The impotent couple: low desire

The role of testosterone in male sexual function

Sexual function, and testosterone (T) levels, progressively decline in aging men. Associated morbidities and metabolic disorders can accelerate the phenomenon. The specific contribution of low T to sexual function impairment in aging men has still not been completely clarified. Similarly, the role of T replacement therapy (TRT), as well as the combination of TRT with phosphodiesterase type 5 inhibitors (PDE5i) for patients with erectile dysfunction (ED), is still conflicting. Here we aim to summarize and critically discuss all available data supporting the contribution of low T to sexual impairment observed with aging as well as the possible role of TRT. Available data on men with sexual dysfunction show that reduced sexual desire is the most important correlate of male hypogonadism. Conversely, aging and associated morbidities substantially attenuate the relationship between ED and T. TRT is effective in improving sexual function in middle-aged and older subjects but its role is small and extremely variable. Lifestyle interventions can result in similar outcomes to those of TRT. In conclusion, it is our opinion that PDE5i along with lifestyle measures should be considered the first approach for treating ED even in subjects with milder T deficiency. When these interventions fail or are difficult to apply, TRT should be considered.

Body Image and Hypoactive Sexual Desire Disorder Relationship in a Representative Sample of Iranian Women

Objective: Hypoactive Sexual Desire Disorder (HSDD) among women is a complicated one which is created by various factors playing roles. One of the potential concerns related to Body Image (BI) is lack of sexual appeal in women. Body Image is often described as what a person perceives of their body encompassing the biological, psychological and social factors. The present research pursues the goal to investigate the association between BI and HSDD among the reproductive age women in Iran. Materials and methods: The current study is a cross-sectional (descriptive -analytical) research done on 1000 reproductive age included woman (15-49 years), performed by systematic random sampling method. The data collection tool includes the socio-demographics and the sexual desire scale in addition to the revised sexual distress scale to measure HSDD completed as self-report by the samples. Univariate and multivariate regression tests have been used in order to analyze the data. Results: The mean ± SD age of the women participating in the study was 32.09 ± 7.33. Having adjusted the confounder variables' effect by logistic regression multivariate analysis; the odd ratio for HSDD has been analyzed. The findings suggested that the odd ratio for HSDD in those not satisfied or slightly feeling fulfilled with their BI has been OR: 4.2 (95% CI: 1.98-9.05) and OR: 3.9 (95% CI: 2.29-6.65), respectively, times more than the ones highly satisfied with their body image. Conclusion: The present study results indicate that being dissatisfied with BI is a determinant factor of HSDD that is more probable in the people with negative image of their body structure and feeling lack of bodily appeal. Thus it is imperative to pay attention to this factor when analyzing HSDD.

Psychiatric disorders in female psychosexual disorders-a nationwide, cohort study in Taiwan : Psychiatric disorders and female psychosexual disorders

We aimed to investigate whether females with psychosexual disorders were associated with the risk of affective and other psychiatric disorders. A total of 2240 enrolled individuals, with 560 patients with psychosexual disorders and 1680 subjects without psychosexual disorders (1:3) matched for age and index year, from the Longitudinal Health Insurance Database, retrieved from the National Health Insurance Research Database (NHIRD), between 2000 and 2015 in Taiwan. The multivariate Cox regression model was used to compare the risk of developing psychiatric disorders during the 15 years of follow-up. There were 98 in the cohort with psychosexual disorders (736.07 per 100,000 person-year) and 119 in the non-cohort without psychosexual disorders (736.07 per 100,000 person-year) that developed psychiatric disorders. The multivariate Cox regression model revealed that the adjusted hazard ratio (HR) was 9.848 (95% CI = 7.298 - 13.291, p < 0.001), after the adjustment of age, monthly income, urbanization level, geographic region, and comorbidities. Female patients with psychosexual disorders were associated with the risk of psychiatric disorders. This finding could be a reminder for clinicians about the mental health problems in patients with psychosexual disorders.

The Impact of Psychosis on Sexual Functioning: A Systematic Review

BACKGROUND

Sexual dysfunction among psychotic patients is highly prevalent. However, most research has focused on antipsychotic side effects on sexual functioning.

AIM

To provide evidence by means of a systematic review of the literature about the impact of psychosis on sexual functioning among unmedicated patients.

METHODS

Systematic search of MEDLINE (PubMed), Scopus, and Google Scholar for studies that reported sexual functioning among psychotic patients, who were drug-naïve or drug-free for at least 3 weeks before the study. Studies were published in English language between January 1994 and October 2019. We used the approach recommended by PRISMA, and the selection process was carried out by 2 reviewers.

OUTCOMES

The outcome measures were sexual function and sexual dysfunctions.

RESULTS

A total of 734 articles were obtained, 658 were obtained after duplicates were removed, 612 were excluded after reading the title and abstract, and 46 were included for a complete review of the articles. 5 papers were finally included. A total of 770 cases were included in the systematic review. The prevalence of sexual dysfunction in psychosis varied from 16.8% to 70% and in ultra-high state was 50%. It is noteworthy that those ultra-high-risk (prodromal) patients who develop psychosis had higher rates of sexual impairment. Therefore, we found higher rates of sexual dysfunction among untreated patients, both psychotic and ultra-high risk patients, than healthy controls.

CLINICAL IMPLICATIONS

The assessment of sexual behavior should be a part of routine psychiatric examination not only in psychotic but also in ultra-high-risk patients.

STRENGTHS & LIMITATIONS

This is the first systematic review about the impact of psychosis on sexual functioning among unmedicated patients. However, scarce and heterogeneous studies were identified.

