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Male sexual function and its disorders: physiology, pathophysiology, clinical investigation, and treatment.

This review is designed to help the reproductive endocrinologist integrate his or her professional activity with those of other disciplines including urology, radiology, neurology, and psychology in order to successfully manage all of the inseparable aspects of male sexual and reproductive functioning. Significant advances in the field of male sexual physiology and pathophysiology and new methods of investigation and treatment of male sexual disorders are outlined. The review synthesizes available data on the following: norms of sexual organs, aging and sexuality, role of central and peripheral neurochemicals in each stage of the sexual cycle, role of corporeal smooth muscles in the hemodynamic control of erection and detumescence, influence of psychological factors, drugs, and disease on all aspects of sexual functioning, and use of nocturnal penile tumescence monitoring, imaging investigations, and neurophysiologic studies in the diagnostic workup of males with sexual dysfunction. Clinical algorithms are presented where appropriate. Extensive discussions on newly developed strategies in psychological and behavioral counseling, drug therapy, tissue engineering, nonsurgical devices, and surgical treatments for all forms of sexual disorders are also provided. Lastly, the effect of sexual dysfunction and its treatment on quality of life in affected men is addressed, along with recommendations for future research endeavors.

Humans↗

Discomforts of the perimenopause.

The transition to menopause is associated with multiple discomforts that affect the whole physical and psychologic self. The physiology of perimenopausal discomforts, treatment modalities, and self-help measures are described. Nurses can teach women about these multisystem effects and promote comfort and a healthy life-style during this time.

Cardiovascular Diseases↗

[The dynamic clinico-physiological indices of sexual function during the management of vertebrogenic pain syndromes].

Sexual changes were registered electrophysiologically in 52 patients with low back pain of vertebrogenic origin. M-response of the bulbocavernous muscle emerged at low threshold. There were shifts in the latency and amplitude of the somatosensory evoked potentials of the brain. These confirm participation of disintegrated functioning of the segmentary and central nervous structures in the genesis of sexual diseases. Treatment-induced positive trends in the above parameters may be used prognostically in relation to the patients' sexual activity.

Adult↗

VIP and drug design.

The following review outlines the physiological outcome of VIP and VIP gene manipulations. Previously, we reviewed the various VIP receptors associated with biological functions ranging from growth regulation, sexual function, bronchodilation, vasodilation and immune interactions to neurotrophism. VIP-based drug design is discussed below.

Animals↗

Reality and expectation of the British National Health Service Consumer.

On the analysis of some 40 000 letters received each year, the author, a medical journalist, has identified nine main categories of queries about health care problems which are not adequately dealt with by the British National Health Services. The problems are concerned with anatomy and physiology, illness, pregnancy and childbirth, contraception, child care, mental health, the old and plastic surgery. By focusing on these unmet needs, a plea is made to rectify the matter.

Adolescent↗

The function of sildenafil on female sexual pathways: a double-blind, cross-over, placebo-controlled study.

OBJECTIVES: To determine the changes, if any, on female sexual pathways using sildenafil (primary outcome), and to verify the safety of this drug (second outcome). STUDY DESIGN: Following previous research on symptomatic women, we wanted to study the effects of sildenafil on asymptomatic women. We would like to make it clear from the outset that this study is part of an ongoing line of research and this drug, and others of its type, should be used under strict medical supervision only on symptomatic patients. A randomized double-blind cross-over, placebo-controlled study was conducted at the Family Planning Centre of the Group for Sexological Research, Department of Microbiological and Gynecological Science, School of Medicine, University of Catania, Italy. Sixty-eight healthy volunteer women aged 19-38 years, asymptomatic for sexual disorders, were enrolled. The study consisted of 4 weeks sildenafil, 2 weeks washout, and 4 weeks placebo, by two possible sequences: sildenafil 50 mg, washout, placebo; or placebo, washout, sildenafil 50 mg. Efficacy of sildenafil was assessed by the Personal Experiences Questionnaire (PEQ) based on the 5-point Likert scale. The questionnaire quantified subjective sexual aspects at baseline, during washout, after treatments, and at the follow-ups. Statistical analysis was done with the Wilcoxon's rank-sum test and Student's t-test. RESULTS: 50/68 women completed the study at the first follow-up, and 38 women reached the second follow-up. Six women withdrew because of adverse events. Sildenafil improved arousal (P<0.001), orgasm (P<0.05), and enjoyment (P<0.001) with respect to placebo. Significant differences were noted during sildenafil usage with respect to the baseline for arousal (P<0.01), orgasm (P<0.001), and sexual enjoyment (P<0.001). The adverse events were transient and mild or moderate. CONCLUSIONS: Our study suggests that sildenafil acts on the different sexual pathways in healthy women, improving their sexual experience. This study could help to understand the physiologic and pathophysiologic aspects of female sexuality. In comparison with current psychosexual therapies, which are long-term, compliance would be improved with use of this drug. Additional studies are required to define the use of sildenafil in a clinical setting.

