Sexual functioning in .NET

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Sexual functioning
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Aging is the most robust risk factor predicting erectile dif culties It is obvious that aging per se is associated with a deterioration of the biologic functions mediating erectile function: hormonal, vascular, and neural processes This is often aggravated by intercurrent disease in old age, such as diabetes mellitus, cardiovascular disease, and use of medical drugs T is only one of the elements which may explain sexual dysfunction with aging It has been repeatedly shown in hypogonadal patients (with a wide age range) that sexual functions only require androgen levels below or at the lower end of reference values of T [8 10] The relative androgen-independence of erections in response to erotic stimuli in the rst studies [33], since then challenged in many others [156], and the relatively low androgen levels required, suggest that T was not a useful treatment for men with erectile dif culties whose T levels were usually only marginally low This was reinforced with the advent of intracorporal smooth muscle relaxants (papaverine, prostaglandin E1), later superseded by the PDE5i, hailed as the ultimate successful treatment of ED As already detailed in p 231, T therapyreplacement alone may not suf ce to restore erectile potency in every case since ED is often multifactorial in aging patients It is a matter of clinical judgment what type of treatment should be tried rst, PDE5i or T, but it is important to remember that insuf cient success of one type of treatment might require
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18 absence of associated ED [23] Testosterone determination is not necessary in the other sexual dysfunctions, unless clinical signs of hypogonadism are associated Some men using the 5 reductase inhibitor, nasteride, for benign prostate hyperplasia, experience an impact on sexual function, especially on ejaculation, although these effects are relatively rare [158]
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addition of the other, as well as treating the underlying medical risk factors
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Diagnosis: clinical symptoms and screening Screening for hypogonadism in sexual dysfunctions
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Several varieties of sexual dysfunction, mainly ED, may be the presenting symptom of hypogonadism, a condition that can reveal diseases with serious nonsexual consequences, such as pituitary tumors In addition, missing a hypogonadism responsible for sexual dysfunction would deprive the patient of an etiologic therapy that would give him the best chance of success This has led to the advocating of routine determination of T in several dysfunctions
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Screening for late onset hypogonadism (LOH)
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In women, age-related hormonal changes are well recognized, generally with a rapid onset and progression, leading to the characteristic menopausal symptoms In males, the changes in the hypothalamic pituitary gonadal axis in general have an insidious onset and a slow progression, do not have clinical manifestations in all men, have a great variability from man to man with the clinical picture of hypogonadism being mild or even nonexistent in many of them [159] The clinical signs and symptoms of LOH can be [2,157] (Table 181): Decreased libido (sexual desire) Erectile dysfunction (diminished quality of the rigidity, intercourse frequency and nocturnal erections) Decrease in lean body mass, muscle volume and strength Decrease in BMD, resulting in osteopenia, osteoporosis and increased risk of bone fractures Increase in visceral fat Changes in mood, with concomitant decreases in intellectual activity, cognitive functions, spatial orientation ability, fatigue, depressed mood and irritability Decrease in body hair Skin alterations Gynecomastia Anemia Hypogonadism is also prevalent in men with insulin resistance [160], especially in those with type 2 diabetes and metabolic syndrome, which are frequent in aging men [161] These symptoms, though, can also be present in many medical conditions and also may be manifested in the normal process of aging In conjunction
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Erectile dysfunction
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Several authors question the recommendation of routine T determination in ED because of the cost of hormone determinations, the low prevalence of hypogonadism in this population, and the limited success rate of T therapy in the hypogonadal ED patient [18,54] They recommend screening only patients with low sexual desire or abnormal physical examination (small and soft testes, reduced body hair, and so on) However, in a study of routine determinations of TT in over 1000 ED patients, the speci city, sensitivity, and ef ciency of low sexual desire in the detection of low T (<3 ng/mL, 104 nmol/L) were very low (66, 48, and 63%, respectively) [18] By combining both clinical signs (low sexual desire, present in 29% of the ED patients, and/or physical signs of hypogonadism, present in 30%), sensitivity was only 59% If T had been determined only in cases of low sexual desire or physical signs of hypogonadism, 40% of the men with low T would have been missed, including 37% of the hypogonadal patients who were subsequently markedly improved with androgen therapy alone Today most published guidelines recommend routine determination of T in ED [2,24,157]
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