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About 56 mg of T is secreted daily into the plasma of men purchase indapamide 1.5 mg mastercard hypertension young male, usually in a pulsatile manner every 6090 min purchase 1.5 mg indapamide with mastercard blood pressure medication good for pregnancy, and in a diurnal rhythm in which peak levels occur during the morning (although less pronounced in older men) (25) generic 1.5 mg indapamide with amex blood pressure hypotension. In addition to intraday uctuations, there is a wide range of normal levels between different individuals. Effects on Sexuality The sex-related impact of T in men has been demonstrated in two groups: (a) those who have been deprived of this hormone in a signicant manner and who are hypogonadal as a result (the most extreme example of which is men who have been castratedphysically or chemicallyfor any reason and in varying degrees) and (b) those who are generally healthy (including their hormone levels, otherwise referred to as eugonadal). The inuence of androgens on sexual desire is particularly prominent and was summarized by Bancroft (26; pp. From his studies on hypogonadal men, he concluded that within 34 weeks of androgen withdrawl: (i) sexual inter- est declines as measured by the frequency of sexual thoughts (ii) sexual activity appears to diminish (as a result of decreased sexual desire) but is more difcult to assess because of the confounding effects of a sexual partner, and (iii) the capacity for ejaculation disappears. When androgen replacement is given, these phenomena are reversed within 710 days. Fantasy (or imagery)-associated erections and nocturnal erections are both androgen-dependent, and cease as a result of androgen withdrawal. The fact that only certain aspects of erectile function are affected suggests that the impact in this area is indirect, that is, on the mans central nervous system rather than directly on his genitalia. Male Hypoactive Sexual Desire Disorder 87 described as performance anxiety superimposed on a biogenic desire disorder (27; p. Segraves and Balon summarize the impact of the therapeutic use of T in eugonadal men by saying that a relatively low level. Changes in Effects with Age The mystery of what happens to T as men age is not easy to unravel and possibly involves three separate issues: changes in production, carrier proteins, and recep- tor sensitivity. The decrease in normal levels of T with age (described previously) seems partly explained by a decrease in function of both testicular tissue (Leydig cells) and the pituitary-hypothalamic axis. A third issue is the possible decline in the level of sensitivity of T receptors (especially those in the central nervous system) which might explain both reduced sexual desire in the aging male and the need for large doses of T in treating hypogonadal states in older men. In a very informative study of men presenting to a clinic because of sexual disorders and who were later found to be hyperprolactinemic, Schwartz et al. Even more striking (and a sobering lesson to those who are not exible in their approach to treating sexual problems in men), sex therapy administered before the hyperprolactinemia was discovered, actually resulted in improvement! Some view sexual difculties from primarily a biomedical perspective and regard sex as natural. Because the reex pathways of sexual functioning are inborn does not mean that they are immune from disruption due to impaired health, cultural condition- ing, or interpersonal stress (30; p. Others look at sexuality and see the absence of intimacy as being crucial to understanding the psychological origins of many sexual difculties (11,32). Likewise, the patients past may not have included the experimental love and sexual relationships of adolescence in which so much learning takes place about oneself and others. Tiefer wrote that the primary inuences on womens sexuality are the norms of the culture, those internalized by women themselves and those enforced by institutions and enacted by signicant others in womens lives (5; p. Male Hypoactive Sexual Desire Disorder 89 even as the word natural is applied to men, it does not explain the contribution to sexual problems of either intimacy issues or cultural variations in sexual behavior. The social and cul- tural environment determines sexual expression and the meaning of sexual experience (31). Nevertheless, the observation is at least noteworthy, and beyond that, may be etiologically meaningful. Segraves and Segraves reported on 906 subjects (including 374 men) who had been recruited for a pharmaceutical company study of sexual disorders (20). Almost half (47%) had a secondary diagnosis of erectile impairment and a few (n 3) had retarded ejaculation (patients with premature ejaculation were excluded from the study). Schiavi reviewed 2500 charts of individuals and couples referred between 1974 and 1991. Together with colleagues, Schiavi also examined the psychobiology of a group of sexually healthy men aged 4574 living in stable sexual relationships (36; pp. One of the issues considered was a comparison of men with and without a sexual dysfunction. Sexual Difculties in a Partner Sexual difculties in a partner, for example, intercourse-related pain experienced by a woman, may result in profound change in the level of sexual desire in the other person. Case Study Rob and Melissa (not their real names), both 23 years old and university stu- dents, were referred because intercourse had not yet occurred in their 3- month-old marriage. History from both, plus her pelvic exam, revealed a diagnosis of vaginismus uncomplicated by vaginal pathology. Conventional treatment of vaginismus was successful in a technical sense (intercourse took place), but Melissa was cha- grined to nd that it was not as pleasurable as she anticipated (12). From the time of Robs initial attempt to insert even part of his penis, he was concerned over her report of intercourse-related pain, and found that his sexual desire had diminished considerably when compared with the pre-treatment level. He found that in general, he was thinking much less about sexual matters, and when he and Melissa were sexual together, his erections were less than full and he was unable to ejaculate in her vagina. His sexual desire slowly returned (but not to the pre-treatment level) as he accepted her reassurance that her intercourse pain was progressively diminishing. Her continuing lack of physical pleasure in intercourse (she looked forward to the closeness) seemed to impede the recovery of his own desire. One study indicated that did not predict sexual dysfunction in a clinical sample of adult men asking for treatment of this disorder (37).