Adult↗

[Sexual examination of spinal cord injured males].

This article describes the sexual examination of spinal cord injured males. It comprises a clinical interview followed by a neurological exam which purpose is to distinguish the lesion level with respect to sacral and thoracic-lumbar innervation of the genitalia. It also comprises a physiological recording of sexual responses to reflexogenic and psychogenic stimulation. The neurological exam allows prediction of sexual responses in 83% of the cases, while the clinical interview only allows a prediction in 47% of the cases. With this sexual examination it has been possible to determine the sexual capacity of spinal cord injured males, a capacity which is discusses with respect to the lesion level and the type of stimulation inducing erection.

Humans↗

Arginine: Clinical potential of a semi-essential amino acid..

Arginine, a semi-essential amino acid, is involved in numerous areas of human biochemistry, including ammonia detoxification, hormone secretion, and immune modulation. Arginine is also well known as a precursor to nitric oxide (NO), a key component of endothelial-derived relaxing factor, an endogenous messenger molecule involved in a variety of endothelium-dependent physiological effects in the cardiovascular system. Because of arginine's NO-stimulating effects, it can be utilized in therapeutic regimens for angina pectoris, congestive heart failure, hypertension, coronary heart disease, preeclampsia, intermittent claudication, and erectile dysfunction. In addition, arginine has been studied in the treatment of HIV/AIDS, athletic performance, burns and trauma, cancer, diabetes and syndrome X, gastrointestinal diseases, male and female infertility, interstitial cystitis, immunomodulation, and senile dementia. Toxicity, dosage considerations, and contraindications are also reviewed.

Animals↗

Sexual assessment and the aging female.

Due to an increasing population of elders, more women are in need of geriatric gynecologic care. Many of these women are capable of being active sexual partners throughout their lifetimes. However, there are a number of factors that can influence sexual relationships, including personal and societal values, the normal physiologic changes associated with aging and the availability of a sexual partner. Obtaining accurate histories and appropriate physical data regarding sexual functioning are important. Measures that will aid the collection of a complete database, along with pertinent physical assessment, are discussed. Options for treatment and education of the elderly woman in the area of sexual needs are presented to assist health care providers in their role as sex educators and counselors for older women.

Aged↗

Effects of finasteride on serum testosterone and body mass index in men with benign prostatic hyperplasia.

OBJECTIVES: To examine the effect of finasteride on serum testosterone in men with benign prostatic hyperplasia (BPH). METHODS: The Proscar Long-Term Efficacy and Safety Study (PLESS) was a 4-year trial comparing the safety and efficacy of finasteride 5 mg with placebo in 3040 men with moderate to severe symptomatic BPH and enlarged prostates. PLESS included the prospective measurement of annual serum testosterone in a randomly selected subset of patients comprising approximately 10% of the randomized population (n = 301). RESULTS: Finasteride treatment led to a modest, but significant (P <0.001), increase relative to placebo in serum testosterone, with this increase greatest in patients who had low baseline testosterone levels. The larger testosterone increases seen in finasteride-treated patients in the lower baseline testosterone tertiles were associated with significant mean reductions relative to placebo at year 4 in body mass index (BMI), ranging from 0.6 to 0.8 kg/m2. No statistically significant between-group difference was found in BMI in the upper testosterone tertile. The sexual adverse experience profiles for finasteride and placebo were similar across the baseline testosterone cohorts examined. CONCLUSIONS: Finasteride treatment led to a generally modest increase relative to placebo in serum testosterone, with the greatest increases occurring in men with low baseline testosterone levels. The physiologic significance of these changes in men with low baseline testosterone levels is unclear, but the associated reduction in BMI is intriguing and may be related, because BMI is known to be negatively correlated with serum testosterone levels in men.