CONCLUSIONS

Impaired sexual functioning is common in the onset of psychosis (or during ultra-high-risk state) and prior to the beginning of treatment. This suggests that psychotic symptoms and sexual dysfunction may have common etiological pathways at the psychosocial and neurobiological levels. Vargas-Cáceres S, Cera N, Nobre P, et al. The Impact of Psychosis on Sexual Functioning: A Systematic Review. J Sex Med 2021;18:457-466.

The Development and Validation of the Sexual and Relationship Distress Scale

BACKGROUND

Sexual distress is an important factor in the etiology, maintenance, and treatment of sexual difficulties, and as such, there is a need for validated measures. A limitation in the research and treatment of distressing sexual difficulties has been the lack of validated measures, and in particular, existing measures are unable to measure the impacts at the relationship level and currently focus on intra-personal distress.

AIM

This study sought to develop and psychometrically evaluate a new measure of distress associated with sexual difficulties.

METHODS

An initial pool of 73 items was created from the results of an earlier qualitative study and administered using an online survey to 1,381 participants (462 men, 904 women, and 14 who identified as "other"), along with measures for the purposes of psychometric evaluation including the Female Sexual Distress Scale-Revised, Couples Satisfaction Index 16-item version, Depression Anxiety and Stress Scale-Short Form, and questions relating to sexual function. Exploratory factor analysis and confirmatory factor analysis in separate split-half samples were conducted, followed by analysis of validity and reliability of the resulting measure.

OUTCOMES

The Sexual and Relationship Distress Scale (SaRDS) was developed to meet the need for a patient-reported outcome measure of individual and relationship distress within the context of sexual dysfunction and resulted in a psychometrically sound 30-item, 14-factor measure of sexual and relationship distress.

RESULTS

The final 30 items explained 77.5% of the total variance and the confirmatory factor analysis showed that this model has an adequate fit (comparative fit index = .97, normed fit index = .95, root mean square error of approximation = .05). The final measure demonstrated good psychometric properties, with strong internal reliability (Cronbach alpha = .95 for the total score with individual sub-scales ranging from .70-.96), and convergent and discriminant validity when compared to current measures (Female Sexual Distress Scale-Revised, r = .82, P < .001; Couples Satisfaction Index, r = -.69, P < .001; Depression Anxiety and Stress Scale-Short Form, r = .37, P < .001).

CLINICAL IMPLICATIONS

The SaRDS may prove useful for researchers and clinicians interested in understanding and improving the distress experienced within the context of sexual difficulties. The new measure is brief (30 items), easy to administer and score, easily understood (Flesch-Kincaid reading level = grade 3.9), and demonstrates high internal consistency, convergent and discriminant validity.

STRENGTHS & LIMITATIONS

The SaRDS has advantages over existing measures as it is brief yet includes sub-scales. However, it must be noted that a community sample was used for this study and it would be beneficial to include a clinical sample in future validation studies.

CONCLUSION

Unlike most measures in this field, the SaRDS is multi-dimensional and assesses 14 distinct yet related types of sexual and relationship distress experienced in the context of sexual dysfunctions. It can be administered across genders and both members of a couple. It therefore has multiple uses within both research and clinical settings. Frost R, Donovan C. The Development and Validation of the Sexual and Relationship Distress Scale. J Sex Med 2018;15:1167-1179.

Anxiety, Dispositional Mindfulness, and Sexual Desire in Men Consulting in Clinical Sexology: A Mediational Model

This study aimed to examine dispositional mindfulness as a mediator of the relationship between anxiety and sexual desire in men consulting in clinical sexology. A sample of 105 adult men seeking sex therapy completed measures of dispositional mindfulness, anxiety, and sexual desire. Close to a third (28.7%) of participants reported lack or absence of sexual desire as their main reason to consult in sex therapy. Path analysis confirmed a mediation model and revealed that the association between anxiety and lower sexual desire was fully mediated by dispositional mindfulness. These findings suggest that mindfulness-based interventions may be a relevant component to integrate in the treatment of men who present anxiety symptoms and low sexual desire.

What factors are associated with reporting lacking interest in sex and how do these vary by gender? Findings from the third British national survey of sexual attitudes and lifestyles

OBJECTIVES

To investigate factors associated with reporting lacking interest in sex and how these vary by gender.

SETTING

British general population.

DESIGN

Complex survey analyses of data collected for a cross-sectional probability sample survey, undertaken 2010-2012, specifically logistic regression to calculate age-adjusted OR (AOR) to identify associated factors.

PARTICIPANTS

4839 men and 6669 women aged 16-74 years who reported ≥1 sexual partner (opposite-sex or same-sex) in the past year for the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

MAIN OUTCOME MEASURE

Lacking interest in sex for ≥3 months in the past year.

RESULTS

Overall, 15.0% (13.9-16.2) of men and 34.2% (32.8-35.5) of women reported lacking interest in sex. This was associated with age and physical and mental health for both men and women, including self-reported general health and current depression. Lacking interest in sex was more prevalent among men and women reporting sexually transmitted infection diagnoses (ever), non-volitional sex (ever) and holding sexual attitudes related to normative expectations about sex. Some gender similarities in associated relationship and family-related factors were evident, including partner having had sexual difficulties in the last year (men: AOR 1.41 (1.07-1.86); women: AOR 1.60 (1.32-1.94)), not feeling emotionally close to partner during sex (men: 3.74 (1.76-7.93); women: 4.80 (2.99-7.69) and ease of talking about sex (men: 1.53 (1.23-1.90);women: 2.06 (1.77-2.39)). Among women only, lack of interest in sex was higher among those in a relationship of >1 year in duration and those not sharing the same level of interest (4.57 (3.87-5.38)) or preferences (2.91 (2.22-3.83)) with a partner.

