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MALE DYSFUNCTIONS 

Erectile dysfunctions
Erectile dysfunction is the impairment of the erectile reflex. The man is unable to have or maintain an erection.
Like other dysfunctions, erectile dysfunction can be either life long or acquired, situational or generalized.
Life long erectile dysfunction is when a man has never had an erection.
Acquired is when a man has in the past had an erection but no longer is able to have or maintain an erection either in certain situations or at all.

As a situational dysfunction, erectile dysfunction is very common, almost universal.
At some time in a man's life he will be unable to have an erection even though he is being sufficiently stimulated. In its situational form, there is a variety of ways it occurs.
For some men they are unable to have an erection during foreplay, while others have difficulty only attempting intercourse. Still other men only have difficulty with specific partners but no dysfunction with other partners.
Definition
"Persistent or recurrent inability to attain, or maintain erection until completion of the sexual activity, an adequate erection."
Erectile dysfunction is more likely than the other dysfunctions to have a physical cause.
Drugs (especially alcohol), diabetes, Parkinson's disease, multiple sclerosis, and spinal cord lesions can all be causes of erectile dysfunction.
It is certainly not uncommon for a man, after a few drinks of alcohol, to experience erectile dysfunction.
 However, according to Kaplan (1975), approximately 85% of the cases of erectile dysfunction are psychogenic.
Anxiety seems to be the most likely psychological cause of erectile dysfunction.  

Male Orgasmic Disorder.
Male Orgasmic Disorder is an involuntary inhibition of the male orgastic reflex.  
As with the other dysfunctions, the man can experience either life long or acquired, situational or generalized Male Orgasmic Disorder.  
Sever over control, i.e., the man who has never ejaculated at all, even on masturbation, is rare. This is fortunate because this extreme form of retardation is difficult to treat. In its milder forms ejaculatory retardation (or ejaculatory incompetence) is relatively common and has as excellent prognosis with sex therapy.  
In moderate forms of this disorder the man can only ejaculate on masturbation when he is alone. Men suffering from milder retardation can climax in the presence of their partner but only in response to manual and/or oral stimulation. 
They cannot ejaculate in the vagina. Still milder forms are situational and some merely require excessively long and vigorous coitus in order to ejaculate.
Kaplan is pointing out the various forms this dysfunction takes. The problem I have with both of these perspectivesis the focus on the receptacle of the vagina as the definition of a male dysfunction.  
Male Orgasmic Disorder in its life long form is a man who has never ejaculated.  
If a man has ejaculated on masturbation but not in the vagina he should be considered to experience life long Male Orgasmic Disorder but of the situational type.  
To maintain the focus on intravaginal ejaculation is to label a large portion of gay males as having Male Orgasmic Disorder.  
Acquired Male Orgasmic Disorder is defined by Masters et al.,  
"...men who have lost their ability to ejaculate intravaginally or who do so infrequently after a prior history of normal coital ejaculation.  
In its life long form, Male Orgasmic Disorder is fairly rare. In its acquired form this dysfunction is not uncommon. In fact the man who can withhold or "last-all-night" is envied. The myth is that he will be able to satisfy all women and thereby be sought after by these women. The man who is considerate of his partner is in reality more likely to experience mutual satisfaction than is the man who simply pounds away at his partner for an extended period of time.  
Male Orgasmic Disorder Defind as:  
"Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person's age, judges to be adequate in focus, intensity, and duration."  
The cause of this dysfunction is rarely physical although it is sometimes confused with retrograde ejaculation.
Retrograde ejaculation is when the man ejaculates into his bladder instead of out the urethra. More often than not, the cause is a traumatic sexual experience, strict religious upbringing, hostility, over control, or lack of trust.

