Premature ejaculation

Premature ejaculation refers to earlier-than-wanted ejaculation during intercourse. It's usually idiopathic and can be treated with psychotherapy, local anaesthetics, or SSRIs.

Delayed ejaculation

Delayed ejaculation refers to later-than-wanted ejaculation during intercourse. It's usually caused by psychological stress and can be treated with psychotherapy.

Erectile dysfunction

Erectile dysfunction (ED) is the persistent inability to achieve and/or maintain a sufficient erection. It usually causes significant psychosexual morbidity, decreased self-esteem, anxiety, and depression, which might worsen the ED, causing an evil cycle.

Epidemiology

Affects 50% of men aged 40 – 70
Prevalence increases with age

Physiological erection

Flaccid penis
- Sympathetic nervous system predominates
- Cavernous smooth muscle is contracted
- Artery is vasoconstricted
Erect penis
- Parasympathetic nervous system predominates
- Cavernous smooth muscle relaxes
- Artery is vasodilated

Diagnosis and evaluation

Diagnosis is clinical
Anamnesis
- International Index of Erectile Function (IIEF)
Physical examination
- Hypogonadism
- Neurological disease
- Vascular disease
Labs
- Testosterone
- CVD risk factors
Nocturnal penile tumescence
- Erections physiologically occur during the night
- This test monitors the penis for erections during the night
  - If erections -> most likely psychogenic ED
  - If no erections -> most likely organic ED

Organic erectile dysfunction

Due to vasculogenic, neurologic, hormonal, or cavernosal abnormalities
Often co-exists with cardiovascular disease
- ED can be an early manifestation of CVD
Etiology
- Hypertension
- Diabetes
- Cardiovascular disease
- Smoking
- Alcohol
- Neurologic disease
- SSRIs
- Radical prostatectomy
- Pelvic injury

Psychogenic erectile dysfunction

Due to central inhibition of the erectile mechanism
Etiology
- Depression
- Anxiety
- Relationship issues
- Stress

Mixed type erectile dysfunction

Features of both organic and psychogenic ED

Treatment

Psychotherapy
First line
- PDE5 inhibitors
  - Sildenafil
  - Vardenafil
  - Tadalafil
  - Contraindicated in patients who take nitrates or other NO-donor drugs
- Vacuum tumescence device
  - Vacuum tube creates negative pressure around the penis
Second line therapy
- Intracavernous injection
- Intraurethral insertion of pellet
- Alprostadil
Third line
- Penile prosthesis implantation

Male infertility

Male infertility refers to the inability to conceive despite 1 year of unprotected intercourse.

Etiology

Idiopathic in 30% of cases
Diabetes mellitus
Hypertension
Obesity
Chronic STD
Alcohol
Anabolic steroids
Varicocele
Testicular trauma

Diagnosis

Anamnesis
Hormone tests
Semen analysis

Semen analysis

Used to evaluate male fertility and confirm sterility after vasectomy
Procedure
- No ejaculation for 3 – 5 days before
- Semen is collected after masturbation into a sterile container
  - Container should be stored at body temperature
- Analysis should be performed within 1 hour
- Analysis should be repeated at least 2x with 12 weeks in-between
Normal parameters
- Volume = 1,5 – 5 mL
- Colour = Whitish
- Liquefaction = Complete within 30 minutes
- pH = 7,2 – 8,0
- Sperm per ejaculate = more than 40 million sperm
- Sperm concentration = more than 15 million per mL
- Vitality = more than 58% sperm should be alive
- Morphology = more than 4% of sperm should be morphologically normal
  - Yes, this sounds very low. But it’s true
- Progressive motility = more than 32%
  - Progressive motility means sperm which move in only one direction
- Fructose content = more than 13 µM
- Leukocytes = < 1 million WBCs per mL
Pathological findings
- Aspermia – no ejaculate
- Hypospermia – ejaculate volume < 1,5 mL
- Azoospermia – no spermatozoa in ejaculate
- Cryptozoospermia – < 1 million spermatozoa/mL
- Oligospermia – < 15 million spermatozoa/mL
- Teratozoospermia – > 4% of spermatozoa are morphologically abnormal
- Asthenozoospermia – < 32% of spermatozoa show progressive motility