SEXUAL PROBLEMS: SEX THERAPY

Unfortunately, many men share similar attitude: They take advice to see a sex therapist as an indication that someone thinks they are crazy. In fact, nothing could be further from the truth. Sex therapy is for people who want to overcome habits and attitudes which sabotage their sex lives—if s usually not for people with serious emotional or mental problems, because often they can’t benefit from it. Generally, a sex therapist will not focus on your unconscious, or attempt to analyze you. A sex therapist will help you define your goals and possibly revise them so they are more attainable; identify problem areas and suggest solutions; and provide suggestions and exercises for making positive changes.

The fact is, sexual problems affect most people at some point in their lives. Think about it: Why would this emotionally packed area of human behavior be any more immune from disturbance than other parts of life? And sex therapy doesn’t take a lifetime. Sometimes, just a brief period of help can make a very positive and rewarding difference.

Although there are lots of variations of sex therapy, modern-day sex therapy began with the work of Masters and Johnson. As the term is usually used, sex therapy is designed to focus on the needs, concerns and expectations of the client. It can be a highly structured, short-term program lasting a few weeks or months, or it may be more flexible in design.

Different forms of sex therapy can benefit men and women with a wide variety of sexual difficulties, but we’re going to concentrate on how sex therapy can help men who experience erection problems.

*177\184\8*

IMPOTENCY: BLOOD FLOW

The arteries in the penis are quite tiny, and zeroing in on them to take the pressure can be difficult. If the wrong arteries get measured, the results will be inaccurate. Generally speaking, if you get a low reading, you can probably figure the test was done correctly, Sometimes, though, you may get a false normal reading, If blood-flow problems are suspected, you then may need a more sophisticated measurement, called the duplex Doppler test.

Using the radar-like duplex Doppler, doctors can actually measure the increase in blood flow that a man is able to generate to get an erection. This sophisticated and nearly painless test can let the doctor actually see the arteries in the penis, and figure out how well they’re doing their job.

For years, doctors have used the duplex Doppler to look at other parts of the body. Tom F. Lue, M.D., and colleagues at the University of California Medical School in San Francisco, developed a new way to use it. We can now measure the increase in blood flow to the penis and the change in diameter of the blood vessels during an erection. This crucial information shows if the arteries are sufficiently healthy to deliver enough blood to the penis to sustain an erection.

Usually, these measurements are taken before and after a penile shot of papaverine which will, of course, usually produce an erection. By checking the change in blood flow between a man’s erect and nonerect state, the doctor knows if the arterial expressways are doing their job.

Sometimes a man with blocked arteries may be advised to have surgery to reroute blood around the defective arteries. If you’re considering this, you’ll need to have an arteriogram which can actually pinpoint the arteries at fault. First, dye is injected into the arteries which supply the penis, and then an X-ray is taken. f

Another artery test, thermography, measures the heat in the penis. The temperature is an indication of the amount of bloopl flow. But thermography has recently fallen out of favor with many urologists, since more accurate measurements of blood flow are now available.

*133\184\8*

CONTROL TOUR EJACULATION: THE STOP-START METHOD

The stop-start method aims at giving the man a sense of control over his ejaculations. It starts with masturbation. In a quiet, private, secure place where he can relax, the man stimulates himself up and down the length of his penis, so that what he feels is similar to what he would enjoy during intercourse. While doing this, he needs to concentrate on how he feels, especially in his penis. When he senses he is going to ejaculate, he stops and waits until this feeling completely passes. Then, he begins self-pleasuring all over again. He may continue in this manner until the fourth time of wanting to ejaculate, when he allows himself to do so. He continues these exercises over a period of time, until he can control his ejaculation to his satisfaction.

Now, if there’s a partner, she can become involved by caressing her lover in the way described above. He can control her hands and stop her when necessary. Sexual fantasies can be an important part of this process.

Once a man can delay his ejaculation with masturbation and with his lover’s manual stimulation, he’s ready to try intercourse. If s best to start with the woman on top, because in this position the man has less general body tension and his partner is free to stop moving when he signals her to do so. When the couple first begins intercourse, the man and woman may lie still for a while or may enjoy caressing each other in nongenital areas. Once thrusting begins, he can use the stop-start technique to avoid early ejaculation. He may want to hold on to her hips to control the movement and the stimulation he feels.

The next-to-the-last step in the process is for the woman to be able to thrust herself while on top, without the man being in control. However, he may stop her if he feels he will ejaculate too soon.

Reaping the benefits of this technique takes time. You should expect premature ejaculation to continue for a while as you’re becoming familiar with the method. Once you have mastered each phase (a week for each period would be expected), you can try other positions during intercourse.

*105\184\8*

PEYRONIE’S DISEASE CAN CAUSE ERECTION PROBLEMS

Peyronie’s disease, named for the doctor who discovered it, can also cause erection problems. Most often, this condition occurs in middle-aged men, who usually show up in the doctor’s office complaining of a penis that curves to one side when erect. Sometimes this curvature makes intercourse difficult. Sometimes there is also pain that disappears when the erection does. And some patients can actually feel a lump in their penis. (They usually think they have cancer, but growths caused by Peyronie’s disease are not cancerous.)

