Evaluation of Sexual Dysfunction

Below we describes few of methods which Dr. Paduch may utilize to better understand your issues and how to best help you. Many of modalities are only available through dr. Paduch office and not offered by other doctors.

  • Ejaculatory dysfunction: time, volume, and quality
    • premature ejaculation is ejaculation that occurs within 1-2 minutes from start of sexual activity with little control from the patient. An average men will ejaculate within 7-14 minutes from insertion.
    • retrograde ejaculation is a process when semen is pushed into the bladder rather outside, mostly seen in men with bladder neck isues
    • delayed ejaculation is condition when it takes men longer than 30 min to ejaculate during intercourse or masturbation
    • anejaculaltion is a condition in which a man does ejaculate at all after at least 30 min of sexual activity, this is mostly related to inability to get normally aroused

The import aspect of evaluation of ejaculatory dysfunction is timing of the problems: is the problem life long or recent, were there any changes to medications patient takes, what is timing to ejaculate from the start of sexual activity, can patient control his time to ejaculate, is he or his partner bothered by timing of ejaculation. Premature ejaculation is often genetically determined but poor quality of erection and sexual inexperience are contributing factors. Delayed ejaculation is result of poor progression of arousal (excitement): here the problems can be fear of pregnancy, fear of being used, but more commonly the sexual boredom, lack of intimacy, issues with communication about sexual needs and wants, inability to concentrate on the act, failure to focus on one’s pleasure are common psychological issues contributing to delayed ejaculation. Most of partners will not continue sexual activity if men is not able to achieve orgasm / ejaculate within 30-40 minutes. During evolution of men with delayed ejaculation we start with biothesiometry, measuring penile sensitivity, and then we perform ejaculatory-arousal study in the sexual medicine lab recording physiological changes in the pelvis and penis during sexual stimulation (masturbation). This pioneering method developed by Dr. Paduch at WCM allows us to determine reasons for delayed ejaculation in over 90% of men. Men are rather repetitive in sexual repertoire and they process information same way during masturbation in the lab or during sex in privacy of their homes. We often identify subtoptimal quality of erection with idiosyncratic patterns of stimulation (forcing erections by tensing pelvic floor muscles), decreased sensitivity in the penis which can be primary due to low concentration of nerve fibers in the glans of penis, or secondary due to peripheral neuropathy, issues with attention during sexual activity, transposition of g-spot along the peno-anal pathway can be primary but we also observe it with men after chemotherapy or long standing alcoholism. Sometimes the delayed ejaculation is caused by abnormal processing of sexual cues in the brain and Dr. Paduch has developed and uses visual block functional MRI of the brain to identify issues with signal processing in brain.

  • Erectile dysfunction. The inability to achieve and or maintain an erection sufficient for satisfactory sexual intercourse  and sexual activity of men’s choice

The main aspect of evaluation of erectile dysfunction is assessment of inflow and outflow of blood from the penis. The standard evaluation starts with penile Doppler ultrasound (DUS). During this non-invasive study we first stimulate erection using combination of vasodilators applied to the penis and then measure blood flow through arteries and veins druing flaccid and rigid erection of the penis. This approach is critical part of every men seen for sexual dysfunction. If blood flow into penis is decreased it often indicates early peripheral vascular disease and patient is treated by us and referred to cardiologist for risk stratification for coronary artery disease. If penile ultrasound is not conclusive Dr. Paduch with collaboration of with Dr. Daniel Margolis at WCM campus radiology have developed unique dynamic penile magnetic angiogram (MRA) to identify vascular anomalies in the penis and pelvis which contribute to erectile dysfunction. This study only offered at WCM campus is critical prior to any revascularization of the penis. We find vascular anomalies in 70% of men who present with erectile dysfunction in their twenties.  In addition to imaging studies we check testosterone, and evaluate men for elevated cholesterol, and diabetes.

  • Hypogonadism ( low testosterone). A condition in which men have low levels of testosterone, which may cause decreased in sexual desire, erectile dysfunction, reduced muscle mass and strength, a reduction in bone density, changes in mood, or an increase in fat mass. Testosterone is produced by testicles under the control of hormones from brain (pituitary). During evaluation of low testosterone we check all the hormonal issues which may result in low testosterone. Often varicocele can contribute to low testosterone and is one of few reversible causes of low testosterone. MRI of brain is used in men with elevated prolactin levels.    
  • Peyronie’s disease: is an acquired curvature and or narrowing of the penis from the scarring. Most commonly Peyronie’s is a result of trauma, diabetes, or genetic predisposition. We always evaluate penis first in flaccid state to check for plaques and pain. Subsequently we perform penile ultrasound to assess extend of plaque and its density (calcification). Photographic documentation every 3-6 months which can be done by patient is an important aspect of assessing treatment response.
  • Concealed or small penis: most of men have normal penis size which is between 5-6 inches for US population. Some men have excessive pubic fat deposition with penis hidden in pubic fat. Occasionally abnormal attachment of suspensory ligament results in shortening of the penis. In men with small penis are first fully evaluated their hormonal profile including growth hormones, adrenaline and noradrenaline levels to differentiate between excessive penile retraction due to high catecholamine levels and true anatomical condition. Subsequently the penis is measured during full erection using penile ultrasound, at same time the fat in pubic area is mapped. MRI of pelvis is used to diagnose suspensory ligament shortening and is required prior to surgical management.
  • Floppy penis or penile hyperflexion: are two spectra of disorder of suspensory ligament. In floppy penis the suspensory ligament is not supporting penis adequately and penis tends to point down even with full rigid erection. Occasionally floppy penis is due to hour glass deformity it the base of penis. Hyperflexion of penis occurs when fully erected penis is pointing toward the nose of the patient rather then within 15degrees of horizontal plane. This condition impairs ability to penetrate. The evaluation of both conditions require exam with full rigid erection first in office and then during penile ultrasound while patient is standing. Additional evaluation is performed in standing MRI unit to plan the surgery.