CROSS-SECTIONAL ASSOCIATIONS OF UROGENITAL PAIN AND SEXUAL FUNCTION IN A COMMUNITY BASED COHORT OF OLDER MEN: OLMSTED COUNTY, MINNESOTA

Chronic scrotal pain may lead to reduced sexual function and interest, while sexual activity may worsen chronic scrotal pain: "double jeopardy"

Background

While it is recognized that chronic pain may adversely impact sexual function and activity in men and we also recognize that sexual activity may worsen the pain for men with chronic scrotal pain (CSP), the effect on sexual functioning and conversely the impact of sex on CSP has not previously been documented.

Methods

Retrospective analysis of a prospectively collected database.

Results

From Feb 2014 to Sep 2015, a total of 128 men presenting for assessment of CSP completed all or parts of a standardized questionnaire. Overall 60% (69/116) of the men felt that the CSP had kept them either a "lot" or "some" of the time from sexual activity and 64% (27/43) had evidence of decreased erectile performance. Those with more severe pain (analog pain scores 7-10/10) had more significant sexual dysfunction than those with less severe pain, with 54% (45/83) vs. 0% (0/33, P<0.01: Fisher's exact test) noting that the pain kept them from sexual activity "a lot" and 70% (23/33) vs. 40% (4/10, P<0.01) noting sexual dysfunction. Diminished libido was also common in the men [43% (55/128)] as were the symptoms of testosterone deficiency [76% (97/128)]. Conversely, sexual activity often exacerbated the pain, with 37% (47/128) finding that ejaculation aggravated their pain and another 38% (48/128) patients found sexual activity aggravated their pain.

Conclusions

Men with severe CSP have significantly reduced sexual function and interest compared to men with moderate or minor levels of pain. The majority of men with CSP who were sexually active were faced with worsening pain with sex and ejaculation. Clinicians should be aware of the twin risks of sexual dysfunction occurring in men with CSP and sexual activity worsening the severity of the CSP.

The pathophysiology of delayed ejaculation

Delayed ejaculation (DE) is probably least studied, and least understood of male sexual dysfunctions, with an estimated prevalence of 1–4% of the male population. Pathophysiology of DE is multifactorial and including psychosexual-behavioral and cultural factors, disruption of ejaculatory apparatus, central and peripheral neurotransmitters, hormonal or neurochemical ejaculatory control and psychosocial factors. Although knowledge of the physiology of the DE has increased in the last two decade, our understanding of the different pathophysiological process of the causes of DE remains limited. To provide a systematic update on the pathophysiology of DE. A systematic review of Medline and PubMed for relevant publications on ejaculatory dysfunction (EjD), DE, retarded ejaculation, inhibited ejaculation, and climax was performed. The search was limited to the articles published between the January 1960 and December 2015 in English. Of 178 articles, 105 were selected for this review. Only those publications relevant to the pathophysiology, epidemiology and prevalence of DE were included. The pathophysiology of DE involves cerebral sensory areas, motor centers, and several spinal nuclei that are tightly interconnected. The biogenic, psychogenic and other factors strongly affect the pathophysiology of DE. Despite the many publications on this disorder, there still is a paucity of publications dedicated to the subject.

[Painful ejaculation]

OBJECTIVE

To clarify definition, epidemiology, diagnosis, evaluation, etiologies and treatment of painful ejaculation (PE).

MATERIAL AND METHODS

Review of the literature performed by searching the Medline database using keywords ejaculation, orgasm, pain, pelvic pain, sexual behavior.

RESULTS

PE is a pelviperineal pain caused by ejaculation or orgasm. Its prevalence rate is between 1 and 4% amongst the general population. Mainly located in the penis, pain usually lasts less than 5 minutes. Assessment is clinical and there is no level of evidence about the strategy of complementary investigations. Benign prostatic hyperplasia, chronic pelvic pain syndrome, radical prostatectomy, prostate brachytherapy and some antidepressant medications are the best estimated etiologies found in the literature. A link between urogenital infections and PE is likely but not clearly established. Alpha-blockers had good therapeutic results in few low level of evidence studies.

CONCLUSION

The assessment of PE is not clearly defined. Some etiologies are known but PE may be a functionnal pain. Only high level of evidence studies would validate the use of the alpha-blockers as an efficient therapeutic option.