Not all men with Peyronie’s disease become impotent, but some do. Sometimes the disease appears to be caused by injury to the penis, and even, according to some experts, by medications. And there appears to be a genetic component, since it sometimes runs in families.

For reasons doctors don’t fully understand, the disease causes scarring in the corpora cavernosa, those all-important cylinders in the penis which must fill up with blood for erections to occur. This scarring can create the lumps, bending and pain which are the hallmarks of the illness.

A whole variety of treatments have been tried to stop the progress of the disease, including medication, radiation, injection of steroids into the penis and surgical removal of the lumps, but none have been proven particularly effective. About half of all patients get better over time (usually after about a year), so it’s important to take the most conservative approach you can live with. If you do decide to try any type of treatment, be sure you’re well informed about all the possible consequences. You may want to get a second (or third) opinion before proceeding. If severe bending with erection persists, an operation to straighten the penis may offer a permanent solution. In some cases, a penile implant may be necessary.

*76\184\8*

ERECTION PROBLEMS: TROUBLE AT HOME

An unhappy relationship coupled with a demanding partner is another possible source of erection problems. In this case, as in others, separating the erection problem from the relationship is often counterproductive. Marion and Walter, for example, had been married for more than 20 years. It was not a happy relationship. Walter did not turn out to be the ambitious, energetic man Marion had wanted. Faced with conflict, he withdrew. Over the years, Marion had built up a lot of anger over her husband’s “failure,” his lack of responsibility, his unwillingness to participate in family events. But she did not deal with the issues openly. Instead, she took the battles into the bedroom. She compared her husband’s sexual skills with those of her best friend’s spouse, with the expected disastrous results. “Mary’s husband doesn’t have erection problems. But you do!”

The predictable result was that Walter’s erection problems increased, and Marion had something else to be angry about.

This was a no-win situation for both partners, but the erection problem was only a part of a very troubled and unfulfilling marriage. Some people might see Walter’s lack of erection as a way of punishing his wife, or as a logical response to a hostile situation. Feeling under attack, he and his penis withdrew.

*45\184\8*

A COMPEDIUM OF DRUGS: BETA-BLOCKERS

Propranolol, metoprolol, atenolol, and timolol are some of the many beta-blockers. Beta-blockers interfere with the effect of adrenaline on the heart, preventing an unnecessary increase in the speed and effort of the heart. Aside from the effect on angina pectoris and hypertension, beta-blockers can prevent and control certain kinds of abnormal heart rhythms. They can be used alone or in conjunction with digoxin, qui-nidine, or disopyramide. Usually, they are taken from one to four times daily. They slow the pulse, and some people may develop an inordinately slow heart rate. In patients with asthma or chronic bronchitis, beta-blockers may exaggerate wheezing. And in certain individuals, they may aggravate the symptoms of heart failure.

A new class of medications has become available for the treatment of angina pectoris. The calcium antagonists or calcium blockers add a new dimension to the control of angina pectoris. Many older people with anginal pain benefit from the use of nifedipine, diltiazem, or verapamil.

Medications used to treat hypertension (high blood pressure) often overlap with those used for various forms of heart disease. Diuretics (“water pills”) are medications that cause the body to lose salt and water. In people who suffer from heart failure, there is an excessive accumulation of fluid because of impaired pumping of the heart. Diuretics allow the excess fluid to be passed through the kidneys and thereby decrease the shortness of breath, bloating, and swelling.

It may be necessary to use diuretics with other medications when high blood pressure is difficult to control. The most common diuretics, the thiazides, come in many forms, as individual medications and sometimes in combination with other drugs. They are slow acting and rarely create an urgency to urinate, as do the faster-acting diuretics, such as furosemide. The fast-acting diuretics are more potent than the thiazides for the treatment of heart failure but are not more effective in treating high blood pressure. The diuretics spironolactone, triamterene, and amiloride are often combined with other diuretics to enhance their effect and prevent excessive loss of potassium, which is often a problem with the other types of medications. Sometimes potassium tablets or syrup may be given with thiazides or furosemide. Potassium should not be taken if you are receiving spironolactone, triamterene or amiloride.    r

Medications for hypertension may cause an excessive loss of salt and water, which can lead to dizziness and fainting, or they may decrease the efficiency of the kidneys. In people who have a tendency to diabetes mellitus, diuretics may increase the level of sugar in the blood (see chapter 18, section on diabetes mellitus). In certain individuals gout may occur. If you are taking diuretics, expect to have periodic blood tests to measure electrolytes, blood sugar, and kidney function.

Some drugs used to treat high blood pressure act on the blood vessels, on the heart, or on the brain. Propranolol and other beta-blockers, as well as methyldopa, hydralazine, prazosin, and clonidine are effective antihypertensive medications.

