Premature ejaculation diagnosis

An accurate diagnosis based on careful analysis of the various potential biological or psychosocial factors in ejaculatory dysfunction can generally be achieved by taking a meticulous medical and sexual history, followed by a proper physical examination. When PE is suspected, the most important facets of the sexual history are estimated intravaginal latency prior to ejaculation, duration and origin of the problem, any difficulty achieving or maintaining erection, degree of desire, frequency of rapid ejaculation, and its effect on the man and the couple. Questions about quality and duration of erections, ejaculatory control, frequency of intercourse, history of prostatitis or thyroid disease, and pain in either partner during or after sex are also helpful. Additional questions should address both partners' degree of sexual satisfaction and level of distress as well as their desire to correct the problem. It behooves the physician to make all of these inquiries tactfully, but also very thoroughly.

For the sake of effective treatment, it is extremely important to differentiate between PE and ED, as the two conditions may occur together, or the patient himself may mix them up. Some men with PE, for example, erroneously consider their loss of erection after rapid ejaculation to represent ED. The physician must question the patient carefully to determine whether ejaculation or the sensation of ejaculation occurs before the loss of erection, which would support the diagnosis of PE.

Unfortunately, about 90% of men who experience ejaculatory disturbance refuse to volunteer any information about it, unless a physician specifically quizzes them; even then, most are not receptive to any investigation or therapy for it. The causes of this voluntary omission include the associated stigma, embarrassment, shyness, and reluctance to discuss intimate problems. False beliefs about PE range from the notion that it is only temporary and corrects itself spontaneously to the idea that all cases are psychological and that no treatment is successful. Some affected men disregard their partners' sexual needs; others argue that, because their partners do not complain, or can reach orgasm themselves within a few minutes, there is nothing of concern.

The physical exam should focus on signs of chronic illness and endocrine dysfunction, secondary sexual characteristics, neurologic assessment, and palpation of the testicles and penis for abnormalities. Checking the chest for gynecomastia (breast enlargement), the urethra for urethritis, and the prostate for infection are also important for discovering possible etiologic factors.

Prosthesis surgery postoperative follow-up

After implantation surgery, the patient is likely to experience variable levels of discomfort, with possible penile and scrotal swelling. Moderate to marked discomfort may last four to six weeks. A brief or bandage is used to hold the penis up on the lower abdomen; if the prosthesis is an inflatable, it is kept fully or partially deflated. Intercourse and use of the prosthesis is not allowed for four to six weeks, and strenuous physical activities, such as heavy lifting, vigorous exercise, and jogging, are also prohibited.

In postsurgical sessions with the treating therapist, significant issues, such as emotional reactions to the prosthesis, the appearance and size of the penis, and any anxieties about resuming sex, are discussed. The couple is encouraged to voice any concerns, uncertainties, or conflicts. Proper techniques for optimal use of the prosthesis are taught. Instructions are provided on different ways to initiate foreplay and sex and when to stop intercourse after ejaculation.

About four to six weeks following surgery, intercourse may be resumed, but without the inflation of the prosthesis. The man then meets again with the therapist, with or without his sexual partner, to evaluate overall satisfaction with the current sexual relationship, discuss any problems or difficulties that may have occurred in the resumption of intercourse, and help resolve any residual sexual difficulties or marital discord. The therapist checks the proper functioning of the prosthesis and ensures that the patient is able to operate it without difficulty. Only then, if the patient is free of pain and infection, is he allowed to inflate the prosthesis for intercourse.

Postoperative follow-up is extremely important to ensure satisfaction with a prosthesis. Depending on any concomitant sexual issues, psychotherapy may be advisable and additional sexual homework exercises may be assigned. Some individuals or couples may require several follow-up postoperative therapy sessions to attain full sexual satisfaction.

PDE-5 inhibitors failure

A failure with PDE-5 inhibitors may be due to such factors as the patient's age; the nature, etiology, and severity of his sexual dysfunction; improper use of the drug; gradual decrease in the response of the cavernous tissues to chronic use of the medication; a low serum testosterone level; or smoking, among other possibilities. One interesting study of nonresponders to Viagra found severe vascular lesions in the penis and atrophy of penile smooth muscle. And in a study of factors in success or failure with Viagra, response rates were best in cases of veno-occlusive disease and worst in cases of neurogenic ED, while age, smoking, and low IIEF score were the strongest predictors of poor response.

