels might prolong
nitrous oxide (NO) effect by delaying
ejaculatory emission
 Prolong erections – may reduce performance
anxiety since have improved erections
Example: Sildenafil

25. Which Option(s) for Patient
 Consider co-morbidities
 e.g. atopic dermatitis, anxiety
 Side effects
 Expense
 Ultimately a shared decision between
patient and provider

26. Education about PE
 Education is important
 Both men and women have unrealistic expections
about the amount of time spent in intercourse
 15-45 minutes is typical
 Getting men to view women as an intimate sexual
friend is important to therapy
 There are exercise that allow for ejaculatory
control
 Men and women that are able to communicate
comfortably about sexual feelings, techniques
and request prevent relapse

27. Delayed Ejaculation
 Normally, a man can achieve orgasm within the
time needed to finish smoking a cigarette or 2-4
minutes of active thrusting during sexual
intercourse.
 Delayed ejaculation occurs when a man
cannot have an orgasm at all or have an orgasm
after prolonged intercourse for 3O -45 minutes or
more.

28. Delayed Ejaculation
Causes:
1. Psychological: anxiety or distraction from
environment.
2. Physical: adaptation to certain masturbation
technique
Diseases: Diabetes, Hypertension, Stroke or damage
to spinal cord, After pelvic surgery.
3. Side effect of medication e.g. antihypertensive,
antidepressant
4. excessive use of alcohol
Treatment is targeting the primary cause(s)

29. Retrograde ejaculation

30. Retrograde ejaculation does not
interfere with a man's ability to
have an erection or to achieve
orgasm, but it can cause
infertility because the sperm
cannot reach the woman's
uterus.
Retrograde ejaculation is
responsible for about 1% [0.3-
2%] of all cases of male
infertility in the United States.

31. Treatment is only needed when
a man wants to father a child.
Ephedrine tablet is effective or
having sperms taken from the
urine for use in artificial
insemination or in vitro
fertilization.

32. Erectile Dysfunction (ED)

33. Erectile Dysfunction (ED)
 “the consistent or recurrent inability of a
man to attain and/or maintain an erection
sufficient for sexual performance”*
*First International Consultation on Erectile Dysfunction, WHO, 1999

34. Evaluation of Patients with ED
Sexual history
 Onset of Symptoms
 Duration of Symptoms
 Circumstances when ED occurs
Problems with having an erection
Problems with maintaining an erection
 Libido
 Concurrent premature ejaculation

35. Medical History in ED
 Any comorbidities?
 CV disease, Diabetes, Depression, Alcoholism
 Smoker?
 Pelvic surgery, radiation, or trauma?
 Neurologic disease?
 Other endocrine disorders?
 Recreational or prescribed medication use?

36. Medications Known to Cause ED
• Anti-hypertensives: - Diuretics
- Beta-blockers
- Calcium channel blockers
- Centrally acting drugs
• Cardiac medications:- Digoxin
• Psychotropic medication: - Major tranquillizers
- Anti-depressants
- Anxiolytics
• Anti-androgens
• 5 alpha-reductase inhibitors
• Hormones

37. Physical Examination
 Blood Pressure Measurement
 Testicular Exam
 Exam of Penis
 Vascular and Neurologic Exam if indicated

38. ED Screening Tool
International Inventory of Erectile Function (IIEF) Score
IIEF Score ED Status
26- 30 Normal
22- 25 Mild ED
17-21 Mild to Moderate ED
11-16 Moderate ED
6-10 Severe ED
A series of questions to determine how severe it is
https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/iief.pdf

39. Laboratory Tests
Aim is to identify/confirm specific etiologies
(eg, hypogonadism or co-morbidities eg, DM,
dysrlipidemia)
Recommended tests typically include
 HbA1C
 Lipid Profile and
 Hormone profile (FT4, TSH, T, PRL).
Additional lab tests may be done in concurrent
illnesses.

40. Neuro-physiological TestsVascular Tests
• Color Duplex Doppler Penile
USG (CDDPU)
• ICI (intracavernous injection
pharmacotesting); office test
• Dynamic infusion
cavernosometry
/cavernosography (DICC)
• Penile-brachial index
• Selective internal pudendal
arteriography (SIPA)
 Bulbocavernous reflex latency
(BRL) test:- most ↑ rated (2B)
for ED.
 Nocturnal penile tumescence
& rigidity (NPTR)
 Corpus cavernosal-EMG (CC-
EMG)
 Biothesiometry (penile
vibration sensation testing)
Endothelial Dysfunction tests: Proposed for routine use
recently.
• Forearm occlusion methods or
• Simple office recording methods (EndoPat)

41. Treatment of ED
 Identify and Treat Organic Comorbidities
and other risk factors
 Counsel and Educate the Patient and
Partner
 Identify and Treat any Psychosexual
Dysfunctions
 Medications and Devices
 Surgery

42. Treatments
Lifestyle modifications
Weight loss
Increase Exercise
Smoking Cessation

43. Oral Drug Therapies
 Phosphodiesterase Type 5 Inhibitors
(PDE5I)
 Yohimbine
Surgical Methods

44. Use of PDE5 Inhibitors
 All are almost similarly effective
 75% of men on medications have
satisfactory erection to complete intercourse
 No large head-to-head trials to compare the
3 available medications
 Some patients prefer one over the others

