Male Libido & Dysfunctions

I previously discussed the issues with medications and libidos, in particular with young adult males. Why? because guys will stop taking medications if it affects that area. It also hurts self-esteem and causes insecurities.

How do you talk about libido? You keep it simple. It doesn’t have to be awkward but it’s important to discuss: I usually say (to ADULTS) let’s discuss options that won’t cause sexual issues (and hence they may feel more comfortable talking about private matters).

For the sake of simplicity, I’m addressing psych medication-related dysfunction and priapism. Pathological sexual disorders, addictions, etc. are separate issues…Also, I will discuss situations in which you may want that response and the most likely medications to help.

Sexual dysfunctions can occur for multiple reasons. It may not be the medication but we don’t want to induce the reaction. Therefore, r/o other conditions and educate about certain lifestyles can be equally as important, i.e. ETOH cessation.

–American Urological Association (AUA)

Little Changes, Big Results

I try to do some form of harm reduction and tell male patients that drinking and smoking will affect their sex life. How? by slowly but surely destroying the blood circulation. What is sildenafil? a vasodilator, that’s used to open up those vessels that have been charred from smoking or other lifestyles. What’s wrong with ETOH? it constantly raises your BP and damage/scars the integrity of the blood vessels as well (vascular insufficiency/impaired venous flow that’s noted above).

male libido — Natural supplements mainly, to dilate those vessels!

About Young Adult Males/Teenager’s Libido

For young kids (before puberty) I don’t worry about this side-effect, mainly because it shouldn’t be an issue. They don’t have or want the capacity of an intentional stimulation unless there are other red flag events occurring…

For the post-puberty kids/teenagers, I will caution parents to watch out for these S/E. Teens may say code phrases like the medication is “too strong”, “not helping”, “makes me feel weird”, “I don’t like it”…etc. If the behaviors/mood have improved, and they want to discontinue medications it shouldn’t be a problem. However, if things are getting worse, truly consider if the medication is actually being taken or make adjustments. The goal is not about gratification, but to make sure they take the medication and mood improvement.

If issues are occurring, they are a few ways to help: (1) take a med vacation, give a break over the summer or on weekends, (2) decrease the dose: try to lower the amount, and increase the dose as needed for additional psych symptoms (however it depends on the severity of the mental illness…); (3) lastly, go into a different class: this happens when the provider will just have to treat it as an adverse reaction. For teenagers/adult males, I would try to use the following options that have low libido S/E:

Antipsychotics: Cariprazine (Vraylar): a great alternative for SSRI, major s/e include akathisia and insomnia. Lurasidone (Latuda): helps with bipolar depressive episodes, exact MOA is unclear; must take with FOOD/350 calories for optimal absorption, same metabolic risks and s/e with atypicals.
Bupropion (Wellbutrin): great option to decrease smoking and improve mood/focus; s/e SZ risks.
Mirtazapine (Remeron): low to minor libido s/e, best to use also as an adjunct.
Mood Stabilizers: lamotrigine, VPA, topiramate, lithium, etc. have minimum libido s/e
TCAs: I don’t recall sexual issues with these medications so it’s still an option for adults. I usually don’t put teens on TCAs.
Vilazodone HCI (Viibryd ): is a serotonin modulator, but less s/e than SSRIs/SNRIs.
Vortioxetine (Trintellix): a serotonin modulator + stimulator so the 5HT is much stronger than vilazodone and more prone to sexual s/e but possibly less than SSRIs. Common s/e is nausea.

Other (s): consider patches or different forms of medications to decrease s/e. Some possibly consider prescribing sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra, Staxyn). These medications are approved by the FDA only to treat sexual problems in men (-Mayo Clinic). I personally don’t prescribe these medications, especially if the patient is young and it’s probably not covered. I also want to preserve men’s natural functions without the use of medications…older men I’ll rather switch the medication than to keep adding meds.

When It’s Needed

I sometimes get patients that want decreased libido or better self-control. The ideal they claim is hopefully, it’ll make the person be more faithful, and that usually doesn’t work but I tell them, sure let’s give it a try. Some patients also assume that maybe it’s a “manic episode” since they can’t control their urges, again I try to correct them by expressing manic episodes require a hospitalization. Overall, I’m trying to be honest with the patient and hold them accountable for these maladaptive behaviors. Plus, no partner will tolerate cheating since the person “just couldn’t help it” no matter what the excuse is… Here are some considerations when I will consider decreasing the libido:

Lack of Self-Control: it’s not just for the sake of the relationship, but if urges are taking place constantly, at inappropriate places, possibly leading to deviant or illegal activities, I will consider meds for that purpose. I don’t want the patient to get arrested or risk more problems.
The Bad Outweighs the Good: if the patient isn’t in a relationship, sometimes it’s the effect they want to overall not worry about their urges and desires. They will tell me how it’s one less thing to worry about…
Safety Reasons: I also don’t want some grandpas or older men, going around trying to fulfill their dreams like they’re in their 20s. If they’re on a phosphodiesterase 5 blocker, maybe they need a decreased sexual lifestyle as well, mainly so they won’t get more heart problems. I know this is a reach, but some people really need more self-control for the sake of their cardiovascular system.