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Prevalence of erectile dysfunction in France: Results of an epidemiological survey of a representative sample of 1004 men buy indapamide 1.5mg mastercard arrhythmia alliance. The Canadian Study of Erectile high potential for patient and partner treatment satisfaction generic 2.5 mg indapamide with amex pulse pressure under 25. To help the patient and partner establish their objec- longstanding relationships exist between the couple and tives of treatment generic 2.5mg indapamide with mastercard blood pressure 4 year old child. To select diagnostic tests based on presenting com- tic alliance which may translate into improved clinical plaints and goals of therapy. To offer treatment choices with comprehensive infor- remain an essential resource for several important reasons: mation on cost, likelihood of success and common 1. Second-line intracavernous and intraurethral vasoac- which would satisfy the patient and partner goals tive therapy may be outside of the practice pattern of treatment. To choose approaches which are reversible when- severe vascular disease or poorly controlled diabe- ever possible. Determine the timing of onset, nature of the prob- Dynamic infusion cavernosography and caver- lem, and signifcance to the partner (if applicable). Establish a likely underlying etiology based on his- A monogamous, heterosexual relationship should not be tory, physical exam, and lab testing. Focused physical examination (directed at anatomic, vascular and neural systems essential for erections). The greatest utility of these questionnaires not add signifcantly to duration of the doctor-patient may be in establishing a response to therapy and determin- encounter. The primary goals of psychotherapy are ment or discomfort for some patients; therefore, every effort to reduce or eliminate performance anxiety, to understand the should be made to ensure privacy and personal comfort. Nocturnal penile tumescence may include fasting glucose, lipid profle and, in select cases, and rigidity testing using Rigiscan should take place for a hormone profle. Hormone profles are used to identify or at least 2 nights, measuring 2 to 5 overnight erections. Vascular testing suggested as a valuable addition to the evaluation and good general practice. This test is Diabetes Association guidelines)2 testing and potential treat- performed less frequently in Canada since the advent of ment for low levels of testosterone is appropriate. In the appropri- sound is normal, as indicated by a peak systolic blood fow ate patient, once treatment with exogenous testosterone is >30 cm/sec and a resistance index >0. If the ultrasound initiated, ongoing follow-up is mandatory according to pub- is abnormal, however, arteriography and dynamic infusion lished guidelines. Patients and partners are made aware of reserved generally for cases of high-fow priapism or planned effcacy, risks and benefts of appropriate treatments, taking vascular bypass. A penile angiogram allows visualization into consideration preferences and expectations. Oral ther- of the penile circulation and directs embolization for the apy failure may often be salvaged by patient re-education unusual case of penile injury induced high-fow priapism. Neuro-physiological testing Success, Unsuccessful This form of testing generally continue consider third-line allows us to measure the sacral treatment therapy refex arc, an indirect measure of the perineal neural integrity, and Penile implant surgery has limited clinical availability and utility. Basic screening tests include the identifcation of car- umented hypogonadism is an option. Local therapy (intracavernous or intraurethral treatment or investigations may be appropriate. Bella is a member of the advisory boards for Lilly, Actavis, American Medical Systems, and Coloplast. There is a Use with alpha blockers potential risk of signifcant hypotension when using non-selective alpha blockers. The assessment of vascular risk with erectile dysfunction: the role of the cardiologist and general physician. J Sex Med investments in many pharmaceutical companies through his diversifed retirement plan. Combination of psychological intervention and phosphodisterase-5 inhibitors for erectile dysfunction: A narrative review and meta-analysis. Standardization of vascular assessment of erectile dysfunc- tion: Standard operating procedures for duplex ultrasound. Standard operating procedures for neurophysiologic assessment of male sexual setting: Importance of risk factors for diabetes and vascular disease. Brock G, Harper W; for Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Guidelines on male sexual dysfunction: Erectile dysfunction and in hypogonadal men with erectile dysfunction: A systematic review. Oral phosphodiesterase-5 inhibitors and hormonal treatments for erectile dysfunction: A systematic review 2002;9:1583-87. Impact of a frst treatment with phosphodiesterase inhibitors 9-200911030-00150 on men and partners quality of sexual life: Results of a prospective study in primary care. Implants, mechanical devices, and vascular surgery for erec- J Sex Med 2010;7:3572-88. MedLine search was supplemented by the term premature ejaculation in all search fields.

