WHAT IS SEXUAL HEALTH MEDICINE?
Sexual Medicine is a young and evolving integrative medical field for the diagnosis and treatment of sexual health concerns, in particular, issues related to the core sexual functions such as libido, genital arousal, and climax/release. Physicians who help patients with their sexual function issues integratively typically come from related medical specialties, such as urology, psychiatry, gynecology, and endocrinology. In a way similar to the evolution of Sleep Medicine or Pain Medicine, an integrated and focused approach of Sexual Medicine has emerged as a modern answer to a typically fragmented, patchy and often limited coverage available in other clinical settings for the assessment and treatment of issues in sexual functioning, which has numerous, complex components and layers. Sexual health physicians offer targeted and integrated biomedical, sexophysiological, psychosexual, behavioral, relational, and other relevant assessments that facilitate a personalized treatment approach which goes beyond the narrower scope of most other clinical settings and practices. Treatment options at this practice include cutting-edge and non-invasive pharmacotherapy (drug treatment) options, various psychological and behavioral therapies with a sex-positive approach, and an integrated utilization of evidence-based physiotherapeutic medical devices.
Although Dr. Duzyurek primarily concentrates on the male sexual dysfunctions within the Sexual Medicine domain of his practice, he addresses sexual function difficulties in his female patients, as well, when encountered within other aspects of his practice.
USEFUL EDUCATIONAL LINKS
SexSmart Films featuring more than 300 sex education, research, and therapy films organized in 32 categories, developed and screened by experts.
In modern Sexual Health practices certain physiotherapeutic medical devices, such as the Viberect, are among the treatment tools for erectile and/or ejaculatory difficulties.
WHAT IS VIBERECT?
Viberect is a physiotherapeutic medical device that can be utilized in an integrated treatment regimen for select patients with certain erectile and/or ejaculatory problems. This recent addition to our treatment tool kit was approved by FDA in June 2011 for helping men with erection and ejaculation problems, as an alternative to, or in combination with, other treatment modalities such as medications or behavioral therapy. It is approved for (1) clinic (in office) use for assessment, treatment, trial, and/or patient instruction by a physician, and (2) at home use by the patient following the prescribing physician's instructions in a treatment program personalized for him. It may be now covered by VA. There are several different ways this device may be utilized in erectile and ejaculatory dysfunctions, as Dr. Duzyurek would discuss with you if indicated. For vibrotherapy operational instructions, click here. On-demand or "before sex" use is only one of the ways Viberect may be utilized. In Dr. Duzyurek's experience, a regular personal application of the device outside of sex with a partner in a professionally guided personalized treatment program is often more helpful and preferable since a treatment regimen with this approach improves natural sexual functioning with a partner over time, thus enhancing treatment satisfaction and/or potentially reducing the need for other treatments.
This is achievable owing to a progressive facilitation of neural and vascular components of the sexual response physiology and a strengthening and bulking of the muscles that wrap around the root of the penis (the two crura penis and the bulbus penis). The device delivers stimulation that is optimized for (1) a strong activation of the pudendo-cavernosal reflex leading to a progressive filling of the erectile tissues with arterial blood and (2) a powerful and continuous activation of the reflexes that flex the muscles wrapping around the root of the penis strongly and persistently, owing to its capacity to generate vibratory stimuli on both upper and lower surfaces of the glans at a physiologically optimum amplitude (2 mm with the standard model ; 3 mm with the X3 model) and frequency (70-110 Hz), and its ability to simultaneously pull the penis outward thus further enhancing the activation of reflexes that contract the muscles involved in the maximization and stabilization of erection. This leads to a very effective and physiotherapeutic workout for the neural and vascular components of the erectile physiology, and for the nerves and muscles of the root of the penis that are necessary for achieving full rigidity and for the maintanence and stabilization of erection until the completion of the sexual activity. See the figure below for a demonstration of the muscles of the root of the penis.
In addition, when used with professional guidance, Viberect (and comparable devices) may be a highly helpful component of a treatment program toward an improvement of various ejaculatory dysfunctions, as it also effectively activates afferent and efferent neural elements of ejaculatory reflexes, and can be used to progressively modulate the physiological readiness potential of these elements. For ejaculatory dysfunctions, on a case-by-case basis, Dr. Duzyurek may recommend the version that generates vibrations with a higher amplitude (Viberect X3). The physiotherapeutic utilization of Viberect integrates well with a pharmacological and/or behavioral therapy program, a sexual rehabilitation / remediation program, or a male pelvic floor therapy regimen, tailored by your doctor according to your circumstances, the nature of the problems, and the treatment goals.
