Keeping the Love Alive: Modern treatments for male and female sexual dysfunction

Male Sexual Health

Erectile dysfunction, or ED, is a condition in which it is hard for a man to get or keep an erection that’s firm enough for sex. ED affects as many as 30 million men.

Most men have problems with erections from time to time. But when it happens more than half of the time, then erectile dysfunction is present. ED can happen when health problems limit blood flow or damage nerves in the penis. It can also be caused by stress or emotional reasons. ED can be an early warning of a more serious illness. Heart disease, high blood pressure, and high blood sugar (diabetes) can all cause ED. If you’re male, finding and treating the cause(s) of your ED can help your sexual health and overall well-being.

The first steps are adequate rest, a healthy diet and regular exercise program. The next step is to take medications. When medications (pills) such as Cialis, Viagra, Levitra etc. no longer work, it might be time to try penile self-injections of “vasoactive” substances that can result in an immediate erection. If you’re unable to tolerate penile injections or they don’t work, you might want to consider a penile external vacuum erection device (VED) that aspirates blood flow in your penis to help with erections.

If all these 3 choices fail, the only remaining solution is a penile implant. There are three major types. A one-piece is malleable and is easy to insert, and had less complications, and requires no pump to inflate. However, it is difficult to conceal and has poor rigidity and penile girth. The two-piece penile prosthesis is easier to implant than the three-piece. However, its penile girth is not as good and the implant less natural compared to the three-piece. The three-piece penile prosthesis, the one I prefer to implant in my patients, is the most natural and gives you the best girth and rigidity. It also has the highest patient satisfaction rate.

Penile implant surgeries take about an hour and are typically done in an outpatient center. A man can resume sexual intercourse 6 weeks after surgery. Most insurance will pay for the surgery, which can cost anywhere from $14,000 to 18,000.

While men who have had prosthesis surgery can see a small surgical scar, other people probably will not be unable to tell that a man has an inflatable penile prosthesis. Most men would not be embarrassed in a locker room or public restroom, for example. Your sexual partner may never know that you have a penile prosthesis. When the penis is inflated, the prosthesis makes the penis stiff and thick, similar to a natural erection. The prosthesis does not change sensation on the skin of the penis or a man’s ability to reach orgasm. Ejaculation is not affected. A fertile man will continue to father children with the penile implant in place.

The 3 Piece Penile Prosthesis Implant
The 3 Piece Penile Prosthesis Implant – Very High Patient Satisfaction Rate

FEMALE SEXUAL HEALTH

Sexual dysfunction is more prevalent in women than in men

It is estimated that approximately 40 million American women are affected by Female Sexual Dysfunction (FSD). Many investigators have found that sexual dysfunction is more prevalent in women (43%) than in men (31%), and increases as women age. It has also been noted that married women have a lower risk of sexual dysfunction than unmarried women. Racial differences have also been noted. Hispanic women consistently report lower rates of sexual problems, whereas African American women have higher rates of decreased sexual desire and pleasure than do white women. Sexual pain (dyspareunia), however, is more likely to occur in white women.

Pathophysiology

Although the exact cause of Female Sexual Dysfunction remains unknown, both physiologic and psychological components are believed to play a part. To better understand FSD, it is necessary to be familiar with normal female sexual function. Many changes occur in the female external and internal genitalia during sexual arousal. Increased blood flow promotes what is called “vasocongestion of the genitalia”. Smooth muscle relaxation allows for lengthening and dilation of the vagina. As the clitoris is stimulated, its length and diameter increases, and engorgement with blood occurs. In addition, the labia minora becomes also engorged because of the increased blood flow. Vaginal temperature increases during arousal.

FSD is psychologically complex. The female sexual response cycle was first characterized by Masters and Johnson in 1966 and included four phases: excitement, plateau, orgasm, and resolution. In 1974, Kaplan modified this theory and characterized it as a three-phase model that included desire, arousal, and orgasm. It is now believed that various biologic and psychological factors can negatively affect this cycle, thereby leading to FSD. Hormonal changes, such as the drop in estrogen seen in post-menopausal women, can also greatly affect sexual desire and vaginal lubrication. Nerve and small vessel disorders seen in conditions such as diabetes, high cholesterol, and cigarette smoking can also affect female sexual function. Women with hypertension and vascular problems are at very high risk of FSD because of diminished blood flow to their genitalia.

Female sexual dysfunction can be divided into five major subtypes: disorder of the libido (sexual desire); arousal dysfunction; vaginal lubrication disorders; disorders related to orgasm; and  vaginismus  and dyspareunia (painful intercourse). Many women with FSD are affected by all or some of the subtypes.

Treatment

For many reasons, treatment options are more difficult and less established in women than in men. Whileoral tablets such as Viagra, Cialis, Levitra –  which are in the category of phosphodiasterase-inhibitors (PDE-5) – have been useful in male ED, they have little value in women. Hormonal manipulation, while often helpful in FSD, must be weighed very carefully against possible side effects such as weight gain or cardiovascular risks. Vacuum erection devices of the clitoris, while available for women, have not been widely used for clitoral engorgement and arousal disorders. Women with lubrication disorders (i.e., dry vagina) can be treated with estrogen vaginal cream or lubricants. This often alleviates dyspareunia (painful intercourse). Psychological counseling and sexual therapy remain at the forefront of FSD that is related to sexual intimacy or psychological disorders. Often, a multispecialty approach is most effective. Women suffering from FSD who desire treatment are best treated with clinicians who specialize in the area.

The US FDA approval of Addyi (Flibanserin) on August 18th, 2015 was a landmark event for female sexual dysfunction in the United States. This medication was the first oral treatment approved for Female Sexual Interest/Arousal Disorder, and the first real FDA-approved treatment for female sexual dysfunction in general.

The arrival of the “Female Viagra” (also called “The pink pill”) was extremely well publicized and sensationalized; however, its scientific background and mechanism has not been well explained in the context of female sexual arousal and interest disorders. For women, the chemistry of their primary sexual organ appears to exist in the brain. Therefore, brain chemistry must be altered to treat female sexual dysfunction.

Flibanserin is a 5HT-1A agonist, 5HT-2A antagonist that works primarily in the brain to increase dopamine and norepinephrine and decrease serotonin levels.  Dopamine and norepinephrine function as “excitatory” hormones to increase sexual desire, while serotonin is an “inhibitory” hormone that depresses sexual function and desire. This medication thus helps make the brain environment “ready” for sexual function, and helps augment sexual desire. Women with normal clitoral blood flow and adequate lubrication are then able to participate in healthy, satisfying sexual experiences.

We also know that the sex hormone testosterone influences female sexual desire and practice. This hormone is present in women, albeit in smaller amounts than men, but is well known to be integral to sexual responsiveness and desire in women. Clinicians have used testosterone replacement therapy in women to augment sexual desire and libido, with mixed results.

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