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From the * Andrology Unit, Department of Clinical
Physiopathology; Diabetes Section Geriatric
Unit, Department of Critical Care; Psychiatry
Unit, Department of Neurological and Psychiatric Sciences, University of
Florence, Florence, Italy; Endocrinology Unit,
Polytechnic University of Marche, Ancona, Italy; ||
International Institute of Sexology, Florence,
Italy; and ¶ Endocrinology Unit Maggiore-Bellaria
Hospital, Bologna, Italy.
| Correspondence to: Prof Mario Maggi, Andrology Unit, Department of Clinical Physiopathology, Viale Pieraccini 6, 50139 Florence, Italy (e-mail: m.maggi{at}dfc.unifi.it). |
| Received for publication April 12, 2005; accepted for publication August 2, 2005. |
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Abstract |
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Key words: Erectile dysfunction, premature ejaculation, SIEDY©, structured interview
When considering male sexual behavior, anxiety could be described as the final common pathway by which social, psychological, and biological stressors disrupt it (Kaplan, 1988). To date, few studies considered the relationship between different anxious syndromes and sexual dysfunctions in men. A systematic study assessing sexual dysfunctions in subjects suffering from social phobia, panic disorder, generalized anxiety disorder and controls found that anxiety-disorder patients report more frequently sexual dysfunction than normal controls, and that patients with panic disorder and social anxiety disorder experienced greater difficulties than subjects with generalized anxiety disorder (Ware et al, 1996). In another study, Angst (1988) found that loss of sexual interest was associated with generalized anxiety disorder, but it was not associated with panic disorder, agoraphobia, or social phobia. Finally, Figueira et al (2001) found that panic disorder patients were more likely to report sexual problems, particularly sexual aversion, than social phobias, whereas PE was the most common sexual problem in men with social phobias. Nonetheless, little research attention has received the idea that anxiety about sexual situation, in particular anxiety about failure to respond sexually, may cause, or at least aggravate, a weak sexual responsiveness. Moreover, no study systematically investigates the real contribution of free-floating anxiety (ie, not phobic and not somatizated) to male sexual dysfunctions, and the biological and relational correlates of free-floating anxiety in patients with ED. Hence, the aim of this study is to define the psychological, relational, and organic correlates of free-floating anxiety symptoms (AS) in a large sample of patients complaining of ED-based sexual problems.
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Materials and Methods |
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Patients were interviewed before the beginning of any treatment and before any specific diagnostic procedures, using the SIEDY© Structured Interview (Petrone et al, 2003). This is a 13-item interview, previously validated for either patients with or without stable relationships, composed of 3 scales, which identify and quantify components concurring to ED. Scale 1 deals with organic disorders, scale 2 with disturbances in relationship with partner, and scale 3 with psychological traits. Scores more than or equal 3.5 of SIEDY© scale 1 are predictive of organic disturbances underlying ED with a sensitivity and specificity of about 70% (Petrone et al, 2003).
Patients were asked to specify any current pharmacological treatment; drugs listed in Broderich and Foremann (1999) were considered capable of interfering with sexual function. Premature ejaculation was defined as ejaculation within 1 minute of vaginal intromission (as reported by the patient) according to previously described criteria (Corona et al, 2004d). One minute is the most widely accepted cut-off limit to define PE (see Waldinger et al, 2004, 2005 for review). Hypoactive sexual desire (HSD) was assessed with question 14 of SIEDY© Structured Interview as previously described (Corona et al, 2004a). Intimacy during sexual intercourses was analyzed using a standard question: "Do you have enough intimacy during your sexual activity?" (rating 0 = always; 1 = in over 50% of occasions; 2 = in less than 50% of occasions; 3 = rarely/never). Self-reported cigarette and cannabis smoking history was obtained from a specific question. Men were defined as current smokers if their history of smoking had lasted for at least 1 year, as past smokers if they had smoked at least 1 year in their life and were not current smokers, and as nonsmokers if they had never smoked or smoked less than 1 year. SIEDY© Appendix A was used for the analysis of ED problems as previously described (Petrone et al, 2003).