SCHOLARLY ARTICLES ON MALE SEXUAL FUNCTION and its DISORDERS
ARTICLES on AUDIOVISUAL SEXUAL STIMULATION (AVSS) and/or VIBROTACTILE STIMULATION in the EVALUATION and MANAGEMENT of MALE SEXUAL DYSFUNCTIONS
The comprehensive and integrated evaluation and treatment approach employed at this practice covers the following problem areas in male sexual functioning
- Erectile Dysfunction (mild to severe; intermittent or persistent; situational or generalized)
- Performance difficulty in penetrative sex with a partner despite having erectile competence with full rigidity in other circumstances, such as self stimulation, oral sex, or foreplay.
- All forms of Premature Ejaculation (for various types of PE see the table below)
- All forms of Delayed Ejaculation (a difficulty with or failure of achieving ejaculatory orgasm)
lifelong or later acquired (due to radiation therapy or surgery for male issues; nerve problems; aging; etc.)
continuous or intermittent
intercourse-specific or other situation-specific, or generalized
OCD or OCPD related; paruresis related; other psychogenic
drug induced; due to inadvertent faulty masturbatory conditioning
- Sexual Rehabilitation, Remediation, or Preventive Care against erectile, ejaculatory, orgasmic or sensation problems, or penis size loss (due to atrophy, fibrosis, or hypersympathetic overcontraction or retraction) related to (1) aging, (2) certain health conditions, such as neurological disorders (e.g., multiple sclerosis or spinal cord injury), hormonal or metabolic problems, (3) treatment effects, such as surgery, radiotherapy, or drug therapy for pelvic conditions, (4) trauma such as compression injury due to cycling, (5) a delayed correct treatment for ED, or (6) following penile implant placement.
- Emission Phase Dysfunctions of Ejaculation (e.g., Premature Emission, Absent or Retarded Emission)
- Poor Orgasms; Nonorgasmic Ejaculation; Loss of Pleasurable Feeling in Penis; and Sexual Anhedonia
- Local Pain or Other Physical Discomfort During or Following Ejaculation
- Partial or Complete Loss of Libido (Low Sex Drive); Sexual Anorexia
- Excessively Increased Libido (Sexual Overdrive)
- Sexual Performance Anxieties and Sexual Confidence Issues
- Sexual Dysfunctions associated with Shy Bladder Syndrome (Psychogenic Inhibition of Micturition)
- Sexual Aversion Disorder; Susceptibility to Sexual Shame
- Postorgasmic Malaise (a.k.a. Postorgasmic Illness Syndrome), including Post-coital Tristesse
- Certain Fetishes or Paraphilias that interfere with functioning in non-paraphilic (conventional) sex, when the latter is also desired by the person.
- Chronic or Recurrent Male Pelvic Pain Syndrome (or Male Pelvic Myoneuralgia)
- Dissatisfaction, concerns or questions about the size or form of penis or testicles
- Receptive Sexual Dysfunctions in gay/bi men such as receptive dyspareunia (painful intercourse)
International Classification of Premature Ejaculation
For what to expect during your first visit click here.
* DR. DUZYUREK DOES NOT HAVE ANY FORM OF FINANCIAL CONNECTION, OR ANOTHER POSSIBLE CONFLICT OF INTEREST, WITH A DEVELOPER, PROVIDER, MANUFACTURER OR SELLER OF ANY MEDICAL DEVICE (SUCH AS VIBERECT), SUPPLEMENT, PRESCRIPTION DRUG, TEST, OR ANY OTHER PRODUCT.