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Urine should also Isolated haematuria on dipstick testing of urine can be sent for cytology discount indapamide 1.5mg fast delivery pulse pressure uk. Macroscopic haema- tract to assess renal size and look for structural lesions turia is always abnormal buy generic indapamide 2.5 mg arrhythmia during stress test. White cells 210 cells/24h (6 per high-power- kidneys are particularly susceptible to ischaemia or eld) cheap 1.5 mg indapamide visa blood pressure medication classes. Hyaline casts are composed of uromucoid The medulla receives less than 10% of renal blood (TammHorsfall protein which is excreted by ow and is at greatest risk of injury. The necrosis of tubular epi- cells (implying glomerular bleeding) or white cells thelial cells is most prominent in the proximal tubules (implying tubular inammation) to the surface of and thick ascending limb of the loop of Henle. Regenerationoftubularcellsleadingtorecovery a result of contamination by cells from the vulva cantakeweeks. In prerenal failure urine osmolality is high usually with a decrease in urine output. The causes (> 500mosmol/kg), urine sodium is low (< 20mmol/ can be divided into prerenal, renal and postrenal. The most striking of hypersensitivity reaction which responds to with- theseisgrossintimalhyperplasia,leadingtoocclusion drawal of the drug and a short course of corticoster- of the lumen in small arteries and arterioles. Eosinophils may be present within the pre- failure is a rapid consequence of this condition if the dominantly mononuclear cell interstitial inltrate) blood pressure is not controlled. Unexplained re- terised by thrombocytopenia (platelet consumption), nal failure complicating liver disease is the microangiopathic haemolytic anaemia (red cell frag- hepatorenal syndrome. It commonly Reinfusion of ascites into the internal jugular vein follows a diarrhoeal illness in infants infected with a via a peritoneo-venous shunt can expand plasma verotoxin-producing strain of Escherichia coli volume and improve renal function, but does not (serotype O157). Familial forms occur due to a mutation in there are no clues on investigations, including complement factor H. Recovery usually occurs over a few weeks (myeloma), antineutrophil cytoplasm antibodies in children, but the prognosis for adults is poor. Postrenal Management Acute urinary tract obstruction from: This should be undertaken in a specialised unit. Investigation Relieve urinary tract obstruction from below (ur- ethral catheterisation with or without ureteric stents) Where there is no obvious cause following careful or above (nephrostomy). Prostatic obstruction in el- history and examination, and preliminary biochem- derly men is the most common cause. The bladder is enlarged Continuing assessment of uid status through in urethral obstruction. Ultrasound to look for inputoutput records, physical examination, daily urinary tract dilatation is the simplest method of weight, lying and standing blood pressure. Fluids excluding obstruction, although dilatation may should be restricted if there is oliguria or anuria, but be absent, particularly if obstruction is acute. In severely ill ring usually indicates chronic interstitial nephritis patients enteral or parenteral nutrition may be or ischaemia). Renal disease 159 Carefulmonitoringof electrolytes, urea, creatinine whereas females typically only have abnormalities and acidbase status. Thin basement must take clinical state into account), severe acidosis membrane disease is a related condition in which (bicarbonate below 1015mmol/l) and uid overload thinning of the basement membrane is associated with pulmonary oedema. Hypertension: estimates of the prevalence of chron- ic renal failure caused by hypertension vary widely, reecting the fact that the diagnosis of renal disease Clinical features causedbyhypertensiondependsontheexclusionof other causes. Many cases may have undiagnosed Screening for renal disease and the availability of di- renal disease. Renal failure because of hypertension alysis mean that the classical manifestations of urae- is much more common in black people than mia (literally urine in the blood) are now seen infre- white people, and within the black population there quently. Chronic kidney disease is typically slow to appears to be familial clustering of renal disease progress and usually presents with lethargy, general caused by hypertension, suggesting a genetic malaise, anorexia and nausea. Patients present with hyper- central nervous system derangements leading to leth- tension, abdominal pain, haematuria or chronic argy, stupor and coma with tting. Progression to renal failure with hyper- Investigations tension is usual, although the age at which renal replacement therapy becomes necessary varies. Creatinine is derived from me- gene, responsible for most non-16p-linked polycys- tabolism of creatine in muscle. Fifty percent loss of renal function is The disease should be considered a multisystem dis- often needed before the serum creatinine rises above ease in which cysts occur in other organs (liver, pan- the normal range; it is therefore not a sensitive creas, testes). There is an increased incidence of car- indicator of mild to moderate renal injury. Kidney damage is dened as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Plasma uric acid is often raised (but clinical gout This is usually calculated by using a web-based cal- is rare). It is chromic normocytic anaemia which responds to par- calculated from the rate of disappearance of a bolus 51 enteral erythropoietin. Renal ultrasound identies obstruction or renal scars Hypocalcaemia stimulates the parathyroid glands and denes renal size (Table 14.

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