Patients were asked to complete the Middlesex Hospital Questionnaire,
modified (MHQ) (Crown and Crisp,
1966), in its Italian version
(Dioguardi et al, 1984), a
brief self-reported questionnaire for the screening of mental disorders in
nonpsychiatric settings, which provides scores for free-floating anxiety
(MHQ-A), phobic anxiety (MHQ-F), obsessive-compulsive traits and symptoms
(MHQ-O), somatization (MHQ-S), depressive symptoms (MHQ-D), and hysterical
traits and symptoms (MHQ-H). MHQ-A was used as a putative marker of
free-floating anxiety. The total score of MHQ (
= sum of scores for
MHQ-A, MHQ-F, MHQ-O, MHQ-S, MHQ-D, and MHQ-H) provides an index of mood and
anxious spectrum psychopathology (Crown
and Crisp, 1966).
All patients underwent a complete physical examination, with measurement of blood pressure (mean of 3 measurements 5 minutes apart, in sitting position, with a standard sphygmomanometer), height, weight, and testis volume (Prader orchidometer). Blood samples were drawn in the morning, after an overnight fast, for determination of blood glucose (by glucose oxidase method; Aeroset Abbott, Rome, Italy), total cholesterol, HDL cholesterol, and triglyceride (by automated enzymatic colorimetric method; Aeroset Abbott, Rome, Italy), total testosterone, prolactin, follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid stimulating hormone (TSH), and prostate specific antigen (PSA) (by electrochemioluminescent method, Modular Roche, Milan, Italy). Penile Doppler ultrasound (PDU) examination was performed before and 20 minutes after PGE1 intracavernous injection (10 µg). We decided to use the same protocol for PDU in all patients studied to make results fully comparable. The following parameters were considered: a) in basal condition, peak systolic velocity and acceleration; b) in dynamic condition (after PGE1 intracavernous injection; 10 µg), peak systolic velocity, end diastolic velocity (EDV), and resistance index (Mancini et al, 2000). Nocturnal penile tumescence and rigidity (NPT) were evaluated with a commercially available home monitor (Rigiscan©, Dacomed Corp, Minneapolis, Minn). The results of the Rigiscan© test were considered normal in case of at least 1 episode of penile tip rigidity greater than 60% and more than 10 minutes in duration during 2 consecutive nights of recording, as previously described (Hatzichristou et al, 1998).
Data were expressed as mean ± SD when normally distributed, and as median (quartiles) for parameters with nonnormal distribution, unless otherwise specified. Differences among more than 2 groups were assessed with 1-way ANOVA or Kruskal-Wallis test, whenever appropriate. Correlations were assessed using Spearman's or Pearson's method whenever appropriate. Unpaired 2-sided Student's t tests were used for comparison of means of normally distributed parameters. In all other cases, the Mann-Whitney U test was used for comparison between groups.
Variables associated with higher MHQ-A scores at univariate analysis were categorized as N = 0 and Y = 1 or more; the categorical variables obtained were used for receiver operating characteristic (ROC) curve analysis with MHQ-A scores. The area under the curve (AUC) of the ROC analysis for each variable was calculated and assumed as an index of the accuracy of its association with free-floating anxiety score.
All statistical association among different parameters and MHQ-A scores
were adjusted for MHQ to discriminate the specific effect of
free-floating anxiety from generic psychological disturbances.
All statistical analysis was performed on SPSS for Windows 12.1.
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Results |
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Symptoms of Sexual Dysfunction
At univariate analysis, ASs were significantly (r = .084;
P < .05) correlated with difficulties in maintaining erection (as
expressed by question 2 of SIEDY© Appendix A). In particular, MHQ-A score
was significantly higher in patients complaining of difficulties in
maintaining erection in more than 25% of attempts when compared with the rest
of the sample (6.5 ± 3.3 vs 5.8 ± 3.3; P < .001).