ARTICLES ON TESTOSTERONE AND SEXUAL FUNCTION
An Evidence-Based Assessment of Erectile Adequacy and Competence Should Include Axial Rigidity Metrics
Subjective reporting or the use of devices that measure an overall penile volume increase (such as a penile plethysmograph) or radial expansion (such as the Erectiometer) or penile radial rigidity (such as the RigiScan) correlate poorly with overall erectile health, and a robust and sustained penetrative competence in penile sexual functioning. While these devices may have some value for certain types of research, for a clinically meaningful assessment or monitoring of penile sexual functioning, it is necessary to determine the axial (not radial) rigidity based on the measurement of axial buckling force magnitudes. Today, fully rigid (grade 4 or grade 4+) erections are recognized as the optimal goal in treatment, and axial rigidity is considered the most important factor that determines erectile fitness, potency and successful intercourse. This metric can be accurately determined utilizing medical devices such as the Digital Inflection Rigidometer (DIR) or the Androerectest. A healthy erection is fully rigid without allowing for any degree of buckling or bending regardless of sexual position, angle of penetration, or how vigorous the intercourse is.
Dr. Duzyurek helps his patients overcome their difficulties in a fully confidential, unrushed, comfortable, and low-pressure atmosphere of a private practice setting.
GUIDED IMAGERY and SIMULATION THERAPY
Dr. Duzyurek offers self-imagery-guided simulative therapy option as part of an integrated and sex-positive treatment program for ejaculatory dysfunctions, as well as certain forms of erectile performance problems when a psychosomatic component is involved. An imagery-facilitated experiential and sensorimotor simulative therapy via therapeutic homeworks is related to medical hypnosis, cognitive-behavioral therapy, biofeedback, and various 'positive psychology' approaches. This form of behavioral therapy is especially helpful for men without a participating partner, either by choice or by necessity. A typical therapy program takes advantage of certain intercourse simulator aids in order to obtain a realistic sensorimotor effect to help enhance the therapeutic 'virtual reality' experience that is central in the treatment process. For erectile performance issues, delayed ejaculation, or anorgasmia, the aim is to cultivate a skill for attaining and maintaining a mental and bodily flow of a natural and autotelic arousal immersed and engaged in the present moment with an openness to the multiple (and sometimes seemingly conflicting) dimensions of the immediate sensual and sexual experience, free of inhibiting or defocusing concerns, or other distracting mental processes or psychological entanglements. For premature ejaculation, the aim is to cultivate an improved capacity for self-control of ejaculatory timing and a neural reconditioning of the ejaculatory response.
An FDA-approved vibro-diagnostic and vibro-therapeutic medical device (Viberect)
Viberect's ability to simultaneously stretch the penis during vibratory stimulation enhances the reflexive engagement of the IC and BC muscles
TAKING ADVANTAGE OF ADVANCED SEXUAL PHARMACOLOGY
Dr. Duzyurek is proud to offer state-of-the-art and cutting-edge therapeutic options to his patients distilled from up-to-date scientific and clinical advances regarding the biology and physiology of penis and core sexual functions (e.g., libido, erectile and ejaculatory responses, and orgasm), allowing him to help his patients via optimized therapeutic regimens that are not necessarily limited to the commonly-employed first-line treatments for achieving better and sustained efficacy and tolerability while maintaining a non-invasive approach (i.e., without involving any injection, puncturing or cutting).
A DIVERSE ARRAY OF NONINVASIVE TREATMENT OPTIONS FOR A WIDE RANGE OF MALE SEXUAL PROBLEMS
Some men with sexual problems (such as a loss of libido; a difficulty with achieving a fully rigid and sustained erection; a difficulty in crossing the ejaculation threshold or in enjoying satisfactory orgasms) do not benefit adequately from using a single medication (monotherapy) while they often do achieve full results, following a detailed assessment, owing to a well-chosen, synergistic, and personalized combination of two or more oral drugs and/or topical agents, such as Befar cream, Vitaros cream, Muse, or a compounded TriMix gel, plus a PDE-5 inhibitor (e.g., Cialis, Viagra, Levitra, Staxyn, Stendra), and other combination therapy options involving naltrexone, piribedil, pentoxifylline, yohimbine, apomorphine, pramipexole, cabergoline, rasagiline, various formulations of selegiline, AT II receptor blockers, amantadine, stimulants, modafinil, bupropion, tianeptine, oral/sublingual