1.

URINARY RETENTION
Urinary retention is the inability to empty the bladder completely. Urinary retention can be
acute or chronic.
Acute urinary retention happens suddenly and lasts only a short time. People with acute
urinary retention cannot urinate at all, even though they have a full bladder. Acute urinary
retention, a potentially life-threatening medical condition, requires immediate emergency
treatment. Acute urinary retention can cause great discomfort or pain.
Chronic urinary retention can be a long-lasting medical condition. People with chronic
urinary retention can urinate. However, they do not completely empty all of the urine from
their bladders. Often people are not even aware they have this condition until they develop
another problem, such as urinary incontinence -- loss of bladder control, resulting in the
accidental loss of urine -- or a urinary tract infection (UTI), an illness caused by harmful
bacteria growing in the urinary tract.
ETIOLOGY
Urinary retention can result from

obstruction of the urethra

nerve problems

medications

weakened bladder muscles

Obstruction of the Urethra
Obstruction of the urethra causes urinary retention by blocking the normal urine flow out of
the body. Conditions such as benign prostatic hyperplasiaalso called BPHurethral
stricture, urinary tract stones, cystocele, rectocele, constipation, and certain tumors and
cancers can cause an obstruction.
Benign prostatic hyperplasia. For men in their 50s and 60s, urinary retention is often caused
by prostate enlargement due to benign prostatic hyperplasia. Benign prostatic hyperplasia is a
medical condition in which the prostate gland is enlarged and not cancerous. The prostate is a
walnut-shaped gland that is part of the male reproductive system. The gland surrounds the
urethra at the neck of the bladder. The bladder neck is the area where the urethra joins the
bladder. The prostate goes through two main periods of growth. The first occurs early in
puberty, when the prostate doubles in size. The second phase of growth begins around age 25
and continues during most of a mans life. Benign prostatic hyperplasia often occurs with the
second phase of growth.
As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall
becomes thicker. Eventually, the bladder may weaken and lose the ability to empty
completely, leaving some urine in the bladder.
Read
more
in Prostate
Enlargement:
Benign
Prostatic
Hyperplasia at www.urologic.niddk.nih.gov.

Urethral stricture. A urethral stricture is a narrowing or closure of the urethra. Causes of

urethral stricture include inflammation and scar tissue from surgery, disease, recurring UTIs,
or injury. In men, a urethral stricture may result from prostatitis, scarring after an injury to the
penis or perineum, or surgery for benign prostatic hyperplasia and prostate cancer. Prostatitis
is a frequently painful condition that involves inflammation of the prostate and sometimes the
areas around the prostate. The perineum is the area between the anus and the sex organs.
Since men have a longer urethra than women, urethral stricture is more common in men than
women.1
Read more in Prostatitis: Inflammation of the Prostate at www.urologic.niddk.nih.gov.
Surgery to correct pelvic organ prolapse, such as cystocele and rectocele, and urinary
incontinence can also cause urethral stricture. The urethral stricture often gets better a few
weeks after surgery.
Urethral stricture and acute or chronic urinary retention may occur when the muscles
surrounding the urethra do not relax. This condition happens mostly in women.
Urinary tract stones. Urinary tract stones develop from crystals that form in the urine and
build up on the inner surfaces of the kidneys, ureters, or bladder. The stones formed or lodged
in the bladder may block the opening to the urethra.
Cystocele. A cystocele is a bulging of the bladder into the vagina. A cystocele occurs when
the muscles and supportive tissues between a womans bladder and vagina weaken and
stretch, letting the bladder sag from its normal position and bulge into the vagina. The
abnormal position of the bladder may cause it to press against and pinch the urethra.
Read more in Cystocele at www.urologic.niddk.nih.gov.
Rectocele. A rectocele is a bulging of the rectum into the vagina. A rectocele occurs when the
muscles and supportive tissues between a womans rectum and vagina weaken and stretch,
letting the rectum sag from its normal position and bulge into the vagina. The abnormal
position of the rectum may cause it to press against and pinch the urethra.
Constipation. Constipation is a condition in which a person has fewer than three bowel
movements a week or has bowel movements with stools that are hard, dry, and small, making
them painful or difficult to pass. A person with constipation may feel bloated or have pain in
the abdomen the area between the chest and hips. Some people with constipation often
have to strain to have a bowel movement. Hard stools in the rectum may push against the
bladder and urethra, causing the urethra to be pinched, especially if a rectocele is present.
Read more in Constipation at www.digestive.niddk.nih.gov.
Tumors and cancers. Tumors and cancerous tissues in the bladder or urethra can gradually
expand and obstruct urine flow by pressing against and pinching the urethra or by blocking
the bladder outlet. Tumors may be cancerous or noncancerous.
Nerve Problems
Urinary retention can result from problems with the nerves that control the bladder and
sphincters. Many events or conditions can interfere with nerve signals between the brain and
the bladder and sphincters. If the nerves are damaged, the brain may not get the signal that
the bladder is full. Even when a person has a full bladder, the bladder muscles that squeeze
urine out may not get the signal to push, or the sphincters may not get the signal to relax.

People of all ages can have nerve problems that interfere with bladder function. Some of the
most common causes of nerve problems include

vaginal childbirth

brain or spinal cord infections or injuries

diabetes

stroke

multiple sclerosis

pelvic injury or trauma

heavy metal poisoning

In addition, some children are born with defects that affect the coordination of nerve signals
among the bladder, spinal cord, and brain. Spina bifida and other birth defects that affect the
spinal cord can lead to urinary retention in newborns.
Read more in Nerve Disease and Bladder Control and Urine Blockage in
Newborns at www.urologic.niddk.nih.gov.
Many patients have urinary retention right after surgery. During surgery, anesthesia is often
used to block pain signals in the nerves, and fluid is given intravenously to compensate for
possible blood loss. The combination of anesthesia and intravenous (IV) fluid may result in a
full bladder with impaired nerve function, causing urinary retention. Normal bladder nerve
function usually returns once anesthesia wears off. The patient will then be able to empty the
bladder completely.
SIGN & SYMPTOM

Difficulty starting to urinate

Difficulty fully emptying the bladder
Weak dribble or stream of urine
Loss of small amounts of urine during the day
Inability to feel when bladder is full
Increased abdominal pressure
Lack of urge to urinate
Strained efforts to push urine out of the bladder
Frequent urination
Nocturia (waking up more than two times at night to urinate)

The symptoms of acute urinary retention may include the following and require immediate
medical attention:

inability to urinate

painful, urgent need to urinate

pain or discomfort in the lower abdomen

bloating of the lower abdomen

The symptoms of chronic urinary retention may include

urinary frequencyurination eight or more times a day

trouble beginning a urine stream
a weak or an interrupted urine stream
an urgent need to urinate with little success when trying to urinate
feeling the need to urinate after finishing urination
mild and constant discomfort in the lower abdomen and urinary tract

DIAGNOSIS
A health care provider diagnoses acute or chronic urinary retention with

a physical exam

postvoid residual measurement

A health care provider may use the following medical tests to help determine the cause of
urinary retention:

cystoscopy

computerized tomography (CT) scans

urodynamic tests

electromyography
Physical Exam
A health care provider may suspect urinary retention because of a patients symptoms and,
therefore, perform a physical exam of the lower abdomen. The health care provider may be
able to feel a distended bladder by lightly tapping on the lower belly.
Postvoid Residual Measurement
This test measures the amount of urine left in the bladder after urination. The remaining urine
is called the postvoid residual. A specially trained technician performs an ultrasound, which
uses harmless sound waves to create a picture of the bladder, to measure the postvoid
residual. The technician performs the bladder ultrasound in a health care providers office, a
radiology center, or a hospital, and a radiologista doctor who specializes in medical
imaginginterprets the images. The patient does not need anesthesia.
A health care provider may use a cathetera thin, flexible tubeto measure postvoid
residual. The health care provider inserts the catheter through the urethra into the bladder, a
procedure called catheterization, to drain and measure the amount of remaining urine. A
postvoid residual of 100 mL or more indicates the bladder does not empty completely. A
health care provider performs this test during an office visit. The patient often receives local
anesthesia.
Medical Tests
Cystoscopy. Cystoscopy is a procedure that requires a tubelike instrument, called a
cystoscope, to look inside the urethra and bladder. A health care provider performs
cystoscopy during an office visit or in an outpatient center or a hospital. The patient will
receive local anesthesia. However, in some cases, the patient may receive sedation and
regional or general anesthesia. A health care provider may use cystoscopy to diagnose
urethral stricture or look for a bladder stone blocking the opening of the urethra.

Read more in Cystoscopy and Ureteroscopy at www.urologic.niddk.nih.gov.

CT scans. CT scans use a combination of x rays and computer technology to create images.
For a CT scan, a health care provider may give the patient a solution to drink and an injection
of a special dye, called contrast medium. CT scans require the patient to lie on a table that
slides into a tunnel-shaped device where a technician takes the x rays. An x-ray technician
performs the procedure in an outpatient center or a hospital, and a radiologist interprets the
images. The patient does not need anesthesia. A health care provider may give infants and
children a sedative to help them fall asleep for the test. CT scans can show

urinary tract stones

UTIs

tumors

traumatic injuries

abnormal, fluid-containing sacs called cysts

Urodynamic tests. Urodynamic tests include a variety of procedures that look at how well
the bladder and urethra store and release urine. A health care provider may use one or more
urodynamic tests to diagnose urinary retention. The health care provider will perform these
tests during an office visit. For tests that use a catheter, the patient often receives local
anesthesia.

Uroflowmetry. Uroflowmetry measures urine speed and volume. Special equipment

automatically measures the amount of urine and the flow ratehow fast urine comes out.
Uroflowmetry equipment includes a device for catching and measuring urine and a
computer to record the data. The equipment creates a graph that shows changes in flow
rate from second to second so the health care provider can see the highest flow rate and
how many seconds it takes to get there. A weak bladder muscle or blocked urine flow
will yield an abnormal test result.

Pressure flow study. A pressure flow study measures the bladder pressure required to
urinate and the flow rate a given pressure generates. A health care provider places a
catheter with a manometer into the bladder. The manometer measures bladder pressure
and flow rate as the bladder empties. A pressure flow study helps diagnose bladder outlet
obstruction.

Video urodynamics. This test uses x rays or ultrasound to create real-time images of
the bladder and urethra during the filling or emptying of the bladder. For x rays, a health
care provider passes a catheter through the urethra into the bladder. He or she fills the
bladder with contrast medium, which is visible on the video images. Video urodynamic
images can show the size and shape of the urinary tract, the flow of urine, and causes of
urinary retention, such as bladder neck obstruction.
Read more in Urodynamic Testing at www.urologic.niddk.nih.gov.
Electromyography. Electromyography uses special sensors to measure the electrical activity
of the muscles and nerves in and around the bladder and sphincters. A specially trained
technician places sensors on the skin near the urethra and rectum or on a urethral or rectal
catheter. The sensors record, on a machine, muscle and nerve activity. The patterns of the
nerve impulses show whether the messages sent to the bladder and sphincters coordinate
correctly. A technician performs electromyography in a health care providers office, an

outpatient center, or a hospital. The patient does not need anesthesia if the technician uses
sensors placed on the skin. The patient will receive local anesthesia if the technician uses
sensors placed on a urethral or rectal catheter.
TREATMENT
A health care provider treats urinary retention with