The difference retained significance even after adjustment for MHQ
(data not shown). No difference in anxiety score was observed in patients
complaining of difficulties in achieving erection or in patients without ED
(data not shown). When we considered other sexual dysfunctions, symptoms of
free-floating anxiety were significantly correlated with the presence of HSD
and PE (r = .150 and .077, respectively; both P < .05).
Accordingly, patients reporting HSD and PE of any degree showed significantly
higher MHQ-A score when compared with the rest of the sample (6.9 ± 3.3
vs 5.8 ± 3.2 and 6.6 ± 3.3 vs 6.1 ± 3.3, respectively;
both P < .05). At multiple regression analysis, after adjustment
for MHQ, only PE retained significant correlation to MHQ-A score
(adjusted r = .051; P < .05). This difference was
confirmed even when patients without ED were excluded (data not shown). PE was
primary in 63.2% and secondary in 26.8% of the sample. This particular
characteristic of PE was not associated with anxiety score (data not
shown).
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SIEDY© Parameters
No correlation was observed between SIEDY© scale 1 (which analyzed the
organic component of ED) and free-floating anxiety symptoms (data not shown).
Conversely, MHQ-A score was significantly and positively related to both
SIEDY© scale 2 (which explores relational component of ED; r =
.101; P < .05) and SIEDY© scale 3 score (which analyzes the
intrapsychic component of ED; r = .323; P < .0001).
Figure 1 reports the effect of
different levels of free-floating anxiety (expressed as MHQ-A quartiles) on
SIEDY© scales. Again, at ANOVA, only scale 2 and 3 scores results were
significantly associated with higher MHQ-A quartiles (P < .05 and
P < .0001, respectively). After adjustment for MHQ, the
correlation between MHQ-A and both scales 2 and 3 retained statistical
significance (adjusted r = .085 and .331, respectively; both
P < .05).
Relational Components
Symptoms of free-floating anxiety were significantly (P < .005)
correlated with the presence of couple's (r = .111) or family's
conflicts (r = .141) (as expressed by questions 6 and 11 of
SIEDY©). Accordingly, a higher MHQ-A score was observed in patients
reporting couple's or family's conflicts when compared with the rest of the
sample (6.7 ± 3.1 vs 5.9 ± 3.3 and 7.1 ± 3.2 vs 6.0
± 3.3, respectively; both P < .001). All these differences
were confirmed after adjustment for MHQ (data not shown). Furthermore,
a low climax and libido in patient's partner (as assessed by questions 8 and 9
of SIEDY© Structured Interview) was significantly associated with
symptoms of free-floating anxiety (r = .085 and .102 respectively;
both P < .05). In particular, higher MHQ-A score was observed in
patients reporting in their partner a low climax or sexual desire of any
degree when compared with the rest of the sample (6.5 ± 3.2 vs 5.9
± 3.3 and 6.6 ± 3.2 vs 5.9 ± 3.3, respectively; both
P < .05). At multiple regression analysis, only low climax in
patient's partner was significantly associated with MHQ-A after adjustment for
MHQ (adjusted r = .048; P < .05). Finally,
patients reporting insufficient intimacy during sexual intercourse showed
higher MHQ-A score when compared with the rest of the sample (7.0 ± 3.1
vs 6.1 ± 3.3; P < .005), even after adjustment for
MHQ (data not shown).
Life Stressors
Lower satisfaction and higher stress at work (as expressed by questions 2
and 3 of SIEDY© Structured Interview) were significantly correlated with
AS (r = .230 and .214, respectively; both P < .0001).
Accordingly, MHQ-A score was higher in patients reporting low satisfaction and
higher stress at work when compared with the rest of the sample (6.8 ±
3.3 vs 5.4 ± 3.2 and 6.8 ± 3.4 vs 5.5 ± 3.1,
respectively; both P < .0001). Furthermore, AS were significantly
(P < .05) correlated with cigarette (r = .108) and
cannabis (r = .072) smoking. In particular, MHQ-A score was higher in
patients reporting cigarette and cannabis smoking when compared with the rest
of the sample (6.5 ± 3.0 vs 6.0 ± 3.5 and 7.3 ± 3.0 vs
6.2 ± 3.3, respectively; both P < .05). All these
differences were confirmed after adjustment for MHQ (data not shown).