phentolamine, doxazocin, tamsulosin, isoxsuprine, trazodone, topical minoxidil (5-15%), metformin, statins, L-citrulline, L-cysteine, S-allyl cysteine, resveratrol, verapamil, oxytocin, endothelial NO inducers (e.g., nebivolol, carvedilol), beta-3 agonists (e.g., mirabegron), various serotonin receptor ligands (e.g., cyproheptadine, pizotifen, and buspirone), and several others. Dr. Duzyurek may also prescribe personalized drug formulations to be obtained at a compounding pharmacy. It may also be necessary to identify and discontinue any offending drug, if possible, and to normalize testosterone levels, when low, for treatment to be fully effective, even though testosterone therapy may not correct the dysfunction all by itself. Clomiphene or aromatase inhibitors may also be considered. Combination therapy enhances efficacy in the case of premature ejaculation (PE), as well. Effective combinations that Dr. Duzyurek may personalize for you in PE treatment may include SSRIs, clomipramine, tramadol, topical anesthetics, guanfacine, clonidine, alpha-receptor blockers, oxcarbazepine, gabapentin, pregabalin, lorcaserin, pindolol, and adjunctive PDE-5 inhibitors, among others. For various dysfunctions, medications are often integrated with other approaches, such as behavioral or physiotherapeutic treatments for a further boost or personalization in treatment. With an individual-specific professional guidance, some of the latter alternatives may work as stand-alone treatments in some cases. Importantly, most herbals and supplements commercially promoted for ED, other dysfunctions, or penis enlargement are not recommended by professional associations in the field of Sexual Medicine and by Dr. Duzyurek since they do not work, and some can be harmful.
SEXUAL MEDICINE Practice
For Male Sexual Function Health
SINAN DUZYUREK, MD, PLLC - Washington, DC
FOR INFO ON THE DIAGNOSTIC ASSESSMENT PROCESS and WHAT TO EXPECT DURING YOUR OFFICE VISIT, CLICK HERE
Full erectile health & fitness requires a capability for briskly achieving a grade 4 or grade 4+ level erection upon adequate stimulation and sustaining it through the completion of a sexual encounter or activity. This is the gold standard as a treatment goal. Having mostly grade 3 erections, and a sluggishness in reaching the grade 4 level, are forms of mild ED, which should not be ignored at any age. Many men with milder forms of ED are either unaware of or complacent about it. An optimized and personalized treatment without delay increases odds toward healing, helps prevent future worsening, and improves prognosis (outcomes).
One in three men of all ages, and more than half of men over 40 have some degree of ED. A quarter of men with newly diagnosed ED are in their teens, 20s or 30s.
Three biophysical determinants of penile rigidity.
Once thought to be relatively rare, Delayed Ejaculation (DE) in various forms and degrees (up to a complete inability to cross the ejaculation threshold) occurs in at least 10% of all men. Its prevalence is up to 30% among men in their 50s, and over 50% in men over 60, as confirmed in a recent study on Ejaculatory Dysfunctions in men over 50 in a large community sample. Click for more info on diagnostic tests and treatments for DE provided by MedlinePlus (a public education service of the US National Library of Medicine and the NIH). It may also be complicated by or confused with an erection maintenance failure. DE is a challenging condition to treat requiring professional expertise and personalized treatment based on a detailed evaluation. This often includes facilitatory medications, removal of medical or behavioral causes, utilization of various physiotherapeutic devices, and/or a form of sex therapy, along with practical tips. Traditional or perfunctory treatment and self-help attempts are known to be unsuccessful. By objective criteria up to 30% of men of all ages have bona fide Premature Ejaculation (PE). Up to 10% have primary (a.k.a. lifelong) PE, consistently ejaculating in under 2 minutes after penetration since puberty. About 3% of men have a severe form, consistently ejaculating within 15 seconds. Primary PE has genetic roots, which we have just begun to elucidate. Later onset (acquired or secondary) PE may develop due to a variety of medical or psychological factors, or medication side effects. In 1/3 of men with PE there is also a form of ED. An efficient, satisfactory and sustained resolution of PE (especially when primary) requires a personalized and effective biomedical treatment regimen, often integrated with behavioral therapy and/or physiotherapy approaches, along with professional tips, based on careful professional evaluation. Unfortunately most men with PE do not get competent professional help. Self-help and cursory treatment attempts tend to be frustrating.