A systematic review of the correlates and management of nonpremature ejaculatory dysfunction in heterosexual men

INTRODUCTION

A better understanding of ejaculatory disorders has led to an increasing interest in nonpremature ejaculatory dysfunction (non-PE EjD). Current reviews on the subject use a symptom-based classification to describe ejaculatory dysfunction even when it is a single case report. While these reviews provide important information on the disorder, a clearer picture of the prevalence of non-PE EjD in relation to the community and various pathophysiologic states is needed.

OBJECTIVES

The objective of this study was to provide a systematic review of studies of non-PE EjD excluding single case reports.

METHODS

A systematic review of Medline for terms including ejaculation, orgasm or hematospermia. Association with terms delay, pain or headache was made. The search was restricted to male gender and articles written in English. Abstracts were reviewed and those mainly concerned with premature ejaculation were excluded.

RESULTS

A total of 333 articles on non-PE EjD were identified. The condition was reported in community-based studies. In certain patient populations, non-PE EjD was commonly reported in association with antidepressant and antipsychotic treatments, in patients with chronic prostatitis/chronic pelvic pain syndrome, patients with lower urinary tract symptoms particularly in association with medical or surgical treatment, patients with retroperitoneal surgery and in patients with neurological diseases. Few articles were concerned with treatment options.

CONCLUSION

There is a significant prevalence of non-PE EjD in the community and in association with particular disease states or as a side effect of medical or surgical interventions. There is a need to direct efforts to prevent and treat these conditions.

Prostatic disease and sexual dysfunction

Prostatitis and benign prostatic hyperplasia (BPH) are common prostatic diseases. Furthermore, the incidence of prostate cancer has recently shown a rapid increase, even in Korea. Pain caused by prostatitis may induce sexual dysfunction, including erectile dysfunction and ejaculatory disturbance. And BPH itself, or treatments for BPH, may affect sexual function. In addition, with increased detection of localized prostate cancer, surgical treatments and radiation therapy have also increased, and the treatments may cause sexual dysfunction. Aging is also an important factor in the deterioration of the quality of life of men. Deterioration of quality of life caused by prostate diseases may be affected not only by the prostate diseases themselves but also by the sexual dysfunction caused by the prostate diseases secondarily. Thus, consideration of these points at the time of treatment of prostate disease is required. Therapies suitable to each condition should be selected with an understanding of the close association of prostate diseases and associated sexual dysfunction with the quality of life of males.

Evaluation of sexual function in men with orchialgia

This study examined the effect of chronic scrotal pain on sexual function using the International Index of Erectile Function (IIEF). We enrolled 50 patients with symptoms consistent with orchialgia and 50 control subjects without orchialgia, who were healthy, sexually active, married, and age-matched. Both groups were evaluated using the IIEF questions for sexual function, and quality of life was investigated using the abbreviated version of the World Health Organization Quality of Life Questionnaire. A significant difference was found in the values of orgasmic function, intercourse satisfaction, sexual desire, overall sexual satisfaction, and total IIEF scores between the patient and control groups; however, there were no significant group differences in the IIEF scores related to erectile function. In the patient group, 39 of 50 subjects reported decreased sexual desire and satisfaction due to a decrease in frequency of sexual activities. Thus, investigation of sexual function was essential for these patients in order to determine the adequate management and treatment of chronic orchialgia.

Predictors of men's sexual desire: the role of psychological, cognitive-emotional, relational, and medical factors

The aim of this study was to evaluate the main predictive factors of male sexual desire, considering medical, psychological, and relationship factors. The study assessed 205 men from the general population on the following variables: psychological adjustment, dysfunctional sexual beliefs, automatic thoughts and emotions during sexual activity, dyadic adjustment, and the presence of medical conditions. Regarding cognitive and emotional factors, restrictive attitudes toward sexuality (β = -.27), lack of erotic thoughts during sexual activity (β = -.35), concerns about erection (β = -.26), emotions of sadness (β = -.23), and shame (β = -.23) in a sexual context were significant predictors of sexual desire. Dyadic adjustment and the presence of medical conditions were not significant predictors of male sexual desire. A multiple regression analysis including all these variables, in addition to age, indicated that lack of erotic thoughts during sexual activity was the only significant predictor of sexual desire (β = -.28). These findings suggest the importance of cognitive dimensions in sexual desire, particularly the role of attentional focus and lack of erotic thoughts during sexual activity.

