History
During the late
16th and 17th centuries in France, male impotence was considered a crime, as
well as legal grounds for a divorce. The practice, which involved inspection of
the complainants by court experts, was declared obscene in 1677.
1.
Erectile
dysfunction (ED), also known as impotence, is a type of
sexual dysfunction characterized by the inability to develop or maintain an
erection of the penis during sexual activity. Erectile dysfunction can have
psychological consequences as it can be tied to relationship difficulties and
self-image.
2.
Premature
ejaculation (PE) occurs when a man experiences orgasm and expels
semen soon after sexual activity and with minimal penile stimulation. It has
also been called early ejaculation, rapid ejaculation, rapid climax, premature climax
and (historically) ejaculation praecox. There is no uniform cut-off defining
"premature", but a consensus of experts at the International Society
for Sexual Medicine endorsed a definition of around one minute after penetration.
The International Classification of Diseases (ICD-10) applies a cut-off of 15
seconds from the beginning of sexual intercourse.
The most
important organic causes of impotence are -
v cardiovascular
disease and diabetes, neurological problems (for example, trauma from
prostatectomy surgery),
v Hormonal
insufficiencies (hypogonadism)
v Drug
side effects.
v Psychological
impotence is where erection or penetration fails due to thoughts or feelings
(psychological reasons) rather than physical impossibility; this is somewhat
less frequent but can often be helped. In psychological impotence, there is a
strong response to placebo treatment.
v Potassium
deficiency or arsenic contamination of drinking water, the first line treatment
of erectile dysfunction consists of a trial of PDE5 inhibitor (such as
sildenafil). In some cases, treatment can involve prostaglandin tablets in the
urethra, injections into the penis, a penile prosthesis, a penis pump or
vascular reconstructive surgery.
Causes
• Medications
(antidepressants, such as SSRIs, and nicotine[citation needed] are most common)
• Neurogenic
disorders
• Cavernosal
disorders (Peyronie's disease
• Hyperprolactinemia
(e.g., due to a prolactinoma)
• Psychological
causes: performance anxiety, stress, and mental disorders
• Surgery
• Aging.
It is four times more common in men aged in their 60s than those in their 40s.
• Kidney
failure
• Diseases
such as diabetes mellitus and multiple sclerosis (MS). While these two causes
have not been proven they are likely suspects as they cause issues with both
the blood flow and nervous systems.
• Lifestyle:
smoking is a key cause of erectile dysfunction. Smoking causes impotence
because it promotes arterial narrowing.
ED can also be
associated with bicycling due to both neurological and vascular problems due to
compression. The increase risk appears to be about 1.7-fold.
Concerns that
use of pornography can cause erectile dysfunction have not been substantiated
in epidemiological studies according to a 2015 literature review. However,
another review and case studies article maintains that use of pornography does
indeed cause erectile dysfunction, and critiques the previously described
literature review.
Pathophysiology
Penile erection
is managed by two mechanisms: the reflex erection, which is achieved by
directly touching the penile shaft,and the psychogenic erection, which is
achieved by erotic or emotional stimuli. The former uses the peripheral nerves
and the lower parts of the spinal cord, whereas the latter uses the limbic
system of the brain. In both cases, an intact neural system is required for a
successful and complete erection. Stimulation of the penile shaft by the
nervous system leads to the secretion of nitric oxide (NO), which causes the
relaxation of smooth muscles of corpora cavernosa (the main erectile tissue of
penis), and subsequently penile erection. Additionally, adequate levels of
testosterone (produced by the testes) and an intact pituitary gland are
required for the development of a healthy erectile system. As can be understood
from the mechanisms of a normal erection, impotence may develop due to hormonal
deficiency, disorders of the neural system, lack of adequate penile blood supply
or psychological problems. Spinal cord injury causes sexual dysfunction
including ED. Restriction of blood flow can arise from impaired endothelial
function due to the usual causes associated with coronary artery disease, but
can also be caused by prolonged exposure to bright light.
Diagnosis
It is analyzed
in several ways:
1.
There are no
formal tests to diagnose erectile dysfunction. Some blood tests are generally
done to exclude underlying disease, such as
2.
Hypogonadism and
3.
prolactinoma.
4.
Impotence is
also related to generally poor physical health,
5.
poor dietary
habits,
6.
obesity, and
7.
Most
specifically cardiovascular disease such as coronary artery disease and
peripheral vascular disease.
Duplex
ultrasound
Duplex
ultrasound is used to evaluate blood flow, venous leak, signs of
atherosclerosis, and scarring or calcification of erectile tissue. Injecting
prostaglandin, a hormone-like stimulator produced in the body, induces the
erection. Ultrasound is then used to see vascular dilation and measure penile
blood pressure.
