i PREVALENCE OF MALE SEXUAL DYSFUNCTION AND ITS CORRELATION AT ANDROLOGY CLINICS IN EGYPT A DISSERTATION BY DR. KHALED ABDEL MONEIM GADALLA A DISSERTATION SUBMITTED TO THE FACULTY OF THE AMERICAN ACADEMY OF CLINICAL SEXOLOGY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY CAIRO, EGYPT 2017 ii Copyright © 2017 by Khaled A. Gadalla All Rights Reserved 3 Dissertation Approval This dissertation submitted by Khaled A. Gadalla has been read and approved by three committee members of the American Academy of Clinical Sexologists. The final copies have been examined by the Dissertation Committee and the signatures which appear here verify the fact that any necessary changes have been incorporated and the dissertation is now given the final approval with reference to content, form and mechanical accuracy. The dissertation is therefore accepted in partial fulfillment of the requirements for the degree of Doctor of Philosophy. Signatures _____________________________ ___________________ Krista Bloom, Ph.D. LCSW Date Committee Chair _____________________________ ___________________ William A. Granzig, Ph.D., FAACS. Date Committee Member _____________________________ ___________________ James Walker, Ph.D., FAACS Date Committee Member 4 Acknowledgments First, I would like to praise and thank Allah (GOD), the most merciful and beneficial for his help to complete this work. I am greatly indebted to Professor Dr William Granzig, Professor Dr James Walker and Professor Dr Krista Bloom, my supervisors, for the guidance and mentorship they rendered to me during the preparation and accomplishment of this dissertation. I would like to acknowledge all members of the American Academy of Clinical Sexologists for their assistance and encouragement during all stages of preparation and accomplishment of this dissertation. I would like to thank all Consultants, Specialists, Residents, Registrars and Nurses at our Man Clinic Andrology Centers and Clinics for all the invaluable assistance and support they offered me during all the stages in the accomplishment of this work. I worked with them very peacefully. Finally, I would like to express my deep gratitude to my parents, my wife and my children-Sara, Omar, Heidi, Shadi & Sandy- for their never ending support throughout all steps of my life. 5 Vita Khaled A. Gadalla received his MD degree from the biggest Islamic university all over the world, Al-Azhar University and working as lecturer of Urology since 2010 and is Fellow of the European Joint Committee of Sexual Medicine, American board of sexology, American Diploma of American board and academy of regenerative medicine, board certified in integrative medicine, and He is one of the most famous Andrologists and Sexologists over Arabic TV shows. 6 Abstract This dissertation in Clinical Sexology examines the prevalence of erectile dysfunction and associated risk factors among men attending Andrology clinics at Man Clinic center for Andrology and Male infertility at Egypt. The results have shown that ED iscommon in our environment. Therefore, there is aneed to upgrade and improve the existing healthcarefacilities, in order to deal with factors responsiblefor its development. Health education on lifestyle modification is also important and can help primarilyin reducing the cardiovascular components of therisk factors. There is also a need for public enlightenment campaigns to reduce stigma andincrease awareness on the causes of ED. This will help in discouraging cultural and traditional approaches to management of erectile dysfunctionin our environment. 7 Table of Contents ACKNOWLEDGENTS……………………………………………………………………………………….. iv VITA……………………………………………………………………………………………………………….. v ABSTRACT………………………………………………………………………………………………………. vi CHAPTER 1: lITERATURE REVIEW 8 A BRIEFON SEXUAL DYSFUNCTION 8 INTRODUCTION………………………………………………………………………………….. 8 CATEGORIES (CLASSIFICATION)…………………………………………………………… 8 CAUSES………………………………………………………………………………………………. 12 LIST OF DISORDERS…………………………………………………………………………….. 15 TREATMENT FOR MALES…………………………………………………………………….. 18 TREATMENT FOR FEMALES…………………………………………………………………. 19 CHAPTER 2: ERECTILE DYSFUNCTION 20 INTRODUCTION…………………………………………………………………………………….. 20 EPIDEIOLOGY………………………………………………………………………………………… 20 ERECTILE DYSFUNCTION IN ARAB COUNTRIES………………………………………. 21 PHYSIOLOGY OF PENILE ERECTION……………………………………………………….. 30 PATHOPHYSIOLOGY AND CAUSES…………………………………………………………. 32 DIAGNOSIS……………………………………………………………………………………………. 37 TREATMENT………………………………………………………………………………………….. 60 CHAPTER 3: 70 METHODOLOGY……………………………………………………………………………………………. 70 CHAPTER 4: 73 RESULTS AND ANALYSIS……………………………………………………………………………….. 73 CHAPTER 5: 91 DISCUSSION AND CONCLUSIONS………………………………………………………………….. 