bladder drainage

urethral dilation

urethral stents

prostate medications

surgery
The type and length of treatment depend on the type and cause of urinary retention.
Bladder Drainage
Bladder drainage involves catheterization to drain urine. Treatment of acute urinary retention
begins with catheterization to relieve the immediate distress of a full bladder and prevent
bladder damage. A health care provider performs catheterization during an office visit or in an
outpatient center or a hospital. The patient often receives local anesthesia. The health care
provider can pass a catheter through the urethra into the bladder. In cases of a blocked
urethra, he or she can pass a catheter directly through the lower abdomen, just above the
pubic bone, directly into the bladder. In these cases, the health care provider will use
anesthesia.
For chronic urinary retention, the patient may require intermittentoccasional, or not
continuousor long-term catheterization if other treatments do not work. Patients who need
to continue intermittent catheterization will receive instruction regarding how to
selfcatheterize to drain urine as necessary.
Urethral Dilation
Urethral dilation treats urethral stricture by inserting increasingly wider tubes into the urethra
to widen the stricture. An alternative dilation method involves inflating a small balloon at the
end of a catheter inside the urethra. A health care provider performs a urethral dilation during
an office visit or in an outpatient center or a hospital. The patient will receive local
anesthesia. In some cases, the patient will receive sedation and regional anesthesia.
Urethral Stents
Another treatment for urethral stricture involves inserting an artificial tube, called a stent, into
the urethra to the area of the stricture. Once in place, the stent expands like a spring and
pushes back the surrounding tissue, widening the urethra. Stents may be temporary or
permanent. A health care provider performs stent placement during an office visit or in an
outpatient center or a hospital. The patient will receive local anesthesia. In some cases, the
patient will receive sedation and regional anesthesia.
Prostate Medications
Medications that stop the growth of or shrink the prostate or relieve urinary retention
symptoms associated with benign prostatic hyperplasia include


dutasteride (Avodart)

finasteride (Proscar)
The following medications relax the muscles of the bladder outlet and prostate to help relieve
blockage:

alfuzosin (Uroxatral)

doxazosin (Cardura)

silodosin (Rapaflo)

tadalafil (Cialis)

tamsulosin (Flomax)

terazosin (Hytrin)
Surgery
Prostate surgery. To treat urinary retention caused by benign prostatic hyperplasia, a
urologista doctor who specializes in the urinary tractmay surgically destroy or remove
enlarged prostate tissue by using the transurethral method. For transurethral surgery, the
urologist inserts a catheter or surgical instruments through the urethra to reach the prostate.
Removal of the enlarged tissue usually relieves the blockage and urinary retention caused by
benign prostatic hyperplasia. A urologist performs some procedures on an outpatient basis.
Some men may require a hospital stay. In some cases, the urologist will remove the entire
prostate using open surgery. Men will receive general anesthesia and have a longer hospital
stay than for other surgical procedures. Men will also have a longer rehabilitation period for
open surgery.
Read
more
in Prostate
Enlargement:
Benign
Prostatic
Hyperplasia at www.urologic.niddk.nih.gov.
Internal urethrotomy. A urologist can repair a urethral stricture by performing an internal
urethrotomy. For this procedure, the urologist inserts a special catheter into the urethra until it
reaches the stricture. The urologist then uses a knife or laser to make an incision that opens
the stricture. The urologist performs an internal urethrotomy in an outpatient center or a
hospital. The patient will receive general anesthesia.
Cystocele or rectocele repair. Women may need surgery to lift a fallen bladder or rectum
into its normal position. The most common procedure for cystocele and rectocele repair
involves a urologist, who also specializes in the female reproductive system, making an
incision in the wall of the vagina. Through the incision, the urologist looks for a defect or
hole in the tissue that normally separates the vagina from the other pelvic organs. The
urologist places stitches in the tissue to close up the defect and then closes the incision in the
vaginal wall with more stitches, removing any extra tissue. These stitches tighten the layers
of tissue that separate the organs, creating more support for the pelvic organs. A urologist or
gynecologista doctor who specializes in the female reproductive systemperforms the
surgery to repair a cystocele or rectocele in a hospital. Women will receive anesthesia.
Tumor and cancer surgery. Removal of tumors and cancerous tissues in the bladder or
urethra may reduce urethral obstruction and urinary retention.
KOMPLIKASI

Complications of urinary retention and its treatments may include

UTIs

bladder damage

kidney damage

urinary incontinence after prostate, tumor, or cancer surgery

UTIs. Urine is normally sterile, and the normal flow of urine usually prevents bacteria from
infecting the urinary tract. With urinary retention, the abnormal urine flow gives bacteria at
the opening of the urethra a chance to infect the urinary tract.
Bladder damage. If the bladder becomes stretched too far or for long periods, the muscles
may be permanently damaged and lose their ability to contract.
Kidney damage. In some people, urinary retention causes urine to flow backward into the
kidneys. This backward flow, called reflux, may damage or scar the kidneys.
Urinary incontinence after prostate, tumor, or cancer surgery. Transurethral surgery to
treat benign prostatic hyperplasia may result in urinary incontinence in some men. This
problem is often temporary. Most men recover their bladder control in a few weeks or months
after surgery. Surgery to remove tumors or cancerous tissue in the bladder, prostate, or urethra
may also result in urinary incontinence.

2. BPH
Benign prostatic hyperplasiaalso called BPHis a condition in men in which the prostate
gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign
prostatic hypertrophy or benign prostatic obstruction.
The prostate goes through two main growth periods as a man ages. The first occurs early in
puberty, when the prostate doubles in size. The second phase of growth begins around age 25
and continues during most of a mans life. Benign prostatic hyperplasia often occurs with the
second growth phase.

RISK FACTOR

Risk factors for developing BPH include:

Obesity
Lack of physical activity
Erectile dysfunction
Increasing age
Family history of BPH
ETIOLOGY
The cause of benign prostatic hyperplasia is not well understood; however, it occurs mainly
in older men. Benign prostatic hyperplasia does not develop in men whose testicles were
removed before puberty. For this reason, some researchers believe factors related to aging
and the testicles may cause benign prostatic hyperplasia.
Throughout their lives, men produce testosterone, a male hormone, and small amounts of
estrogen, a female hormone. As men age, the amount of active testosterone in their blood
decreases, which leaves a higher proportion of estrogen. Scientific studies have suggested
that benign prostatic hyperplasia may occur because the higher proportion of estrogen within
the prostate increases the activity of substances that promote prostate cell growth.
Another theory focuses on dihydrotestosterone (DHT), a male hormone that plays a role in
prostate development and growth. Some research has indicated that even with a drop in blood
testosterone levels, older men continue to produce and accumulate high levels of DHT in the
prostate. This accumulation of DHT may encourage prostate cells to continue to grow.
Scientists have noted that men who do not produce DHT do not develop benign prostatic
hyperplasia.

PATOFISIOLOGI
Pembesaran prostat menyebabkan penyempitan lumen uretra pars prostatika dan akan
menghambat aliran urine. Keadaan ini menyebabkan peningkatan tekanan intravesikal. Untuk
dapat mengeluarkan urin, buli-buli harus berkontraksi lebih kuat guna melawan tahanan itu.
Kontraksi yang terus-menerus ini menyebabkan perubahan anatomik dari buli-buli berupa
hipertrofi otot detrusor, trabekulasi, terbentuknya selula, sakula, dan divertikel buli-buli. Fase
penebalan otot detrusor ini disebut fase kompensasi.
Perubahan struktur pada buli-buli dirasakan oleh pasien sebagai keluhan pada saluran kemih
sebelah bawah atau lower urinary tract symptom (LUTS) yang dahulu dikenal dengan gejalagejala prostatismus.
Dengan semakin meningkatnya resistensi uretra, otot detrusor masuk ke dalam fase
dekompensasi dan akhirnya tidak mampu lagi untuk berkontraksi sehingga terjadi retensi
urin. Tekanan intravesikal yang semakin tinggi akan diteruskan ke seluruh bagian buli-buli
tidak terkecuali pada kedua muara ureter. Tekanan pada kedua muara ureter ini dapat
menimbulkan aliran balik urin dari buli-buli ke ureter atau terjadi refluks vesico-ureter.
Keadaan ini jika berlangsung terus akan mengakibatkan hidroureter, hidronefrosis, bahkan
akhirnya dapat jatuh ke dalam gagal ginjal.
Hiperplasi prostat

Penyempitan lumen uretra posterior

Tekanan intravesikal
Buli-buli Ginjal dan Ureter

Hipertrofi otot detrusor Refluks vesiko-ureter

Trabekulasi Hidroureter

Selula Hidronefrosis

Divertikel buli-buli Pionefrosis Pilonefritis

Gagal ginjal
Pada BPH terdapat dua komponen yang berpengaruh untuk terjadinya gejala yaitu komponen
mekanik dan komponen dinamik. Komponen mekanik ini berhubungan dengan adanya
pembesaran kelenjar periuretra yang akan mendesak uretra pars prostatika sehingga terjadi
gangguan aliran urine (obstruksi infra vesikal) sedangkan komponen dinamik meliputi tonus
otot polos prostat dan kapsulnya, yang merupakan alpha adrenergik reseptor. Stimulasi pada
alpha adrenergik reseptor akan menghasilkan kontraksi otot polos prostat ataupun kenaikan
tonus. Komponen dinamik ini tergantung dari stimulasi syaraf simpatis, yang juga tergantung
dari beratnya obstruksi oleh komponen mekanik.
SIGN & SYMPTOM

urinary frequencyurination eight or more times a day

urinary urgencythe inability to delay urination
trouble starting a urine stream
a weak or an interrupted urine stream
dribbling at the end of urination
nocturiafrequent urination during periods of sleep
urinary retention
urinary incontinencethe accidental loss of urine
pain after ejaculation or during urination
urine that has an unusual color or smell

DIAGNOSIS
A health care provider diagnoses benign prostatic hyperplasia based on

a personal and family medical history

a physical exam
medical tests

Personal and Family Medical History

Taking a personal and family medical history is one of the first things a health care provider
may do to help diagnose benign prostatic hyperplasia. A health care provider may ask a man

what symptoms are present

when the symptoms began and how often they occur
whether he has a history of recurrent UTIs
what medications he takes, both prescription and over the counter
how much liquid he typically drinks each day
whether he consumes caffeine and alcohol
about his general medical history, including any significant illnesses or surgeries

Physical Exam

A physical exam may help diagnose benign prostatic hyperplasia. During a physical exam, a
health care provider most often

examines a patients body, which can include checking for

o
discharge from the urethra
o
enlarged or tender lymph nodes in the groin
o
a swollen or tender scrotum
taps on specific areas of the patients body
performs a digital rectal exam

A digital rectal exam, or rectal exam, is a physical exam of the prostate. To perform the exam,
the health care provider asks the man to bend over a table or lie on his side while holding his
knees close to his chest. The health care provider slides a gloved, lubricated finger into the
rectum and feels the part of the prostate that lies next to the rectum. The man may feel slight,
brief discomfort during the rectal exam. A health care provider most often performs a rectal
exam during an office visit, and men do not require anesthesia. The exam helps the health
care provider see if the prostate is enlarged or tender or has any abnormalities that require
more testing.
Many health care providers perform a rectal exam as part of a routine physical exam for men
age 40 or older, whether or not they have urinary problems.

Digital rectal exam

Medical Tests

A health care provider may refer men to a urologista doctor who specializes in urinary
problems and the male reproductive systemthough the health care provider most often
diagnoses benign prostatic hyperplasia on the basis of symptoms and a digital rectal exam. A
urologist uses medical tests to help diagnose lower urinary tract problems related to benign
prostatic hyperplasia and recommend treatment. Medical tests may include

urinalysis
a prostate-specific antigen (PSA) blood test
urodynamic tests
cystoscopy
transrectal ultrasound
biopsy

Urinalysis. Urinalysis involves testing a urine sample. The patient collects a urine sample in
a special container in a health care providers office or a commercial facility. A health care
provider tests the sample during an office visit or sends it to a lab for analysis. For the test, a
nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine.
Patches on the dipstick change color to indicate signs of infection in urine.
PSA blood test. A health care provider may draw blood for a PSA test during an office visit
or in a commercial facility and send the sample to a lab for analysis. Prostate cells create a
protein called PSA. Men who have prostate cancer may have a higher amount of PSA in their
blood. However, a high PSA level does not necessarily indicate prostate cancer. In fact,
benign prostatic hyperplasia, prostate infections, inflammation, aging, and normal
fluctuations often cause high PSA levels. Much remains unknown about how to interpret a
PSA blood test, the tests ability to discriminate between cancer and prostate conditions such
as benign prostatic hyperplasia, and the best course of action to take if the PSA level is high.