CONCLUSIONS

Both gender similarities and differences were found in factors associated with lacking interest in sex, with the most marked differences in relation to some relationship variables. Findings highlight the need to assess, and if appropriate, treat lacking interest in sex in a holistic and relationship-specific way.

Incidence and Prevalence of Sexual Dysfunction in Women and Men: A Consensus Statement from the Fourth International Consultation on Sexual Medicine 2015

INTRODUCTION

The incidence and prevalence of various sexual dysfunctions in women and men are important to understand to designate priorities for epidemiologic and clinical research.

AIM

This manuscript was designed to conduct a review of the literature to determine the incidence and prevalence of sexual dysfunction in women and men.

METHODS

Members of Committee 1 of the Fourth International Consultation on Sexual Medicine (2015) searched and reviewed epidemiologic literature on the incidence and prevalence of sexual dysfunctions. Key older studies and most studies published after 2009 were included in the text of this article.

MAIN OUTCOME MEASURES

The outcome measures were the reports in the various studies of the incidence and prevalence of sexual dysfunction among women and men.

RESULTS

There are more studies on incidence and prevalence for men than for women and many more studies on prevalence than incidence for women and men. The data indicate that the most frequent sexual dysfunctions for women are desire and arousal dysfunctions. In addition, there is a large proportion of women who experience multiple sexual dysfunctions. For men, premature ejaculation and erectile dysfunction are the most common sexual dysfunctions, with less comorbidity across sexual dysfunctions for men compared with women.

CONCLUSION

These data need to be treated with caution, because there is a high level of variability across studies caused by methodologic differences in the instruments used to assess presence of sexual dysfunction, ages of samples, nature of samples, methodology used to gather the data, and cultural differences. Future research needs to use well-validated tools to gather data and ensure that the data collection strategy is clearly described.

Delayed orgasm and anorgasmia

Delayed orgasm/anorgasmia defined as the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress. Delayed orgasm and anorgasmia are associated with significant sexual dissatisfaction. A focused medical history can shed light on the potential etiologies, which include medications, penile sensation loss, endocrinopathies, penile hyperstimulation, and psychological etiologies. Unfortunately, there are no excellent pharmacotherapies for delayed orgasm/anorgasmia, and treatment revolves largely around addressing potential causative factors and psychotherapy.

Treatment expectations of men with ED and their female partners: an exploratory qualitative study based on grounded theory

Erectile dysfunction (ED) can impair the quality of life and the relationship. An early treatment is necessary to avoid the development of comorbid complaints. To arise the help-seeking behavior and to improve the treatment of affected men, it is necessary to be aware of the treatment expectations. The objective of this study was to investigate the treatment expectations of men with ED and their female partners. This is an explorative qualitative study using semistructured telephone interviews with 12 men with ED and their female partners. Interviews were tape-recorded, transcribed and analyzed on the basis of the grounded theory. We could identify various treatment expectations, which could be differentiated into expectations according to the conditions (for example, low costs and an early access), the handling of the practitioner (for example, showing interest and taking the patient seriously or incorporate the female partner), the treatment itself (for example, clearing the causes and helpful medication) and the treatment outcome (for example, having no ED and more sexual desire). Considering the identified expectations could increase treatment motivation and compliance. We derive five theses from our data, how to implement our findings.

Serum testosterone and gonadotropins levels in patients with premature ejaculation: A comparison with normal men

BACKGROUND

To investigate the role of testosterone (T) in the pathogenesis of ejaculatory symptoms, particularly premature ejaculation (PE).

MATERIALS AND METHODS

A total of 41 male patients with PE as well as 41 controls with no sexual dysfunction were recruited in this cross-sectional study. We used the stopwatch measurement to monitor the intravaginal ejaculatory latency time (IELT). Patients with mean IELT values lower than 60 s were considered to have PE. Serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), total testosterone (TT) and free testosterone (FT) were measured in patients as well as controls. Patients with thyroid dysfunction, hypogonadism, hypertension and dyslipidemia were excluded from the study.

RESULTS

The serum levels of FT and FSH were significantly higher in cases (P = 0.036 and 0.003, respectively). There was no significant difference between TT, LH and PRL levels of the two groups.

CONCLUSION

Patients with PE have higher FT and FSH levels compared with normal men. The causative relationship between these entities and also the clinical importance of this finding has to be determined by more comprehensive studies.

Serum PSA as a predictor of testosterone deficiency

INTRODUCTION

The relationship between serum prostate-specific antigen (PSA) and testosterone (T) levels is still controversial. According to the "saturation hypothesis," a significant relationship is apparent only in the low T range.

AIM

To verify whether, in a large sample of male subjects seeking medical care for sexual dysfunction (SD), PSA might represent a reliable marker of T levels.

METHODS

A consecutive series of 3,156 patients attending our unit for SD was studied. Among them, only subjects without history of prostate disease and with PSA levels<4 ng/mL (N=2,967) were analyzed.

MAIN OUTCOME MEASURES

Several hormonal and biochemical parameters were studied, along with structured interview on erectile dysfunction (SIEDY), ANDROTEST, and PsychoANDROTEST.

