Human sexuality

The scheme of examination of patients with erectile dysfunction.

Identification of diagnostic signs of psychogenic erectile dysfunction;
1. Persistent spontaneous erections in sleep and in the morning awakening.
2. The presence of erections during masturbation.
3. The emergence of an erection with caresses and its subsequent weakening when trying to introitus.
4. The appearance of an erection in situations that provoke sexual arousal, if a man excludes the possibility of sexual intimacy.
5. The selectivity of erectile dysfunction (their situational nature – sexual problems arise with a specific partner or only in certain situations).

Investigation of genital blood flow;
– Palpation of pulsations of the penial arteries.
– Determination of pento-brachial index (PBI) – the ratio of the magnitude of systolic blood pressure in the brachial artery to the systolic pressure in the arteries of the penis. Normally, the values ​​of PBI are 0.65 – 1.0, while indicators of 0.6 and below suggest the presence of pathology of the arterial bed supplying the genitals. It should be noted that the diagnostic value of PBI does not exceed 78%, and in other cases it is possible to obtain both false-positive (when spasming penile arteries) and false-negative (with isolated lesions of the internal genital arteries) results. – Pharmacological testing by intracavernous administration of 10 μg of alprostadil (caverject).

In the absence of vasculogenic erectile dysfunction, the onset of complete erection occurs 5 to 10 minutes after the injection of the drug, and the erection continues for at least 30 minutes.
A violation of the arterial blood flow is indicated by an incomplete erection and a delay in its occurrence for more than 15 minutes.
The possible pathological venous outflow from the cavernous bodies is indicated by incomplete erection and early (in less than 30 minutes) loss of stiffness of the penis.

Doppler ultrasound (UZDG) of the vessels of the penis with pharmacological load (10 µg caverject). Initially, at rest, the peripheral resistance index (K1), the pulsation index (P1), maximum (Vmax), minimum (Vmin) and average (Vmid) system speed are examined. Then, similar indicators are recorded after intracavernous injection of 10 μg of caverject in the phase of tumescence and erection. The lack of asymmetry of the blood flow in the penilysh arteries, the achievement of its peak linear velocity of more than 33 cm / sec., With values ​​of K1> 1.0 and P1> 5.0 indicate the safety of normal hemodynamic mechanisms of erection. USDG with pharmacological load is a highly informative method of research, which in 95% of cases correlates with the results of selective angiography of the genital arteries.

Neurological examination:

– Determination of the safety of tactile and painful sensitivity of the genitals, the study of genital reflexes (the definition of the bulbocavernosum reflex is most informative, but its diagnostic value lasts until about 50 years).
– Evaluation of the vibration sensitivity of the penis using a biotensiometer.
Electromyography of the muscles of the perineum; study of the refractoriness of the sacral nerves; registration of evoked cerebral potentials after stimulation of the dorsal nerve of the penis; computed tomography of the brain.

Research of urinogenital and endocrine systems:

– Evaluation of penis size; the state of the cavernous bodies during palpation; pigmentation of the scrotum, its tone; size and consistency of the testes, appendages; digital examination of the prostate and analysis of its secret.

Symptoms that indirectly indicate the presence of androgen deficiency are: penis hypoplasia (in the non-erect state, its normal length is 9–9.5 cm); depigmentation, atony of the scrotum, its small size and drooping; change in the size of the testicles (less than 40 mm in the dlinnik) and their soft-elastic consistency; the symptom of the “sickle” is flattening and retraction of the upper segment of the prostate, and its lower segment in the form of a roller fringes the formed cavity.

Ejaculate analysis: indirect indicators of androgenic saturation – volume of ejaculate (normal 3.0 – 3.5 ml), levels of fructose (normal 150-500 mg% and citric acid (normal 300-500 mg%).

Hormonal sample Rigoni-Golyani (a mixture of 0.3 ml of 1% testosterone propionate and 0.2 ml of physiological saline is injected intracutaneously into the outer surface of the upper third of the forearm). Evaluation of the results of the Rigoni-Golyani test is carried out in 15-20 minutes as follows: bright red hyperemia ++++ (hyperemia area at the injection site more than 30 mm) – the test is sharply positive; bright hyperemia +++ (area of ​​hyperemia 26 – 29 mm) – positive test; soft pink ++ (zone of hyperemia 10 – 14 mm) is a doubtful test; weak hyperemia or lack thereof – a negative test. It was established that sharply positive or positive Rigoni-Golyani samples clearly correlate with normal serum testosterone levels obtained by the radioimmunoassay method.

Determination of testosterone level (normal 4.9 ± 0.38 μg / l), LH (normal 2.16 ± 0.19 μg / l), FSH (normal 2.44 ± 0.26 μg / l), prolactin (normal 5.2 ± 1.9 μg / l), estradnol (normal 27.5 ± 0.13 μg / l) in serum, 17-Cs in urine (daily excretion normal 6.6 – 23 , 4 mg, but only 30-40% of urinary ketosteroids of testicular origin, and 60-70% are produced by the adrenal cortex).

Visualization of the Turkish saddle using craniography; for suspected pituitary adenoma, computed go NMR imaging.

Examination of women with sexual arousal disorder involves a standard sex examination, during which special attention should be paid to identifying various trends in sexual attraction (homosexual, etc.) and determining the reactivity of erogenous zones. Additionally, a thorough gynecological examination is carried out, hormonal studies are shown – determining the amount and ratio of LH, FSH, prolactin, estrogen, progesterone, testosterone hormones in the blood, as well as 17-KS, 17-OXS in the urine, taking smears of the vaginal flora to exclude inflammatory infectious diseases.

Treatment aims to improve the quality of an erection to a degree sufficient for satisfactory sexual intercourse; in women – increased sexual arousal and lubrication during sexual contact. It involves the combined use of pharmacotherapy, psychotherapy, physiotherapy and reflex therapy.

Pharmacotherapy in men:

– in case of violations of the blood supply of the genitals – course assignment of combinations of vasoactive drugs of general action (nicergolin, iohimbin, actovegin, extract of gingko biloba leaves, pentoxifylline), as well as means of selective action (sildenafil, alprostadil);
– in case of disturbances of the conductive nerve pathways – neuro-muscular conduction improvers (strychnine nitrate, prozerin, distigmin bromide);
– with endogenous and organic mental disorders – treatment of the underlying disease;
– in case of psychogenic erectile dysfunctions – a combination of daily tranquilizers (tofisopam, mesopam) and a2 adrenergic blockers (nicergoline, iohimbin); for a quick effect, a single, double application of sildenafil is possible (after preliminary psychotherapeutic correction of the fear of coitus and against the background of psychotherapeutic mediation).

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