Other Sexual Problems

Page updated Winter 2021.
DisclaimerMedicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Testosterone Deficiency

Diagnostic criteria

Low total testosterone levels 

and

Symptoms and/or signs of testosterone deficiency



Tests

Testosterone:

Early morning- times 2

LH

Prolactin:

If low/normal luteinizing hormone levels

Estradiol

If breast symptoms or gynecomastia

Hemoglobin and hematocrit

PSA:

In men over 40 years of age 

Testosterone Therapy

Indications:

Men with low testosterone levels 

and 

Clinical symptoms of hypogonadism

Absolute contraindications:

Breast cancer

Polycythemia (hematocrit > 54%)

Prostate cancer

PSA > 4 ng/mL

Nodules/induration on digital rectal examination


Relative contraindications:

Baseline hematocrit > 50%

Desire for fertility

Severe lower urinary tract symptoms

Other cautions:

Testosterone should not be given for 3-6 months after
cardiovascular events.

Goal

To achieve a total testosterone level in the middle tertile of the normal reference range.


Testosterone Preparations

Intramuscular injections:

Testosterone cypionate (Depo-Testosterone)

Testosterone enanthate (Delatestryl)

Testosterone undecanoate (Aveed)

Buccal testosterone (Striant)

Intranasal gel (Natesto)

Pellets (Testopel)

Transdermal gel

Androgel 1% or 1.62%

Fortesta

Testim 1%

Transdermal patch (Androderm)

Transdermal solution (Axiron)


HCG Treatment

Indications:

Hypogonadotrophic hypogonadal patients with fertility issues 

Dose 

1,500-5,000 IU administered intramuscularly or subcutaneously
 twice weekly

FSH Treatment

Indication:

Patients who are receiving HCG

Reasoning:

Induction of testosterone synthesis by hCG alone may lead to
suppression of FSH.

Dose 

150 IU three times weekly- intramuscular or subcutaneous

Other Potential Options in Men Who Still Want to Father a Child

Aromatase inhibitors

Selective estrogen receptor modulators (SERMs)

Follow- up

Testosterone levels: every 6-12 months

Other tests:

Hematocrit, hemoglobin

PSA




Premature Ejaculation

Concomitant Erectile Dysfunction

Erectile dysfunction should be treated first.


Topical Anesthetics:

Lidocaine 2.5%/prilocaine 2.5% (EMLA Cream)


Serotonin Reuptake Inhibitors (SRIs)

Options:

Paroxetine

Sertraline

Fluoxetine


Tramadol

On-demand

In men who have failed first-line pharmacotherapy

Refer to mental health professional with expertise in sexual health.

Delayed Ejaculation


Treat erectile dysfunction.

Address low testosterone if present.

Address medications that may contribute to delayed ejaculation.

Refer to mental health professional with expertise in sexual health.

Peyronie’s Disease

Oral Medications

Non-steroidal anti-inflammatory drugs

For pain management

Intralesional Injections

Collagenase (Xiaflex)

The only FDA-approved medication for Peyronie's disease

Disease should be stable.

May be used in patients with penile curvature >30° and <90°, and intact erectile function with or without the use of medications.

Steps

1- Inducing penile erection: A single intracavernosal injection of 10 or 20 micrograms of Alprostadil

2- Identifying the target area

3- Waiting for penis to become flaccid

4- Injecting 0.58 mg XIAFLEX into the target plaque

 5- Repeating the injection in 1 to 3 days 

6- Performing  penile modeling procedure 1 to 3 days after the second injection 

Up to four treatment cycles may be administered. 

Each treatment cycle may be repeated at approximately six-week intervals. 

If the curvature deformity is less than 15 degrees after the first, second or third treatment cycle, treatment should be stopped. 

Patient should  not have sex or any other sexual activity between the first and second injections of a treatment cycle.

Patient should not have sex or have any other sexual activity for at least 4 weeks after the second injection..

Interferon α-2b 

Verapamil


Surgery:

Prerequisite:

Peyronie’s disease should be stable for at least three months (without pain or deformity deterioration)

Surgical options:

Tunica plication- If:

Rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy) 

There is adequate penile length

Curvature < 60° 

There is no special deformities (hour-glass, hinge)

Plaque incision or excision and/or grafting- If:

Rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy)

There is not adequate penile length

Curvature > 60º 

There is special deformities (hour-glass, hinge)

Penile prosthesis- If:

Rigidity is not adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy)

Inflatable penile prosthesis is recommended in Peyronie's disease.

Congenital Penile Curvature 

Nesbit surgery

Other plication techniques

Priapism 

Diagnosis

CBC- diff

Coagulation profile

Corporal aspiration and blood gas analysis

Ischemic priapism: 

pO2 (mmHg) <30

pCO2 (mmHg) >60

pH < 7.25

Duplex ultrasound

To differentiate between ischemic and non-ischemic priapism as an alternative or adjunct to blood gas analysis.

Magnetic Resonance imaging

In cases of prolonged ischemic priapism

To check smooth muscle viability

Treatment of Ischemic Priapism

First step

Therapeutic aspiration (with or without irrigation) 

Aspirate the corpora cavernosa until fresh red blood is obtained.

Intracavernosal  phenylephrine injection

First, decompress by penile aspiration.

Dilute it with normal saline.

Concentration of 100 to 500 mcg/mL is needed.

Inject 1 mL every 3 to 5 minutes for approximately one hour.

Lower concentrations in smaller volumes is needed in children and patients with severe cardiovascular disease.

Blood pressure and electrocardiogram monitoring are needed in patients with high cardiovascular risk.

Second step

Corporoglanular shunt

Options:

Winter: using large biopsy needle 

Ebbehøj: using scalpel 

Al-Ghorab: excising a piece of the tunica albuginea at the tip of the corpus cavernosum

Third step

Proximal shunt
Options are:

Quackels

Grayhack 

Forth step

Penile prosthesis

Consider it if :

Priapism episode is > 36 hours after onset.

Other interventions have failed.

Treatment of Priapism in Sickle Cell Anemia

Follow above steps.

Oxygen 

Intravenous hydration

Alkalization with bicarbonates

Blood exchange transfusions


Treatment of Recurrent Priapism

Medical treatment

Gonadotropin-releasing hormone (GnRH) agonists

Antiandrogens

Hormonal agents should not be used in pediatrics.

Intracavernosal self-injection

Phenylephrine

If patient fails or rejects systemic treatment.


Treatment of Non Ischemic Priapism

First step

Observation

Second step

Selected pudendal arteriogram 

Superselective arterial embolization

Autologous clot and absorbable gel are preferred to coils and chemicals, which are permanent.

Third step

Surgery