Urodynamic tests. Urodynamic tests include a variety of procedures that look at how well
the bladder and urethra store and release urine. A health care provider performs urodynamic
tests during an office visit or in an outpatient center or a hospital. Some urodynamic tests do
not require anesthesia; others may require local anesthesia. Most urodynamic tests focus on
the bladders ability to hold urine and empty steadily and completely and may include the
following:

uroflowmetry, which measures how rapidly the bladder releases urine

postvoid residual measurement, which evaluates how much urine remains in the
bladder after urination
reduced urine flow or residual urine in the bladder, which often suggests urine
blockage due to benign prostatic hyperplasia

Read more in Urodynamic Testing at www.urologic.niddk.nih.gov.

Cystoscopy. Cystoscopy is a procedure that uses a tubelike instrument, called a cystoscope,
to look inside the urethra and bladder. A urologist inserts the cystoscope through the opening
at the tip of the penis and into the lower urinary tract. A urologist performs cystoscopy during
an office visit or in an outpatient center or a hospital. The urologist will give the patient local
anesthesia; however, in some cases, the patient may require sedation and regional or general
anesthesia. A urologist may use cystoscopy to look for blockage or stones in the urinary tract.
Read more in Cystoscopy and Ureteroscopy at www.urologic.niddk.nih.gov.
Transrectal ultrasound. Transrectal ultrasound uses a device, called a transducer, that
bounces safe, painless sound waves off organs to create an image of their structure. The
health care provider can move the transducer to different angles to make it possible to
examine different organs. A specially trained technician performs the procedure in a health
care providers office, an outpatient center, or a hospital, and a radiologista doctor who
specializes in medical imaginginterprets the images; the patient does not require
anesthesia. Urologists most often use transrectal ultrasound to examine the prostate. In a
transrectal ultrasound, the technician inserts a transducer slightly larger than a pen into the
mans rectum, next to the prostate. The ultrasound image shows the size of the prostate and
any abnormalities, such as tumors. Transrectal ultrasound cannot reliably diagnose prostate
cancer.
Biopsy. Biopsy is a procedure that involves taking a small piece of prostate tissue for
examination with a microscope. A urologist performs the biopsy in an outpatient center or a
hospital. The urologist will give the patient light sedation and local anesthetic; however, in
some cases, the patient will require general anesthesia. The urologist uses imaging techniques
such as ultrasound, a computerized tomography scan, or magnetic resonance imaging to
guide the biopsy needle into the prostate. A pathologista doctor who specializes in

examining tissues to diagnose diseasesexamines the prostate tissue in a lab. The test can
show whether prostate cancer is present.

TREATMENT
Treatment options for benign prostatic hyperplasia may include

lifestyle changes

medications

minimally invasive procedures

surgery
A health care provider treats benign prostatic hyperplasia based on the severity of symptoms,
how much the symptoms affect a mans daily life, and a mans preferences.
Men may not need treatment for a mildly enlarged prostate unless their symptoms are
bothersome and affecting their quality of life. In these cases, instead of treatment, a urologist
may recommend regular checkups. If benign prostatic hyperplasia symptoms become
bothersome or present a health risk, a urologist most often recommends treatment.
Lifestyle Changes
A health care provider may recommend lifestyle changes for men whose symptoms are mild
or slightly bothersome. Lifestyle changes can include

reducing intake of liquids, particularly before going out in public or before periods of
sleep

avoiding or reducing intake of caffeinated beverages and alcohol

avoiding or monitoring the use of medications such as decongestants, antihistamines,

antidepressants, and diuretics

training the bladder to hold more urine for longer periods

exercising pelvic floor muscles

preventing or treating constipation

Medications
A health care provider or urologist may prescribe medications that stop the growth of or
shrink the prostate or reduce symptoms associated with benign prostatic hyperplasia:

alpha blockers

phosphodiesterase-5 inhibitors

5-alpha reductase inhibitors

combination medications
Alpha blockers. These medications relax the smooth muscles of the prostate and bladder
neck to improve urine flow and reduce bladder blockage:

terazosin (Hytrin)

doxazosin (Cardura)

tamsulosin (Flomax)

alfuzosin (Uroxatral)

silodosin (Rapaflo)

Phosphodiesterase-5 inhibitors. Urologists prescribe these medications mainly for erectile

dysfunction. Tadalafil (Cialis) belongs to this class of medications and can reduce lower
urinary tract symptoms by relaxing smooth muscles in the lower urinary tract. Researchers
are working to determine the role of erectile dysfunction drugs in the long-term treatment of
benign prostatic hyperplasia.
5-alpha reductase inhibitors. These medications block the production of DHT, which
accumulates in the prostate and may cause prostate growth:

finasteride (Proscar)

dutasteride (Avodart)
These medications can prevent progression of prostate growth or actually shrink the prostate
in some men. Finasteride and dutasteride act more slowly than alpha blockers and are useful
for only moderately enlarged prostates.
Combination medications. Several studies, such as the Medical Therapy of Prostatic
Symptoms (MTOPS) study, have shown that combining two classes of medications, instead
of using just one, can more effectively improve symptoms, urinary flow, and quality of life.
The combinations include

finasteride and doxazosin

dutasteride and tamsulosin (Jalyn), a combination of both medications that is available

in a single tablet

alpha blockers and antimuscarinics

A urologist may prescribe a combination of alpha blockers and antimuscarinics for patients
with overactive bladder symptoms. Overactive bladder is a condition in which the bladder
muscles contract uncontrollably and cause urinary frequency, urinary urgency, and urinary
incontinence. Antimuscarinics are a class of medications that relax the bladder muscles.
Minimally Invasive Procedures
Researchers have developed a number of minimally invasive procedures that relieve benign
prostatic hyperplasia symptoms when medications prove ineffective. These procedures
include

transurethral needle ablation

transurethral microwave thermotherapy

high-intensity focused ultrasound

transurethral electrovaporization

water-induced thermotherapy

prostatic stent insertion

Minimally invasive procedures can destroy enlarged prostate tissue or widen the urethra,
which can help relieve blockage and urinary retention caused by benign prostatic hyperplasia.
Urologists perform minimally invasive procedures using the transurethral method, which
involves inserting a cathetera thin, flexible tubeor cystoscope through the urethra to
reach the prostate. These procedures may require local, regional, or general anesthesia.
Although destroying troublesome prostate tissue relieves many benign prostatic hyperplasia
symptoms, tissue destruction does not cure benign prostatic hyperplasia. A urologist will
decide which procedure to perform based on the mans symptoms and overall health.

Transurethral needle ablation. This procedure uses heat generated by radiofrequency

energy to destroy prostate tissue. A urologist inserts a cystoscope through the urethra to the
prostate. A urologist then inserts small needles through the end of the cystoscope into the
prostate. The needles send radiofrequency energy that heats and destroys selected portions of
prostate tissue. Shields protect the urethra from heat damage.
Transurethral microwave thermotherapy. This procedure uses microwaves to destroy
prostate tissue. A urologist inserts a catheter through the urethra to the prostate, and a device
called an antenna sends microwaves through the catheter to heat selected portions of the
prostate. The temperature becomes high enough inside the prostate to destroy enlarged tissue.
A cooling system protects the urinary tract from heat damage during the procedure.

Medical Therapies
Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing
the smooth muscle of the prostate and bladder to improve urine flow and reduce bladder
outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they usually

do not reduce the size of the prostate. They are usually taken orally; once or twice a day and
work almost immediately. Commonly prescribed alpha blockers include:
alfuzosin
terazosin
doxazosin
tamsulosin
All of these drugs have the same equal level of effectiveness and side effects. Side effects
can include headaches, dizziness, lightheadedness, fatigue and ejaculatory dysfunction. These
medications are beneficial for patients who have bothersome to moderate severe BPH.
Patients who are undergoing cataract surgery may be advised by their physician against
taking this medication until after their surgery.
5-alpha-reductase inhibitors: Finasteride and dutasteride are oral medications used to treat
BPH. In select men, finasteride and dutasteride can relieve BPH symptoms, increase urinary
flow rate and actually shrink the prostate though it must be used indefinitely to prevent
symptoms. Studies suggest that these medications may be best suited for men with relatively
large prostate glands. These drugs reduce the risk of BPH complications such as acute urinary
retention (suddenly being unable to urinate) and the eventual need for BPH surgery. Side
effects generally are sexually related and include: erectile dysfunction decreased libido and
reduced semen released during ejaculation.
Finasteride should not be used if men do not have prostate enlargement. Finasertide has been
shown to cause more adverse effects in the beginning of its use; however, over a period of
time the side effects between finasteride and dutasteride become equal.
Combination Therapy: The use of both alpha blockers and 5-alpha-reductase inhibitors have
shown to be superior to single drug therapies in men with larger prostates. The combination

approach prevents the progression of disease and improves bothersome symptoms. However,
this improved benefit may be associated with more side effects (possible side effects from
both medications).
Anticholinergics: Another medical therapy that is an appropriate and effective treatment
alternative for the management of symptoms related to BPH.
Complementary and Alternative Medicines/Phytotherapies: These compounds, also know
as herbal therapies, are very popular self treatment remedies. Currently there is no dietary
supplement, complementary alternative medicine or therapy that is recommended for the
management of BPH. Furthermore, the quality and purity of these over-the-counter
supplements are not rigorously monitored, adding further uncertainty about the value and
safety of these products.
Saw palmetto one of the more popular dietary supplements used by men has been shown to
provide no benefit over a placebo for the treatment of BPH conditions and LUTS.
Minimally Invasive Therapies
Since the advent of medical therapy for symptomatic BPH with 5-alpha reductase inhibitors
and alpha-adrenergic blockers, the need for immediate surgical intervention in symptomatic
prostatic obstruction has been reduced substantially. However, alpha-blockers do not modify
prostate growth, and even the use of prostatic growth inhibitors such as finasteride or
dutasteride often fails to prevent the recurrent LUTS of BPH and urinary retention. In the
past, these patients would almost certainly have undergone more invasive treatment earlier in
the disease process.

PRIASPISMUS

Priapism is a prolonged erection of the penis. Priapism is an erection that lasts far longer than
normaloften for four hours or more. It may start as a regular erection when youre sexually
aroused. Or, it can pop up without any stimulation. The erection can last for several hours,
and can be very painful.
ETIOLOGY
An erection normally occurs in response to physical or psychological stimulation. This
stimulation causes certain blood vessels to relax and expand, increasing blood flow to spongy
tissues in the penis. Consequently, the blood-filled penis becomes erect. After stimulation
ends, the blood flows out, and the penis returns to its nonrigid (flaccid) state.
Priapism occurs when some part of this system the blood, blood vessels or nerves
changes normal blood flow. Subsequently, an unwanted erection persists. Factors that can
contribute to priapism include the following.
Blood disorders
Blood-related diseases may contribute to priapism usually ischemic priapism, when blood
isn't being able to flow out of the penis. These disorders include:

Sickle cell anemia

Leukemia

Sickle cell anemia is the most common cause of priapism in boys. Sickle cell anemia is an
inherited disorder characterized by abnormally shaped red blood cells. These abnormally
shaped cells can block the flow of blood.
Prescription medications
Priapism, usually ischemic priapism, is a known side effect of a number of drugs. The
following drugs can sometimes cause priapism:

Oral medications used to manage erectile dysfunction, such as sildenafil (Viagra),

tadalafil (Cialis) and vardenafil (Levitra)

Drugs injected directly into the penis to treat erectile dysfunction, such as papaverine

Antidepressants, such as fluoxetine (Prozac) and bupropion (Wellbutrin)

Drugs used to treat psychotic disorders, such as risperidone (Risperdal) and

olanzapine (Zyprexa)

Blood thinners, such as warfarin (Coumadin) and heparin

Alcohol and drug use

Misuse of prescription drugs, and alcohol and drug abuse can cause priapism, particularly
ischemic priapism. Possible causes include:

Recreational use of erectile dysfunction drugs

Drinking too much alcohol

Use of illegal drugs such as marijuana or cocaine

Injury
A common cause of nonischemic priapism a persistent erection caused by excessive blood
flow into the penis is trauma or injury to your genitals, pelvis or the perineum, the region
between the base of the penis and the anus.
Other factors
Other causes of priapism include:

Spinal cord injury

Blood clots

Poisonous venom, such as venom from scorpions or black widow spiders

In some cases, doctors are unable to identify the specific cause for priapism.
PATOFISIOLOGI
Priapismus terjadi saat keseimbangan fisiologis dari aliran darah menuju dan keluar dari
corpora cavernosa terhalang (interrupted). Ini menyebabkan ereksi badan cavernosa tanpa
disertai ereksi corpus spongiosum atau glans.
Priapismus biasanya disebabkan karena obat-obatan, trauma atau karena suatu
penyakit; bukan disebabkan karena gairah seksual. Pada ereksi penis yang normal; darah
akan mengisi dan memenuhi tabung ereksi sehingga penis menjadi ereksi. Tidak seperti penis
normal dimana ereksi akan mereda setelah aktivitas seksual selesai.
Sedangkan pada keadaan priapismus, ereksi terjadi terus menerus karena darah yang
berada dalam tabung ereksi tidak dapat mengalir keluar. Batang penis menegang dengan
keras sedangkan ujung penis lembek. Jika keadaan ini tidak segera teratasi maka priapismus
dapat menyebabkan kerusakkan jaringan penis dan selanjutnya mengganggu ereksi penis
yang normal.