91 GLOSSARY……………………………………………………………………………………………………. 96 LIST OF TABLES……………………………………………………………………………………………. 97 LIST OF FIGURES………………………………………………………………………………………….. 98 REFERENCES……………………………………………………………………………………………….. 99 8 Chapter 1 Literature Review A brief on sexual dysfunction Introduction Sexual dysfunction or sexual malfunction is difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including physical pleasure, desire, preference, arousal or orgasm. According to the DSM-5, sexual dysfunction requires a person to feel extreme distress and interpersonal strain for a minimum of 6 months (excluding substance or medication-induced sexual dysfunction). Sexual dysfunctions can have a profound impact on an individual's perceived quality of sexual life (Nolen-Hoeksema 2014, 366-367). A thorough sexual history and assessment of general health and other sexual problems (if any) are very important. Assessing (performance) anxiety, guilt, stress and worry are integral to the optimal management of sexual dysfunction. Many of the sexual dysfunctions that are defined are based on the human sexual response cycle, proposed by William H. Masters and Virginia E. Johnson, and then modified by Helen Singer Kaplan (Kaplan 1974, 255). Categories (Classification) Sexual dysfunction disorders may be classified into four categories, (1) sexual desire disorders, (2) arousal disorders, (3) orgasm disorders and (4) pain disorders. Sexual desire disorders Sexual desire disorders or decreased libido are characterized by a lack or absence for some period of time of sexual desire or libido for sexual activity or of sexual fantasies. The condition ranges from a general lack of sexual desire to a lack of sexual desire for the current partner. The condition may have started after a period of normal sexual functioning or the person may always have had no/low sexual desire (Coretti & Baldi 2007, 58-59). The causes vary considerably, but include a possible decrease in the production of normal estrogen in women or testosterone in both men and women. Other causes may be aging, fatigue, pregnancy, medications (e.g., SSRIs) or psychiatric conditions, such as depression and anxiety. Loss of libido from SSRIs usually reverses after SSRIs are discontinued, but in some cases it does not. This has been called "Post-Ssri Sexual Dysfunction, PSSD"; however, this is not a classification that would be found in any current 9 medical text. While a number of causes for low sexual desire are often cited, only some of these have ever been the object of empirical research. Many rely entirely on the impressions of therapists (Maurice 2007, 26). Sexual arousal disorders Sexual arousal disorders were previously known as "frigidity in women" and "impotence in men", though these have now been replaced with less judgmental terms. Impotence is now known as erectile dysfunction, and frigidity has been replaced with a number of terms describing specific problems with, for example, desire or arousal (Laan et al. 2008, 1424-35). For both men and women, these conditions can manifest themselves as an aversion to, and avoidance of, sexual contact with a partner. In men, there may be partial or complete failure to attain or maintain an erection, or a lack of sexual excitement and pleasure in sexual activity. There may be medical causes to these disorders, such as decreased blood flow or lack of vaginal lubrication. Chronic disease can also contribute, as well as the nature of the relationship between the partners (Laan et al. 2008, 1424-35). Erectile dysfunction Erectile dysfunction or impotence is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis. There are various underlying causes, such as damage to the Nervi erigentes which prevents or delays erection, or diabetes as well as cardiovascular disease, which simply decreases blood flow to the tissue in the penis, many of which are medically reversible. The causes of erectile dysfunction may be psychological or physical. Psychological erectile dysfunction can often be helped by almost anything that the patient believes in; there is a very strong placebo effect. Physical damage is much more severe. One leading physical cause of ED is continual or severe damage taken to the Nervi erigentes. These nerves course besides the prostate arising from the sacral plexus and can be damaged in prostatic and colo-rectal surgeries (Montague et al. 2005, 230-9). Due to its embarrassing nature and the shame felt by sufferers, the subject was taboo for a long time, and is the subject of many urban legends. Folk remedies have long been advocated, with some being advertised widely since the 1930s. The introduction of perhaps the first pharmacologically effective remedy for impotence, sildenafil (trade