Premature Ejaculation
Exactly what constitutes premature ejaculation is unclear. According to Masters et al., (1970),  
"A man is considered to ejaculate prematurely if his partner wasn't orgasmic in at least 50 percent of their coital episodes."  
 Kaplan (1974) suggested that premature ejaculation occurred if the male did not have voluntary control over when he ejaculated.  
Although there is rarely a physical cause, occasionally there exists unusual nerve sensitivity around the opening of the penile glands and frenulum which can lead to premature ejaculation.
Some infections of the urethra and prostate, neglected gonorrhea and an overly tight uncircumcised foreskin have also been seen as possible causes of premature ejaculation.  
More commonly the man has not learned to pay attention to the sensory feedback that signals ejaculation. He has essentially taught himself to not pay attention to erotic sensation.  
Often Men, in an effort to prolong the duration of intercourse, will distract themselves during sexual interaction.  
 Another possible cause is conditioning. Men often train themselves to ejaculate as soon as possible for fear of being discovered. One man spoke of his adolescent masturbatory practices as follows:  
He used to time myself in the bathroom when I was a kid. If I took too long people would know I was jacking off so I would limit myself to two minutes.  

DYSFUNCTION OF EITHER MALE OR FEMALE 

Inhibited Sexual Desire (ISD)  
Although this is, strictly speaking, not a sexual dysfunction, it is a disorder that can severely disrupt the sexual relationship of a couple.
ISD is the persistent and pervasive inhibition of sexual desire.  
ISD is present if there is both a low rate of sexual activity and a subjective lack of desire for sexual activity; desire here includes sexual dreams and fantasies, attention to erotic material, awareness of wishes for sexual activity, noticing attractive potential partners, and feelings of frustration if deprived of sex.
What this emphasizes is that the effect that a lack of sexual interest has on the relationship is an essential aspect of defining ISD. Also important is the realization that desire differs for each individual and that differences between individuals does not necessarily indicate a ISD.
Both physical and psychological factors contribute to ISD.
Physical causes include: hormone deficiencies; depression; stress; alcoholism; kidney failure; and chronic illness.
Psychological causes include: relationship problems, e.g. power struggles, conflict, hostility; sexual trauma, e.g. rape; major life changes, e.g. death of a family member, childbirth, geographic relocation; and pairing negative memories with sexual interaction.
People who are angry, fearful, or distracted are usually not desirous of sexual intimacy.  

RELATIONSHIP BETWEEN MALE AND FEMALE DYSFUNCTIONS

Erectile Dysfunction / Female Sexual Arousal Disorder.  
Both are conditions which are caused by inhibition of the vasocongestive phase of the sexual response. For both there is a failure to respond to erotic stimulation.
The man does not achieve an erection and the female does not lubricate. For both it is possible to experience either dysfunction without affecting the orgastic response.  
Male Orgasmic Disorder / Female Orgasmic Disorder.  
In both there is a specific inhibition of the orgasmic phase of the sexual response. It is also possible to experience either dysfunction without affecting the arousal phase of sexual response.
Premature Ejaculation / ?  
Typically it is believed that premature ejaculation has no female counterpart. However Steven Lipsius believes that some women are in fact premature and he suggests the squeeze technique as treatment.  
 In reality, if a women were to orgasm quickly, few people would report this as a problem. The belief is, if the woman has an orgasm and her male partner is not `finished' he can continue and she may even have another orgasm in the process.  
This type of thinking potentially paves the way for a variety of sexual problems in the future. 
Vaginismus / ? Vaginismus has no male counterpart.

IMPOTENCE  

The term "impotence," as applied to the title of this conference, has traditionally been used to signify the inability of the male to attain and maintain erection of the penis sufficient to permit satisfactory sexual intercourse.  
However, this use has often led to confusing and unintepreptible results in both clinical and basic science investigations. This, together with its pejorative implications, suggests that the more precise term "erectile dysfunction" be used instead to signify an inability of the male to achieve an erect penis as part of the overall multifaceted process of male sexual function.
Erectile dysfunction affects millions of men. Although for some men erectile function may not be the best or most important measure of sexual satisfaction, for many men erectile dysfunction creates mental stress that affects their interactions with family and associates.
Many advances have occurred in both diagnosis and treatment of erectile dysfunction.  
However, its various aspects remain poorly understood by the general population and by most health care professionals. Lack of a simple definition, failure to delineate precisely the problem being assessed, and the absence of guidelines and parameters to determine assessment and treatment outcome and long-term results, have contributed to this state of affairs by producing misunderstanding, confusion, and ongoing concern.  
That results have not been communicated effectively to the public has compounded this situation.  
Cause-specific assessment and treatment of male sexual dysfunction will require recognition by the public and the medical community that erectile dysfunction is a part of overall male sexual dysfunction.  
The multifactorial nature of erectile dysfunction, comprising both organic and psychologic aspects, may often require a multidisciplinary approach to its assessment and treatment. This consensus report addresses these issues, not only as isolated health problems but also in the context of societal and individual perceptions and expectations.