RESULTS

Receiver operating characteristic curve analysis for predicting severe hypogonadism (T<8 nmol/L) showed an accuracy of PSA=0.612±0.022 (P<0.0001), with the best sensitivity and specificity at PSA<0.65 ng/mL (65.2% and 55.5%, respectively). In the entire cohort, 254 subjects (8.6%) showed T<8 nmol/L and, among them, more than half (N=141, 4.8%) had PSA<0.65 ng/mL. After adjusting for age, low PSA was associated with hypogonadism-related features (i.e., delayed puberty, lower testis volume) and associated conditions, such as metabolic syndrome (hazard ratio [HR]=1.506 [1.241-1.827]; P<0.0001), type 2 diabetes (HR=2.044 [1.675-2.494]; P<0.0001), and cardiovascular diseases (HR=1.275 [1.006-1.617]; P=0.045). Furthermore, low PSA was associated with impaired sex- and sleep-related erections. The association between low PSA and hypogonadal symptoms and signs as well as with metabolic syndrome was retained even after adjusting for T levels. Sensitivity and positive predictive values of low PSA increased, whereas specificity and negative predictive value decreased as a function of age.

CONCLUSIONS

PSA is a marker of T concentrations and it may represent a new tool in confirming hypogonadism. The determination of PSA levels might give insights not only on the circulating levels of total T but also on its active fractions.

Impaired masturbation-induced erections: a new cardiovascular risk factor for male subjects with sexual dysfunction

INTRODUCTION

Erectile dysfunction (ED) is considered an early surrogate marker of silent, or even overt, cardiovascular diseases (CVD). However, epidemiological studies take into account only sexual intercourse-related erections. Although autoeroticism is a very common practice, data on masturbation-induced erections as a possible predictor of major adverse cardiovascular events (MACE) are lacking.

AIM

To evaluate the clinical correlates of impaired masturbation-induced erections and to verify the importance of this sexual aspect in predicting MACE.

METHODS

A consecutive series of 4,031 male patients attending the Outpatient Clinic for sexual dysfunction for the first time was retrospectively studied. Among these subjects, 64% reported autoeroticism during the last 3 months, and only this subset was considered in the following analyses. In the longitudinal study, 862 subjects reporting autoeroticism were enrolled.

MAIN OUTCOME MEASURES

Several clinical, biochemical, and instrumental (Prostaglandin E1 [PGE1 ] test and penile color Doppler ultrasound) parameters were studied.

RESULTS

Subjects with an impaired erection during masturbation (46% of those reporting autoeroticism) had more often a positive personal or family history of CVD, a higher risk of reduced intercourse- and sleep-related erections, hypoactive sexual desire and perceived reduced ejaculate volume, and impaired PGE1 test response. Prolactin levels were lower in those having impaired erection during masturbation. In the longitudinal study, unadjusted incidence of MACE was significantly associated with impaired masturbation-induced erections. When dividing the population according to the median age and diagnosis of diabetes, the association between impaired masturbation-induced erections and incidence of MACE was maintained only in the youngest (<55 years old) and in nondiabetic subjects, even after adjusting for confounders (hazard ratio [HR] = 3.348 [1.085-10.335], P = 0.032 and HR = 2.108 [1.002-4.433], P = 0.049; respectively).

CONCLUSION

This study indicates that, in subjects with male sexual dysfunction, evaluating an often neglected sexual parameter, such as masturbation-induced erections, can provide further insights on forthcoming MACE in particular in "low risk" subjects.

Treatment motivation of men with ED: what motivates men with ED to seek professional help and how can women support their partners?

Although ED can impair sexual satisfaction as well as the quality of partnership and life, men affected often avoid seeking treatment. There is growing evidence that women have an influence on their partner's help-seeking behavior. This qualitative study examined men with ED and their female partners in order to detect motivational factors for men to seek treatment and motivational actions of the women to support their partners. Twelve couples took part in a semi-structured telephone interview, which was performed separately in men and women. Analysis was on the basis of the Grounded Theory. The identified motivational factors could be divided into extrinsic (for example, media, female partner) and intrinsic (for example, desire to clarify the cause of the ED, hope for improvement) factors. Women can support their partners in treatment-seeking through various motivational actions such as talking with each other, showing interest and dealing actively with the problem, appealing to the male self-esteem, supporting the doctor's visit, forcing the treatment, active cooperation and participation in the treatment or initiating sexual intercourse. On the basis of these findings, recommendations for women were developed to support their partners and increase the probability of help-seeking behavior.

Metabolic and cardiovascular outcomes of fatherhood: results from a cohort of study in subjects with sexual dysfunction

INTRODUCTION

Previous cross-sectional and longitudinal studies reported a negative correlation between fatherhood and testosterone (T) levels, likely due to a centrally mediated downregulation of the hypothalamic-pituitary-gonadal axis. Moreover, epidemiological data indicate that fatherhood might affect metabolic and cardiovascular outcomes, although different results have been reported. Up to now, no studies have evaluated these associations in a population of men seeking treatment for sexual dysfunction (SD).

AIM

To explore biological and clinical correlates of number of children (NoC) and its possible associations with forthcoming major cardiovascular events (MACE) in a sample of men with SD.

METHODS

A consecutive series of 4,045 subjects (mean age 52 ± 13.1 years old) attending the Outpatient Clinic for SD was retrospectively studied. A subset of the previous sample (N = 1,687) was enrolled in a longitudinal study.

MAIN OUTCOME MEASURES

Information on MACE was obtained through the City of Florence Registry Office.