An apparent treatment failure with one of these medications, however, is not necessarily the end of the story, as certain factors contributing to nonresponse may be discovered and corrected. For example, in cases when failure of a PDE-5 inhibitor may be related to low serum testosterone, testosterone replacement by gel or patches applied daily to the skin may result in a good response to the drug. For some patients with elevated levels of low-density lipoprotein (LDL, the "bad" cholesterol), treatment with a cholesterol-lowering drug such as Lipitor (atorvastain) can improve their response to a PDE-5 inhibitor. For other patients, a poor response to PDE-5 inhibitors may be due to low sexual desire, inadequate sexual stimulation, psychological disturbances, poor sexual skills, and/or conjugal problems, which should be addressed with psychotherapy and sex therapy.

An often overlooked, potentially reversible factor in failure with a PDE-5 inhibitor is inadequate patient instruction regarding the need to take four to six pills before giving up and to use the medications properly or risk a poor response. One study of 100 nonresponders to Viagra found that 45 did not use the highest recommended dose, 32 took it on a full stomach right after meals, 22 took it right before initiating intercourse, 12 ignored the fact that sexual stimulation is necessary for response, and 8 used the highest recommended dose despite medical contraindications. On follow-up, after proper instructions were given and reemphasized, 31 of those patients then responded to Viagra. This highlights how important it is for patients to obtain - and follow - precise instructions regarding the use of the PDE-5 inhibitor medications.

Taking adequate doses of PDE-5 inhibitors, avoiding fatty meals for a few hours before and after their ingestion (particularly with Viagra and Levitra), and increasing sexual stimulation can salvage a substantial number of ED cases that did not initially respond to these medications. In certain cases, switching from one drug to another, such as trying Levitra with patients who are not responding to Viagra, may yield good results, although this practice is still controversial.

If treatment with these drugs is a definitive failure, the next move is to try other nonaggressive therapies such as a vacuum device, intraurethral inserts, or intracorporeal injections. Combining a PDE-5 inhibitor with inserts or injections may also yield good results, especially in cases of failure of these therapies alone (but the combination of PDE-5 inhibitors and intracorporeal injections is still not approved). A recent study involving patients with ED following radical prostatectomy, and for whom high-dose Viagra treatment had failed, combined administration of Viagra (50 milligrams) with four biweekly intrapenile injections of alprostadil (synthetic prostaglandin 1, or PGE1) for four weeks. This combination pharmacotherapy demonstrated good results on the patients' IIEF-domain scores, which reflect the degree of erectile improvement and the success of vaginal intromission and intercourse.

How to choose better urologist

No man who suspects he has ED, or has been previously diagnosed with ED, should proceed with any form of ED treatment before consulting a physician with expertise in this area - preferably a urologist - for a complete medical evaluation to detect any medical conditions causing or contributing to his sexual dysfunction.

In choosing a physician and/or therapist, a patient must focus on the clinician's experience, knowledge, skills, character, qualifications, objectivity, past results, and bedside manner as well as the scientific methods he or she applies to the problem and the confidence he or she instills. It is always advisable, if possible, to check with other patients who have been treated by the various physicians or therapists being considered. Such patients can offer valuable insight into the clinicians' skills and the results and satisfaction that can be expected.

The patient must be alert to the so-called specialist who wants to impose opinions on him and be wary of anyone who wants to try nonapproved herbs, potions, lotions, or devices, or who claims expertise in some obscure and unconventional procedure. He must keep away from any physician who refuses to discuss the problem, answer all his questions, or provide all the information he needs on the full range of available treatment options. And of course, he must ensure that he does not fall into the hands of a quack promising a magic pill or potion as a sure and fast cure for his sexual dysfunction.

These remarks carry a connotation of "buyer beware" - and indeed, there is a perception on the part of many people, both inside and outside the medical community, of an ethics problem in the so-called ED trade. Some scientists and clinicians may be too eager for personal recognition and/or financial reward. A researcher, for example, can shade the results of a study into a conclusion that has no basis in factual evidence, or a doctor can apply undue pressure on a patient to undergo an expensive surgical procedure, when a less expensive therapy could yield results as good or better and without the long-term risks and complications.

A man seeking help for a sexual problem must insist on being fully educated about the anatomy and physiology of the sexual organs, the details of normal sexual mechanisms, and the causes of his dysfunction. He must also satisfy himself as to the expertise and general motivation of his doctor or therapist before agreeing to any diagnostic testing and/or treatment. If a patient is not fully confident in the treating clinician, or if he has any lingering doubts about the proposed treatment, he would be wise to seek other medical opinions.

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