Penile nerves
function
Tests such as
the bulbocavernosus reflex test are used to determine if there is sufficient
nerve sensation in the penis. The physician squeezes the glans (head) of the
penis, which immediately causes the anus to contract if nerve function is
normal. A physician measures the latency between squeeze and contraction by
observing the anal sphincter or by feeling it with a gloved finger inserted
past the anus.
Nocturnal penile
tumescence (NPT)
It is normal for
a man to have five to six erections during sleep, especially during rapid eye
movement (REM). Their absence may indicate a problem with nerve function or
blood supply in the penis. There are two methods for measuring changes in
penile rigidity and circumference during nocturnal erection: snap gauge and
strain gauge. A significant proportion of men who have no sexual dysfunction
nonetheless do not have regular nocturnal erections.
Corpus
cavernosometry
Cavernosography
measurement of the vascular pressure in the corpus cavernosum. Saline is
infused under pressure into the corpus cavernosum with a butterfly needle, and
the flow rate needed to maintain an erection indicates the degree of venous
leakage. The leaking veins responsible may be visualized by infusing a mixture
of saline and x-ray contrast medium and performing a cavernosogram. In Digital
Subtraction Angiography (DSA), the images are acquired digitally.
Treatment
Exercise,
particularly aerobic exercise during midlife is effective for preventing ED;
exercise as a treatment is under investigation. For tobacco smokers, cessation
results in a significant improvement.
Medication
The PDE5
inhibitors sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are
prescription drugs which are taken orally.
A cream
combining alprostadil with the permeation enhancer DDAIP has been approved in
Canada as a first line treatment for erectile dysfunction.
One of the
following medications may be injected into the penis: papaverine, phentolamine,
and prostaglandin E1
Although men
with premature ejaculation describe feeling that they have less control over
ejaculating, it is not clear if that is true, and many or most average men also
report that they wish they could last longer. Men's typical ejaculatory latency
is approximately 4–8 minutes. The opposite condition is delayed ejaculation.
Men with PE
often report emotional and relationship distress and some avoid pursuing sexual
relationships because of PE-related embarrassment. Compared with men, women consider
PE less of a problem, but several studies show that the condition also causes
female partners distress.
Cause
The causes of
premature ejaculation are unclear. Many theories have been suggested, including
that PE was the result of masturbating quickly during adolescence to avoid
being caught, performance anxiety, and passive-aggressiveness or having too
little sex; but there is little evidence to support any of these theories.
Several
physiological mechanisms have been hypothesized to contribute to causing
premature ejaculation, including serotonin receptors, a genetic predisposition,
elevated penile sensitivity and nerve conduction atypicalities.
The nucleus
paragigantocellularis of the brain has been identified as having involvement in
ejaculatory control. Scientists have long suspected a genetic link to certain
forms of premature ejaculation. However, studies have been inconclusive in
isolating the gene responsible for lifelong PE. Other researchers have noted
that men who have premature ejaculation have a faster neurological response in
the pelvic muscles.
PE may be caused
by prostatitis or as a medication side effect.
Mechanism
The physical
process of ejaculation requires two actions: emission and expulsion. The
emission is the first phase. It involves deposition of fluid from the ampullary
vas deferens, seminal vesicles and prostate gland into the posterior urethra.The
second phase is the expulsion phase. It involves closure of bladder neck,
followed by the rhythmic contractions of the urethra by pelvic-perineal and
bulbospongiosus muscle and intermittent relaxation of external urethral sphincters.
Sympathetic
motor neurons control the emission phase of ejaculation reflex, and expulsion
phase is executed by somatic and autonomic motor neurons. These motor neurons
are located in the thoracolumbar and lumbosacral spinal cord and are activated
in a coordinated manner when sufficient sensory input to reach the ejaculatory
threshold has entered the central nervous system.
Intromission
time
The 1948 Kinsey
Report suggested that three-quarters of men ejaculate within two minutes of
penetration in over half of their sexual encounters.
Current evidence
supports an average intravaginal ejaculation latency time (IELT) of six and a
half minutes in 18- to 30-year-olds. If the disorder is defined as an IELT
percentile below 2.5, then premature ejaculation could be suggested by an IELT
of less than about two minutes. Nevertheless, it is possible that men with
abnormally low IELTs could be satisfied with their performance and do not
report a lack of control. Likewise, those with higher IELTs may consider
themselves premature ejaculators, suffer from detrimental side effects normally
associated with premature ejaculation, and even benefit from treatment.
Diagnosis
Premature
ejaculation as a medical problem under evidence-based criteria generated by the
International Society for Sexual Medicine in 2014 as being not the result of a
nonsexual mental illness, a problem in a given relationship, or caused by
medication, by the person ejaculating around a minute after penetration and
before the person wants to ejaculate, occurring for a duration longer than 6
months and happening almost every time, and causing significant distress for
person. These factors are identified by talking with the person, not through
any diagnostic test.