RESULTS

Among patients studied, 31.6% had no children, while 26.3% reported having one child, 33.4% two, and 8.8% three or more children. Although fatherhood was negatively related with follicle-stimulating hormone levels and positively with testis volume, we found a NoC-dependent, stepwise decrease in T plasma levels, not compensated by a concomitant increase in luteinizing hormone. NoC was associated with a worse metabolic and cardiovascular profile, as well as worse penile blood flows and a higher prevalence of metabolic syndrome (MetS). In the longitudinal study, after adjusting for confounders, NoC was independently associated with a higher incidence of MACE. However, when the presence of MetS was introduced as a further covariate, the association was no longer significant.

CONCLUSIONS

This study supports the hypothesis that bond maintenance contexts and fatherhood are associated with an adaptive downregulation of the gonadotropin-gonadal axis, even in a sample of men with SD. Moreover, our data suggest that NoC predicts MACE, most likely because of an unfavorable, lifestyle-dependent, parenthood-associated behavior.

The hormonal control of ejaculation

Hormones regulate all aspects of male reproduction, from sperm production to sexual drive. Although emerging evidence from animal models and small clinical studies in humans clearly point to a role for several hormones in controlling the ejaculatory process, the exact endocrine mechanisms are unclear. Evidence shows that oxytocin is actively involved in regulating orgasm and ejaculation via peripheral, central and spinal mechanisms. Associations between delayed and premature ejaculation with hypothyroidism and hyperthyroidism, respectively, have also been extensively documented. Some models suggest that glucocorticoids are involved in the regulation of the ejaculatory reflex, but corresponding data from human studies are scant. Oestrogens regulate epididymal motility, whereas testosterone can affect the central and peripheral aspects of the ejaculatory process. Overall, the data of the endocrine system in regulating the ejaculatory reflex suggest that widely available endocrine therapies might be effective in treating sexual disorders in these men. Indeed, substantial evidence has documented that treatments of thyroid diseases are able to improve some ejaculatory difficulties.

SIEDY scale 3, a new instrument to detect psychological component in subjects with erectile dysfunction

INTRODUCTION

We previously developed and validated a structured interview (SIEDY) dealing with the organic (Scale 1), relational (Scale 2), and psychological (Scale 3) components of erectile dysfunction (ED).

AIM

To identify a pathological threshold for SIEDY Scale 3 and to analyze Scale 3 score with biological and psychological correlates in subjects with sexual dysfunction.

METHOD

A pathological threshold of SIEDY Scale 3 score in predicting subjects with a medical history of psychopathology and using psychiatric drugs was identified through receiver operating characteristic (ROC) curve analysis in a sample of 484 patients (Sample A).

MAIN OUTCOME MEASURE

Sensitivity and specificity, along with possible interactions with biological and psychological (Middlesex Hospital Questionnaire, MHQ-score) correlates were verified in a further sample of 1,275 patients (Sample B).

RESULTS

In sample A, 39 (8%) and 60 (12.4%) subjects reported a positive medical history for psychiatric disturbances or for the use of psychotropic medication, respectively. The association with both conditions was present in 28 (5.8%) subjects. ROC curve showed that SIEDY Scale 3 score predicts psychopathology with an accuracy of 69.5 ± 5.9% (P<0.002), when a threshold of 3 was chosen. When the same threshold was applied in Sample B, it identified a higher ranking in MHQ-A (free-floating anxiety), MHQ-S (somatized anxiety) and MHQ-D (depressive symptoms) subscales, even after adjustment for age and Σ-MHQ (a broader index of general psychopathology). In the same sample, we also confirmed that pathological Scale 3 score was related to a higher risk of psychopathology at medical history or to the use of psychotropic drugs as well as with risky lifestyle behaviors, including smoking and alcohol abuse, and elevated BMI.

CONCLUSIONS

SIEDY represents an easy tool for the identification of patients with a relevant intra-psychic component who should be considered for psychological/psychiatric treatment.

Hormonal causes of male sexual dysfunctions and their management (hyperprolactinemia, thyroid disorders, GH disorders, and DHEA)

INTRODUCTION

Besides hypogonadism, other endocrine disorders have been associated with male sexual dysfunction (MSD).

AIM

To review the role of the pituitary hormone prolactin (PRL), growth hormone (GH), thyroid hormones, and adrenal androgens in MSD.

METHODS

A systematic search of published evidence was performed using Medline (1969 to September 2011). Oxford Centre for Evidence-Based Medicine-Levels of Evidence (March 2009) was applied when possible.

MAIN OUTCOME MEASURES

The most important evidence regarding the role played by PRL, GH, thyroid, and adrenal hormone was reviewed and discussed.

RESULTS

Only severe hyperprolactinemia (>35 ng/mL or 735 mU/L), often related to a pituitary tumor, has a negative impact on sexual function, impairing sexual desire, testosterone production, and, through the latter, erectile function due to a dual effect: mass effect and PRL-induced suppression on gonadotropin secretion. The latter is PRL-level dependent. Emerging evidence indicates that hyperthyroidism is associated with an increased risk of premature ejaculation and might also be associated with erectile dysfunction (ED), whereas hypothyroidism mainly affects sexual desire and impairs the ejaculatory reflex. However, the real incidence of thyroid dysfunction in subjects with sexual problems needs to be evaluated. Prevalence of ED and decreased libido increase in acromegalic patients; however, it is still a matter of debate whether GH excess (acromegaly) may create effects due to a direct overproduction of GH/insulin-like growth factor 1 or because of the pituitary mass effects on gonadotropic cells, resulting in hypogonadism. Finally, although dehydroepiandrosterone (DHEA) and its sulfate have been implicated in a broad range of biological derangements, controlled trials have shown that DHEA administration is not useful for improving male sexual function.