5-alpha Reductase Inhibitors↗

Psychological perspectives of sex and aging.

Older patients have many assaults on their sexuality. Our culture often discourages sexual interest in older persons. Changes in sexual physiology and the effects of chronic illness and medications can further contribute to negative expectations and can impair sexual performance. The emotional and relational stresses of aging can lead to depression, thus further compounding sexual slowdown. Failure to appreciate psychological factors can result in inappropriate treatment by the physician and actually add to the patient's distress. This report considers the mind/body relationship in sexual performance and offers guidance to the physician in the diagnosis of physical and emotional factors affecting the older person's sexual life.

Aged↗

Sexual response after hysterectomy-oophorectomy: recent studies and reconsideration of psychogenesis.

Recent studies conducted in the United Kingdom show that 33% to 46% of women report decreased sexual response after hysterectomy-oophorectomy. The prevailing theory in the United States for over 30 years in counseling women is that such decreases are infrequent and, if they do occur, are psychogenic. The postulates of the psychogenesis theory were examined and found no longer tenable in the light of current physiologic knowledge of female sexuality, which suggests that when sexual response is diminished after this surgery, hormonal changes (including ovarian androgens) and anatomic changes (removal of the cervix-uterus as a trigger for orgasm in some women) may be etiologic factors. The newer knowledge may now be utilized in counseling the one of four women who reaches menopause through surgery. In cases of decreased response, women may be helped by hormone replacement therapy and/or conjoint sex therapy.

Castration↗

Urogenital atrophy: diagnosis, sequelae, and management.

It is estimated that 17% of our population will be over the age of 65 by the year 2030. As the body ages, many physiologic processes begin to decline. Health-care providers will need to be well-educated in the many sequelae of aging. Practitioners will especially need to focus on the health-care needs of women, since women have a longer life expectancy than men. Estrogen deprivation occurs in all women. Some will not have any symptoms, while others may experience all of its debilitating side effects: hot flashes, osteoporosis, insomnia, irritability, depression, and urogenital atrophy. Even though the latter is not life-threatening, it can alter a woman's quality of life considerably. Because it is easily treatable with minimal risk, all practitioners should become familiar with its presentation and management. This article discusses the many sequelae of urogenital atrophy: vulvovaginal irritation, urinary tract irritative symptoms and infection, urinary incontinence, and sexual dysfunction. Diagnosis and current management strategies are also discussed in detail.

Aged↗

Endocrinology in aging.

Aging is a time of reduced adaptability to metabolic perturbation. This is particularly true in endocrinology which, after all, is the science of chemically regulated biologic systems. There is no evidence that equilibrium concentrations of the principal hormones are altered with age. However, the systems utilized to reach those equilibria become progressively taxed, and new equilibria may be achieved reflecting that regulatory problem. Thus, with advancing age there are significant alterations in hormone production, metabolism, and action. Some of these changes may play a role in the pathophysiology of senescence, although the evidence for that is limited. The magnitude of age-related alterations is highly variable and sex dependent. Whereas only subtle changes occur in pituitary dynamics, adrenal gland physiology, and thyroid function, the changes in glucose homeostasis, reproductive function, and calcium metabolism are more apparent. In the elderly, the interpretation of endocrine tests should reflect the nutritional status of the patient and the presence of coexisting illnesses. In this review, we describe the principles of endocrinology in the geriatric population and elaborate on the changes in specific glandular functions with aging. We also define strategies of evaluation and management protocols appropriate for the elderly with suspected endocrine dysfunction.

Aged↗

The sexuality of spinal cord injured women: physiology and pathophysiology. A review.