SIGN & SYMPTOM

Priapism causes abnormally persistent erections not related to sexual stimulation. Priapism
symptoms may vary depending on the type of priapism. There are two main types: ischemic
and nonischemic priapism.
Ischemic priapism
Ischemic, also called low-flow, priapism is the result of blood not being able to leave the
penis. It's the more common type of priapism. Signs and symptoms include:

Unwanted erection lasting more than four hours

Unwanted erection off and on for several hours (stuttering priapism)

Rigid penile shaft, but usually soft tip of penis (glans)

Usually painful or tender penis

Nonischemic priapism
Nonischemic, or high-flow, priapism occurs when too much blood flows into the penis.
Nonischemic priapism is usually painless. Signs and symptoms include:

Unwanted erection lasting at least four hours

Erect but not rigid penile shaft

DIAGNOSIS
If you have an erection lasting more than four hours, you need emergency care. The
emergency room doctor will determine first whether you have ischemic priapism or
nonischemic priapism. This is necessary because the treatment for each is different, and
treatment for ischemic priapism needs to be done as soon as possible.
Medical history and exam
To determine what type of priapism you have, your doctor will likely ask numerous questions
and examine your genitals, abdomen, groin and perineum. He or she may be able to
determine what type of priapism you have based on the rigidity and sensitivity of the penis.
This exam may also reveal signs of injury or tumors that could be causing priapism. An
injury, for example, would suggest that nonischemic priapism is more likely.

Diagnostic tests
Diagnostic tests may be necessary to determine what type of priapism you have. Additional
tests may identify the cause of priapism. In an emergency room setting, your treatment may
begin before all test results are received if the doctor is confident about what kind of priapism
you have. Diagnostic tests include:

Blood gas measurement. In this test, a tiny needle is inserted into your penis to
remove a sample of blood. If the blood is dark deprived of oxygen the condition is
most likely ischemic priapism. If it's bright red, the priapism is most likely nonischemic.
A laboratory test measuring the amounts of certain gases in the blood can confirm the
type of priapism.

Blood tests. Your blood can be tested to measure the number of red blood cells and
platelets present. Results may provide evidence of diseases, such as sickle cell anemia,
other blood disorders or certain cancers.

Ultrasound. You may have color duplex ultrasonography, which uses sound waves to
create an image of internal organs. This test can be used to measure blood flow within
your penis that would suggest ischemic or nonischemic priapism. The exam may also
reveal an injury, tumor or abnormality that may be an underlying cause.

Toxicology test. Your doctor may order a test to screen for illegal or prescription
drugs that may be the cause of priapism. This test may be done with blood or urine
samples.

TREATMENT
Ischemic priapism
Ischemic priapism the result of blood not being able to exit the penis is an emergency
situation that requires immediate treatment. This treatment usually begins with a combination
of draining blood from the penis and using medications.

Aspiration. After your penis is numbed with local anesthetic, excess blood is drained
from it, using a small needle and syringe. As part of this procedure, the penile veins may
also be flushed with a saline solution. This treatment relieves pain, removes oxygen-poor
blood and may stop the erection. This treatment may be repeated until the erection ends.

Medication. A medication called an alpha-adrenergic sympathomimetic, such as

phenylephrine, may be injected into the spongy tissue of the penis. This drug constricts
blood vessels that carry blood into the penis. This action allows blood vessels that carry

blood out of the penis to open up and allow increased blood flow out. This treatment may
be repeated over several hours if necessary. There is some risk of side effects, such as
headache, dizziness and high blood pressure, particularly if you have high blood pressure
or heart disease.

Surgery. If other treatments aren't successful, a surgeon may implant a device that
reroutes blood flow (a shunt) so that blood can move through your penis normally.

Additional treatments. If you have sickle cell anemia, you may receive additional
treatments that are used to treat disease-related episodes, such as supplemental oxygen or
an intravenous solution to keep you hydrated.

Nonischemic priapism
Nonischemic priapism often goes away with no treatment. Because there isn't a risk of
damage to the penis, your doctor may suggest a watch-and-wait approach. Putting ice and
pressure on the perineum the region between the base of the penis and the anus may
help end the erection.
Surgery may be necessary in some cases to insert material that temporarily blocks blood flow
to the penis. The body eventually absorbs the material. Surgery may also be necessary to
repair arteries or tissue damage resulting from an injury.

3. PEYRONI DISEASE
Peyronie's (pay-roe-NEEZ) disease is the development of fibrous scar tissue inside the penis
that causes curved, painful erections.
ETIOLOGY
Medical experts do not know the exact cause of Peyronies disease. Many believe that
Peyronies disease may be the result of

acute injury to the penis

chronic, or repeated, injury to the penis

autoimmune diseasea disorder in which the bodys immune system attacks the
bodys own cells and organs
Injury to the Penis
Medical experts believe that hitting or bending the penis may injure the tissues inside. A man
may injure the penis during sex, athletic activity, or an accident. Injury ruptures blood
vessels, which leads to bleeding and swelling inside the layers of the tunica albuginea.
Swelling inside the penis will block blood flow through the layers of tissue inside the penis.
When the blood cant flow normally, clots can form and trap immune system cells. As the
injury heals, the immune system cells may release substances that lead to the formation of too
much scar tissue. The scar tissue builds up and forms a plaque inside the penis. The plaque
reduces the elasticity of tissues and flexibility of the penis during erection, leading to
curvature. The plaque may further harden because of calcificationthe process in which
calcium builds up in body tissue.
Autoimmune Disease
Some medical experts believe that Peyronies disease may be part of an autoimmune disease.
Normally, the immune system is the bodys way of protecting itself from infection by
identifying and destroying bacteria, viruses, and other potentially harmful foreign substances.
Men who have autoimmune diseases may develop Peyronies disease when the immune
system attacks cells in the penis. This can lead to inflammation in the penis and can cause
scarring. Medical experts do not know what causes autoimmune diseases. Some of the
autoimmune diseases associated with Peyronies disease affect connective tissues. Connective
tissue is specialized tissue that supports, joins, or separates different types of tissues and
organs of the body.
SIGN & SYMPTOM
Peyronie's disease signs and symptoms might appear suddenly or develop gradually. The
most common signs and symptoms include:

Scar tissue. The scar tissue (plaques) associated with Peyronie's disease can be felt
under the skin of the penis as flat lumps or a band of hard tissue.

A significant bend to the penis. Your penis might be curved upward, downward or
bent to one side. In some cases, the erect penis might have narrowing, indentations or an
hourglass appearance, with a tight, narrow band around the shaft.

Erection problems. Peyronie's disease might cause problems getting or maintaining

an erection (erectile dysfunction).

Shortening of the penis. Your penis might become shorter as a result of Peyronie's
disease.

Pain. You might have penile pain, with or without an erection.

The curvature associated with Peyronie's disease might gradually worsen. At some point,
however, it stabilizes in the majority of men.
In most men, pain during erections improves within one to two years, but the scar tissue and
curvature often remain. For a few men, both the curvature and pain associated with
Peyronie's disease improve without treatment.

DIAGNOSIS
A physical exam is often sufficient to identify the presence of scar tissue in the penis and
diagnose Peyronie's disease. Rarely, other conditions cause similar symptoms and need to be
ruled out.
Tests to diagnose Peyronie's disease and understand exactly what's causing your symptoms
might include the following:

Physical exam. Your doctor will feel (palpate) your penis when it's not erect, to
identify the location and amount of scar tissue. He or she might also measure the length
of your penis. If the condition continues to worsen, this initial measurement helps
determine whether the penis has shortened.
Your doctor might also ask you to bring in photos of your erect penis taken at home. This
can determine the degree of curvature, location of scar tissue or other details that might
help identify the best treatment approach.

Other tests. Your doctor might order an ultrasound or other tests to examine your
penis when it's erect. Before taking images of your penis, you'll likely receive an injection
directly into the penis that causes it to become erect.

Ultrasound is the most commonly used test for penis abnormalities. Ultrasound tests use
sound waves to produce images of soft tissues. These tests can show the presence of scar
tissue, blood flow to the penis and any other abnormalities.

TREATMENT
Your doctor might recommend a wait-and-see (watchful waiting) approach if:

The curvature of your penis isn't severe and is no longer worsening

You can still have sex without pain

Pain during erections is mild

You have good erectile function

If your symptoms are severe or are worsening over time, your doctor might recommend
medication or surgery.
Medication
The goals of treatment with medication include reducing plaque formation and pain, as well
as minimizing curvature of the penis.
There is one medication approved by the Food and Drug Administration for the treatment of
Peyronie's disease. It's called collagenase Clostridium histolyticum (Xiaflex). This medicine
is approved for use in men with a palpable lump from plaque in the penis that causes a
curvature of at least 30 degrees during erection.
The treatment works by breaking down the buildup of collagen that causes penile curvature.
It involves a series of in-office injections, directly into the penile lump, as well as penile
modeling brief exercises to gently stretch and straighten the penis.
In clinical trials, this collagenase therapy significantly reduced curvature and bothersome
symptoms associated with Peyronie's disease in many participants. Discuss potential side
effects of this medication with your doctor, as some of them can be serious.
Examples of off-label use of medications for Peyronie's disease include an oral medication
called pentoxifylline (Trental), verapamil (injections or topical gel) and interferon
(injections).

Surgery
Most experts recommend against surgery during the early inflammatory phase of Peyronie's
disease. Your doctor might suggest surgery if the deformity of your penis is severe, especially
bothersome, or prevents you from having sex. Surgery usually isn't recommended until the
curvature of your penis stops increasing.
Surgical methods include:

Suturing (plicating) the unaffected side. A variety of procedures, such as Nesbit

plication, can be used to suture (plicate) the longer side of the penis (the side without scar
tissue). This can straighten the penis, but it might result in actual or perceived penile
shortening. In some cases, plication procedures cause erectile dysfunction.

Incision or excision and grafting. Generally used in cases of more severe curvature,
this procedure is linked to greater risks of worsening erectile function compared with
plication procedures. The surgeon makes one or more cuts in the scar tissue, sometimes
removing some of that tissue, allowing the sheath to stretch out and the penis to
straighten. The surgeon may sew in a piece of tissue (graft) to cover the holes in the
tunica albuginea, a membrane within the penis that helps maintain an erection.

Penile implants. Surgically inserted penile implants replace the spongy tissue that
fills with blood during an erection. The implants might be semirigid manually bent
down most of the time and bent upward for sexual intercourse. Another type of implant is
inflated with a pump implanted in the scrotum. Penile implants might be considered if
you have both Peyronie's disease and erectile dysfunction.