The prevalence of AS was not correlated to number of cigarettes or to amount
of cannabis consumed or to duration of smoking (data not shown). Finally,
patients reporting a diagnosis of psychiatric disease or currently treated
with benzodiazepine medications showed higher MHQ-A score when compared with
the rest of the sample (7.7 ± 3.2 vs 6.1 ± 3.3 and 7.6 ±
3.5 vs 6.1 ± 3.2, respectively, for psychiatric diseases and
benzodiazepine; both P < .01). However, these differences were not
confirmed at multiple regression analysis, after adjustment for MHQ
(data not shown).
Strength of Associations of MHQ-A Scores With Other Parameters
Figure 2 reports the ROC AUC
for each variable that was significantly correlated to MHQ-A. ROC AUC is an
index of accuracy of association of each variable with AS score. The presence
of problems at work (ie, high stress and low satisfaction) underlies the
highest AUC value for MHQ-A score (0.620 ± 0.02 and 0.612 ±
0.02, respectively; both P < .0001).
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Discussion |
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We found that free-floating anxiety has a relevant impact in 2 of the most common male sexual problems, that is, failure to maintain erection during intercourse and premature ejaculation, confirming previous observations (Corona et al, 2004d, 2005). Moreover, as we previously reported (Corona et al, 2004d), only few patients reported PE without ED showing that, although PE is considered the most common sexual dysfunction in males, most men start to seek medical help for this problem only after they have erectile difficulties (Waldinger, 2002). The development of PE is often coupled with ED, most probably because men having no confidence in the reliability to maintain their erection ejaculate prematurely (Corona et al, 2005). When an individual consistently experiences the self-monitoring perspective in a sexual context, sexual performance culminates with both failure to maintain erection (Corona et al, 2005) and PE (Corona et al, 2004d). Both sexual problems have been classically related to an anxiety-induced excessive sympathetic outflow, which increases smooth-muscle tone in either the penis or in the male genital tract favoring, on the one hand, penile detumescence (Krane et al, 1989; Maggi et al, 2000; Filippi et al, 2003; Brien et al, 2004; Corona et al, 2005) and, on the other hand, PE (Strassberg et al, 1987, 1990; Rowland et al, 2000; Corona et al, 2004d; Waldinger, 2004; Mancina et al, 2005). According to a previous interpretation (Aversa et al, 1996), an increased sympathetic tone might also underlie the significant association we found between anxiety scores and increased EDV, at PDU examination. In fact, it has been reported that an increased EDV could be often reversed by intracavernous administration of the alpha-adrenergic antagonist phentolamine (Aversa et al, 1996, 2000; Wilkins et al, 2003). It is noteworthy that anxiety is capable of increasing sympathetic activity (Tanaka et al, 2000).
We did not find any significant association between severity of AS and any degree of inability to obtain an erection. This is in keeping with the lack of correlation of MHQ-A scores with both basal and dynamic (after PGE-1 injection) peak systolic velocity at PDU examination and with abnormal NPT test results. In addition, hormonal and metabolic profiles were not different in patients with or without anxiety. These findings corroborate the notion that anxiety is not primarily associated with the most organic forms of ED. Accordingly, SIEDY© scale 1 score, which evaluates the organic contribution to the pathogenesis of ED, is unrelated to MHQ-A rating. In contrast, we found that free-floating anxiety was significantly associated with the other scales of the SIEDY© interview (ie, scales 2 and 3), exploring the relational and the intrapsychic domains. In ED patients, to quantify the accuracy of single SIEDY© items to variation of free-floating anxiety's score, we employed the AUC of ROC analysis. We found that problems with employment have the highest impact in free-floating anxiety score. Loss or reduced job satisfaction (item 2 of SIEDY©) might in fact impair self-esteem, pushing men to feel disgraced, weakened, and frightened, negative feelings that can be further exported to sexual life, impairing it and further increasing frustration. Negative stress at work is another obvious source of anxiety, which can be exported to private life, damaging sexual response and therefore handicapping the patient's self-esteem which, in turn, increases anxiety and impairs performance.
