Erectile dysfunction is a common problem among older and younger men with risk factors such as high blood pressure, diabetes or elevated cholesterol, but men of all ages, the same as women, suffer from low sexual drive, problems with orgasm, and ejaculatory dysfunction. Male orgasmic dysfunction for years has been an area of taboo among the men themselves, as well as their physicians, but with changing social attitudes about men and their health, more men feel comfortable talking to their physicians not only about the quality of their erections but also about problems with sex drive, orgasmic sensation, and ejaculatory function. Until recently the main obstacle in the evaluation of orgasmic and ejaculatory dysfunction has been the lack of well established and objective methods of measuring at a neurophysiological level what happens during male orgasm or ejaculation.We have recently developed and validated a new method of measuring physiological changes in the pelvic floor muscle, specifically the function of the bulbocavernosus muscle and pudendal nerve using highly sophisticated ultrasonographic image processing. Using an ultrasound placed on the skin in the groin area we have measured and described physiological events in men with normal and abnormal orgasm and ejaculation. The aim of this study was to evaluate use of transperineal ultrasound in evaluation of orgasmic and ejaculatory function in men who presented with anorgasmia, hypoorgasmia, decreased penile sensation, and ejaculatory dysfunction. Material and methods: 60 men age 18 to 60 years seen in single academic practice were evaluated with resolution 8-10MHZ linear probe with real-time signal acquisition. The diameter of bulbous urethra (BU), thickness of bulbocavernosus muscle (BCM), amplitude, frequency and timing of BCM activity, and change in crosssection of BU were recorded before intracavernosal injection with vaso-active agent, at maximum dilation of BU, and at patient reported orgasm or ejaculation. The quality of orgasm and ejaculation were measured using visual scale. Video-assisted vibratory stimulation (FertileCare) was used in patients with decreased penile sensation or idiosyncratic pattern of self-stimulation. All files were processed using Premiere Pro 3 and ImagePro software. Results: 20 men with ED but normal ejaculatory and orgasmic function served as control. Those men had on average 7 (from 3-12) contractions of BCM per orgasm, with >40 % of decrease in cross section area of BU lasting on average 15 s. The thickness of BCM decreased from 3.08 mm to 2 mm prior to ejaculation, P<0.05. Three men with primary anejaculation who had normal BCM contractions underwent follow-up simultaneous TRUS and cystoscopy to diagnose functional SV obstruction. 7 men suffered from anorgasmia secondary to inadequate stimulation - all ejaculated with with normal BCM response. Out of 8 patients who presented with secondary anorgasmia 3 had decreased thickness of BCM b/o hypogonadism, 4 had poor amplitude of BCM contractions. Conclusions: Transperineal US is well accepted by patient, easy to master study which allows for objective assessment of BCM activity. We hope that this report will aid in development of validated and objective instruments to help those men who present with anorgasmia and ejaculatory dysfunction. This study showed that men who have no orgasm or decreased sensation of orgasm have dramatically decreased amplitude and frequency of bulbocavernosus muscle contractures. This technique will help in identifying men with most central nervous system problems which may be more amendable to pharmacological treatment, and peripheral nervous system problems such as decreased sensation secondary to pudendal nerve neuropathy which may sometimes necessitate surgical treatment. Although initial studies focused on men with a history of prostate cancer who had decreased sensation of orgasm, now most of his patients are young men in their 20 and 30s, for whom problems with ejaculation and orgasm are especially embarrassing and may negatively affect building confidence and interpersonal relationships. This novel approach represents a milestone in the objective measurement of one of the most intimate aspects of male sexuality, and has significant potential for improving success in the treatment of certain forms of sexual disorders in men. Although further research is needed in the optimal algorithm to evaluate men with orgasmic and ejaculatory dysfunction, this study takes us meaningfully closer to understanding the mechanisms by which the mind and body work together to express sexual response.

Department of Urology Weill Cornell Medical College Cornell University New York

3. český a mezinárodní andrologický kongres, Štiřín, 13.-15.6.2008