CONCLUSIONS

While the association between hyperprolactinemia and hypoactive sexual desire is well defined, more studies are needed to completely understand the role of other hormones in regulating male sexual functioning.

Phosphodiesterase type 5 (PDE5) inhibitors in erectile dysfunction: the proper drug for the proper patient

INTRODUCTION

Erectile dysfunction (ED) is a very common multidimensional disorder affecting men worldwide. Physical illness, reaction to life stresses, or an unhappy couple relationship influence clinical outcome. Phosphodiesterase type 5 (PDE5) inhibitors are recognized as efficacious and well tolerated, and are the first-line treatment for ED. Sildenafil, tadalafil, and vardenafil are the most widely used and studied PDE5 inhibitors. Data acquired during a routine diagnostic workup for ED should be taken into account when choosing the best PDE5 inhibitor for the individual patient, creating an individualized treatment plan, and going beyond "experience-based" subjective opinion and unfounded ideas and prejudice regarding currently available drugs.

AIM

As the process of matching a given patient's profile to any selected PDE5 inhibitor often relies more on physician's personal convictions than on solid evidence, the aim of this review is to identify the main clinical, demographic, and relational factors influencing the choice of the PDE5 inhibitor to be used for the treatment of ED.

METHODS

A systematic literature search and current treatment guidelines were evaluated in a systematic manner.

MAIN OUTCOME MEASURES

The main clinical, cultural, and demographical factors to be considered for the treatment of ED have been identified.

RESULTS

Main factors influencing the choice of the treatment for ED have been described. A short list of items that may help in choosing the right PDE5 inhibitor for the treatment of different patients in daily clinical practice has been prepared.

CONCLUSIONS

The simple algorithms prepared should be a useful tool to be used in daily practice, which may help in choosing the right treatment for each subject affected by ED.

Biopsychosocial determinants of men's sexual desire: testing an integrative model

INTRODUCTION

There is a severe lack of studies on male sexual desire and its biopsychosocial determinants. Most of the studies are focused on female sexual interest and are based on the contribution of single dimensions instead of the interaction between them.

AIM

The aim of the present study was to test a conceptual model considering the interrelated role of biopsychosocial factors on male sexual desire. This model allowed us to test not only the unique impact of predictors that are traditionally related to sexual desire, but also how their interaction affects sexual desire in men.

METHODS

Two hundred and thirty seven men from the general population were assessed according to age (mean age = 35, standard deviation = 11), medical problems, psychopathology, dyadic adjustment, and cognitive-emotional factors.

MAIN OUTCOME MEASURES

Psychopathology measured by the Brief Symptom Inventory, dysfunctional sexual beliefs measured by the Sexual Dysfunctional Beliefs Questionnaire, thoughts and emotions in sexual context measured by the Sexual Modes Questionnaire, dyadic adjustment measured by the Dyadic Adjustment Scale, medical condition measured by the Medical History Formulation, and sexual desire measured by the Sexual Desire subscale of the International Index of Erectile Function.

RESULTS

Results showed that cognitive factors (sexual beliefs and automatic thoughts during sexual activity) were the best predictors of sexual desire in men. Specifically, beliefs related to restrictive attitudes toward sexuality, erection concerns, and lack of erotic thoughts in sexual context, had a significant direct effect on reduced sexual desire. Moreover, this set of cognitive-emotional factors also mediated the relationship between medical problems, age, and sexual desire.

CONCLUSION

Results from this integrative approach highlighted the role of cognitive factors related to cultural values (dysfunctional sexual beliefs) and distraction mechanisms during sexual context (automatic thoughts) in male sexual interest. Findings support the need to include cognitive dimensions in the assessment and treatment of sexual desire problems, considering their involvement as vulnerability or resiliency factors for deficient sexual desire in men. Moreover, these factors surpassed the importance of the remaining factors (particularly, of medical factors and psychopathology), showing that, despite the lack of studies, male sexuality is better conceptualized from a biopsychosocial perspective.

Psychobiological correlates of women's sexual interest as perceived by patients with erectile dysfunction

INTRODUCTION

We have recently reported that the perceived loss of a partner's sexual desire is independently associated with an increased incidence of major cardiovascular events in patients with erectile dysfunction (ED). No study has ever evaluated the specific impact of men's perception of women's sexual desire on male sexual function and lifestyle attitudes in ED subjects.

AIM

To evaluate the clinical correlates of the perception of a partner's sexual desire [hypoactive sexual desire (HSD)] in a consecutive series of subjects seeking medical care for ED.

METHODS

A consecutive series of 2,303 heterosexual male patients (mean age 58.1 ± 10.5) was studied.

MAIN OUTCOME MEASURES

Patients were interviewed with the Structured Interview on Erectile Dysfunction (SIEDY) structured interview. They also completed the Middlesex Hospital Questionnaire, a brief questionnaire for the screening of the symptoms of mental disorders.

RESULTS

Among the patients studied, 458 (19.9%) reported a mild loss of their partner's desire, 302 (13.1%) a moderate reduction of libido, while 118 (5.1%) complained of a complete absence of sexual interest on the part of their partner. After adjustment for confounding factors, the perceived women's HSD was associated with different sexual, lifestyle, and relational factors. In particular, more extra-marital affairs, a longer and more hostile couple relationship, as well as a stressful job and both alcohol and smoking abuse were all significantly associated with perceived women's HSD. In addition, the perceived women's moderate to severe HSD was significantly associated with severe ED and less frequent sexual intercourse. Finally, partner HSD was significantly associated with a stepwise increase of free-floating anxiety and depressive symptoms (adj. r = 0.081, P < 0.05 and 0.158, P < 0.0001, respectively).