Concerning relational partnership results, it is important to note that the data are derived from patients' perception and not from partner interviews. However, the data are relevant because they represent the scenario the patient is often dealing with, and therefore it mirrors the true couple relationship, at least as perceived by the patient. In addition, patient's perception of these relational life events are at the base of narcissistic perturbation, which undermines self-image, causing fear of scrutiny by the partner and further contributing to subsequent failure and performance anxiety (Hedon, 2003). For instance, an adequate climax reaction of the partner during intercourse would reinforce the patient's narcissistic ejaculatory and erectile competence, therefore corroborating his sexual self-esteem. Accordingly, in our sample, patient-perceived partner's orgasmic failure is significantly associated with anxiety, most probably because of pessimistic attribution of inadequate sexual performance with overall negative effect on gender cognition (male = dominant role in lovemaking) and related coping strategies. In addition, an overt conflict between the couple or in other domestic inhabitant relationships, with their associated negative feelings, such as hostility, resentment, and anger, might interfere with the man's ability to be sexually self-confident, generating anxiety. In fact, the majority of couples perceived that family support (or lack of support) had an effect on the quality of their couple relationship and even of their sexual life. Cross-sectional surveys, such as the present one, do not allow any speculation on causal relationship. In fact, in this sample, anxiety could be considered either a cause or a consequence of sexual dysfunction. Any speculation on pathogenetic relationship should be confirmed through prospective studies or intervention trials. A further limitation is represented by the fact that enrolled patients were all Italian men seeking help for ED in an andrology clinic; the extension of results to different settings needs caution.
In conclusion, in patients with ED-based sexual problems, higher scores in the majority of SIEDY© scale 2 and 3 items (those related to relational and intrapsychic domains, respectively) are associated with a higher score in free-floating anxiety, supporting previous views on psychogenic ED (Norton and Jehu, 1984; Krane et al, 1989; Lue, 2000; Ralph and McNicholas, 2000; Brotons et al, 2004). Although this cross-sectional study does not allow the investigation of causal relationships, it could be speculated that the cognitive component of anxiety contributes to the psychological one and is associated with performance disturbance. The resulting increased sympathetic activity might determine smooth-muscle contractions with failure to maintain erection and PE. Conversely, organic problems are not primarily associated with MHQ-A scores.
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Acknowledgments |
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References |
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TopAbstractMaterials and MethodsResultsDiscussionReferences |
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Aversa A, Bonifacio V, Moretti C, Frajese G, Fabbri A. Re-dosing of prostaglandin-E1 versus prostaglandin-E1 plus phentolamine in male erectile dysfunction: a dynamic color power Doppler study. Int J Impot Res. 2000;12: 33 -40.[Medline]
Aversa A, Rocchietti-March M, Caprio M, Giannini D, Isidori A, Fabbri A. Anxiety-induced failure in erectile response to intracorporeal prostaglandin-E1 in non-organic male impotence: a new diagnostic approach. Int J Androl. 1996; 19: 307 -313.[Medline]
Bodner DR. Impotence: evaluation and treatment. Prim Care. 1985;12: 719 -733.[Medline]
Brien SE, Smallegange C, Gofton WT, Heaton JP, Adams MA. Development of a rat model of sexual performance anxiety: effect of behavioural and pharmacological hyperadrenergic stimulation on APO-induced erections. Int J Impot Res. 2002; 14: 107 -115.[Medline]
Broderick GA, Foremann MM. Iatrogenic erectile dysfunction: pharmacological and surgical therapies that alter male sexual behaviour and erectile performance. In: Carson C, Kirby R, Goldstein I, eds. Textbook of Erectile Dysfunction. Isis Medical Media Ltd: Oxford, United Kingdom; 1999: 149 -168.