The type of surgery will depend on your condition. Your doctor will consider the location of
scar tissue, the severity of your symptoms and other factors.
Other treatments
A technique known as iontophoresis uses a weak electrical current to deliver a combination of
verapamil and dexamethasone noninvasively through the skin. Research shows conflicting
results.
Several nondrug treatments for Peyronie's are being investigated, but evidence is limited on
how well they work and possible side effects. These include using intense sound waves to
break up scar tissue (shock wave therapy), devices to stretch the penis (penile traction
therapy) and vacuum devices.

4. DISFUNGSI EREKSI
Erectile dysfunction (impotence) is the inability to get and keep an erection firm enough for
sex.
ETIOLOGY
Male sexual arousal is a complex process that involves the brain, hormones, emotions,
nerves, muscles and blood vessels. Erectile dysfunction can result from a problem with any of
these. Likewise, stress and mental health concerns can cause or worsen erectile dysfunction.
Sometimes a combination of physical and psychological issues causes erectile dysfunction.
For instance, a minor physical condition that slows your sexual response might cause anxiety
about maintaining an erection. The resulting anxiety can lead to or worsen erectile
dysfunction.
Physical causes of erectile dysfunction
In most cases, erectile dysfunction is caused by something physical. Common causes include:

Heart disease

Clogged blood vessels (atherosclerosis)

High cholesterol

High blood pressure

Diabetes

Obesity

Metabolic syndrome a condition involving increased blood pressure, high insulin

levels, body fat around the waist and high cholesterol

Parkinson's disease

Multiple sclerosis

Peyronie's disease development of scar tissue inside the penis

Certain prescription medications

Tobacco use

Alcoholism and other forms of substance abuse

Sleep disorders

Treatments for prostate cancer or enlarged prostate

Surgeries or injuries that affect the pelvic area or spinal cord

Psychological causes of erectile dysfunction

The brain plays a key role in triggering the series of physical events that cause an erection,
starting with feelings of sexual excitement. A number of things can interfere with sexual
feelings and cause or worsen erectile dysfunction. These include:

Depression, anxiety or other mental health conditions

Stress

Relationship problems due to stress, poor communication or other concerns

RISK FACTOR
As you get older, erections might take longer to develop and might not be as firm. You might
need more direct touch to your penis to get and keep an erection. This might indicate
underlying health conditions or be a result of taking medications
Various risk factors can contribute to erectile dysfunction, including:

Medical conditions, particularly diabetes or heart conditions

Tobacco use, which restricts blood flow to veins and arteries, can over time
cause chronic health conditions that lead to erectile dysfunction
Being overweight, especially if you're obese
Certain medical treatments, such as prostate surgery or radiation treatment for
cancer
Injuries, particularly if they damage the nerves or arteries that control erections
Medications, including antidepressants, antihistamines and medications to treat high
blood pressure, pain or prostate conditions
Psychological conditions, such as stress, anxiety or depression

Drug and alcohol use, especially if you're a long-term drug user or heavy drinker

Prolonged bicycling, which can compress nerves and affect blood flow to the penis,
may lead to temporary or permanent erectile dysfunction

PATOFISIOLOGI
DE dapat disebabkan dari tiga mekanisme dasar ini: (1) kegagalan menginisiasi
(psikogenik, endokrinologik, atau neurogenic); (2) kegagalan pengisian (arteriogenik); atau
(3) kegagalan untuk menyimpan volume darah yang adekuat didalam jaringan lacunar
(disfungsi venooklusif). Kategori ini dapat terjadi secara bersamaan. Sebagai contoh,
mengurangnya tekanan pengisian (filling pressure) dapat menyebabkan adanya kerusakan
venous. Faktor psikogenik seringkali terjadi bersama dengan faktor etiologi lainnya.
Diabetes, atherosclerosis, dan penyebab akibat obat terhitung pada 80% kasus DE pada pria
dewasa.
Vaskulogenik
Penyebab organic paling sering untuk DE adalah gangguan aliran darah ked an dari
penis. Atherosclerosis atau penyakit arterial traumatic dapat menurunkan aliran ke ruang
lacunar, menyebabkan menurunnya rigiditas dan memanjangnya waktu untuk ereksi penuh.
Aliran yang berlebihan pada vena, walaupun adekuat jumlahnya, dapat menyebabkan DE.
Perubahan structural pada komponen fibroelastik pada corpora dapat menyebabkan
berkurangnya komplians dan ketidakmampuan untuk menyempitkan vena pada.
Neurogenic
Gangguan yang mengenai medulla spinalis bagian sacral atau jaras saraf otonom
menuju penis dapat mencegah terjadinya aktivitas sistem relaksasi saraf pada otot halus
penis, sehingga hal ini mengakibatkan DE. Pada pasien dengan cedera medulla spinalis,
derajat dari DE bergantung pada tingkat kerusakan dan lokasi lesi. Pasien dengan lesi parsial
atau cedera pada bagian atas dari medulla spinalis cenderung masih memiliki kemampuan
ereksi dibandingkan seseorang yang memiliki lesi sempurna atau terdapat pada bagian bawah
medulla spinalis. Walaupun sekitar 75% pasien dengan cedera medulla spinalis memiliki
kemampuan untuk ereksi, hanya 25% dari jumlah tersebut yang memiliki ereksi yang cukup
untuk penetrasi. Gangguan neurologist lainnya yang umumnya berkaitan dengan DE
termasuk multiple sclerosis atau neuropati perifer. Yang terakhir disebabkan oleh diabetes
atau alkoholisme. Operasi pelvis juga dapat menyebabkan DE akibat terganggunya suplai
saraf otonom.
Endokrinologik
Androgen meningkatkan libido, namun peran pastinya terhadap fungsi ereksi masih
tetap belum jelas. Seseorang dengan kadar testosterone yang rendah dapat mencapai ereksi
dari stimulus visual atau seksual. Namun, kadar testosteron normal sepertinya penting untuk
fungsi ereksi, terutama pada pria tua. Terapi alih androgen dapat memperbaiki fungsi ereksi

yang menurun jika diakibatkan hypogonadism; namun, terapi ini tidak bermanfaat pada DE
jika kadar testosterone masih normal. Peningkatan hormon prolactin dapat menurunkan libido
dengan menekan hormone gonadotropin-releasing hormone (GnRH), dan juga dapat
menurunkan kadar testosterone. Terapi untuk hiperprolaktinemia dapat menggunakan agonis
dopamine yang dapat mengembalikan libido dan testosterone.
Diabetes
DE terjadi pada 35-75% pria dengan diabetes mellitus. Mekanisme patologis
utamanya berkaitan dengan komplikasi vaskuler dan neurologik DM. Komplikasi
makrovaskuler diabetes biasanya berkaitan dengan umur, dimana komplikasi mikrovaskuler
berhubungan dengan durasi lamanya diabetes dan derajat pengendalian glikemia. Seseorang
dengan diabetes juga memiliki penuruna nitric oxide synthase pada jaringan endotel dan
neural.
Psikogenik
Dua mekanisme yang berkontribusi terhadap inhibisi ereksi pada DE psikogenik.
Pertama, stimulus psikogenik pada sacral medulla spinalis dapat menghambat respon
reflexogenik, akibatnya menghambat aktivasi aliran vasodilator menuju penis. Kedua,
stimulasi simpatis berlebihan pada pria cemas dapat meningkatkan tonus otot halus penis.
Penyebab paling umum dari DE psikogenik adalah kecemasan, depresi, konflik suatu
hubungan, kehilangan rasa memikat, hambatan seksual, konflik dengan partner sex,
pelecehan sexual pada masa kecil, dan ketakutan akan penyakit menular sexual. Kebanyakan
pasien dengan DE yang sudah jelas memiliki dasar penyebab organic, dapat terkena efek
psikologis sebagai reaksi terhadap DE, sehingga memberikan beban ganda.
Akibat Pengobatan
DE yang disebabkan oleh obat diperkirakan terjadi pada 25% pria yang ditemukan
pada klinik rawat jalan. Diantara agen antihipertensi, diureik thiazida dan beta blocker yang
paling sering menjadi penyebab. Calcium channel blocker dan ACE inhibitor lebih jarang
dilaporkan. Obat-obat ini dapat bekerja secara langsung pada tingkat corporal (mis. Ca
channel blocker) atau secara tidak langsung dengan menurunkan tekanan darah pada pelvis,
dimana penting untuk mempertahankan kontraksi penis. Adrenergik blocker jarang menjadi
penyebab DE. Estrogen, agonis GnRH, H2 antagonis, dan spironolactone menyebabkan ED
dengan menekan produksi gonadotropin atau dengan menghambat kerja androgen. Agen
antidepresi dan antipsikosis terutama neuroleptik, tricyclic, dan SSRI berhubungan
dengan kesulitan dalam ereksi, ejakulasi, orgasme, atau kepuasan seksual lainnya.

Daftar obat yang dapat menyebabkan disfungsi ereksi

Classification

Drugs

Diuretics

Thiazides, Spironolactone

Antihypertensives

Calcium
channel
blockers,
Clonidine,
Reserpine,
Guanethidine

Cardiac/anti-hyperlipidemics

Digoxin, Gemfibrozil, Clofibrate

Antidepressants

Selective
serotonin
reuptake
Tricyclic
antidepressants,
Monoamine oxidase inhibitors

Tranquilizers

Butyrophenones, Phenothiazines

H2 antagonists

Ranitidine, Cimetidine

Hormones

Progesterone,
Estrogens,
Corticosteroids
GnRH
agonists,
5-Reductase
inhibitors
Cyproterone acetate

Cytotoxic agents

Cyclophosphamide,
Roferon-A

Anticholinergics

Disopyramide, Anticonvulsants

Recreational

Ethanol, Cocaine,Marijuana

Methyldopa
Beta-Blockers

inhibitors
Lithium

Methotrexate

Walaupun banyak pengobatan yang menyebabkan DE, pasien sering memiliki faktor
resiko sebelumnya yang membingungkan gambaran klinis. Jika terdapat hubunfan kuat antara

pemberian obat dan onset DE, pengobatan lain sebaiknya dipertimbangkan. Namun umum
dilakukan di klinik untuk menambah pengobatan DE tanpa melakukan perubahan banyak
pada pengobatan suatu penyakit, karena mungkin sulit untuk menegakkan peran kausal dari
suatu obat terhadap DE.

SYMPTOM
Erectile dysfunction symptoms might include persistent:

Trouble getting an erection

Trouble keeping an erection

Reduced sexual desire

DIAGNOSIS
For many men, a physical exam and answering questions (medical history) are all that's
needed for a doctor to diagnose erectile dysfunction and recommend a treatment. If you have
chronic health conditions or your doctor suspects that an underlying condition might be
involved, you might need further tests or a consultation with a specialist.
Tests for underlying conditions might include:

Physical exam. This might include careful examination of your penis and testicles
and checking your nerves for sensation.

Blood tests. A sample of your blood might be sent to a lab to check for signs of heart
disease, diabetes, low testosterone levels and other health conditions.

Urine tests (urinalysis). Like blood tests, urine tests are used to look for signs of
diabetes and other underlying health conditions.

Ultrasound. This test is usually performed by a specialist in an office. It involves

using a wandlike device (transducer) held over the blood vessels that supply the penis. It
creates a video image to let your doctor see if you have blood flow problems.
This test is sometimes done in combination with an injection of medications into the penis
to stimulate blood flow and produce an erection.

Overnight erection test. Most men have erections during sleep without remembering
them. This simple test involves wrapping a special device around your penis before you
go to bed.

This device measures the number and strength of erections that are achieved overnight. It
can help to determine if your erectile dysfunction is related to psychological or physical
causes.

Psychological exam. Your doctor might ask questions to screen for depression and
other possible psychological causes of erectile dysfunction.