CONCLUSIONS

Perceived sexual interest (éros) on the part of the woman can be seen for men not only as a fun and enjoyable behavior, but also a safe strategy for improving a man's overall health and life expectancy.

Clinical and therapeutic aspects of Klinefelter's syndrome: sexual function

Klinefelter's syndrome (KS) is the most common sex chromosomal aberration among men, with estimated prevalence of about 1 in 500 newborn males. The classical phenotype of KS is widely recognized, but many affected subjects present only very mild signs. While the association between KS and infertility has been well documented, few studies have investigated sexual function in the KS patients. In the present paper we reviewed studies addressed to emotional processing and sexual function in KS. We searched the following databases Medline, Pubmed, Embase, for Klinefelter's syndrome, sexuality. We focus on the peculiar contribution of genetic and hormonal background, which characterizes sexual dysfunction in KS. Abnormal structure and function of the emotional brain circuits have been described in KS. These alterations were less pronounced when the patients underwent to testosterone replacement therapy suggesting that they were mediated by testosterone deficiency. Accordingly, clinical studies indicate that sexual dysfunctions, eventually present in KS, are not specifically associated with the syndrome but are related to the underlying hypogonadism. In conclusion, androgen deficiency more than chromosomal abnormality is the major pathogenic factor of sexual dysfunction in KS.

Contribution of androgen receptor sensitivity to the relation between testosterone and sexual desire: An exploration in male-to-female transsexuals

BACKGROUND

Low sexual desire is present in 1/3 of male-to-female transsexuals (post-operative male-to-female transsexual persons on estrogen replacement). Several studies report lower endogenous testosterone (T) levels in this group compared to community dwelling women. However, no relationship between T and sexual desire has been found in male-to-female transsexuals. Considering its role in androgen sensitivity, cytosine-adenine-guanine (CAG) trinucleotide repeat sequence in the androgen receptor (AR) might modify the relationship between T levels and sexual desire in male-to-female transsexuals.

AIM

This study aims to assess the potential contribution of the number of CAG repeats in the association between T and sexual desire in male-to-female transsexuals. MATERIAL, SUBJECTS, AND METHODS: Thirty-four post-operative male-to-female transsexuals participated in a cross-sectional study. The Sexual Desire Inventory, a questionnaire measuring sexual desire, was completed. Serum levels of total (TT) and free T (FT), DHEA-S, SHBG, and LH were measured in morning blood samples. AR gene CAG repeat length was determined by automated DNA fragment analysis of exon 1 of the AR gene.

RESULTS

The CAG repeat length ranged from 14 to 28 with a median of 21. CAG polymorphism was correlated with FT (r=0.389; p=0.023) but not with TT (r=0.191; p=0.280). The observed interaction between TT and CAG was significant only for solitary sexual desire (p=0.002). The interaction of CAG repeats and FT on sexual desire failed to reach significance.

CONCLUSIONS

We could not establish that CAG repeat length is a consistent modulating factor in the relationship between TT or FT and sexual desire in male-to-female transsexuals.

The role of testosterone in erectile dysfunction

Erectile dysfunction (ED) is a clinical disorder that results from a continuous spectrum of clinical factors, including physical illness (comprising the organic component of ED), reaction to stress (the intrapsychic component of ED) and relationship difficulties (the relationship component of ED). Testosterone clearly has a relevant role in all three causes of ED; the usefulness of this hormone in the treatment of ED has not, however, been completely clarified. The main physiological action of testosterone in the male sexual response is to regulate the timing of the erectile process as a function of sexual desire, thereby coordinating penile erection with sex. The link between ED, hypogonadism and underlying disorders (such as metabolic syndrome and type 2 diabetes mellitus) is nowadays well documented. The recognition of underlying disorders might be useful in motivating men with ED to improve their health-related lifestyle choices. Hence, patients with ED might be considered 'lucky', because their disorder offers the opportunity to undergo medical examinations to detect underlying disease. Both ED and hypogonadism are treatable conditions. A range of testosterone preparations are available for supplementation; their combination with phosphodiesterase 5 inhibitors might improve outcomes in some cases.

Risk factors for incident erectile dysfunction among community-dwelling men

INTRODUCTION

Compared to the prevalence of erectile dysfunction (ED), fewer studies have focused on the incidence of ED and even fewer have focused on nonmedical risk factors.

AIM

We examined psychosocial, demographic/socioeconomic, medical/behavioral, and sexual function risk factors at T1 (1987-1989) and development of incident ED at T2 (1995-1997).

METHODS

Longitudinal population-based epidemiologic study of 814 community-dwelling men participating in the Massachusetts Male Aging Study.

MAIN OUTCOME MEASURE

ED was defined according to a validated, discriminant-analytic formula based on questionnaire responses and categorized as moderate/complete ED vs. none/minimal. Multivariate logistic regression models (odds ratios [ORs] and 95% confidence intervals [CI]) were used to estimate the association of risk factors with ED.

RESULTS

Among 814 men free of ED at T1, 22% developed moderate/complete ED at T2 (on average, approximately 8.8 years later). In a multivariate model, sexual function variables captured at baseline were inversely associated with ED (e.g., more or similar level of sexual arousal compared to adolescence vs. less, OR = 0.56, 95% CI: 0.34, 0.92; frequency of sexual thoughts at least two to three times weekly vs. less, OR = 0.55, 95% CI: 0.33, 0.92) after adjustment for age, education, and other risk factors.