Often, a combination of medications is given simultaneously. Each medication can have its own side effects. The main problem is the excessive lowering of the blood pressure, which often leads to dizziness and fainting. This can usually be reversed by decreasing the dosage. Medications known as ACE inhibitors, such as enalapril and captopril, can be prescribed for some people to lower blood pressure and/or treat heart failure. The use of these drugs must be carefully followed by your physician because they are usually started in very small doses and then gradually increased.

*46\166\2*

CANDIDIASIS – DEFINITION

Yeasts commonly colonise the gastrointestinal tract and vagina. If their presence is associated with local irritation, the condition may be referred to as candidiasis, moniliasis or thrush. Candidiasis is the commonest cause of vaginitis. Candida albicans is the most common yeast found and most cases of candidiasis are due to this species. Other Candida species are occasionally found but are rarely pathogenic; Torulopsis glabrata is common and is sometimes associated with a mild vaginitis. Yeasts are not usually acquired as sexually transmitted infection.

Candidiasis may occur when the balance between host and yeast is disturbed by:

use of oral contraceptives;

use of antibiotics;

use of corticosteroids;

menstruation;

pregnancy;

diabetes mcllitus;

immunosuppression or immunodeficiency.

*117/56/1*

HUMAN IMMUNODEFICIENCY VIRUS INFECTION – CLINICAL MANIFESTATIONS (OTHER GROUPS 2)

Subgroup E—Other conditions

Defined as the presence of other clinical conditions which may be attributable to HIV infection but not listed above.

Although this system allows for ready classification for epidemiological purposes, patients typically present with one of the following:

Pulmonary presentations

P carinii pneumonia is the commonest presentation of AIDS. It usually presents with fever, non-productive cough and increasing dyspnoea of several weeks duratioa

Other infections may present as pulmonary disease including CMV, cryptococcosis and mycobacterial disease (including tuberculosis and atypical mycobacteriosis).

Gastrointestinal presentations

Oral candidiasis and oral hairy leukoplakia occur commonly.

Oesophageal candidiasis is suggested by dysphagia with retrosternal pain accompanied by oral candidiasis.

Low volume diarrhoea with weight loss and malaise is a frequent presentation of early AIDS. In many cases no specific pathogen is found. HIV can infect bowel mucosa and may be the sole aetiological agent for diarrhoea in some cases.

Diarrhoea associated with an opportunistic infection such as cryptosporidiosis, isosporiasis, CMV, and MAI may be severe with dehydration and extreme weight loss. Stools should also be examined for other pathogens including Salmonella sp. Shigella sp, Giardia lamblia, Clostridium difficile, Campylobacter sp and various enteroviruses.

Herpes can cause oesophagitis, proctitis or severe ulcerative perianal lesions.

Kaposi’s sarcoma or lymphoma may present with gastrointestinal symptoms.

*91/56/1*

SYPHILIS – ANTIBIOTIC TREATMENT

Parenteral penicillin is the drug of choice. Alternative antibiotics should only be used where there is a history of penicillin sensitivity.

Early syphilis

Aqueous procaine penicillin G 1.5 g daily intramuscularly for a minimum of 10 days;

Benzathine penicillin G 1.8 g intramuscularly in a single dose for patients unable to comply with daily injections, preferably repeated 7 days later.

Late latent syphilis

Aqueous procaine penicillin G 1.5 g daily intramuscularly for 15 days; OR

Benzathine penicillin 1.8 g intramuscularly at 7 day intervals for 3 doses for patients unable to comply with daily injections.

Benign gummatous syphilis

Aqueous procaine penicillin G 1.5 g daily intramuscularly for 21 days; OR

Benzathine penicillin G 1.8 g intramuscularly at 7 day intervals for 3 doses for patients unable to comply with daily injections. This should never be used in late syphilis unless the CSF is negative.

*66/56/1*

GONORRHOEA – CLINICAL MANIFESTATIONS

The incubation period is usually 2 to 7 days but may be as short as 24 hours or as long as a month. In many patients infection is asymptomatic.

Classically gonococcal urethritis in males begins with urethral discomfort then dysuria and mucoid discharge followed by a yellow discharge which is at first turbid and then opaque and sufficiently profuse to stain the underclothes.

Without treatment, infection can spread to the posterior urethra causing pain, frequency, urgency and terminal haematuria. Further ascent can produce prostatitis and vesiculitis manifested by deep genital pain and tenderness on rectal palpation. Epididymitis may cause scrotal pain, tenderness and swelling which should not be confused with torsion of the testis. If gonococcal urethritis is not adequately treated, sequelae may include urethral stricture and chronic prostatitis or epididymitis.

Cervicitis is the commonest type of infection in females and is often asymptomatic. It may be associated with profuse discoloured vaginal discharge sometimes with vaginal or vulval irritation which may be misdiagnosed as a vulvovaginitis. In premcnarchal girls, gonococcal infection can cause a vulvovaginitis.

*42/56/1*