Brotons FB, Campos JC, Gonzalez-Correales R, Martin-Morales A, Moncada I, Pomerol JM. Core document on erectile dysfunction: key aspects in the care of a patient with erectile dysfunction. Int J Impot Res. 2004;16(suppl 2): S26 -S39.
Corona G, Mannucci E, Mansani R, Petrone L, Bartolini M, Giommi R, Forti G, Maggi M. Organic, relational and psychological factors in erectile dysfunction in men with diabetes mellitus. Eur Urol. 2004c; 46: 222 -228.[CrossRef][Medline]
Corona G, Mannucci E, Mansani R, Petrone L, Bartolini M, Giommi R, Mancini M, Forti G, Maggi M. Aging and pathogenesis of erectile dysfunction. Int J Impot Res. 2004b; 16: 395 -402.[CrossRef][Medline]
Corona G, Mannucci E, Petrone L, Giommi R, Mansani R, Fei L, Forti G, Maggi M. Psycho-biological correlates of hypoactive sexual desire in patients with erectile dysfunction. Int J Impot Res. 2004a; 16: 275 -281.[CrossRef][Medline]
Corona G, Petrone L, Mannucci E, Jannini EA, Mansani R, Magini A, Giommi R, Forti G, Maggi M. Psycho-biological correlates of rapid ejaculation in patients attending an andrologic unit for sexual dysfunctions. Eur Urol. 2004d; 46: 615 -622.[CrossRef][Medline]
Corona G, Petrone L, Mannucci E, Mansani R, Balercia G, Krausz C, Giommi R, Forti G, Maggi M. Difficulties in achieving vs maintaining erection: organic, psychogenic and relational determinants. Int J Impot Res. 2005;17: 252 -258.[Medline]
Crown S, Crisp AH. A short clinical diagnostic self-rating scale
for psychoneurotic patients. The Middlesex Hospital Questionnaire (M.H.Q.).
Br J Psychiatry. 1966; 112: 917
-923.
Dioguardi N, Comazzi AM, Nielsen NP. Psychological of the spa user. Preliminary study of motivation for spa treatment. Minerva Med. 1984;75: 2793 -2798.[Medline]
Figueira I, Possidente E, Marques C, Hayes K. Sexual dysfunction: A neglected complication of panic disorder and social phobia. Arch Sex Behav. 2001;30: 369 -377.[Medline]
Filippi S, Marini M, Vannelli GB, Crescioli C, Granchi S, Vignozzi
L, Luconi M, Ferruzzi P, Morelli A, Forti G, Ledda F, Maggi M. Effects of
hypoxia on endothelin-1 sensitivity in the corpus cavernosum. Mol
Hum Reprod. 2003;9: 765
-774.
Hatzichristou DG, Hatzimouratidis K, Ioannides E, Yannakoyorgos K, Dimitriadis G, Kalinderis A. Nocturnal penile tumescence and rigidity monitoring in young potent volunteers: reproducibility, evaluation criteria and the effect of sexual intercourse. J Urol. 1998; 159: 1921 -1926.[CrossRef][Medline]
Hedon F. Anxiety and erectile dysfunction: a global approach to ED enhances results and quality of life. Int J Impot Res. 2003; 15(suppl 2): S16 -S19.
Hendry WF, Althof SE, Benson GS. Male orgasmic and ejaculatory disorders. In: Jardin A, Wagner G, Khoury S, eds. Erectile Dysfunction, Proceedings of the 1st International Consultation on Erectile Dysfunction. Plymouth, United Kingdom: Health Publications Ltd; 2000 : 477-506.
Kaplan HS. Anxiety and sexual dysfunction. J Clin Psychiatry. 1988;49(suppl): 21 -25.
