Sexual (Sex) Problems in Men - Part.2

What Is Erectile Dysfunction?
Also known as impotence, erectile dysfunction is defined as the inability to attain and/or maintain an erection suitable for intercourse. Causes of erectile dysfunction include diseases affecting blood flow, such as atherosclerosis (hardening of the arteries); nerve disorders; psychological factors, such as stress, depression, and performance anxiety (nervousness over his ability to sexually perform); and injury to the penis. Chronic illness, certain medications, and a condition called Peyronie's disease (scar tissue in the penis ) also can cause erectile dysfunction.

What Is Inhibited Sexual Desire?
Inhibited desire, or loss of libido, refers to a decrease in desire for, or interest in sexual activity. Reduced libido can result from physical or psychological factors. It has been associated with low levels of the hormone testosterone. It also may be caused by psychological problems, such as anxiety and depression; medical illnesses, such as diabetes and high blood pressure; certain medications, including some anti-depressants; and relationship difficulties.

How Are Male Sexual Problems Diagnosed?
The doctor likely will begin with a physical exam and a thorough history of symptoms. He or she may order other tests to rule out any medical problems that may be contributing to the dysfunction. The doctor may refer you to other doctors, including an urologist (a doctor specializing in the urinary tract and male reproductive system), an endocrinologist (a doctor specializing in glandular disorders), a neurologist (a doctor specializing in disorders of the nervous system), sex therapists, and other counselors.

What Tests Are Used to Evaluate Sexual Problems?

• Blood tests -- These tests are done to evaluate hormone levels.
• Vascular assessment -- This involves an evaluation of the blood flow to the penis. A blockage in a blood vessel supplying blood to the penis may be contributing to erectile dysfunction.
• Sensory testing -- Particularly useful in evaluating the effects of diabetic neuropathy (nerve damage), sensory testing measures the strength of nerve impulses in a particular area of the body.
• Nocturnal penile tumescence and rigidity testing -- This test is used to monitor erections that occur naturally during sleep. This test can help determine if a man's erectile problems are due to physical or psychological causes.

How Is Male Sexual Dysfunction Treated?
Many cases of sexual dysfunction can be corrected by treating the underlying physical or psychological problems. Treatment strategies may include the following:

• Medical treatment -- This involves treatment of any physical problem that may be contributing to a man's sexual dysfunction.
• Medications -- New medications, such as Viagra or Levitra, may help improve sexual function in men by increasing blood flow to the penis.
• Hormones -- Men with low levels of testosterone may benefit from hormone injections. The FDA has approved the use of a testosterone patch to raise testosterone levels to a normal range. Testosterone replacement by pills and implantable pellets also is being evaluated.
• Psychological therapy -- Therapy with a trained counselor can help a person address feelings of anxiety, fear or guilt that may have an impact on sexual function.
• Mechanical aids -- Aids such as vacuum devices and penile implants may help men with erectile dysfunction.
• Education and communication -- Education about sex and sexual behaviors and responses may help a man overcome his anxieties about sexual performance. Open dialogue with your partner about your needs and concerns also helps to overcome many barriers to a healthy sex life.

Can Sexual Problems Be Cured?

The success of treatment for sexual dysfunction depends on the underlying cause of the problem. The outlook is good for dysfunction that is related to a treatable or reversible physical condition. Mild dysfunction that is related to stress, fear, or anxiety often can be successfully treated with counseling, education, and improved communication between partners.

Can Sexual Problems Be Prevented?

While sexual problems cannot be prevented, dealing with the underlying causes of the dysfunction can help you better understand and cope with the problem when it occurs. There are some things you can do to help maintain good sexual function:

• Follow your doctor's treatment plan for any medical/health conditions.
• Limit your alcohol intake.
• Quit smoking.
• Deal with any emotional or psychological issues such as stress, depression, and anxiety. Get treatment as needed.
• Increase communication with your partner.

When Should I Call My Doctor?