Erectile dysfunction is often assumed to be a natural concomitant of the aging process, to be tolerated along with other conditions associated with aging.  
This assumption may not be entirely correct. For the elderly and for others, erectile dysfunction may occur as a consequence of specific illnesses or of medical treatment for certain illnesses, resulting in fear, loss of image and self-confidence, and depression.  
For example, many men with diabetes mellitus may develop erectile dysfunction during their young and middle adult years. Physicians, diabetes educators, and patients and their families are sometimes unaware of this potential complication. Whatever the causal factors, discomfort of patients and health care providers in discussing sexual issues becomes a barrier to pursuing treatment.  

Erectile dysfunction can be effectively treated with a variety of methods.  
Many patients and health care providers are unaware of these treatments, and the dysfunction thus often remains untreated, compounded by its psychological impact.  
Concurrent with the increase in the availability of effective treatment methods has been increased availability of new diagnostic procedures that may help in the selection of an effective, cause-specific treatment. This conference was designed to explore these issues and to define the state of the art.  
Prevalence and Association with Age:  
Estimates of the prevalence of impotence depend on the definition employed for this condition.  
More recent estimates suggest that the number of U.S. men with erectile dysfunction may more likely be near 10-20 million. Inclusion of individuals with partial erectile dysfunction increases the estimate to about 30 million. The majority of these individuals will be older than 65 years of age.
 The prevalence of erectile dysfunction has been found to be associated with age.
 A prevalence of about 5 percent is observed at age 40, increasing to 15-25 percent at age 65 and older. One-third of older men receiving medical care  
Causes contributing to erectile dysfunction can be broadly classified into   two categories:  
Organic and psychologic.  
In reality, while the majority of patients with erectile dysfunction are thought to demonstrate an organic component, psychological aspects of self-confidence, anxiety, and partner communication and conflict are often important contributing factors.  
Clinical, Psychological, and Social Impact:  
Geographic, Racial, Ethnic, Socioeconomic, and Cultural Variation in Erectile Dysfunction. Very little is known about variations in prevalence of erectile dysfunction across geographic, racial, ethnic, socioeconomic, and cultural groups.  

One report from a recent community survey concluded that erectile failure was the leading complaint of males attending sex therapy clinics. Other studies have shown that erectile disorders are the primary concern of sex therapy patients in treatment. This is consistent with the view that erectile dysfunction may be associated with depression, loss of self-esteem, poor self-image, increased anxiety or tension with one's sexual partner, and/or fear and anxiety associated with contracting sexually transmitted diseases, including AIDS.  
. The impact of this condition depends very much on the dynamics of the relationship of the individual and his sexual partner and their expectation of performance.
When changes in sexual function are perceived by the individual and his partner as a natural consequence of the aging process, they may modify their sexual behavior to accommodate the condition and maintain sexual satisfaction. Increasingly, men do not perceive erectile dysfunction as a normal part of aging and seek to identify means by which they may return to their previous level and range of sexual activities. Such levels and expectations and desires for future sexual interactions are important aspects of the evaluation of patients presenting with a chief complaint of erectile dysfunction.
In men of all ages, erectile failure may diminish willingness to initiate sexual relationships because of fear of inadequate sexual performance or rejection. Because males, especially older males, are particularly sensitive to the social support of intimate relationships, withdrawal from these relationships because of such fears may have a negative effect on their overall health.  

WHAT ARE THE RISK FACTORS CONTRIBUTING TO IMPOTENCE? CAN THESE BE UTILIZED IN PREVENTING DEVELOPMENT OF IMPOTENCE?  