Antidepressants most likely to cause sexual side effects include:

Selective serotonin reuptake inhibitors (SSRIs), which include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva), and sertraline (Zoloft).
Serotonin and norepinephrine reuptake inhibitors (SNRIs), which include venlafaxine (Effexor XR), desvenlafaxine (Pristiq), and duloxetine (Cymbalta).
Tricyclic and tetracyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and clomipramine (Anafranil). (again, I rarely see this with TCAs)
Monoamine oxidase inhibitors (MAOIs), such as isocarboxazid (Marplan), phenelzine (Nardil), and tranylcypromine (Parnate). However, selegiline (Emsam), an MAOI that you stick on your skin as a patch, has a low risk of sexual side effects.

–Mayo Clinic

What’s Going On/Assessing?

According to most studies, it’s not clear why or how antidepressants cause sexual dysfunction. We know it has something to do with serotonin hence, the SSRIs are the biggest culprit but some people don’t have that reaction. A decrease in sexual function may be due to depression, the medications, lifestyle, or all of the above. However, if you need to obtain more detailed information the following article is helpful:

The sources of [sexual] dysfunctional patterns are scientifically not well established. Yet, for practical purposes, clinicians offer a variety of therapeutic interventions based on their history taking and their preferred understanding of pathogenesis. Although many mysteries of sexual pathophysiology await illumination, patients sometimes expect mental health professionals to provide guidance about their persistent sexual disappointments.

3 basic clinical concepts

The first is to categorize the specific problem as seemingly always present (lifelong) or acquired after a period of normal sexual function (acquired) and as specific to a partner or a type of sexual activity (situational) or present with all partners and sexual circumstances (generalized). These distinctions help clinicians focus on the relevant history of the presenting problem-that is, to focus on the situation before the symptoms began or, if lifelong, to focus on past important developmental experiences.

The second is to keep in mind that all sexual behavior-solitary and partnered, normal and dysfunctional, morally acceptable or socially disapproved of-is constructed with biological, psychological, interpersonal, and cultural contributions. This concept helps clinicians to put generalizations about sexual dysfunction into perspective, to remain humble, and to bring an intelligent skepticism to pronouncements about causality and treatment claims. It is also why the need for clinical judgment in this arena is stressed so heavily within DSM-5. As psychiatry’s interest in sexual dysfunctions has lessened over the past several decades, sexual medicine has become more prominent. The latter is dominated by research and clinical interventions in urology and gynecology, and pharmaceutical research into prosexual agents. Nonetheless, a broad array of clinicians encounter patients’ sexual concerns. These include psychiatrists, psychologists, relationship therapists, sex therapists, counselors, infectious disease specialists, physical therapists, and primary care physicians. Each stakes out a narrow band of sexual concerns and dysfunctions. Each tends to have a biologic or psychological bias when it comes to explaining the problem and recommending treatment. A urologist, for instance, is more likely to prescribe a phosphodiesterase-5 inhibitor (PDE-5i) than to refer a man with erectile dysfunction to a mental health professional. A psychologist who confronts new lower desire and difficulty with ejaculation is less likely to consider a prolactinoma than would a primary care physician. The sexual lives of patients, however, are rarely as simple as various professionals’ interventions suggest. Care is frequently optimized when medical and nonmedical professionals collaborate to bring their different skills and knowledge to patients.

The third basic concept is to keep in mind that sexual function, while very important to general well-being, is merely one aspect of a person’s life. While specialists tend to focus on the sexual problem, the process of determining the specific psychological, interpersonal, biological, and cultural determinants of a presenting problem often leads mental health professionals to realize that almost any sexual dysfunction can be a symptom of other DSM-5 diagnoses. MDD, for example, can lead to insufficient or excess sexual desire and impairment of arousal or orgasm. The clinician is called upon to separate:

Sexual dysfunction that’s the product of a psychiatric disorder from
Reactive symptoms that stem from having the sexual dysfunction from
Current life dilemmas beyond a DSM-5 diagnosis that impair sexual function or satisfaction from
Remote adversities during childhood or adolescence that undermined the person’s ability to feel safe during the recurring intimate life experience

The skillful treatment of sexual dysfunction begins with a careful history to reveal the psychological, interpersonal, and biological health of the patient and his or her partner.

–Psychiatric Times

About Priapism

It’s defined by AUA as an erection that occurs without stimulation that lasts >4 hours. It’s rare but it happens, I’ve seen it and it looks PAINFUL. It’s considered a type of compartment syndrome and I’ve seen it a lot in the ER, mainly because of the high number of sickle-cell patients. With medications, it can occur with SGAs, SSRIs, bupropion, and trazodone. I would say a stimulation >2 hours should consider going to the ER or at least calling the clinic.

Even if you’re the best lover in the world, you will eventually scream from the discomfort. Sometimes if it’s too painful/significant ischemia/clotting, it’ll require surgical interventions (shunt placement and needle aspiration of the penis). Just to be clear, it takes a while for the blood to “clot” but it could be sooner depending on conditions like sickle cell or certain blood disorders. There are also non-ischemic or non-painful erections –(Mayo Clinic).

Again, patient education is important, because a guy may initially think they’re in heaven. I usually ask patients to call the clinic if there are any concerns instead of heading to the ER. In this case, if the patient called, it’s best if they go ASAP or before the pain becomes unbearable. They probably already waited a long time due to the embarrassment so I’ll rather be safe than sorry. I normally caution with teens and it’s one of the reasons why I start low with meds but again it’s overall rare.