Longitudinal evaluation of sexual function in a male cohort: the Olmsted county study of urinary symptoms and health status among men

INTRODUCTION

The presence of erectile or ejaculatory dysfunction may indicate physical problems; however, individual perceptions (e.g., sexual satisfaction) may reflect the degree of concern about these changes. Long-term data showing how changes in multiple sexual function domains track together may be useful in understanding the importance of physical declines vs. sexual satisfaction.

AIM

The aim of this study was to describe changes in sexual function among a population-based sample of aging men.

METHODS

A population-based cohort study using data from the Olmsted County Study of Urinary Symptoms and Health Status among Men. Sexual function was assessed biennially from 1996 to 2004 using a previously validated questionnaire in a random sample of 2,213 men.

MAIN OUTCOME MEASURES

Changes in erectile function, libido, ejaculatory function, sexual problems, and sexual satisfaction.

RESULTS

Overall, we observed declines in all of the sexual function domains, ranging from an annual decrease of 0.03 point per year for sexual satisfaction to an annual decrease of 0.23 point per year in erectile function. Moderate correlations were observed among all longitudinal changes in sexual function (range in age-adjusted r(s) = 0.14-0.43); however, significantly smaller correlations between changes in the functional domains and changes in sexual satisfaction and problem assessment were observed among older men (range in age-adjusted r(s) = 0.03-0.29).

CONCLUSION

Overall, these results demonstrate that longitudinal changes in five sexual function domains change together over time in our community-based cohort. Erectile function, ejaculatory function, and sexual drive decrease over time with greater rates of decline for older men. However, older men may be less likely to perceive these declines as a problem and be dissatisfied. These data may prove helpful to patients and clinicians in understanding and discussing changes in multiple aspects of sexual function.

The associations between serum sex hormones, erectile function, and sex drive: the Olmsted County Study of Urinary Symptoms and Health Status among Men

INTRODUCTION

Testosterone replacement therapy has been used in the treatment of sexual dysfunction; however, its use remains controversial, and the effectiveness and long-term health implications are unknown.

AIM

To evaluate the association between sex hormone serum levels, erectile function, and sexual drive in a population-based sample of men.

METHODS

A stratified random sample of men residing in Olmsted County, Minnesota, completed a questionnaire containing questions from the Brief Male Sexual Function Inventory (BMSFI), and participated in a clinical exam, which included serum hormone measurements.

MAIN OUTCOME MEASURES

Levels of sexual drive (libido) and erectile function as assessed by the BMSFI and serum testosterone, bioavailable testosterone, and estradiol measurements.

RESULTS

Out of 414 men, 294 had a regular sexual partner and androgen measurements at the 14th year of follow-up. Total testosterone and erectile function were significantly correlated even after adjustment for age (r = 0.12, P = 0.04). Conversely, total testosterone was not significantly correlated with sex drive (r = 0.08, P = 0.17). Bioavailable testosterone was significantly correlated with both erectile function and sex drive (r = 0.16, P = 0.01 and r = 0.20, P = 0.001, respectively). However, these associations disappeared after age adjustment (r = 0.04 and r = 0.09).

CONCLUSIONS

These cross-sectional results suggest the relationship between sex hormones and sexual function is complex, and that the age-related decline in sexual function may be due to age-related declines in levels of bioavailable testosterone rather than total testosterone levels.

Urogenital infections and male sexuality: effects on ejaculation and erection

The relation of urogenital infections and sexual dysfunction in men was largely neglected in the past but has attracted increasing interest recently. Despite direct anatomical and physiological interactions of the pelvic structures, an adverse effect of chronic prostatitis on quality of life and well-being should be considered to be another crucial point for any sexual disorder. Erectile dysfunction, premature ejaculation and painful ejaculation are the leading sexual symptoms in urogenital infections. On the other hand, chronic prostatitis has been found with a high frequency especially in men presenting with secondary premature ejaculation and the importance of a careful physical and microbiological examination of the prostate before any pharmacologic or psychosexual therapy for sexual disorder should be considered.

Snoring as a risk factor for sexual dysfunction in community men

INTRODUCTION

Severe obstructive sleep apnea has been associated with sexual dysfunction; however, it is unclear whether milder forms of sleep disturbances might also be associated with sexual problems.

AIM

To evaluate the association between snoring and five measures of sexual dysfunction in a population-based sample of men.

METHODS

A stratified random sample of men residing in Olmsted County, Minnesota completed a questionnaire containing questions from the Brief Male Sexual Function Inventory (BMSFI) and a sleep questionnaire.