45. PDE-5i Standard
Dose
Take (h)
Prior to Sex
Duration (h)
of Action
Sildenafil 50-100 mg 1.0 < 4
Tadalafil 10-20 mg 0.5 - 12 36
Vardenafil 10-20 mg 0.5-1.0 < 5
Avanafil 50-200 mg 30 > 6
Comparison of PDE5 Inhibitors
*Based on average price reported

46. PDE5 Inhibitors
Precaution/contraindication
• Nitrates (12/24 h separation)
• Guanylate cyclase
activators (pulmonary
hypertension)
• Protease inhibitors
(ritonavir, saquinavir)
• Alpha blockers
• CYP3A4 inhibitors
(grapefruit juice)
• Poor cardiac reserve
(2 flights of stairs)
Side effects
 Headache
 Facial flushing
 GI effects (Heartburn)
 Nasal congestion
 Visual disturbances:
- PDE6 inhibition
-Diplopia, blurred vision
 Myalgia

47. Patient Counselling about PDE5is Use
 Still require sexual stimulation to have
erection
 Sildenafil’s absorption may be reduced by
foods – especially fatty foods
 Expect maximal efficacy in 1 hour (2 hours
after tadalafil)
 First few doses may not be successful –
try 6-8 times before giving up

48. Follow-up
 Recommended for all patients
 Efficacy
 Side Effects
 Any significant change in health status
(including new medications)

49. Algorithm for PDE5i Prescription
Patient with ED
Sexual activity
Frequency
≤2/week
Predictable Not Predictable
Sildenafil/Avanafil/
Vardenafil On
Demand
Tadalafil
On Demand
≥3/week
Tadalafil 5 mg daily +
On Demand extra dose

50. Why Treatment Failures
 Food or Drug interactions
 Timing of Dose
 ?Maximal Dose
 Lack of Sexual Stimulation
 Heavy Alcohol Use
 Relationship Problems

51. Yohimbine for ED
 Derived from the bark of the yohimbine
tree in Central Africa
 Traditionally used to treat all forms of
impotence
 Believed to work through the Central
Nervous System
 An alpha-2 adrenoreceptor blocker

52. Yohimbine for ED
 Meta-analysis shows yohimbine superior to
placebo (Odds ratio of 3.85)*
 Relatively safe medication
 Low cost
 American Urology Association does not
recommend its use at this time
*Ernst, Pittler; J Urol (1998); 159: 433-436

53. • Anti-coagulation
• Poor penile sensation
• Poor cognitive
function
• Peyronie’s disease
Vacuum Device
Therapy
Precautions &
Contraindications
Otto Lederer (patent with technical drawing for his vacuum device from 1913).

54. Intracavernosal Injection Therapy
 PGE1: cAMP activator
Alprostadil/Caverject
• Papaverine: non-specific PDE
inhibitor
• Phentolamine: nonselective α-
blocker
• Bypasses neural input
• CCSM health affects
efficacy
Agents
Technique
Papaverine & Phentolamine (Androskat)
Papaverine, Phentolamine & PGE1 (trimix)
VIP & phentolamine (invicorp®)
Combination
• Direct injection into corpus
cavernosum
• 2/10 o’clock positions

55. Intracavernosal Injection(ICI)
Therapy
Precautions
• H/o Priapism
• Conditions predisposing to
priapism: Sickle cell disease,
Multiple myeloma
Leukemia.
• MAOI drugs
• Coagulopathy
• Poor manual dexterity
• Poor vision
• Peyronie’s dis.
Side effects
 Priapism
 Bruising
 Pain (PGE1
hypersensitivity)
 Cavernosal fibrosisAnticoagulation is not a contraindication

56. Intra-urethral PGE1 (MUSE)
• Priapism
• Urethral bleeding
• Penile pain (PGE1
hypersensitivity)
• Inconsistent
response
• Vaginal irritation
Complications
•PGE1- Both ICI &
intraurethral are effective;
• Injection is more effective

57. Surgical Treatment for
Erectile Dysfunction
Surgery Evidence Scope/Indication
Arterial revas-
cularization
Retrospective studies; No
comparative prospective,
randomized study
Very Limited/ Strict selection criteria.
Age<55, Isolated IP artery stenosis,
Non- smoker, no DM or CVOD
Cavernous
veno-occlusive
dysfunction
(CVOD)
Controvertial & Invest-
igational. Selection Criteria
yet to be unequi-vocally
developed.
Penile
prosthesis
Numerous studies have
shown ↑ satisfaction rates
for both partners.
•Failed /contra-indicated medical Rx
and other therapies.
• Well-motivation to continue sexual
activity.

58. Types
• Malleable (non-inflatable)
• 2-piece inflatable (no reservoir)
• 3-piece inflatable (reservoir)
 Infection (3%)
 Mechanical malfunction (20%)
 Crossover
 Perforation: urethral / crural
 Mis-sizing
 Delayed erosion
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 66
Penile Prosthesis
Complications

59. Malleable Penile prosthesis

60. Summary of Treatment of ED
 Causes of ED need to identified and targeted
first
 Patient counseling, life style modification &
initial medical therapy constitute the basic
management of ED.
 Oral PDE5I constitute the 1st line of medical
therapy

61. Summary of Treatment of ED
 Vacuum erection device is an alternative in
1st line therapy.
 Intracavernous, intraurethral and topical
pharmaco-therapy are in 2nd line therapy.
 Penile prosthesis is an ultimate & surgical
alternatives.