Erectile Dysfunction
Because adequate arterial supply is critical for erection, any disorder that impairs blood flow may be implicated in the etiology of erectile failure. Most of the medical disorders associated with erectile dysfunction appear to affect the arterial system. Some disorders may interfere with the corporal veno-occlusive mechanism and result in failure to trap blood within the penis, or produce leakage such that an erection cannot be maintained or is easily lost.

Damage to the autonomic pathways innervating the penis may eliminate "psychogenic" erection initiated by the central nervous system. Lesions of the somatic nervous pathways may impair reflexogenic erections and may interrupt tactile sensation needed to maintain psychogenic erections. Spinal cord lesions may produce varying degrees of erectile failure depending on the location and completeness of the lesions.  

Not only do traumatic lesions affect erectile ability, but disorders leading to peripheral neuropathy may impair neuronal innervation of the penis or of the sensory afferents. The endocrine system itself, particularly the production of androgens, appears to play a role in regulating sexual interest, and may also play a role in erectile function.  

Psychological processes such as depression, anxiety, and relationship problems can impair erectile functioning by reducing erotic focus or otherwise reducing awareness of sensory experience. This may lead to inability to initiate or maintain an erection. Etiologic factors for erectile disorders may be categorized as neurogenic, vasculogenic, or psychogenic, but they most commonly appear to derive from problems in all three areas acting in concert.

Risk Factors:  
Little is known about the natural history of erectile dysfunction.
This includes information on the age of onset, incidence rates stratified by age, progression of the condition, and frequency of spontaneous recovery
There also are very limited data on associated morbidity and functional impairment. To date, the data are predominantly available for whites, with other racial and ethnic populations represented only in smaller numbers that do not permit analysis of these issues as a function of race or ethnicity.
Erectile dysfunction is clearly a symptom of many conditions, and certain risk factors have been identified, some of which may be amenable to prevention strategies.
Diabetes mellitus, hypogonadism in association with a number of endocrinologic conditions, hypertension, vascular disease, high levels of blood cholesterol, low levels of high density lipoprotein, drugs, neurogenic disorders, Peyronie's disease, priapism, depression, alcohol ingestion, lack of sexual knowledge, poor sexual techniques, inadequate interpersonal relationships or their deterioration, and many chronic diseases, especially renal failure and dialysis, have been demonstrated as risk factors. Vascular surgery is also often a risk factor.
Age appears to be a strong indirect risk factor in that it is associated with an increased likelihood of direct risk factors. Other factors require more extensive study.
 Smoking has an adverse effect on erectile function by accentuating the effects of other risk factors such as vascular disease or hypertension. To date, vasectomy has not been associated with an increased risk of erectile dysfunction other than causing an occasional psychological reaction that could then have a psychogenic influence. Accurate risk factor identification and characterization are essential for concerted efforts at prevention of erectile dysfunction.

PREVENTION
Although erectile dysfunction increases progressively with age, it is not an inevitable consequence of aging.
Knowledge of the risk factors can guide prevention strategies. Specific antihypertensive, antidepressant, and antipsychotic drugs can be chosen to lessen the risk of erectile failure.
In the individual patient, the physician can modify the regimen in an effort to resolve the erectile problem.
It is important that physicians and other health care providers treating patients for chronic conditions periodically inquire into the sexual functioning of their patients and be prepared to offer counsel for those who experience erectile difficulties.
Lack of sexual knowledge and anxiety about sexual performance are common contributing factors to erectile dysfunction. Education and reassurance may be helpful in preventing the cascade into serious erectile failure in individuals who experience minor erectile difficulty due to medications or common changes in erectile functioning associated with chronic illnesses or with aging.

WHAT DIAGNOSTIC INFORMATION SHOULD BE OBTAINED IN ASSESSMENT OF THE IMPOTENT PATIENT? WHAT CRITERIA SHOULD BE EMPLOYED TO DETERMINE WHICH TESTS ARE INDICATED FOR A PARTICULAR PATIENT?

