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Home , Cock ring, Delayed ejaculation, Ejaculation, Erectile dysfunction, Erection

Sexual Dysfunction in College-Age Males

David S. Reitman, M.D., M.B.A. Medical Director American University Student Health Center

Attending in Adolescent Medicine Associate Professor of Pediatrics Medstar-Georgetown University Hospital Disclosures and Disclaimers

• Nothing to Disclose

• Some Off Label use

• Any reference to “male” is only meant to apply to biologic or assigned /gender.

• Data on tends to be heteronormative.

Case #1: John

• 20 year-old Junior in college • “I can’t believe that I am 20 years-old and having to talk to a doctor about this” • Problems keeping an • Was never a problem before 6 months ago • Drinking at party. Had 4-5 drinks • Went home with a girl (Consensual) • Became erect and started sex with a • 5 minutes into sex, lost the erection John Continued

• 3 weeks later, meets a different girl at a party. Has 1 drink. • During sex, erection loss again • “What’s the matter? Don’t you think I’m pretty enough?” Anatomical Review Erectile Erectile Physiology Other muscles involved in Erection

IschioCavernosus and Bulbocavernosus muscles Put obstructive pressure on Corpus Spongiosum Contribute to engorogement of the glans Nervous Stimulation

• Psychogenic Erection • Fantasy, visual stimulation • Reflexogenic Erection • Stimuli of skin • Combination CNS and Reflex • Nocturnal erection • REM • Cholinergic Activation

• ISSM definition:

Consistent or recurrent inability to attain or maintain a penile erection sufficient to achieve sexual satisfaction. Erectile Dysfunction- Incidence • Increase in rates over the past 10-14 years • 1999: 8% • 2014: 14%

• Recent Surveys • 23%-33% Erectile Dysfunction Etiologies

• Organic • Psychogenic • Cardiovascular • Endocrine • Neurogenic • Medication/substance Induced

Many cases of ED is are a mix of organic and psychogenic Erectile Dysfunction – Cardiovascular Etiology

• Focal Occlusion • Subclinical Endothelial • Direct Trauma Dysfunction • Chronic, repetitive trauma • Mild elevations in • Eg. Bicycling • BP • Collagen and connective tissue • CRP formation in Corpus Cavernosa • Cholesterol and Triglycerides • Carotid intimal-media thickness

• (A harbinger of vascular disease?) Erectile Dysfunction- Endocrine Etiologies • Deficiency • Thryoid • • Both hyper and hypo caused ED • Commonly seen in Kleinfelters compared to controls

• • Increased incidence in diabetics compared to controls • 68/1000 vs 26/1000 in general pop Erectile Dysfunction- Neurogenic Etiology • , • Epilepsy (3x as likely to have ED) • Femoral fractures, • Lumbar spine decompression (seen in 34% of men under 50) Erectile Dysfunction Psychogenic etiologies • • 3800 Swiss Army Men age 18-25: • Strong association between ED and Depression • ?Chicken vs

•

• Longer sexual lives (since first intercourse)Decreased anxiety Acquired Psychogenic ED

Changes in sexual functioning Precipitating Event

Decreased sexual initiation 1st Erectile Failure

Worse performance anxiety Performance anxiety

2nd erectile failure Erectile Dysfunction Medication Induced • Antihypertensives • B- Blockers • • SSRIs • • Risperadone, Phenothiazines • • Phenytoin • Antihistamines • H2 Antagonists • • Recreational Drugs • EtOH (“whiskey dick”) • MDMA Erectile Dysfunction- Evaluation

• Duration of problem? • Headaches • Sudden or gradual onset? • Fatigue • Previous relationships? • Chest pain • concerns? • Penile Trauma • History of psych trauma? • Depression • Substance use (incl EtOH) • Anxiety • Persistent vs intermittent • • Problems with or • Morning • Able to masturbate with erections Physical examination

• Visual Field Defects • Fundal disks • development • Femoral pulses • Testicular size (atrophy/masses) • Penile strictures (Peyronie’s disease) Lab Evaluation (not necessarily indicated if psychogenic) • Testosterone (first AM level) • • TSH • Hepatic/Kidney Function Referral

Duplex Doppler imaging Inject with vasodilating agent (PGE) Venous leak Nocturnal Penile Testing (NPT) Arterial Obstruction Erectile Dysfunction Treatments

• First Line: • REASSURANCE AND • CV Lifestyle Changes • PDE -5 inhibitors • Testosterone if hypogonadic • Psychological Treatment if psychogenic

• Second Line: • Vacuum Device • Injectable (alprostadil) or Urethral Suppositories • ”” • Third Line: • Penile • Corrective Erectile Dysfunction- Treatments PDE-5 inhibitors • They do not create a spontaneous erection! • Common Side effects: • Flushing (12%) • Headache (11%) • Dyspepsia (5 %) • Visual Effects (3%) • (Rare) • NOT to be taken with Nitrites PDE-5 inhibitors

• (Viagra) • (Cialis) • Lasts 4 hours • Much longer duration of action • Take on empty stomach, 40 • Up to 36 hours minutes before sex • Daily low dose for severely impacted men

• (Levitra or Staxyn) • (Stendra) • Similar to Sildenafil • Fastest acting (15-30min peak) • Less Visual disturbance • ODT - faster acting • Avoid with high-fat meals (less absorption) Treatment algorithm

• Normalize the issue • Discuss changing the inner monologue • Rx shorter acting PDE5-I • 3- 5 doses • Trial Run • Reset system Case #2: Gregory

• 19 year-old male, here for physical • Sexarche was approximately 1 year ago • When taking a sexual history denies all concerns. • As you get to the end of the visit, he states that he has a question…

