Sexual dysfunction of chronic kidney disease. Razieh salehian.md psychiatrist

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2 Sexual dysfunction of chronic kidney disease Razieh salehian.md psychiatrist

3 Disturbances in sexual function are a common feature of chronic renal failure. Sexual dysfunction is inversely associated with GFR and is improved after renal transplantation, suggesting that CKD per se may contribute to sexual dysfunction in these patients.

4 Sexual dysfunction in uremic male

5 SD is a multifactorial problem: Sexual dysfunction in uremia is primarily organic in nature, as demonstrated by abnormal nocturnal penile tumescence. Some of organic factors : Hormonal disturbances Anemia and mineral and bone disorder peripheral neuropathy Autonomic dysfunction peripheral vascular disease pharmacologic therapy Psychologic and physical stresses

6 Depression Anxiety Poor self-esteem Body image issues Fear of disability and death Social withdrawal Marital discord Loss of employment Financial difficulties

7 Spermatogenesis Chronic renal failure is associated with testicular damage and impaired spermatogenesis, often leading to infertility. Testicular histology : Damage to the seminiferous tubules Decreased spermatogenic activity Interstitial fibrosis and calcifications Atrophy of Sertoli cells Semen analysis: Decreased volume of ejaculate Oligo or complete azospermia low percentage of motile sperm

8 Uremia also impairs gonadal steroidogenesis The serum total and free testosterone concentrations are typically reduced. Concentration of SHBG (sex hormone binding globulin) are normal. Subnormal and delayed testosterone response to the administration of human chorionic gonadotropin (HCG) Total plasma estrogen concentration is frequently elevated. The serum estradiol concentration is typically normal.

9 The serum concentration of luteinizing hormone (LH) is elevated in uremic men due to diminished testosterone feedback. Follicle stimulating hormone (FSH) secretion is also elevated, although to a more variable degree probably the result of decreased testosterone and inhibin, a Sertoli cell product. It has been suggested that increased FSH levels may portend a poor prognosis for recovery of spermatogenic function after renal transplantation.

10 Elevated plasma prolactin concentrations are found in the majority of dialyzed patients. In men who have normal renal function, hyperprolactinemia tends to cause a decrease in LH and consequently in testosterone, independently causing impotence. In men with renal failure, however, LH is higher than normal. When bromocriptine is administered to men with renal failure, it lowers prolactin levels to near normal, but the effect on libido and potency is inconsistent. Gynecomastia occurs in approximately 30 percent of men on maintenance hemodialysis. The pathogenesis of gynecomastia in this setting is unclear.

11 Over 50 percent of uremic men complain of SD. The principal complaint is impotence. Only 25 % of patients discuss about SD with their physicians. Decreased libido Erectile dysfunction (50% of male predialysis CKD patients and 80% of male dialysis patients have ED). The prevalence of erectile dysfunction in male dialysis patients has been found to increase with age (63% <50 years versus 90% 50 years Difficulty reaching orgasm

12 Obtain sexual history Changes in the frequency of intercourse Sexual desire arousal orgasmic capability fertility Time of the onset of these problems in relation to the stage of CDK. MH : diabetes anemia neurological illness lumbar disk endocrinological disease ( PRL T gonad) vascular risk factors (HTNhypercholesterolemia smoking) DH: cimetidine TCA phenothiazines metoclopramide PSYCHOSOCIAL : psychiatric illness stress factor (loss of job / home)

13 History and physical examination Oral sildenafil test 50 mg or 75 mg, In non responders, it is necessary to explore other factors (hormonal, psychological, neurological, vascular, or particular drugs) Control and correct HB level Control and correct hormonal profile Control and correct pharmacological therapy Nocturnal penile tumescence test (npt) Psychologic testing and evaluation of stress, depresssion Penile doppler velocimetry with PGE1 test PGE1 intra urethral/cavernous injection Cavernous bodies biopsy or intravenous nitric oxide levels after PGE1 test Surgical implant of penile prosthesis