MAIN OUTCOME MEASURES

Levels of sexual drive (libido), erectile function, ejaculatory function, sexual problem assessment, and sexual satisfaction as assessed by the BMSFI.

RESULTS

Of 827 men with a regular sexual partner, subjects were divided into categories of heavy (N = 95), moderate (N = 573), and none/mild (N = 159) snoring. Their median age was 64 years (range 51-90). The sexual satisfaction domain score was significantly lower in the heavy snoring group (P value = 0.01). The odds of low sexual satisfaction was 2.3 (95% CI 1.2, 4.1) among the heavy snorers compared with the none/mild snoring group. This association remained statistically significant after adjustment for smoking, medical comorbidities, and mental health status. However, there was no significant difference in ejaculatory function, erectile function, sexual drive, and sexual problem assessment across snoring categories.

CONCLUSIONS

These data provide evidence of an association between snoring severity and reduced sexual satisfaction in a population of elderly community males. Snoring was not associated with biologic measures of sexual dysfunction.

Painful ejaculation

We reviewed previous publications on post-orgasmic pain with reference to prevalence, epidemiology and treatment options, using the Ovid and PubMed (updated May 2006) databases to comprehensively search MEDLINE for reports on post-orgasmic pain that included peer-reviewed English-language articles. Official proceedings of internationally known scientific societies were also assessed. Because of the heterogeneity of the studies we did not apply meta- analytic techniques to the data. The incidence of post-orgasmic pain is 1-9.7%. The ejaculatory pain is associated with prostatitis, chronic pelvic pain syndrome, benign prostatic hyperplasia, and ejaculatory duct obstruction; it is also described in patients after procedures like radical prostatectomy. Aetiopathogenic theories include those referring to bladder neck closure and pudendal neuropathy. The treatment options vary from self-care, a 'perineal hyperprotection programme' to medication with the alpha-blocker, topiramate, and even surgical procedures like removing a section of the sacrotuberous ligament, neurolysis of the pudendal nerve or removing a section of the sacrospinous ligament. This is the first update of the subject, with reference to prevalence, epidemiology and treatment options. There is a need for adequately powered, prospective randomized trials on aetiology and treatment options.

Diabetes and sexual dysfunction: results from the Olmsted County study of urinary symptoms and health status among men

PURPOSE

We examined the association of diabetes and domains of sexual dysfunction in a population based sample of men residing in Olmsted County, Minnesota.

MATERIALS AND METHODS

A cohort of 2,115 white men 40 to 79 years old as of January 1, 1990 was randomly selected from the Olmsted County population. Men who had a history of prostate or bladder surgery, urethral surgery or stricture, or medical or other neurological condition that could affect normal urinary function were excluded from analysis. Diabetes itself was not used as an exclusionary criterion, although those with end stage organ failure as a result of diabetes were excluded. A previously validated male sexual function index was included in the questionnaires administrated to the cohort in 1996, which consisted of 11 questions on the 5 sexual function domains of sexual drive, erectile function, ejaculatory function, sexual problem assessment and sexual satisfaction. The baseline questionnaire also included whether they had ever been diagnosed by a physician as having diabetes. Only men with regular sexual partners were included.

RESULTS

Individuals with diabetes at baseline had significantly greater dysfunction in all 5 sexual function domains. In multivariate adjusted analyses diabetes was significantly associated with all sexual dysfunction domains. The associations remained significant after adjusting for numerous predictors of sexual dysfunction.

CONCLUSIONS

The presence of diabetes at baseline was significantly associated not only with erectile dysfunction but with all aspects of sexual dysfunction, including sexual drive, ejaculatory function, sexual problems and sexual satisfaction in this population based sample of men residing in Olmsted County.

Sexual Dysfunction in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Improvement After Trigger Point Release and Paradoxical Relaxation Training

PURPOSE

The impact of chronic pelvic pain syndrome on sexual function in men is underestimated. We quantified sexual dysfunction (ejaculatory pain, decreased libido, erectile dysfunction and ejaculatory difficulties) in men with chronic pelvic pain syndrome and assessed the effects of pelvic muscle trigger point release concomitant with paradoxical relaxation training.

MATERIALS AND METHODS

We treated 146 men with a mean age of 42 years who had had refractory chronic pelvic pain syndrome for at least 1 month with trigger point release/paradoxical relaxation training to release trigger points in the pelvic floor musculature. The Pelvic Pain Symptom Survey and National Institutes of Health-Chronic Prostatitis Symptom Index were used to document the severity/frequency of pain, urinary and sexual symptoms. A global response assessment was done to record patient perceptions of overall therapeutic effects at an average 5-month followup.