• “Are there any treatments or techniques that can get me to last…y’know….longer?” What do you want to know? vs Ejaculation Physiology

• Orgasm • Ejaculation • Hyperventilation (40bpm) • Emission • Tachycardia • Closure of bladder neck • Increased BP • Prostatic secretions into • Pelvic muscle contractions • Seminal Vesicle (alkyline) secretions • Ischocavernosis • Bulbocavernossi • Expulsion • Rectal sphincter contraction • Contractions of pelvic striated muscles • Grimacing • Expulsion of secretions out of • Prolactin and release urethra Neural Control of Ejaculation

• Dorsal transmit sensation to . Neurochemicals in Ejaculation

• Dopamine • Oxytocin • Serotonin • Increases 20-360% post ejaculation • 5HT inhibits ejaculation • (Think SSRIs) • Prolactin • • Inhibits sexual desire • Increases after ejaculation • Thyroid • Higher levelsdecreased Ejaculatory latency • Testosterone • Low levels

• ISSM Definition • ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration from the first sexual experience (lifelong premature ejaculation), • OR, a clinically significant reduction in latency time, often to about 3 minutes or less(acquired premature ejaculation), • the inability to delay ejaculation on all or nearly all vaginal penetrations, • and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy Other possibilities

Anthropologic Survival Learned Behavior Premature Ejaculation- Epidemiology • 2014- 9000 Swiss males age 18-25 surveyed (mean=19). • Prevalence 11.4% • PE group associated with • less physical activity • Illegal Drug use • Being a student • 2013- Assessment of males using “Premature Ejaculation Diagnostic Tool” • Positive tests in 11.3%-50% Variants on Premature Ejaculation Premature Ejaculation- Organic Etiology • Neurobiology • Chronic • 5- HT1A Serotonin Receptor • Urinary Symptoms • Shortens ejaculatory times • Pelvic/scrotal pain • 5- HT2C Serotonin Receptor • Screponi (2001)- 56% of men with • Increases ejaculatory times PE had chronic prostatic inflammation • Bartoletti (2007) – Men with • ? Ejaculatory delay/PE related to chronic prostatitis had significantly receptor diversity increased rates of PE Premature Ejaculation- Organic Etiology • Endocrine • Testosterone levels Leads to PE • Prolactin levels lead to increased testosterone • Thyroid hormone PE. • Carani (2005)- 50% of hyperthyroid patients had PE. Prevalence decreased to 15% after treatment Erectile Dysfunction- Psychogenic Etiology • PE Guilt, performance anxiety, depression and fear • Men with PE worry about control of ejaculation--> sympathetic NSLower ejaculatory threshold. • Relationship to ED Premature Ejaculation- Evaluation • Lifelong vs Acquired PE • Erectile Function assessment • Relationship impact • Previous Treatment • Impact on life quality Premature Ejaculation Physical Exam and workup • If Aquired PE • GU exam • ? examination • Thyroid hormone? Premature Ejaculation- Treatments

• PSYCHOSEXUAL EDUCATION • Reassurance • Breathing • Practice for longevity • Focus on the sensation

• Kegel Methods • Pastore et al 2014: 82% of men increased IELT • IELT <1min 240 second mean • Results maintained at 6 months

• Tension and release of pelvic floor muscles Premature Ejaculation- Psychotherapy • Indicated if suspicion of psychogenicity • Sex with partner • Frequently not realistic in young males Premature Ejaculation- Medication

• Lidocaine-Prilocaine combination applied 5 minutes before sex

• PDE-5 Inhibitors • Only useful as a first line if ED is also an issue Premature Ejaculation- SSRIs Case #3: Alejandro

• 22 yo Senior. Identifies as gay. • Concerns about inability to ejaculate when with a partner. • This has been a problem for about 2 years • During sex, becomes sore and exhausted

• Not on any medications Delayed Ejaculation

• Primary: Lifelong inability to ejaculate in 75-100% sessions of sexual activity, which causes : • Distress • Exhaustion • Genital irritation • May not lead to ejaculation with • Acquired A distressing lengthening of time (>50%) after a period of normal ejaculatory function • May or may not affect masturbation Delayed Ejaculation- Organic Etiology • Overexpression of 5-HT2C Receptors • Underexpression of 5-HT1A Receptors

• Hormonal: Corona et al (2011) • Decreased Testosterone • Increased TSH and Decreased T4 • Increased prolactin Delayed Ejaculation Medication Interactions • SSRIs • Increased activation of 5--H2C receptors Delayed Ejaculation Althof’s Psychogenic Theory (2012) 1. Insufficient Mental and 3. Disguised Desire Disorder Physical Stimulation • Issues with compulsive sex • Related to decreased tactile • over actual sex stimulation 4. Psychic Conflict • Typically not an issue for young men • Self esteem • Fear of ejaculation • Religious guilt 2. Atypical Masturbation Patterns • Fear of • Fantasy • Masturbatory technique Role of Pornography

• 14% of boys exposed to porn before age 13. • 5.2% view it daily • Sun et al (2016) • 487 college students • Pornography use associated with decreased enjoyment of real-life sex Delayed Ejaculation Treatment • If organic, treat underlying issue • Testosterone replacement (if low T) • Switch to a different SSRI Delayed ejaculation- Treatment for Psychogenic Causes • Insufficient mental stimulation

• Atypical Masturbation Pattern • Masturbatory retraining

• Disguised Desire Disorder • Avoidance of Pornography suggested • Treatment for compulsive sex disorder

• Psychic Conflict • Psychotherapy Conclusions

• Ya gotta ask

• Most sexual dysfunction in young males is psychogenic • (But keep the organic issues in the back of your mind)