The 2007 ICD-10
defined PE as ejaculating without control, and within around 15 seconds.
Treatments
Several
treatments have been tested for treating premature ejaculation. A combination
of medication and non-medication treatments is often the most effective method.
Self-treatment
Many men attempt
to treat themselves for premature ejaculation by trying to distract themselves,
such as by trying to focus their attention away from the sexual stimulation.
There is little evidence to indicate that it is effective and it tends to
detract from the sexual fulfilment of both partners. Other self-treatments
include thrusting more slowly, withdrawing the penis altogether, purposefully
ejaculating before sexual intercourse, and using more than one condom. Using
more than one condom is not recommended as the friction will often lead to breakage.
Some men report these to have been helpful.
By the 21st
century, most men with premature ejaculation could cure themselves; either on
their own or with a partner, using self-help resources, and only those with
unusually severe problems had to consult sex therapists, which cured 75 to 80
percent.
Psychoanalysis
Freudian theory
postulated that rapid ejaculation was a symptom of underlying neurosis. It
stated that the man suffers unconscious hostility toward women, so he
ejaculates rapidly, which satisfies him but frustrates his lover, who is
unlikely to experience orgasm that quickly. Freudians claimed that premature
ejaculation could be cured using psychoanalysis. But even years of
psychoanalysis accomplished little, if anything, in curing premature ejaculation.
There is no
evidence that men with premature ejaculation harbor unusual hostility toward
women.
Sex therapy
Several
techniques have been developed and applied by sex therapists, including Kegel
exercises (to strengthen the muscles of the pelvic floor) and Masters and
Johnson's "stop-start technique" (to desensitize the man's responses)
and "squeeze technique" (to reduce excessive arousal).
These techniques
appear to work for around half of people, in the short term studies that had
been done as of 2017.
Medications
Drugs that
increase serotonin signalling in the brain slow ejaculation and have been used
successfully to treat PE. These include selective serotonin reuptake inhibitors
(SSRIs), such as paroxetine or dapoxetine, as well as clomipramine. Ejaculatory
delay typically begins within a week of beginning medication. The treatments
increase the ejaculatory delay to 6–20 times greater than before medication.
Men often report satisfaction with treatment by medication, and many
discontinue it within a year.[8] However, SSRIs can cause various types of
sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished
libido.
Dapoxetine is a
short-acting SSRI which appears to work when taken as needed for PE. It is
generally well tolerated. Tramadol, an atypical oral analgesic, appears to be
effective.
Desensitizing
topical medications like lidocaine that are applied to the tip and shaft of the
penis can also be used. These are applied "as needed", 10–15 minutes
before sexual activity and have fewer potential systemic side effects as
compared to pills.Use of topicals is sometimes disliked due to the reduction of
sensation in the penis as well as for the partner (due to the medication
rubbing onto the partner).
Epidemiology
Premature
ejaculation is a prevalent sexual dysfunction in men; however, because of the variability in time
required to ejaculate and in partners' desired duration of sex, exact
prevalence rates of PE are difficult to determine. In the "Sex in
America" surveys (1999 and 2008), University of Chicago researchers found
that between adolescence and age 59, approximately 30% of men reported having
experienced PE at least once during the previous 12 months, whereas about 10
percent reported erectile dysfunction (ED). Although ED is men's most prevalent
sex problem after age 60, and may be more prevalent than PE overall according
to some estimates, premature ejaculation remains a significant issue that,
according to the survey, affects 28 percent of men age 65–74, and 22 percent of
men age 75–85. Other studies report PE prevalence ranging from 3 percent to 41
percent of men over 18, but the great majority estimate a prevalence of 20 to
30 percent—making PE a very common sex problem
There is a
common misconception that younger men are more likely to suffer premature
ejaculation and that its frequency decreases with age. Prevalence studies have
indicated, however, that rates of PE are constant across age groups.
Ayurvedic formulations
useful in different stage of ED &
PME
1.
Chandraprabha
vati
2.
Shri Gopal
tailam
3.
Vanari Gutika
4.
Medha vati
5.
Akarkarbhadi
churnam
6.
Swarn raj
bangeshwar rash
7.
Jatifaladi
churnam
8.
Saraswat churnam
9.
Manmantha rasha
10.
Shilajeet
11.
Vasant kushmakar
rasha
12.
Narshingh churnam
13.
Sidhha makardhwaj
bati
14.
Utar basti
15.
Anuvashan basti
16.
Ashwagandha
17.
Satavari
18.
Tribang bhashma
19.
Kapikacchu churnam
20.
Ashwagandharishta
21.
Arjuna churnam