Many men experience a problem with sexual function from time to time. However, when the problems are persistent, they can cause distress for the man and his partner, and have a negative impact on their relationship. If you consistently experience sexual function problems, especially with erectile dysfunction, see your doctor for evaluation and treatment.

Reviewed by the doctors at The Cleveland Clinic Urological Institute. Edited by Charlotte E. Grayson, MD, Oct. 2003. Portions of this page © The Cleveland Clinic 2000-2003

Sexual (Sex) Problems in Men - Part.1

Introduction
Sexual problem, or sexual dysfunction, refers to a problem during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity. The sexual response cycle has four phases: excitement, plateau, orgasm, and resolution.

While research suggests that sexual dysfunction is common (43% of women and 31% of men report some degree of difficulty), it is a topic that many people are hesitant to discuss. Fortunately, most cases of sexual dysfunction are treatable, so it is important to share your concerns with your partner and doctor.

What Causes Sexual Problems?
Sexual dysfunction can be a result of a physical or psychological problem.

• Physical causes: Many physical and/or medical conditions can cause problems with sexual function. These conditions include diabetes, heart and vascular (blood vessel) disease, neurological disorders, hormonal imbalances, chronic diseases such as kidney or liver failure, and alcoholism and drug abuse. In addition, the side effects of certain medications, including some antidepressant drugs, can affect sexual desire and function.
• Psychological causes: These include work-related stress and anxiety, concern about sexual performance, marital or relationship problems, depression, feelings of guilt, and the effects of a past sexual trauma.

Who Is Affected by Sexual Problems?
Both men and women are affected by sexual problems. It is more common in the early adult years, with the majority of people seeking help during their late 20s and early 30s. Sexual dysfunction also is common in the geriatric population, which may be related to a decline in health associated with aging.

How Do Sexual Problems Affect Men?
The most common sexual problems in men are ejaculation disorders, erectile dysfunction, and inhibited sexual desire.

What Are Ejaculation Disorders?
There are different types of ejaculation disorders, including:

• Premature ejaculation -- This refers to ejaculation that occurs before or soon after penetration.
• Inhibited or retarded ejaculation -- This is when ejaculation does not occur.
• Retrograde ejaculation -- This occurs when, at orgasm, the ejaculate is forced back into the bladder rather than through the urethra and out the end of the penis.

In some cases, premature and inhibited ejaculation are caused by psychological factors, including a strict religious background that causes the person to view sex as sinful, a lack of attraction for a partner and past traumatic events. Premature ejaculation, the most common form of sexual dysfunction in men, often is due to nervousness over how well he will perform during sex. Certain drugs, including some anti-depressants, may affect ejaculation, as can nerve damage to the spinal cord or back.

Retrograde ejaculation is most common in males with diabetes who suffer from diabetic neuropathy (nerve damage). This is due to problems with the nerves in the bladder and the bladder neck that allow the ejaculate to flow backward. In other men, retrograde ejaculation occurs after operations on the bladder neck or prostate, or after certain abdominal operations. In addition, certain medications, particularly those used to treat mood disorders, may cause problems with ejaculation.

Continued to Part.2 ....

Reviewed by the doctors at The Cleveland Clinic Urological Institute. Edited by Charlotte E. Grayson, MD, Oct. 2003. Portions of this page © The Cleveland Clinic 2000-2003

Men's Health...Some Facts

Many Married Men Choose A Vasectomy For Birth Control
Approximately half a million vasectomies are performed in the United States each year. A vasectomy is an extremely effective birth control method. A vasectomy does not protect a man from sexually transmitted diseases. The operation does not affect production or release of testosterone, the male hormone responsible for a man's masculine traits, such as sex drive, beard, deep voice, and others.

Correlation Between Obesity In Men And Watching Television
Research shows that men who watch three or more hours of television a day are twice as likely to be obese as men who watch television for less than an hour. Government statistics indicate that the rate of male obesity is 35% for ages 35-44, 35% for ages 45-54, 40% for ages 55-64, 42% for ages 65-74, and 26% for males 75 years and over. Limit your television watching, start eating sensible meals, eliminate after-dinner snacks, and exercise regularly to stay fit.

