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 Medication use • Any reference to “male” is only meant to apply to biologic or assigned sex/gender. • Data on Sexual Dysfunction 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 erection • 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 condom • 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 Physiology 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 Penis skin • Combination CNS and Reflex • Nocturnal erection • REM sleep • Cholinergic Activation Erectile Dysfunction • 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 Artery 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 • Testosterone Deficiency • Thryoid • Hypogonadism • Both hyper and hypo caused ED • Commonly seen in Kleinfelters compared to controls • Diabetes • Increased incidence in diabetics compared to controls • 68/1000 vs 26/1000 in general pop Erectile Dysfunction- Neurogenic Etiology • Multiple Sclerosis, • Epilepsy (3x as likely to have ED) • Femoral fractures, • Lumbar spine decompression (seen in 34% of men under 50) Erectile Dysfunction Psychogenic etiologies • Depression • 3800 Swiss Army Men age 18-25: • Strong association between ED and Depression • ?Chicken vs egg • Anxiety • 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 • Antidepressants • SSRIs • Antipsychotics • Risperadone, Phenothiazines • Anticonvulsants • Phenytoin • Antihistamines • H2 Antagonists • Cimetidine • Recreational Drugs • EtOH (“whiskey dick”) • MDMA Erectile Dysfunction- Evaluation • Duration of problem? • Headaches • Sudden or gradual onset? • Fatigue • Previous relationships? • Chest pain • Sexual orientation concerns? • Penile Trauma • History of psych trauma? • Depression • Substance use (incl EtOH) • Anxiety • Persistent vs intermittent • Medications • Problems with sexual desire or ejaculation • Morning erections • Able to masturbate with erections Physical examination • Visual Field Defects • Fundal disks • Breast development • Femoral pulses • Testicular size (atrophy/masses) • Penile strictures (Peyronie’s disease) Lab Evaluation (not necessarily indicated if psychogenic) • Testosterone (first AM level) • Prolactin • TSH • Hepatic/Kidney Function Urology Referral Duplex Doppler imaging Inject with vasodilating agent (PGE) Venous leak Nocturnal Penile Tumescence Testing (NPT) Arterial Obstruction Erectile Dysfunction Treatments • First Line: • REASSURANCE AND SEX EDUCATION • CV Lifestyle Changes • PDE -5 inhibitors • Testosterone if hypogonadic • Psychological Treatment if psychogenic • Second Line: • Vacuum Device • Injectable (alprostadil) or Urethral Suppositories • ”cock ring” • Third Line: • Penile implant • Corrective Surgery 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%) • Priapism (Rare) • NOT to be taken with Nitrites PDE-5 inhibitors • Sildenafil (Viagra) • Tadalafil (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 • Vardenafil (Levitra or Staxyn) • Avanafil (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? Orgasm vs Ejaculation Physiology • Orgasm • Ejaculation • Hyperventilation (40bpm) • Emission • Tachycardia • Closure of bladder neck • Increased BP • Prostatic secretions into urethra • Pelvic muscle contractions • Seminal Vesicle (alkyline) secretions • Ischocavernosis • Bulbocavernossi • Expulsion • Rectal sphincter contraction • Contractions of pelvic striated muscles • Facial Grimacing • Expulsion of secretions out of • Prolactin and Oxytocin release urethra Neural Control of Ejaculation • Dorsal Nerves transmit sensation to spinal cord. Neurochemicals in Ejaculation • Dopamine • Oxytocin • Serotonin • Increases 20-360% post ejaculation • 5HT inhibits ejaculation • (Think SSRIs) • Prolactin • Nitric Oxide • Inhibits sexual desire • Increases after ejaculation • Thyroid hormone • Higher levelsdecreased Ejaculatory latency • Testosterone • Low levelsdelayed ejaculation Premature Ejaculation • 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 Prostatitis • 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 NSLower 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 • ?Prostate 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 therapy 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