Sexual Dysfunction

Sexual Dysfunction in the Male

The initial concern in the treatment of any sexual dysfunction is the diagnosis of its cause. Male sexual dysfunctions sometimes amenable to pharmacologic treatment are premature ejaculation, retrograde ejaculation, and impotence. The primary treatment of these conditions is psychotherapy, with drug treatment merely serving an adjuvant role. For example, drugs which inhibit ejaculation may be helpful in the management of premature ejaculation. Chlorpromazine (Thorazine), thioridazine (Mellaril), and chlorprothixine (Taractan) and other antipsychotic drugs with a-adrenergic blocking qualities may be of benefit in some cases. However, their anticholinergic actions may adversely effect potency so they should be used with caution.

Retrograde ejaculation is most commonly the result of a neurologic lesion such as spinal cord injury, cancer resection with nerve destruction, or diabetic neuropathy. The antihistamine brompheniramine (Dimetane) and the a-adrenergic agent synephrine have been used to overcome parasympathetic stimulation of the bladder sphincter and thereby reverse retrograde ejaculation.

Impotence is the most troublesome and prevalent problem, particularly in the aged, where it is present in 75 percent of men over 60. Causes of impotence may be psychogenic, organic, or drug related. Atherosclerosis may cause organic impotence in many older men and may be diagnosed with vasodilators.

For a drug related impotence the drug should be eliminated or changed to an alternative agent. If this is not feasible, the lowest effective dose and psychological support for the couple are important. Lording emphasizes that both partners should be involved in management, even if the problem is organic.

Impotence associated with hypogonadism is treated with long-acting testosterone esters such as testosterone propionate, testosterone enanthate, or testosterone decanoate. The drug is usually administered parenterally every 1 to 4 weeks. In the future subcutaneous implants should become more widely available. Oral testosterone forms usually are not used as they are rapidly metabolized by the liver and are therefore poorly effective. Androgens can cause polycythemia due to stimulation of erythropoietin which increases red cell production. Salt and water retention and elevated cholesterol are other adverse effects to note. Since prostatic tumors may be stimulated by testosterone, the elderly patient should be evaluated carefully for prostatic enlargement.

In cases where impotence, infertility, and sometimes galactorrhea are associated elevated serum prolactin, bromocriptine (Parlodel) may restore potency. In Europe this drug, an ergot alkaloid which is a dopamine-receptor agonist in the CNS and an inhibitor of prolactin secretion, is being heralded as a panacea for sexual dysfunction and infertility. Few studies support this assertion and the drug can cause neurologic side effects.

Other clinicians and researchers have recommended the use of other endocrine or gonadotropic hormones alone or in various combinations with testosterone to treat hypogonadal impotence and the impotence associated with aging. Teter recommended testosterone and estrogens, attributing good results to vasodilation caused by the estrogens. Kupperman found that human chorionic gonadotropin with testosterone after the climacteric decreased testicular atrophy and impotence and increased libido. Other drugs which interact with the pituitary-testicular axis, such as clomiphene (Clomid), a female fertility drug, and luteinizing hormone releasing hormone, have been recommended; increased libido and potency have been reported with their use. Considerably more research is needed before the place of these agents in the treatment of impotence is clarified.

A combination of nux vomica, yohimbine, and methyltestosterone was marketed under the name Afrodex, recommended for use in impotence. Numerous research projects were conducted on the product and analysis of the many studies representing over 10,000 cases indicated that the drug was 1.7 to 5.4 times more effective than the placebo. However, review of the data analysis reveals a significant placebo effect. The product was removed from the market in 1995 by the Food and Drug Administration on the grounds that efficacy for substances that it contained had not been established.

In a double-blind study Jakobovits found a favorable response in 78 percent of the 100 cases of impotent men using a methyltestosterone/thyroid combination. Further study of this method of treatment is needed. While use of androgens in nonhypogonadal men over 50 is controversial, many clinicians support it for its general anabolic effects, allaying of anxiety, and placebo effect.

Sexual Dysfunction in the Female

Pharmacologic management plays a small role in sexual dysfunction of the female, since psychotherapy is a primary treatment modality. Anxiolytic drugs, particularly the benzodiazepines, have been used for their dis-inhibiting effect in the treatment of sexual frigidity, but the abuse potential of these drugs dictates that they play a minor role in treatment of sexual problems.

Hormonal replacement for the menopausal woman is a common practice, although this approach is being challenged by those who feel the practice may be dangerous. Obviously the woman who experiences dyspareunia from atropic vaginitis is a candidate for local or systemic estrogens. Those who experience an improved sense of well-being and sexual responsiveness with estrogen replacement should probably not be deprived of these benefits, although the problems associated with uterine bleeding, the risk of thrombophlebitis, and possible links to cancer of the uterus should be explained to the woman.

Greenblatt has recommended low-dose androgens for the elderly woman with decreased libido, to replace decreasing adrenal androgens.

An understanding of the potentially profound effects of therapeutic agents and social drugs upon human sexual function, as well as some of the issues in the treatment of sexual dysfunction, is essential for the nurse clinician. By the same token the nurse must appreciate how very limited is our ability to control or even to accurately predict these profound effects.   

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Category: Sex & Sexuality