RESULTS

At baseline 133 men (92%) had sexual dysfunction, including ejaculatory pain in 56%, decreased libido in 66%, and erectile and ejaculatory dysfunction in 31%. After trigger point release/paradoxical relaxation training specific Pelvic Pain Symptom Survey sexual symptoms improved an average of 77% to 87% in responders, that is greater than 50% improvement. Overall a global response assessment of markedly or moderately improved, indicating clinical success, was reported by 70% of patients who had a significant decrease of 9 (35%) and 7 points (26%) on the National Institutes of Health-Chronic Prostatitis Symptom Index (p < 0.001). Pelvic Pain Symptom Survey sexual scores improved 43% with a markedly improved global response assessment (p < 0.001) but only 10% with moderate improvement (p = 0.96).

CONCLUSIONS

Sexual dysfunction is common in men with refractory chronic pelvic pain syndrome but it is unexpected in the mid fifth decade of life. Application of the trigger point release/paradoxical relaxation training protocol was associated with significant improvement in pelvic pain, urinary symptoms, libido, ejaculatory pain, and erectile and ejaculatory dysfunction.

Sexual dysfunction in the patient with prostatitis

Prostatitis (chronic prostatitis/chronic pelvic pain syndrome ) is a common condition in men that accounts for a significant number of visits to a medical doctor or urologist. It is one of the most widely diagnosed conditions in men who attend urologic clinics. Erectile dysfunction, defined as the consistent inability to obtain and/or maintain a penile erection sufficient for adequate sexual relations, also is a common problem. This review explores the links between sexual dysfunction and prostatitis. Most of the data linking lower urinary tract symptoms and erectile dysfunction suggest that lower urinary tract symptoms impair the overall quality of life and that a low quality of life contributes to or causes erectile dysfunction. Prostatitis-like symptoms such as perineal, penile, and suprapubic discomfort or pain during or after ejaculation and voiding complaints such as irritative and obstructive voiding symptoms (urinary frequency, urgency, and dysuria) may affect the global emotional well-being of a man. Erectile dysfunction also is strongly associated with a negative impact on the quality of life. The available literature demonstrating the influence of CP/CPPS on the incidence of erectile dysfunction is scant. From the literature, it is known that lower urinary tract symptoms and benign prostatic hyperplasia are definitely related to erectile dysfunction. Any kind of pain is likely to be the most significant symptom in men with CP/CPPS as it relates to sexual dysfunction. Sexual dysfunction such as ejaculation discomfort is described as a symptom of CP/CPPS. Most of the data linking the two suggest that CP/CPPS impairs the overall quality of life and it is this that contributes to or causes erectile dysfunction.

Sexual dysfunction in the patient with prostatitis

PURPOSE OF REVIEW

Prostatitis [chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)] is a common condition in men that accounts for a significant number of visits to a medical doctor or urologist. It is one of the most widely diagnosed conditions in men attending urologic clinics. Erectile dysfunction, defined as the consistent inability to obtain and/or maintain a penile erection sufficient for adequate sexual relations, is also a common problem. This review explores the links between sexual dysfunction and prostatitis.

RECENT FINDINGS

Most of the data linking lower urinary tract symptoms and erectile dysfunction suggest that lower urinary tract symptoms impair the overall quality of life and that a low quality of life contributes to or causes erectile dysfunction. Prostatitis-like symptoms such as perineal, penile, and suprapubic discomfort or pain during or after ejaculation and voiding complaints such as irritative and obstructive voiding symptoms: urinary frequency, urgency, and dysuria may affect the global emotional well-being of a man. Erectile dysfunction is also strongly associated with a negative impact on the quality of life.

SUMMARY

The available literature demonstrating the influence of CP/CPPS on the incidence of erectile dysfunction is scant. From the literature, it is known that lower urinary tract symptoms and benign prostatic hyperplasia are definitely related to erectile dysfunction. Any kind of pain is likely to be the most significant symptom in men with CP/CPPS as it relates to sexual dysfunction. Sexual dysfunction like ejaculation discomfort is described as a symptom of CP/CPPS. Indeed, most of the data linking the two suggest that CP/CPPS impairs the overall quality of life and it is this that contributes to or causes erectile dysfunction.