Krane RJ, Goldstein I, Saenz de Tejada I. Impotence. N Engl J Med. 1989;14: 1648 -1659.
Lue TF. Erectile dysfunction. N Engl J Med. 2000; 342: 1802
-1813.
Maggi M, Filippi S, Ledda F, Magini A, Forti G. Erectile dysfunction: from biochemical pharmacology to advances in medical therapy. Eur J Endocrinol. 2000; 143: 143 -154.[Abstract]
Mancina R, Filippi S, Marini M, Morelli A, Vignozzi L, Salonia A,
Montorsi F, Mondaini N, Vannelli GB, Donati S, Lotti F, Forti G, Maggi M.
Expression and functional activity of phosphodiesterase type 5 in human and
rabbit vas deferens. Mol Hum Reprod. 2005; 11: 107
-115.
Mancini M, Bartolini M, Maggi M, Innocenti P, Villari N, Forti G. Duplex ultrasound evaluation of cavernosal peak systolic velocity and waveform acceleration in the penile flaccid state: clinical significance in the assessment of the arterial supply in patients with erectile dysfunction. Int J Androl. 2000; 23: 199 -204.[CrossRef][Medline]
Master WH, Johnson VE. Human Sexual Inadequacy. Boston, Mass: Little Brown; 1970 .
Norton GR, Jehu D. The role of anxiety in sexual dysfunctions: a review. Arch Sex Behav. 1984; 13: 165 -183.[Medline]
Petrone L, Mannucci E, Corona G, Bartolini M, Forti G, Giommi R, Maggi M. Structured Interview on Erectile Dysfunction (SIEDY©): a new, multidimensional instrument for quantification of pathogenetic issues on erectile dysfunction. Int J Impot Res. 2003; 15: 210 -220.[CrossRef][Medline]
Ralph D, McNicholas T. UK management guidelines for erectile
dysfunction. BMJ. 2000; 321: 499
-503.
Rowland DL, Strassberg DS, de Gouveia Brazao CA, Slob AK. Ejaculatory latency and control in men with premature ejaculation: an analysis across sexual activities using multiple sources of information. J Psychosom Res. 2000;48: 69 -77.[Medline]
Sommer F, Obenaus K, Engelmann U. Creative-dynamic image synthesis: a useful addition to the treatment options for impotence. Int J Impot Res. 2001;13: 268 -274.[Medline]
Strassberg DS, Kelly MP, Carroll C, Kircher JC. The psychophysiological nature of premature ejaculation. Arch Sex Behav. 1987;16: 327 -336.[Medline]
Strassberg DS, Mahoney JM, Schaugaard M, Hale VE. The role of anxiety in premature ejaculation: a psychophysiological model. Arch Sex Behav. 1990;19: 251 -257.[CrossRef][Medline]
Tanaka M, Yoshida M, Emoto H, Ishii H. Noradrenaline systems in the hypothalamus, amygdala and locus coeruleus are involved in the provocation of anxiety: basic studies. Eur J Pharmacol. 2000; 405: 397 -406.[CrossRef][Medline]
Waldinger MD. The neurobiological approach to premature ejaculation. J Urol. 2002; 168: 2359 -2367.[CrossRef][Medline]
Waldinger MD. Lifelong premature ejaculation: definition, serotonergic neurotransmission and drug treatment. World J Urol. 2005;23: 102 -108.[Medline]
Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic review and metaanalysis. Int J Impot Res. 2004;16: 369 -381.[CrossRef][Medline]
Ware MR, Emmanuel NP, Johnson MR, Brawman-Mintzer O, Knapp R, Crawford-Harrison M, Lydiard RB. Self-reported sexual dysfunctions in anxiety disorder patients. Psychopharmacol Bull. 1996; 32: 530 .
Wilkins CJ, Sriprasad S, Sidhu PS. Colour Doppler ultrasound of the penis. Clin Radiol. 2003; 58: 514 -523.[CrossRef][Medline]
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