OPTIMUM EJACULATION TIMING
CORRECTING the UNDERLYING ILLNESS PROCESSES by SLOWING, HALTING, and REVERSING HARMFUL CHANGES WITHIN the PENIS, and PREVENTION of an ENTRENCHMENT of the DISORDER MUST BE THE GOAL IN TREATMENT, IN ADDITION TO A FAST SYMPTOMATIC FIX of the PROBLEM
In most cases, ED involves undesirable structural and functional changes in the erectile tissues of the penis, such as arteriosclerotic changes, and/or smooth muscle loss or atrophy, along with a diffuse fibrosis in the cavernous bodies, and sometimes an autonomic neuropathy. These degenerative changes appear to start at a relatively young age in many men (e.g., in their twenties or thirties) and begin to cause noticable erectile dysfunction when an uncorrected progression of these processes later reach a symptomatic threshold, or as other (psychological, hormonal, neurological, vascular, iatrogenic, etc.) factors are added. Without corrective measures and an ongoing optimized treatment of ED, these underlying changes tend to persist or progress over time. Some loss in erect penis length and/or girth may also occur. Earlier and correct interventions improve prognosis and the odds of success in stopping, and actually reversing, these undesirable changes. This principle also applies to ejaculatory disorders, especially delayed ejaculation. Some forms of treatment offer very little or no organ-protective and organ-healing value over time. In fact, treatments based on erection-inducing injections into the penis may actually have a detrimental effect in the long-run, for example, by worsening or triggering an irreversible fibrosis in the erectile tissues. We can often find an effective treatment solution without turning to penis injections - even after firstline treatment options (such as Viagra or Cialis) failed - while also aiming for a treatment approach that actually heals progressively and helps to prevent further problems.
Penis Size Preservation
Some men with sexual functioning issues waste precious time without seeking professional treatment, or with poorly-chosen attempts at a solution, as they are unaware of, or they act complacently about, the importance of getting an effective, personalized and optimized treatment without an undue delay. No man should simply settle with less than fully hard sustained erections that are achieved relatively briskly upon good-enough mental and/or physical stimulation, regardless of factors like age, penis geometry or size, relationship status, or physical and mental health status. Similarly, problems involving ejaculations or orgasms should not be ignored. Like many other medical conditions, various progressive mechanisms underlie most sexual dysfunctions, leading to an entrenchment of the problem and potentially additional complications over time. For example, an untreated erectile dysfunction (ED), regardless of its original cause or severity, will likely lead, over time, to a gradual degeneration in the fine architecture of erectile tissues, as well as in the overall structural integrity of the penis, simply by the virtue of a reduction in the frequency, duration or quality of erections. Untreated ED begets more ED over time. Its incorrect or delayed treatment may also cause the penis to literally lose length and girth.
Clinical experience and evidence lend support to the medical adage "healthy erections bring more healthy erections". The main reason for this is that regular, fully rigid erections with an adequate duration are necessary for the penis to maintain its optimal structural and functional integrity. When this penis-maintaining and penis-nourishing function of full erections with adequate frequency and duration is compromised, a progressive atrophy in key anatomical elements of the penile tissues takes place, along with diffuse fibrotic changes within the erectile bodies of the penis, causing a decrease in erectile tissue volume, stretchiness, expandability and fillability, along with an insufficient (leaky) blockage of the blood flow in veins that drain the erectile tissues. This appears to be the underlying reason for the veno-occlusive dysfunction, which probably is the most common cause of organic ED. (Also, various causes of ED themselves are known to be directly and progressively degenerative towards neural, vascular and/or connective tissue elements involved in penile functioning and structural integrity.) It is crucial to prevent this course and outcome, and to reverse any early degenerative changes. The importance of regular, frequent, and fully rigid erections that last 15 minutes or longer can also be inferred from the widely-accepted function of the REM-sleep-induced erections that the males of mammals evolved to have. These sleep-erections are especially frequent, prolonged, and fully rigid in every male mammal that lost through evolution its baculum (a.k.a. os penis, or penis bone), including men, as they have to rely on the structural and functional integrity and coordination of numerous components which need to work like a team, instead of a push-button raising of the penis bone. These inherently softer body elements need to perform a complexly coordinated and modulated choreography in order to achieve a bone-like rigidity based on hydrolic principles. In humans these erections occur in 3-6 episodes every night, each lasting 15-50 minutes, including the longest-lasting terminal ones experienced as morning erections or "morning wood". These also occur during REM periods