Men And Heart Attacks
Heart disease is the leading cause of death among men in the United States. 1 in 3 men can expect to develop some major cardiovascular disease before the age of 60. High blood pressure and elevated levels of cholesterol and triglycerides are leading contributors to the development of heart and blood vessel disease. Heightened stress increases your risk ratio. Work with your doctor to develop your own heart healthy program which should include regular exercise and eating foods that are low in fat and high in fiber.

85% Of Lung Cancers In Men Are Related To Smoking
Despite anti-smoking campaigns, health statistics indicate that the rate of male smoking is 33% for ages 25-34, 33% for ages 35-44, 29% for ages 45-64, and 16% for males 65 and over. If you quit smoking, your lungs can begin to repair themselves thereby reducing your risk of developing lung cancer. After 15 to 20 years of non-smoking, your risk of contracting lung cancer becomes similar to someone who never smoked.

High Risk Group For Having A Stroke
Men are 30 % more likely to suffer a stroke than women are. Risk factors for a stroke include high blood pressure, cigarette smoking, and heart disease. Quit smoking, have your cholesterol, triglycerides, and blood pressure checked regularly, and consult your doctor to assess your stroke risk factors.

What causes high blood pressure?

Two forms of high blood pressure have been described--essential (or primary) hypertension and secondary hypertension. Essential hypertension is a far more common condition and accounts for 95% of hypertension. The cause of essential hypertension is multifactorial, that is, there are several factors whose combined effects produce hypertension. In secondary hypertension, which accounts for 5% of hypertension, the high blood pressure is secondary to (caused by) a specific abnormality in one of the organs or systems of the body. (Secondary hypertension is discussed further in a separate section below.)

Essential hypertension affects approximately 75 million Americans, yet its basic causes or underlying defects are not always known. Nevertheless, certain associations have been recognized in people with essential hypertension. For example, essential hypertension develops only in groups or societies that have a fairly high intake of salt, exceeding 5.8 grams daily. In fact, salt intake may be a particularly important factor in relation to essential hypertension in several situations. Thus, excess salt may be involved in the hypertension that is associated with advancing age, African American background, obesity, hereditary (genetic) susceptibility, and kidney failure (renal insufficiency). For additional information about high blood pressure and diet, see the "DASH Diet" article.

Genetic factors are thought to play a prominent role in the development of essential hypertension. However, the genes for hypertension have not yet been identified. (Genes are tiny portions of chromosomes that produce the proteins that determine the characteristics of individuals.) The current research in this area is focused on the genetic factors that affect the renin-angiotensin-aldosterone system. This system helps to regulate blood pressure by controlling salt balance and the tone (state of elasticity) of the arteries.

Approximately 30 % of cases of essential hypertension are attributable to genetic factors. For example, in the United States, the incidence of high blood pressure is greater among African Americans than among Caucasians or Asians. Also, in individuals who have one or two parents with hypertension, high blood pressure is twice as common as in the general population. Rarely, certain unusual genetic disorders affecting the hormones of the adrenal glands may lead to hypertension. (These identified genetic disorders are actually considered secondary hypertension.)

The vast majority of patients with essential hypertension have in common a particular abnormality of the arteries. That is, they have an increased resistance (stiffness or lack of elasticity) in the tiny arteries that are most distant from the heart (peripheral arteries or arterioles). The arterioles supply oxygen-containing blood and nutrients to all of the tissues of the body. The arterioles are connected by capillaries in the tissues to the venous system (or the veins), which returns the blood to the heart and lungs. Just what makes the peripheral arteries become stiff is not known. Yet, this increased peripheral arteriolar stiffness is present in those individuals whose essential hypertension is associated with genetic factors, obesity, lack of exercise, overuse of salt, and aging. Inflammation also may play a role in hypertension since a predictor of the development of hypertension is the presence of an elevated C reactive protein level (a blood test marker of inflammation) in some individuals.