After a review of the literature concerning sexuality in spinal cord injured women, the authors studied the female paraplegic sexual responses, dependent on the different levels of injury, above thoracic 10; between thoracic 10 and thoracic 12; and distal to thoracic 12. Allowing for specific sexual differences, genito-sexual innervation appears to be analogous in males and in females. Sexual behaviour is, above all, determined by several neuro-psychological reactions. Pregnancy and delivery are also discussed according to the different levels of spinal cord injury. It is noted that the paraplegic mother and the fetus are exposed to additional risks during pregnancy. During delivery, two problems are considered, autonomous dysreflexia and caesarean section.

Adult↗

Multiple sclerosis and the urologist.

PURPOSE: We provide an updated reference detailing the neurological and urological state of the art approach to multiple sclerosis (MS) with special emphasis on the pathology and physiology, effects on the genitourinary tract, diagnostic evaluation, and treatment of neurological and urological manifestations. MATERIALS AND METHODS: A MEDLINE computerized reference search and manual bibliography review were performed to find pertinent peer reviewed articles on the neurological and urological manifestations and treatment of MS. A meta-analysis was performed on the urodynamic findings of 22 studies involving 1,882 patients from well-defined MS populations. RESULTS: The majority of patients with MS have genitourinary symptoms ranging from urgency, urge incontinence and frequency to urinary retention. Symptoms do not accurately reflect the underlying urological pathology but parallel pyramidal tract dysfunction. Urodynamic evaluation has an important role in determining proper bladder management. The most common urodynamic finding is detrusor hyperreflexia in 62% of these patients, followed by detrusor-sphincter dyssynergia in 25% and hypocontractility in 20%. Less than 1% of patients has renal deterioration and most may be treated with conservative measures. If conservative measures fail, new forms of bladder reconstruction and diversion may be effectively used. The incidence of sexual dysfunction is up to 80% in men and 72% in women, and treatment focuses on improvement of overall disability and erectile or orgasmic function. CONCLUSIONS: Although the genitourinary consequences of MS are rarely life threatening, they can cause significant morbidity and patient frustration. With the rapid advances in the medical management of MS the urologist should be actively involved in multispecialty treatment of these patients.

Female↗

Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function.

OBJECTIVES/HYPOTHESIS: To evaluate the impact of a pelvic fracture on a woman's physical, sexual, and reproductive functioning. DESIGN: Retrospective review. SETTING: Level one trauma center. PATIENTS: Two groups of female multitrauma patients: those with pelvic fractures (subjects) and those with extremity fractures but no pelvic fracture (controls). MAIN OUTCOME MEASUREMENTS: Of the 302 women eligible for participation in this study, 255 (80%; 123 subjects, 118 controls) were interviewed by blinded professional interviewers regarding genitourinary symptoms, sexual function, and reproductive history. RESULTS: Urinary complaints occurred significantly more frequently in subjects than in controls (21 versus 7%, respectively; p = 0.003), in subjects with residual pelvic fracture displacement > or = 5 mm than in those without displacement (33 versus 14%, respectively; p = 0.018), and in subjects with residual lateral (60%) or vertical (67%) displacement than in those with medially displaced fractures (21.4%) (p = 0.04). Although both groups reported increased rates of cesarean section, this increase was statistically significant only in the subject group: 14.5% preinjury versus 48% postinjury (p < 0.0001). Adjusting for previous cesarean sections, cesarean section was significantly more frequent in subjects with fractures initially displaced > or = 5 mm (80%) than in those with fractures initially displaced < 5 mm (15%) (p = 0.02). There was no difference in the incidence of miscarriage or infertility between the groups. Problems with physiologic arousal or orgasm were rare. Pain during sex (dyspareunia) was more common in subjects with fractures displaced > or = 5 mm than in those with nondisplaced fractures (43 versus 25%, respectively; p = 0.04). CONCLUSIONS: We found that pelvic trauma negatively affected the genitourinary and reproductive function of female patients. The increased rate of cesarean section in women after pelvic trauma may be multifactorial in origin and warrants further investigation.

Adolescent↗