CONCLUSIONS

Our results indicate that in the context of other risk factors, sexual desire variables at baseline were associated with incident ED. This in turn suggests that indications of reduced function appear earlier than ED itself, and that there may be a time window for intervention before a loss of erectile function.

Sexual dysfunction in subjects with Klinefelter's syndrome

While the association of Klinefelter's Syndrome (KS) with infertility is well-known, very few investigations have evaluated the prevalence of sexual dysfunction in KS. The aim of the present study was to systematically analyse the prevalence of KS in a consecutive series of adult male patients consulting for sexual problems and to investigate its specific correlates. Among a consecutive series of 1386 men (mean age 48.9 +/- 12.7 years old), 23 (1.7%) subjects with KS were found. Patients with KS were younger and more often hypogonadal when compared with the rest of the sample. Among patients with KS, five (22.7%) subjects reported severe erectile dysfunction, 14 (60.9%) hypoactive sexual desire (HSD), two (9.5%) premature and two (9.5%) delayed ejaculation. Only the association between KS and HSD was confirmed after adjustment for age [HR = 3.2 (1.37-7.5)], however, when patients with KS were compared with age, smoking habit, and testosterone matched controls, even the association between KS with HSD disappeared. In comparison to matched hypogonadal controls, subjects with KS had lower levels of education, a higher frequency of cryptorchidism and poorer pubertal progression. In conclusion, our results indicate that sexual dysfunction present in KS is not specifically associated with the syndrome but is caused by the underlying hypogonadal state. Further studies are needed to evaluate the efficacy of testosterone substitution in ameliorating the hypoactive sexual desire often reported in subjects with KS.

Autoeroticism, mental health, and organic disturbances in patients with erectile dysfunction

INTRODUCTION

Masturbation is a common, but often neglected, male sexual behavior.

AIM

To investigate the psychobiological correlates of self-reported masturbation in the last 3 months.

METHODS

A consecutive series of 2,786 heterosexual male patients (mean age 48.4 +/- 13.2) consulting an outpatient clinic for erectile dysfunction (ED) was studied.

MAIN OUTCOME MEASURES

Several hormonal, biochemical and instrumental parameters (penile Doppler ultrasound [PDU]) were investigated. Patients were interviewed, prior to the beginning of any treatment, with Structured Interview on Erectile Dysfunction (SIEDY) and ANDROTEST structured interviews. They also completed the Middlesex Hospital Questionnaire, a brief self-reported questionnaire for the screening of the symptoms of mental disorders in a nonpsychiatric setting.

RESULTS

Among the patients studied, 1,781 (61.9%) reported they had masturbated at least once per month in the preceding 3 months. The frequency of masturbation was inversely related to age (r = -0.329; P < 0.0001) and directly associated with education level (adj r = 0.052, P < 0.05 after adjustment for age). A feeling of guilt during masturbation was reported by 274 (15.4%) patients. After adjusting for age, masturbation was positively associated with testosterone levels, stressful conditions, and both unstable and long-lasting couple relationship. Urogenital problems such as varicocele and prostate abnormalities also increased the chance of masturbation. Reported guiltiness during autoeroticism was associated with psychological disturbances, low prolactin, low testosterone, and increased relational problems. An erection not normal during masturbation was declared by 1,361 (76.4%) patients and associated with a prevalent organic component of ED, because of lower peak systolic velocity PDU and higher SIEDY Scale 1 scores.

CONCLUSIONS

This study indicates that masturbation is a relatively frequent behavior in male subjects with ED. Inquiring about this sexual behavior is an important issue for understanding overall patients' sexual attitudes and behavior.

Selective serotonin reuptake inhibitor-induced sexual dysfunction

INTRODUCTION

Sexual dysfunctions are often present in subjects with mood disturbances; however. antidepressants can induce per se sexual dysfunctions.

AIM

To explore the relationship between the use of selective serotonin reuptake inhibitors (SSRIs), non-SSRIs antidepressants and benzodiazepines (BDZ), hormonal parameters, and reported sexual dysfunction (as assessed by the Structured Interview on Erectile Dysfunction [SIEDY]) in male subjects with comparable psychopathological symptoms (as assessed by the Middlesex Hospital Questionnaire [MHQ] a self-reported test for the screening of mental disorders in a non-psychiatric setting).

METHODS

A consecutive series of 2,040 (mean age 51 +/- 13 years) male patients with sexual dysfunction was studied.

MAIN OUTCOME MEASURES

Several hormonal and biochemical parameters were investigated, along with SIEDY and the MHQ.

RESULTS

Higher prolactin was observed only in patients using SSRIs, whereas no other hormonal difference was found after adjustment for confounders. Use of SSRIs was associated with a twofold risk for patient hypoactive sexual desire and with a higher impairment of reported erectile function. However, no difference in penile blood flow was observed. A very high risk (sevenfold) for delayed ejaculation (DE) was observed in SSRI users. Interestingly, the association with the mild, but not severe, form of DE was observed also in subjects using non-SSRI antidepressants (3.35 [1.48-7.59]; P < 0.005). Different life stressors and relational parameters were also associated with SSRI use. SSRI users reported less enjoyment with masturbation and decreased partner desire and climax. Conversely, a lack of significant association was observed among BDZ or non-SSRI antidepressant users and all the aforementioned life-stressors and relational parameters.

CONCLUSIONS

SSRIs can negatively affect all the steps of the male sexual response cycle (desire-arousal-excitement-orgasm). SSRI-associated sexual dysfunction has a deleterious effect on both auto- and couple-erotic performances. Conversely, other antidepressants and BDZ are less often associated with sexual impairment.