How is the blood pressure measured?

The blood pressure usually is measured with a small, portable instrument called a blood pressure cuff (sphygmomanometer). (Sphygmo in Greek means pulse, and a manometer measures pressure.) The blood pressure cuff consists of an air pump, a pressure gauge, and a rubber cuff. The instrument measures the blood pressure in units called millimeters of mercury (mm Hg).

The cuff is placed around the upper arm and inflated with the air pump to a pressure that blocks the flow of blood in the main artery (brachial artery) that travels through the arm. With the arm extended at the side of the body at the level of the heart, the pressure of the cuff on the arm and artery is gradually released. As the pressure in the cuff decreases, the health practitioner listens with a stethoscope over the artery at the front of the elbow. The pressure at which the practitioner first hears a pulsation over the artery is the systolic pressure. As the cuff pressure decreases further, the pressure at which the pulsation finally stops is the diastolic pressure.

How is high blood pressure defined?

Since blood pressure can be affected by several factors, it is important to standardize the environment with this in mind when blood pressure is determined. For at least one hour before measuring the BP one should avoid eating, strenuous exercise (which can lower blood pressure), smoking, and caffeine intake. Other stresses may alter the blood pressure and need to be considered when blood pressure is measured.

Even though most insurance companies, quite reasonably, consider high blood pressure to be 140/90 and higher for the general population, these levels may not be appropriate cut-offs for all individuals. As a matter of fact, many experts in the field of hypertension view blood pressure levels as a continuum, or range, from lower levels to higher levels. Such a continuum implies that there are no clear or precise cut-off values to separate normal blood pressure from high blood pressure. Individuals with so-called pre-hypertension (defined as a blood pressure between 120/80 and 139/89) may benefit from lowering of blood pressure by life style modification and possibly medication especially if there are other risk factors for end-organ damage such as diabetes or kidney disease (appropriate life style changes are discussed below).

For some people, blood pressure readings that are lower than 140/90 may be a more appropriate normal cut-off level. For example, in certain situations, such as in patients with long duration (chronic) kidney diseases that spill (lose) protein into the urine (proteinuria), the blood pressure is ideally kept at 130/80, or even lower. The purpose of reducing the blood pressure to this level in these patients is to slow the progression of kidney damage. Patients with diabetes (diabetes mellitus) may likewise benefit from blood pressure that is maintained at a level lower than 130/80. In addition, African Americans, who have an increased risk for developing the complications of hypertension, may decrease this risk by reducing their systolic blood pressure to less than 135 and the diastolic blood pressure to 80 mm Hg or less.

In line with the thinking that the risk of end-organ damage from high blood pressure represents a continuum, statistical analysis reveals that beginning at a blood pressure of 115/75 the risk of cardiovascular disease doubles with each increase in blood pressure of 20/10. This type of analysis has led to an ongoing "rethinking" in regard to who should be treated for hypertension, and what the goals of treatment should be.

Isolated systolic high blood pressure

Remember that the systolic blood pressure is the top number in the blood pressure reading and represents the pressure in the arteries as the heart contracts and pumps blood into the arteries. A systolic blood pressure that is persistently higher than 140 mm Hg is usually considered elevated, especially when associated with an elevated diastolic pressure (over 90). Isolated systolic hypertension, however, is defined as a systolic pressure that is above 140 mm Hg with a diastolic pressure that still is below 90. This disorder primarily affects older people and is characterized by an increased (wide) pulse pressure. The pulse pressure is defined as the difference between the systolic and diastolic blood pressures. An elevation of the systolic pressure without an elevation of the diastolic pressure, as occurs in isolated systolic hypertension, therefore, increases the pulse pressure. Stiffening of the arteries contributes to this widening of the pulse pressure.