Diagnosis at Mayo Clinic

Mayo Clinic offers a full range of tools for evaluating erectile dysfunction. Doctors will
likely perform a physical exam and blood and urine tests. They might also use a sexual health
questionnaire to help understand your problem.
Some men might require specialized tests. Mayo Clinic provides both noninvasive and
invasive testing for erectile dysfunction, which can include:

Color duplex Doppler ultrasonography

Injecting dye to see blood flow in arteries carrying blood to the penis (penile
arteriography)

Magnetic resonance imaging (MRI)

Nocturnal penile erection monitoring

TREATMENT
The first thing your doctor will do is to make sure you're getting the right treatment for any
health conditions that could be causing or worsening your erectile dysfunction.
Depending on the cause and severity of your erectile dysfunction and any underlying health
conditions, you might have various treatment options. Your doctor can explain the risks and
benefits of each treatment and will consider your preferences. Your partner's preferences also
might play a role in your treatment choices.
Oral medications
Oral medications are a successful erectile dysfunction treatment for many men. They include:

Sildenafil (Revatio, Viagra)

Tadalafil (Adcirca, Cialis)

Vardenafil (Levitra, Staxyn)

Avanafil (Stendra)

All four medications enhance the effects of nitric oxide a natural chemical your body
produces that relaxes muscles in the penis. This increases blood flow and allows you to get an
erection in response to sexual stimulation.
Taking one of these tablets will not automatically produce an erection. Sexual stimulation is
needed first to cause the release of nitric oxide from your penile nerves. These medications
amplify that signal, allowing men to function normally. Oral erectile dysfunction medications
are not aphrodisiacs, will not cause excitement and are not needed in men who get normal
erections.
The medications vary in dosage, how long they work and side effects. Possible side effects
include flushing, nasal congestion, headache, visual changes, backache and stomach upset.
Your doctor will consider your particular situation to determine which medication might
work best. These medications might not fix your erectile dysfunction immediately. You might
need to work with your doctor to find the right medication and dosage for you.
Before taking any medication for erectile dysfunction, including over-the-counter
supplements and herbal remedies, get your doctor's OK. Medications for erectile dysfunction
might not work or might be dangerous if you:

Take nitrate drugs commonly prescribed for chest pain (angina) such as
nitroglycerin (Minitran, Nitro-Dur, Nitrostat, others), isosorbide mononitrate (Monoket)
and isosorbide dinitrate (Dilatrate-SR, Isordil)

Take a blood-thinning (anticoagulant) medication or high blood pressure medications

Have heart disease or heart failure

Have had a stroke

Have very low blood pressure (hypotension) or uncontrolled high blood pressure
(hypertension)

Other medications
Other medications for erectile dysfunction include:

Alprostadil self-injection. With this method, you use a fine needle to inject
alprostadil (Caverject Impulse, Edex) into the base or side of your penis. In some cases,
medications generally used for other conditions are used for penile injections on their
own or in combination. Examples include papaverine, alprostadil and phentolamine.

Each injection generally produces an erection that lasts about an hour. Because the needle
used is very fine, pain from the injection site is usually minor.
Side effects can include bleeding from the injection, prolonged erection (priapism) and
formation of fibrous tissue at the injection site.

Alprostadil urethral suppository. Alprostadil intraurethral (Muse) therapy involves

placing a tiny alprostadil suppository inside your penis in the penile urethra. You use a
special applicator to insert the suppository into your penile urethra.
The erection usually starts within 10 minutes and lasts between 30 and 60 minutes. Side
effects can include pain, minor bleeding in the urethra and formation of fibrous tissue
inside your penis.

Testosterone replacement. Some men have erectile dysfunction that might be

complicated by low levels of the hormone testosterone. In this case, testosterone
replacement therapy might be recommended as the first step.

Penis pumps, surgery and implants

If medications aren't effective or appropriate in your case, your doctor might recommend a
different treatment. Other treatments include:

Penis pumps. A penis pump (vacuum erection device) is a hollow tube with a handpowered or battery-powered pump. The tube is placed over your penis, and then the pump
is used to suck out the air inside the tube. This creates a vacuum that pulls blood into your
penis.
Once you get an erection, you slip a tension ring around the base of your penis to hold in
the blood and keep it firm. You then remove the vacuum device.
The erection typically lasts long enough for a couple to have sex. You remove the tension
ring after intercourse. Bruising of the penis is a possible side effect, and ejaculation will
be restricted by the band. Your penis might feel cold to the touch.
If a penis pump is a good treatment choice for you, your doctor might recommend or
prescribe a specific model. That way, you can be sure it suits your needs and that it's
made by a reputable manufacturer. Penis pumps available in magazines and sex ads might
not be safe or effective.

Penile implants. This treatment involves surgically placing devices into both sides of
the penis. These implants consist of either inflatable or semirigid rods. Inflatable devices
allow you to control when and how long you have an erection. The semirigid rods keep
your penis firm but bendable.

Penile implants are usually not recommended until other methods have been tried first.
Implants have a high degree of satisfaction among men who have tried and failed moreconservative therapies. As with any surgery, there's a risk of complications, such as
infection.

Blood vessel surgery. Rarely, leaking or obstructed blood vessels can cause erectile
dysfunction. In this case, surgical repair, such as vascular stenting or a bypass procedure,
might be needed.

Psychological counseling
If your erectile dysfunction is caused by stress, anxiety or depression or the condition is
creating stress and relationship tension your doctor might suggest that you, or you and
your partner, visit a psychologist or counselor.

5. EARLY EJACULATION
Premature ejaculation is uncontrolled ejaculation either before or shortly after sexual
penetration, with minimal sexual stimulation and before the person wishes. Premature
ejaculation occurs when a man ejaculates sooner during sexual intercourse than he or his
partner would like.
ETIOLOGY
The exact cause of premature ejaculation isn't known. While it was once thought to be only
psychological, doctors now know premature ejaculation is more complicated and involves a
complex interaction of psychological and biological factors.
Psychological causes
Some doctors believe that early sexual experiences may establish a pattern that can be
difficult to change later in life, such as:

Situations in which you may have hurried to reach climax in order to avoid being
discovered
Guilty feelings that increase your tendency to rush through sexual encounters

Other factors that can play a role in causing premature ejaculation include:

Erectile dysfunction. Men who are anxious about obtaining or maintaining an

erection during sexual intercourse may form a pattern of rushing to ejaculate, which can
be difficult to change.

Anxiety. Many men with premature ejaculation also have problems with anxiety
either specifically about sexual performance or related to other issues.

Relationship problems. If you have had satisfying sexual relationships with other
partners in which premature ejaculation happened infrequently or not at all, it's possible
that interpersonal issues between you and your current partner are contributing to the
problem.

Biological causes
A number of biological factors may contribute to premature ejaculation, including:

Abnormal hormone levels

Abnormal levels of brain chemicals called neurotransmitters

Abnormal reflex activity of the ejaculatory system

Certain thyroid problems

Inflammation and infection of the prostate or urethra

Inherited traits

Nerve damage from surgery or trauma (rare)

DIAGNOSIS
In addition to asking about your sex life, your doctor will ask about your health history and
may perform a general physical exam. Your doctor may order a urine test to rule out possible
infection. If you have both premature ejaculation and trouble getting or maintaining an
erection, your doctor may order blood tests to check your male hormone (testosterone) levels
or other tests.
In some cases, your doctor may suggest that you go to a urologist or a mental health
professional who specializes in sexual dysfunction.

TREATMENT
Common treatment options for premature ejaculation include behavioral techniques, topical
anesthetics, oral medications and counseling. Keep in mind that it may take a little time to
find the treatment or combination of treatments that will work for you.
Behavioral techniques
In some cases, therapy for premature ejaculation may involve taking simple steps, such as
masturbating an hour or two before intercourse so that you're able to delay ejaculation during
sex. Your doctor also may recommend avoiding intercourse for a period of time and focusing
on other types of sexual play so that pressure is removed from your sexual encounters.
The pause-squeeze technique
Your doctor may instruct you and your partner in the use of a method called the pausesqueeze technique. This method works as follows:
1.

Begin sexual activity as usual, including stimulation of the penis, until you feel almost
ready to ejaculate.

2.

Have your partner squeeze the end of your penis, at the point where the head (glans)
joins the shaft, and maintain the squeeze for several seconds, until the urge to ejaculate
passes.

3.

After the squeeze is released, wait for about 30 seconds, then go back to foreplay. You
may notice that squeezing the penis causes it to become less erect, but when sexual
stimulation is resumed, it soon regains full erection.

4.

If you again feel you're about to ejaculate, have your partner repeat the squeeze
process.

By repeating this as many times as necessary, you can reach the point of entering your partner
without ejaculating. After a few practice sessions, the feeling of knowing how to delay
ejaculation may become a habit that no longer requires the pause-squeeze technique.
Topical anesthetics
Anesthetic creams and sprays that contain a numbing agent, such as lidocaine or prilocaine,
are sometimes used to treat premature ejaculation. These products are applied to the penis a
short time before sex to reduce sensation and thus help delay ejaculation. A lidocaine spray
for premature ejaculation (Promescent) is available over-the-counter.
Although topical anesthetic agents are effective and well-tolerated, they have potential side
effects. For example, some men report temporary loss of sensitivity and decreased sexual
pleasure. In some cases, female partners also have reported these effects. In rare cases,
lidocaine or prilocaine can cause an allergic reaction.
Oral medications
Many medications may delay orgasm. Although none of these drugs is specifically approved
by the Food and Drug Administration to treat premature ejaculation, some are used for this
purpose, including antidepressants, analgesics and phosphodiesterase-5 inhibitors. These
medications may be prescribed for either on-demand or daily use, and may be prescribed
alone or in combination with other treatments.

Antidepressants. A side effect of certain antideph3essants is delayed orgasm. For this

reason, selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft),
paroxetine (Paxil) or fluoxetine (Prozac, Sarafem), are used to help delay ejaculation. If
SSRIs don't improve the timing of your ejaculation, your doctor may prescribe the
tricyclic antidepressant clomipramine (Anafranil). Unwanted side effects of
antidepressants may include nausea, dry mouth, drowsiness and decreased libido.

Analgesics. Tramadol (Ultram) is a medication commonly used to treat pain. It also

has side effects that delay ejaculation. It may be prescribed when SSRIs haven't been
effective. Unwanted side effects may include nausea, headache and dizziness.

Phosphodiesterase-5 inhibitors. Some medications used to treat erectile dysfunction,

such as sildenafil (Viagra, Revatio), tadalafil (Cialis, Adcirca) or vardenafil (Levitra,
Staxyn), also may help premature ejaculation. Unwanted side effects may include
headache, facial flushing, temporary visual changes and nasal congestion.

Counseling
This approach, also known as talk therapy, involves talking with a mental health provider
about your relationships and experiences. These sessions can help you reduce performance
anxiety and find better ways of coping with stress. Counseling is most likely to help when it's
used in combination with drug therapy.
Medications are a relatively new form of treatment for PE. Doctors first noticed that men and
women who were taking drugs for the treatment of depression (antidepressants) also had
delayed orgasms. Doctors then began to use these drugs "off-label" (this implies using a
medication for a different illness than what it was originally manufactured for) to treat PE.
These medications include antidepressants that affect serotonin such as fluoxetine,
paroxetine, sertraline and clomipramine.
If one medication fails to work, a second one is usually recommended. If the second one fails,
trying a third medication will not likely be beneficial. An alternative is to combine
medication with behavioral therapy and/or creams.
For use in PE, the doses of antidepressants are usually lower than those recommended for the
treatment of depression. Common side effects of antidepressants can include nausea, dry
mouth, drowsiness and reduced desire for sexual activity.
These drugs can be taken either every day or only taken before sexual activity. Your doctor
will decide how you should take the medication based on the frequency of intercourse. The
best time for taking the antidepressant medications before sexual activity has not been
established, but most doctors will recommend from two to six hours depending on the
medication. Because PE can recur when the medication is not taken, you most likely will
need to take it on a continuing basis.
Local anesthetic creams can be used to treat PE. These creams are applied to the head of the
penis about 20 to 30 minutes before intercourse to lessen the sensitivity. Prior to sexual
intercourse, a condom (if used) may be removed and the penis washed clean of any remaining

cream. A loss of erection can occur if the anesthetic cream is left on the penis for a longer
period of time than recommended. Also, the anesthetic cream should not be left on the
exposed penis during vaginal intercourse since it may cause vaginal numbness.