14 Lifestyle changes and risk factor modification must precede or accompany ED Maximizing the delivered dose of dialysis. Discontinuing culprit medications (if possible). Correcting the anemia of chronic renal disease. PDE5 I used as first line therapy for psychologic, vascular, or neurogenic causes. Zinc Potency, libido, and frequency of intercourse also improved in patients given zinc. Dopamine agonists in men with increased serum prolactin. Testosterone in hypogonadic nonresponders to PDE5 Is. Psychotherapy and/or psychoactive medications. Vacuum tumescence device in uremic impotent males unresponsive to medical therapy. Alprostadil (prostaglandin E1, MUSE) Renal transplantation

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16 Sexual function may improve but rarely normalize with the institution of maintenance dialysis, commonly resulting in a decreased quality of life. By comparison, a well functioning renal transplant is much more likely to restore sexual activity; however, some features of reproductive function may remain impaired, particularly reduced libido and erectile dysfunction.

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18 Fertility Disturbances in menstruation (amenorrhea, menorrhagia) Anovulation Delayed sexual development Premature menopause Sexual function : Decreased libido (HSDD is the most common sexual problem in women with CKD) Impaired vaginal lubrication( 55% of female dialysis patients reporting difficulty with sexual arousal) Dyspareunia Reduced ability to reach orgasm

19 Anemia CKD mineral and bone disorder Hormonal disturbances Medications Comorbid illness Psychological factors

20 Endocrine abnormality (Elevated levels of FSH and LH Decreased in estrogen production) The elevated prolactin levels may impair hypothalamic pituitary function and contribute to sexual dysfunction and galactorrhea in these patients. Bromocriptine treatment corrects the hyperprolactinemia in these patients but does not restore normal menses.

21 A detailed history of menstrual patterns should be obtained. Screening Tools for Female SD (Female Sexual Function Index (FSFI) Hormonal levels (testosterone, estrogen, FSH, LH, TSH, PTH, and prolactin level). Medications Address the psychosocial factors that might contribute to SD.

22 Maximizing the delivered dose of dialysis Discontinuing culprit medications (if possible) Correcting the anemia of chronic renal failure Topical estrogen cream and vaginal lubricants may be helpful in Decreased libido. Topical estrogen cream and vaginal lubricants may be helpful in dyspareunia. Bromocriptine may help restore sexual function in hyperprolactinemia. Estrogen supplementation may improve sexual function in women with low circulating levels of estradiol. Address the psychosocial factors that might contribute to SD. Successful transplantation is clearly the most effective means to restore normal sexual desire in women with chronic renal failure.

23 The generalized use of testosterone by women has been advised against, because of inadequate indications and lack of long term data. Postmenopausal women who are distressed by their decreased sexual desire and who have other identifiable cause may be candidates for testosterone therapy. Androgens may also be used by those women who are hypogonadal as a result of pituitary problems in premenopause. Transdermal patches and topical gel or creams are preferred over oral products because of first pass hepatic effects documented with oral formulation. The major side effects of androgens are hirsutism and acne. No safety with regard to testosterone implants. There is no indication for increased frequency of breast cancer.

24 Oligomenorrhea or amenorrhea The administration of a progestin (eg, 5 to 10 mg of medroxyprogesterone acetate ) for 10 days each month to women with renal failure and chronic anovulation but a serum estradiol concentration within the normal range for the follicular phase, will result in menses. The chronic administration of a progestin frequently terminates menstrual flow in a woman with metrorrhagia. Regular menses While pregnancy can rarely occur spontaneously in women on chronic dialysis, restoration of fertility as a therapeutic goal should be discouraged. In comparison, the abnormalities in ovulation can usually be reversed and successful pregnancy achieved in women with a well functioning renal transplant. Uremic women who are menstruating normally should be encouraged to use birth control.

25 Thanks for your Attention

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