The appropriate evaluation of all men with erectile dysfunction should include a medical and detailed sexual history (including practices and techniques), a physical examination, a psycho-social evaluation, and basic laboratory studies.
When available, a multidisciplinary approach to this evaluation may be desirable.
In selected patients, further physiologic or invasive studies may be indicated.
A sensitive sexual history, including expectations and motivations, should be obtained from the patient (and sexual partner whenever possible) in an interview conducted by an interested physician or another specially trained professional. A written patient questionnaire may be helpful but is not a substitute for the interview.
The sexual history is needed to accurately define the patient's specific complaint and to distinguish between true erectile dysfunction, changes in sexual desire, and orgasmic or ejaculatory disturbances.
The patient should be asked specifically about perceptions of his erectile dysfunction, including the nature of onset, frequency, quality, and duration of erections; the presence of nocturnal or morning erections; and his ability to achieve sexual satisfaction.
Psychosocial factors related to erectile dysfunction should be probed, including specific situational circumstances, performance anxiety, the nature of sexual relationships, details of current sexual techniques, expectations, motivation for treatment, and the presence of specific discord in the patient's relationship with his sexual partner.
The sexual partner's own expectations and perceptions should also be sought since they may have important bearing on diagnosis and treatment recommendations.
The general medical history is important in identifying specific risk factors that may account for or contribute to the patient's erectile dysfunction. These include vascular risk factors such as hypertension, diabetes, smoking, coronary artery disease, peripheral vascular disorders, pelvic trauma or surgery, and blood lipid abnormalities.
Decreased sexual desire or history suggesting a hypogonadal state could indicate a primary endocrine disorder. Neurologic causes may include a history of diabetes mellitus or alcoholism with associated peripheral neuropathy.
Neurologic disorders such as multiple sclerosis, spinal injury, or cerebrovascular accidents are often obvious or well defined prior to presentation. It is essential to obtain a detailed medication and illicit drug history since an estimated 25 percent of cases of erectile dysfunction may be attributable to medications for other conditions.
Past medical history can reveal important causes of erectile dysfunction, including radical pelvic surgery, radiation therapy, Peyronie's disease, penile or pelvic trauma, prostatitis, priapism, or voiding dysfunction. Information regarding prior evaluation or treatment for "impotence" should be obtained.
A detailed sexual history, including current sexual techniques, is important in the general history obtained. It is also important to determine if there have been previous psychiatric illnesses such as depression or neuroses.
Physical examination should include the assessment of male secondary sex characteristics, femoral and lower extremity pulses, and a focused neurologic examination including perianal sensation, anal sphincter tone, and bulbocavernosus reflex.
More extensive neurologic tests, including dorsal nerve conduction latencies, evoked potential measurements, and corpora cavernosal electromyography lack normative (control) data and appear at this time to be of limited clinical value.
Examination of the genitalia includes evaluation of testis size and consistency, palpation of the shaft of the penis to determine the presence of Peyronie's plaques, and a digital rectal examination of the prostate with assessment of anal sphincter tone.
Endocrine evaluation consisting of a morning serum testosterone is generally indicated.
Although not indicated for routine use, nocturnal penile tumescence (NPT) testing may be useful in the patient who reports a complete absence of erections (exclusive of nocturnal "sleep" erections) or when a primary psychogenic etiology is suspected.
After the history, physical examination, and laboratory testing, a clinical impression can be obtained of a primarily psychogenic, organic, or mixed etiology or erectile dysfunction. Patients with primary or associated psychogenic factors may be offered further psychologic evaluation, and patients with endocrine abnormalities may be referred to an endocrinologist to evaluate the possibility of a pituitary lesion or hypogonadism.
Unless previously diagnosed, suspicion of neurologic deficit may be further assessed by complete neurologic evaluation. No further diagnostic tests appear necessary for those patients who favor noninvasive treatment (e.g., vacuum constrictive devices, or pharmacologic injection therapy).
Patients who do not respond satisfactorily to these noninvasive treatments may be candidates for penile implant surgery or further diagnostic testing for possible additional invasive therapies.
A rigid or nearly rigid erectile response to intracavernous injection of pharmacologic test doses of a vasodilating agent (see below) indicates adequate arterial and veno-occlusive function.
This suggests that the patient may be a suitable candidate for a trial of penile injection therapy. Genital stimulation may be of use in increasing the erectile response in this setting.
Young men with a history of significant perineal or pelvic trauma, who may have anatomic arterial blockage (either alone or with neurologic deficit) to account for erectile dysfunction.

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