5. DELAYED EJAKULATION
Delayed ejaculation sometimes called impaired ejaculation is a condition in which it
takes an extended period of sexual stimulation for a man to reach sexual climax and release
semen from the penis (ejaculate). Some men with delayed ejaculation are unable to ejaculate
at all.
ETIOLOGY
Delayed ejaculation can result from certain chronic health conditions, surgeries and
medications. Or it may be caused by substance abuse or a mental health concern, such as
depression, anxiety or stress. In many cases, delayed ejaculation is due to a combination of
physical and psychological concerns.
Physical causes of delayed ejaculation include:

Certain birth defects affecting the male reproductive system

Injury to the pelvic nerves that control orgasm

Certain infections, such as a urinary tract infection

Prostate surgery, such as transurethral resection of the prostate (TURP) or prostate

removal

Neurological diseases, such as diabetic neuropathy, stroke or nerve damage to the

spinal cord

Hormone-related conditions, such as low thyroid hormone (hypothyroidism) or low

testosterone (hypogonadism)

Retrograde ejaculation, a condition in which the semen goes backward into the
bladder rather than out of the penis

Psychological causes of delayed ejaculation include:

Depression, anxiety or other mental health conditions

Relationship problems due to stress, poor communication or other concerns

Anxiety about performance

Poor body image

Cultural or religious taboos

Differences between the reality of sex with a partner and sexual fantasies

Medications and other substances that can cause delayed ejaculation include:

Some antidepressants

Certain high blood pressure medications

Certain diuretics

Some antipsychotic medications

Some anti-seizure medications

Alcohol particularly drinking too much (alcohol abuse or alcoholism)

For some men, a minor physical problem that causes a delay in ejaculation may cause anxiety
about ejaculating during a sexual encounter. The resulting anxiety may worsen delayed
ejaculation

SIGN & SYMPTOM

Some men with delayed ejaculation need 30 minutes or more of sexual stimulation to have an
orgasm and ejaculate. Or, they may not be able to ejaculate at all (anejaculation).
But, there's no specific time that indicates a diagnosis of delayed ejaculation. Instead, a man
is probably experiencing delayed ejaculation if the delay is causing him distress or
frustration, or if he has to stop sexual activity due to fatigue, physical irritation, loss of
erection or a request from his partner.
Often, a man might have difficulty reaching orgasm during sexual intercourse or other sexual
activities with a partner. Some men can ejaculate only when masturbating.
Delayed orgasm is divided into the following types based on symptoms:

Lifelong vs. acquired. With lifelong delayed ejaculation, the problem is present from
the time a male reaches sexual maturity. Acquired delayed ejaculation occurs after a
period of normal sexual functioning.

Generalized vs. situational. Generalized delayed ejaculation isn't limited to certain

sex partners or certain kinds of stimulation. Situational delayed ejaculation occurs only
under certain circumstances.

These categories help in diagnosing an underlying cause, and determining what might be the
most effective treatment.

DIAGNOSIS
A physical exam and medical history may be all that's needed to recommend treatment for
delayed ejaculation. However, if delayed ejaculation appears to be caused by an underlying
problem that might need treatment, you may need further tests or you may need to see a
specialist.
Tests for underlying problems can include:

Physical exam. This may include careful examination of your penis and testicles. The
doctor will use light touch to make sure you have normal sensation in your genitals.

Blood tests. A sample of your blood may be sent to a lab to check for signs of heart
disease, diabetes, low testosterone levels and other health problems.

Urine tests (urinalysis). Urine tests are used to look for signs of diabetes, infection
and other underlying health conditions.

TREATMENT
Delayed ejaculation treatment depends on the underlying cause, but may include taking a
medication or making changes to medications you currently take, undergoing psychological
counseling, or addressing alcohol abuse or illegal drug use.
Medications
If you're taking medication that may be causing delayed ejaculation, reducing the dose of a
medication or switching medications may fix the problem. Sometimes, adding a medication
may help.
There aren't any drugs that have been specifically approved for the treatment of delayed
ejaculation. Medications used to treat delayed ejaculation are used primarily to treat other
conditions.
Medications sometimes used to treat delayed ejaculation include:

Amantadine (Parkinson's)

Buspirone (antianxiety)

Cyproheptadine (allergy)

Psychological counseling (psychotherapy)

Psychotherapy can help by addressing underlying mental health problems leading to delayed
ejaculation, such as depression or anxiety. It's also used to address psychological issues that
directly affect your ability to ejaculate.
Counseling may involve seeing a psychologist or mental health counselor on your own, or
along with your partner. Depending on the underlying cause, you may benefit most from
seeing a sex therapist a mental health counselor who specializes in talk therapy for sexual
problems. The type of counseling that's best for you will depend on your particular concerns.

6. RETROGADE EJACULATION
Retrograde ejaculation occurs when semen enters the bladder instead of emerging through the
penis during orgasm. Although you still reach sexual climax, you may ejaculate very little or
no semen. This is sometimes called a dry orgasm. Retrograde ejaculation isn't harmful, but it
can cause male infertility.
ETIOLOGY
During a male orgasm, a tube called the vas deferens transports sperm to the prostate, where
they mix with other fluids to produce liquid semen (ejaculate). The muscle at the opening of
the bladder (bladder neck muscle) tightens to prevent ejaculate from entering the bladder as it
passes from the prostate into the tube inside the penis (urethra). This is the same muscle that
holds urine in your bladder until you urinate. With retrograde ejaculation, the bladder neck
muscle doesn't tighten properly. As a result, sperm can enter the bladder instead of being
ejected out of your body through the penis.
Several conditions can cause problems with the muscle that closes the bladder during
ejaculation. These include:

Surgery, such as bladder neck surgery or prostate surgery

Side effect of certain medications used to treat high blood pressure, prostate
enlargement and mood disorders

Nerve damage caused by a medical condition, such as diabetes, multiple sclerosis or a

spinal cord injury

A dry orgasm is the primary sign of retrograde ejaculation. But dry orgasm the ejaculation
of little or no semen can also be caused by other conditions, including:

Surgical removal of the prostate (prostatectomy)

Surgical removal of the bladder (cystectomy)

Radiation therapy to treat cancer in the pelvic area

SIGN & SYMPTOM

Retrograde ejaculation doesn't affect your ability to get an erection or have an orgasm but
when you climax, semen goes into your bladder instead of coming out of your penis.
Retrograde ejaculation signs and symptoms include:

Dry orgasms, orgasms in which you ejaculate very little or no semen out of your penis

Urine that is cloudy after orgasm (because it contains semen)

Inability to get a woman pregnant (male infertility)

DIAGNOSIS

Ask you a number of questions about your symptoms and how long you've had them.
Your doctor may also ask about any health problems, surgeries or cancers you've had and
what medications you take.

Do a physical examination, which will likely include an exam of your penis, testicles
and rectum.

Examine your urine for the presence of semen after you have an orgasm. This
procedure is usually done at the doctor's office. Your doctor will ask you to empty your
bladder, masturbate to climax, and then provide a urine sample for laboratory analysis. If
a high volume of sperm is found in your urine, you have retrograde ejaculation.

If you have dry orgasms, but your doctor doesn't find semen in your bladder, you may have a
problem with semen production. This can be caused by damage to the prostate or semenproducing glands as a result of surgery or radiation treatment for cancer in the pelvic area.
If your doctor suspects your dry orgasm is something other than retrograde ejaculation, you
may need further tests or a referral to a specialist to find the cause.

TREATMENT
Retrograde ejaculation typically doesn't require treatment unless it interferes with fertility. In
such cases, treatment depends on the underlying cause. Drugs may work for retrograde
ejaculation caused by nerve damage. This can be caused by diabetes, multiple sclerosis,
certain surgeries, and other conditions and treatments.
Drugs generally won't help if retrograde ejaculation is due to surgery that causes permanent
physical changes of your anatomy. Examples include bladder neck surgery and transurethral
resection of the prostate.
If your doctor thinks drugs you are taking may be affecting your ability to ejaculate normally,
he or she may have you stop taking them for a period of time. Drugs that can cause retrograde
ejaculation include certain medications for mood disorders and alpha blockers drugs used
to treat high blood pressure and some prostate conditions.

Drugs to treat retrograde ejaculation are drugs primarily used to treat other conditions. They
include:

Imipramine (Tofranil)

Chlorpheniramine and brompheniramine

Ephedrine, pseudoephedrine and phenylephrine

These medications help keep the bladder neck muscle closed during ejaculation. While
they're often an effective treatment for retrograde ejaculation, all of these medications can
cause side effects. Some of the side effects are minor, but others can be more serious:

Some medications used to treat retrograde ejaculation can cause serious reactions
when combined with other medications.

Certain medications used to treat retrograde ejaculation can increase your blood
pressure and heart rate, which can be dangerous if you have high blood pressure or heart
disease.

Infertility
If you have retrograde ejaculation, you'll likely need treatment to get your partner pregnant.
In order to achieve a pregnancy, you need to ejaculate enough semen to carry your sperm into
your partner's vagina and into her uterus.
If medication doesn't allow you to ejaculate semen, you will likely need infertility procedures
known as assisted reproductive technology to get your partner pregnant. In some cases, sperm
can be recovered from the bladder, processed in the laboratory and used to inseminate your
partner (intrauterine insemination). Occasionally, more-advanced assisted reproductive
techniques may be needed. Many men with retrograde ejaculation are able to get their
partners pregnant once they seek treatment.

7. NOCTURIA
Nocturia is a condition in which you wake up during the night because you have to urinate
intentionally. This condition becomes more common as people age and occurs in both men
and women, sometimes for different reasons.
ETIOLOGY
There are three ways in which nocturia can be caused:

By problems of fluid balance

By neurological diseases affecting bladder control

By disorders of the lower urinary tract (LUT)[3]

It is easy to overlook the first two categories while concentrating on the urinary tract.
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Fluid balance causes of nocturia[2]
Polyuria (day and night) - defined as urine volume >40 ml/kg/24 hours

Excess fluid intake - including alcohol[4]

Diabetes mellitus (DM)

Diabetes insipidus

Hypercalcaemia

Renal failure (more likely in chronic kidney diseaserather than acute kidney injury)[5]

Nocturnal polyuria - defined as normal 24-hour urine volume, with nocturnal volume
>35% total

Excessive evening fluid intake, including alcohol[4]

Diuretics (may depend on time of day taken)

Disruption of normal vasopressin (antidiuretic hormone) secretion - more common in

the elderly

Nocturnal redistribution of fluid - cardiac failure; other causes of oedema - eg, venous
stasis

Sleep apnoea (unknown mechanism)

Neurological causes of nocturia

The bladder is controlled via the brain, spinal cord tracts, sacral segments S2-S4 and
peripheral nerves. Therefore, many neurological conditions affect bladder function. Nocturia
may be a symptom because:

The neurological problem may cause urinary frequency: this can occur in multiple
sclerosis (MS), and has been reported as an early feature of cervical cord compression
and tethered spinal cord syndrome (TSCS).[6]

The neurology may cause retention of urine, which either results in frequency and true
nocturia, or leads to overflow incontinence, which may be misinterpreted as nocturia.

Doctors should be aware that:

If retention occurs in women or patients aged under 60, who are unlikely to have
bladder obstruction, neurological causes need to be considered.

Important, urgent conditions to diagnose are:

Cord compression and cauda equina syndrome (CES); the bladder innervation
is easily damaged, and prompt referral/treatment can save bladder function.