Once considered to be harmless, an elevation of the pulse pressure is now thought to lead to health problems. In other words, a high pulse pressure is considered an important precursor or indicator of potential end-organ damage. Thus, isolated systolic hypertension is associated with a 2 to 4 times increased future risk of an enlarged heart, a heart attack (myocardial infarction), a stroke (brain damage), and death from heart disease or a stroke. Clinical studies in patients with isolated systolic hypertension have indicated that a reduction in systolic blood pressure by at least 20 mm to a level below 160 mm Hg reduces these increased risks.

White coat high blood pressure

A single elevated blood pressure reading in the doctor's office can be misleading because the elevation may be only temporary. Presumably, such an elevation is caused by the patient's anxiety that is related to the stress of the examination and fear that something will be wrong with their health. The initial visit to the physician’s office is often the cause of a spuriously high blood pressure that may disappear with repeated testing after rest and with followup visits and blood pressure checks. In fact, the suggestion has been made that about one out of four people that are thought to have mild hypertension actually may have normal blood pressure when they are outside of the physician's office. This sort of elevated blood pressure, that is, an increase noted only in the doctor's office, is called white coat hypertension. The name, of course, suggests that the white coat, which is symbolic for the physician, induces the patient's anxiety and a transient increase in blood pressure. A diagnosis of white coat hypertension might imply that it is not a clinically important or dangerous finding.

However, caution is warranted in assessing white coat hypertension. An elevated blood pressure that is induced by the stress and anxiety of a visit to the doctor may not necessarily always be a harmless finding since other stresses in the patient's life may likewise cause elevations in the blood pressure that are not ordinarily being measured. Accordingly, monitoring the blood pressure at home by blood pressure cuff or continuous monitoring equipment or at a pharmacy can help estimate the frequency and consistency of higher blood pressure readings. Additionally, conducting appropriate tests to search for any complications of hypertension can help evaluate the significance of variable blood pressure readings.

Borderline high blood pressure

Borderline hypertension is defined as mildly elevated blood pressure that is found to be higher than 140/90 mm Hg at some times and lower than that at other times. As in the case of white coat hypertension, patients with borderline hypertension need to have their blood pressure taken on several different occasions and their end-organ damage assessed in order to establish whether their hypertension is significant.

Keep in mind that people with borderline hypertension may have a tendency, as they get older, to develop more sustained or higher elevations of blood pressure. Accordingly, they have a modestly increased risk of developing heart-related (cardiovascular) disease. Therefore, even if the hypertension does not appear to be significant initially, people with borderline hypertension should have continuing follow-up of their blood pressure and monitoring for the complications of hypertension.

If, during the follow-up of a patient with borderline hypertension, the blood pressure becomes persistently higher than 140/ 90 mm Hg, an anti-hypertensive medication is usually started. Even if the diastolic pressure remains at a borderline level (usually under 90 mm Hg, yet persistently above 85) treatment may be started in certain circumstances. (See the section below on the approach to the treatment of hypertension.)

What is high blood pressure?

High blood pressure or hypertension means high pressure (tension) in the arteries. The arteries are the vessels that carry blood from the pumping heart to all of the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase the blood pressure. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called “pre-hypertension”, and a blood pressure of 140/90 or above is considered high blood pressure. The systolic blood pressure, which is the top number, represents the pressure in the arteries as the heart contracts and pumps blood into the arteries. The diastolic pressure, which is the bottom number, represents the pressure in the arteries as the heart relaxes after the contraction. The diastolic pressure, therefore, reflects the minimum pressure to which the arteries are exposed.

An elevation of the systolic and/or diastolic blood pressure increases the risk of developing heart (cardiac) disease, kidney (renal) disease, hardening of the arteries (atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are often referred to as end-organ damage because damage to these organs is the end result of chronic (long duration) high blood pressure. Accordingly, the diagnosis of high blood pressure in an individual is important so that efforts can be made to normalize the blood pressure and, thereby, prevent the complications. Since hypertension affects approximately 1 in 4 adults in the United States, it is clearly a major public health problem.

Whereas it was previously thought that diastolic blood pressure elevations were a more important risk factor than systolic elevations, it is now known that for individuals older than 50 years of age systolic hypertension represents a greater risk.