of daytime naps. These automatic penis-maintenance erections, which are dependent on adequate testosterone and REM sleep, increase the blood and oxygen supply of the erectile tissues (the two corpora cavernosa and the corpus spongiosum), activate anti-apoptotic (against "cell suicide"), cell-protective and pro-growth genes in the epithelial, smooth muscle and neural cells, including their stem cells, activate mechanisms to remove cellular debris, and induce the synthesis and release of certain biochemical factors (such as nitric oxide) that are necessary for the maintenance of the structural and functional integrity and health of the erectile tissues. In addition, regular, fully rigid erections activate anti-fibrotic mechanisms and exercise the spongy elastic tissue components, thus helping to maintain their elasticity. Otherwise, the normally stretchy (elastic) tissue components gradually die off ("atrophy") and become insidiously and diffusely replaced by nonstretchy (inelastic) and shrinkage-causing fiber-like tissue components ("fibrosis"). Normally, sleep-induced ("nocturnal") erections function as a safety net mechanism for maintaining the penis fitness. However, in almost all forms of ED (including most common forms of psychosomatic ED such as depression-related ED), nocturnal erections are negatively impacted, as well, either in terms of quantity (frequency and duration) or quality (degree of rigidity), or both. In addition, for the maintenance of optimal penis structure and function, erections during sleep must be supplemented by regular awake erections triggered by commands from the erotic arousal centers of the brain, as well. These awake erections have certain additional features that are different from sleep erections physiologically and a lack of their contribution to penis health and fitness may not be fully compensated by REM-sleep-induced erections alone. The earliest sign of an ED process in a young male may be starting to have relatively weaker or less robust erections in masturbation, but this is often ignored or rationalized.
Therefore, an initially mild or intermittent ED, when not acknowledged and effectively treated, is capable of becoming a driver of its own persistence and worsening in time by creating a vicious cycle, which not only causes a progressive entrenchment and down-spiraling of the problem, but may also cause an insidious penis shrinkage (size loss), as reported by a significant group of patients. This shortening and/or thinning of the soft and hard penis may become particularly pronounced in the presence of certain other factors, such as a prolonged testosterone deficiency or use of anti-testosterone medications, hypertension, diabetes, abdominal obesity, cholesterol problems, certain neurological conditions, advancing age, smoking, alcohol and certain other drug abuse, certain sleep disorders (such as sleep apnea), chronic inflammation, or treatment of prostate problems or male cancers with surgery, drugs or radiation. Certain forms of treatment for ED have emerged in recent studies as more successful than other alternatives in terms of preventing, and even reversing, the degenerative changes (atrophy and fibrosis) involved. Therefore, it is crucial for a man with any type or degree of ED to get optimal treatment expeditiously even when he may not be having partnered sex currently, or may not even be planning to be sexually active with a partner in the foreseeable future. A male with any degree of ED at any age should not see this only as a practical performance issue to be symptomatically fixed at the present time, but also as an insidiously penis-degenerative condition which should be preempted by treating it effectively, integratively, correctly, organ-protectively, and without complacency for as long as he values maintaining his full penis function and fitness into his future. Similarly, the importance of avoiding a prolonged delay in getting an effective and neuroprotectively optimized treatment appears to apply to other problems in sexual functioning, such as libido or orgasm problems, and ejaculatory dysfunction. In addition, sexual function health and overall health can not be isolated from one another. Sexual function problems can be an indicator or harbinger of various other physical, mental, or relational health problems , and they can lead to other complications.
Ischiocavernosus (IC) and Bulbocavernosus (BC) Muscles wrap around the part of the penis that is buried in the body (the root of the penis). The IC muscles are essential for accomplishing the full rigidity phase of erection by increasing the cavernous body pressures to suprasystolic levels, and for the stabilization and maintenance of erection through their squeezing action. The BC muscles participate in the tourniquet action on the veins draining the penis, in the ejection reflex of ejaculation, and in the triggering of orgasm feelings. Included among pelvic muscles involved in Kegel exercises, these muscles are capable of staying contracted for prolonged periods, but they can not be flexed voluntarily in isolation (i.e., selectively). Their selective and prolonged contractions are controlled by reflexes, which are very strongly activated by the correct use of the Viberect, allowing for an isolated workout.
Some Additional Educational and Fun Video Links (For other links on male sexual function health, see above)
A SEXUAL HEALTH MESSAGE FOR MEN
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