TSCS - although usually less acute, this again needs early referral.[6]

Other common neurological disorders causing urinary symptoms are:

Parkinson's disease[7]

Diabetic cystopathy

LUT causes of nocturia[2]

This is a 'low nocturnal bladder capacity', which can be classified as due to:

Bladder outflow obstruction (where chronic retention in effect lowers any additional
bladder capacity):

Prostatic disease: benign prostatic hypertrophy, prostate cancer

Urethral disease - this occurs both in men and in women[8]

Bladder overactivity

Sensory urgency

Urinary tract infection

Inflammation - eg, interstitial cystitis

Malignancy

Pregnancy

There are many possible causes of nocturia, depending on the type:

Causes of polyuria
High fluid intake
Untreated diabetes (Type 1 and Type 2)
Diabetes insipidus, gestational diabetes (occurs during pregnancy)
Causes of nocturnal polyuria
Congestive heart failure
Edema of lower extremities (swelling of the legs)
Sleeping disorders such as obstructive sleep apnea (breathing is interrupted or stops
many times during sleep)

Certain drugs, including diuretics (water pills), cardiac glycosides, demeclocycline,

lithium, methoxyflurane, phenytoin, propoxyphene, and excessive vitamin D
Drinking too much fluid before bedtime, especially coffee, caffeinated beverages, or
alcohol
Causes of low nocturnal bladder capacity
Bladder obstruction
Bladder overactivity
Bladder infection or recurrent urinary tract infection
Bladder inflammation (swelling)
Interstitial cystitis (pain in the bladder)
Bladder malignancy
Benign prostatic hyperplasia (men), a non-cancerous overgrowth of the prostate that
obstructs the flow of urine
Possible causes of mixed nocturia
Any of the possible causes listed under nocturnal polyuria and low nocturnal bladder capacity

Due to obvious anatomical differences, men and women experience nocturia for different
reasons. Women generally experience nocturia as a consequence of childbirth, menopause,
and/or pelvic organ prolapse. In men, nocturia can be directly attributed to benign prostatic
hyperplasia (BPH), also known as enlarged prostate.
Additional factors that can contribute to nocturia in both sexes include:

Behavioral patterns. This is something you have conditioned your body to do as a

routine

Diuretic medications

Caffeine

Alcohol

Overactive bladder treatment

Excessive fluids before bedtime

Diminished nocturnal bladder capacity. Urine production exceeds the bladder

capacity causing the individual to be awakened in order to void.

Fluid redistribution

SYMPTOM
Normally, you should be able to sleep six to eight hours during the night without having to
get up to go to the bathroom. People who have nocturia wake up more than once a night to
urinate. This can cause disruptions in a normal sleep cycle.
Nocturia may result from several different causes:

You produce a great deal of urine (more than 2 liters) a day (polyuria)
Your body produces a large volume of urine while you sleep (nocturnal polyuria)
You produce more urine at night than your bladder is able to hold (low nocturnal
bladder capacity). This causes you to wake up at night because you need to empty your
bladder.
a combination of nocturnal polyuria and low nocturnal bladder capacity (mixed
nocturia)
Poor sleep some people who have poor sleep and awaken frequently will go to the
bathroom whenever they awaken. Typically in these cases, it is not the need to void that
awakens them.

DIAGNOSIS
Examination

Percuss the abdomen to examine for an enlarged bladder.

Establish whether there is leg oedema present.

Urine dipstick will screen for, but not exclude, DM, infection, haematuria and
proteinuria.

Other relevant examination, depending on the suspected cause:

Cardiovascular

Neurological - especially important if there is urinary retention where

obstructive causes are unlikely, ie in women and the under-60s

Rectal examination (men) to assess the prostate; pelvic examination (women)

Investigations in primary care[1]

Voiding diary by the patient, including the time and volume of fluid intake and urine
output.

Blood tests: renal function, electrolytes, glucose and calcium.

Midstream urine culture and microscopy.

Urodynamics: GPs may have direct access to these clinics, which assess urinary flow
rate and residual volume. Some clinics perform additional measurements, such as
bladder capacity by ultrasound, bladder pressures using a urethral catheter, or
fluoroscopic pressure and flow measurement.

TREATMENT
MANAGEMENT

Mattress Covers. A variety of products exist to protect the bed including vinyl,
waterproof, and absorbing mattress covers or even sheet protectors, which can make
cleanup easier.

Absorbent Briefs. These products are a form of modified underwear designed to

absorb liquid, therefore preventing leakage. Both reusable and disposable products are
available.

Skincare Products. Many products exist to protect the skin from irritation and
soreness that occur when a person experiences nocturnal enuresis. A range of soaps,
lotions, and cleansing cloths exist for various skin types.

BEHAVIORAL MODIFICATIONS

Restriction of Fluid Intake. Naturally, limiting the intake of fluids in the evening
results in a decreased amount of urine produced at night.

Afternoon Naps. This can help reduce fluid build up by allowing liquid to be
absorbed in the bloodstream. When awakening from a nap, you can use the bathroom
and eliminate excess urine.

Elevation of Legs. Like naps, elevating your legs helps redistribute fluids so it can be
reabsorbed into the blood stream.

Compression Stockings. Creating an effect similar to elevating your legs, these

elastic stockings exert pressure against the leg while decreasing pressure on the veins.
This allows fluids to be redistributed and reabsorbed into the bloodstream.

PHARMACEUTICAL TREATMENT
Different medicinal options exist to alleviate and even treat nocturia. These may be used
alone or combined with some of the behavioral modifications listed above, which has been
proven to be more effective. A word of caution about medications: Used alone, studies have
confirmed that the medication works only as long as it is taken. Once off the medication,
relapses are quite common.
Anticholinergic medications are prescription medications that are effective for treating
enuresis with detrusor overactivity, demonstrating success in 5-40% of cases. The main side
effects with anticholinergic medications are dry mouth, dizziness, and blurred vision.

Darifenacin. This medication relieves bladder spasms and treats overactive bladder.

Oxybutynin. This medication relaxes the detrusor muscle of the bladder.

Tolterodine. This medication is an antimuscarinic and functions much like

oxybutynin.

Trospium Chloride. This medication treats an unstable bladder by blocking

cholinergic receptors that are found on muscle cells in the wall of the bladder. Once
the receptors are blocked the bladder then can relax so overactivity does not occur.

Solifenacin. This is a recently introduced anticholinergic that is a more selective

antimuscarinic agent with fewer anticholinergic side-effects.

If this first line drug therapy is considered ineffective, one or more of the following may be
prescribed.

Desmopressin. By mimicking ADH or vasopressin, the kidney produces less urine.

Imipramine. This medication boasts a 40% success rate but also has a fine line
between an effective dose and toxic dose.

Furosemide. This loop diuretic helps regulate urine production in the daytime in
order to decrease urine production during sleep. Furosemide blocks ion flow in the
kidneys, allowing urine production to be more controlled.

Bumetanide. This loop diuretic assists in regulating urine production prior to sleep so
waking during the nighttime does not occur. Bumetanide must be taken with caution
and consultation with a healthcare professional prior to taking this medication is
highly recommended.

Nocturia can be a debilitating problem for many people as it creates chronic sleep
impairment. However, with proper management, motivation, and dedication this condition
can be overcome for a better quality of life.

Interventions:

Restrict fluids in the evening (especially coffee, caffeinated beverages, and alcohol).
Time intake of diuretics (take mid- to late afternoon, six hours before bedtime).
Take afternoon naps.
Elevate the legs (helps prevent fluid accumulation).
Wear compression stockings (helps prevent fluid accumulation).
Medications:
Anticholinergic medications: reduce symptoms of overactive bladder
Bumetanide (Bumex), Furosemide (Lasix): diuretics that assist in regulating urine
production
Desmopressin (DDAVP): helps the kidneys produce less urine

8. ENURESIS
is an inability to control urination during sleep, often referring to people who are old enough
to be able to exercise urinary control. It is a common childhood condition, especially among
young children.
TYPE
There are two main types of enuresis:

Nocturnal enuresis - this is bedwetting. Urination during sleep. 75% of cases are boys.

Diurnal enuresis - this is daytime wetting. This is more common in girls than boys.

Nocturnal enuresis is classed in two ways:

PNE (primary nocturnal enuresis) - the child has not yet had a prolonged dry period.

SNE (secondary nocturnal enuresis) - the child is bedwetting again after a prolonged
dry period (usually 6 months or more).

ETIOLOGY
Many factors may be involved in the development of enuresis. Involuntary, or nonintentional, release of urine may result from:

A small bladder
Persistent urinary tract infections
Severe stress
Developmental delays that interfere with toilet training
Voluntary, or intentional, enuresis may be associated with other mental disorders, including
behavior disorders or emotional disorders such as anxiety. Enuresis also appears to run in
families, which suggests that a tendency for the disorder may be inherited (passed on from
parent to child, particularly on the father's side). In addition, toilet training that was forced or
started when the child was too young may be a factor in the development of the disorder,
although there is little research to make conclusions about the role of toilet training and the
development of enuresis.
Children with enuresis are often described as heavy sleepers who fail to awaken at the urinary
urge to void or when their bladders are full.

PATOFISIOLOGI
Humans who do not wet their beds, stay dry for two reasons:

A anti-diuretic hormone is produced during sleep which reduces urine production. The
hormone is called AVP (arginine vasopressin). At about sunset each day the human body
starts releasing ACP, which reduces kidney urine output. The bladder is less likely to get
full during the night. Most children develop this hormone cycle between the ages of 2 and
6 years - some may take longer. The longer a child takes, the more likely they will
continue bedwetting for longer.

If the bladder is full during sleep, the person wakes up to go to the toilet. Most
children develop this ability at about the same time as when the AVP hormone cycle starts.
If the child is a very deep sleeper, or if the nerves around the bladder are not yet developed
enough (or a combination of the two), it may take a while before he/she wakes up when
the bladder is full.

During the process of becoming dry at night, a child develops these processes (hormone cycle
and waking up when the bladder is full). Experts say some hereditary factors may influence
when
these
two
processes
become
completely
active.
In some cases the child's bladder may not have developed enough - it is still too small and
cannot
hold
much
urine.
Persistent constipation can

increase

the

risk

of

bedwetting.

A child whose parents did not have nocturnal enuresis has only a 15% risk developing the
condition. When both parents were bedwetters as children, the probability for the child is
77% (for just one parent, the risk is 44%). Genetic studies reveal that bedwetting is linked to
the genes on chromosomes 13q and 12q, and possible two others.
Extreme stress can cause bedwetting, such as bullying, a death in the family, sexual abuse, or
domestic
violence.
Caffeine, which exists not only in coffee but many fizzy drinks, increases urine production.
In extremely rare cases there might be a link to a food allergy. Experts say further research is
needed
to
confirm
the
existence
of
a
link
DIAGNOSIS
First, the doctor will take a medical history and perform a physical exam to rule out any
medical disorder that may be causing the release of urine, which is called incontinence. Lab
tests may also be performed, such as a urinalysis and blood work to measure blood sugar,
hormones,
and kidney function.
Physical
conditions
that
could
result
inincontinence include diabetes, an infection, or a functional or structural defect causing a
blockage in the urinary tract.

Enuresis also may be associated with certain medicines that can cause confusion or changes
in behavior as a side effect. If no physical cause is found, the doctor will base a diagnosis of
enuresis on the child's symptoms and current behaviors.

TREATMENT
f the doctor has ruled out a physical abnormality or underlying disease, they will advise the
parents to wait and offer the child comfort and support. In the vast majority of cases
the problem will
resolve
without
treatment.
In the UK, treatment is most definitely not recommended for children under the age of 5
years, and is only considered for children between 5 and 7 if the impact on the child is
significant, or the child, parent and doctor believe they are old enough to cope with treatment.
If the child is over the age of 7 and the bedwetting occurs frequently, and the problem is
having a significant impact on the child (and the family), then treatment may be considered.
Enuresis alarms - this is a tiny sensor which is attached to the child's underwear. As soon as
it senses wetness it makes a noise and wakes up the child. After a while the child will
eventually most likely wake up automatically when his/her bladder is full. Some sensors
vibrate
as
well.
Medication - desmopressin tablets are sometimes prescribed. The doctor may recommend
this medication if the child is going away for a few days, perhaps a sleepover, a school trip, or
camping. Desmopressin makes the kidneys produce less urine during the night. It is very
important that the child and parents follow the doctors instructions carefully.
Absorbent underwear - these may reduce embarrassment and give the child some control
over his/her bedwetting.