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These patients commonly experience impairment of genital sensation cholesterol foods list discount crestor 20 mg line, vaginal lubrication cholesterol levels canada chart order crestor 10mg otc, and orgasm. Also, bladder, bowel, and pelvic floor dysfunction; pain; spasticity; and autonomic dysreflexia were common. Altered vaginal sensation (absent, reduced, fluctuating, or position dependent) was frequently reported. According to the National Spinal Cord Injury Statistical Center, there are 270,000 Americans with a spinal cord injury. The study demonstrates that despite the physical limitation caused by the injury, most women desire and engage in relationships and see sex as an important part of their lives. The sexual education should go beyond merely discussing the possibility of pregnancy or discussing the appropriate birth control. Knowing the possibilities of childbearing is a relevant factor in the "womanhood" of these patients. The overall prevalence of low sexual desire with distress in premenopausal and postmenopausal women ranged from approximately 8% to 19%. With aging, the intensity of sexual desire generally decreases, whereas the distress associated with low desire decreases. Associations have also been drawn between distressing low sexual desire and lower health-related quality of life (QoL), as well as psychosocial factors such as dissatisfaction with sex life, partner, or marriage and negative emotional states, including frustration, hopelessness, anger, poor self-esteem, and loss of femininity (Hayes etal. Symptoms are evident over a period of at least several months and are not secondary to a sexual pain disorder. This revision was based on data suggesting that sexual response is not always a linear process and that the distinction between desire and arousal may be artificial (Basson, 2001; Binik et al. Diagnosis requires a minimum duration of approximately 6 months, and loss of desire needs to be associated with personal distress rather than partner or relationship issues. Excitatory and inhibitory effects of neurotransmitters and hormones on sexual desire. Pregnancy, breastfeeding, or a postmenopausal state can also be associated with decreased libido. It has been shown that middle-aged women had the highest prevalence of decreased desire with distress (Rosen et al. Neuroendocrine changes of aging (such as declining testosterone, loss of estrogen) can decrease sexual desire. Furthermore, the intensity and duration of the genital stimulation may need to be higher as a result of the diminished genital sensation that commonly occurs in middle-aged and postmenopausal women (Kingsberg et al. Hypoestrogenism may induce vulvovaginal atrophy and dyspareunia, which eventually leads to decreased sexual desire (Levine et al. Sexual abuse and trauma in childhood and puberty, perceived stress, distraction, self-focused attention or anxiety, personality disorders, and body image or self-consciousness have all been shown to negatively affect desire (Brotto et al. Sexual desire is the result of a delicate balance between neuromodulators of excitatory pathways. Evaluation Health care providers should initiate the general discussion and assessment of sexual concerns because patients are often reluctant to bring up the topic. It has been shown that 73% of premenopausal women and 81% of postmenopausal women never mentioned their desire problems to a health care provider according to survey results including 450 premenopausal and postmenopausal women with self-reported low sexual desire (Kingsberg, 2014). A variety of screening instruments can be used to help identify women who suffer from low desire. It was found to be easy to use by clinicians who are not specialized in sexual medicine and had greater accuracy when compared with an expert clinician interview (Goldfischer et al. A complete medical history is essential to identify contributing factors that may reveal the cause of low sexual desire. A variety of systemic comorbidities and urogynecologic problems might interfere with sexual desire (Table 74. Presence of depression increases the risk for sexual dysfunction in the range of 50% to 70%. In the past, was your level of sexual desire or interest good and satisfying to you

These changes may influence subsequent sperm transport in the vas deferens and therefore procedural success after vasectomy reversal (Dixon et al cholesterol medication kidney function buy discount crestor 5mg on line. Cytoarchitecture the human vas deferens is lined by pseudostratified epithelium (Paniagua et al cholesterol levels vldl crestor 5 mg on line. The height of the epithelium decreases along the length of the vas deferens from the testis to the seminal vesicle. In addition, the longitudinal epithelial folds are simpler near the testis and become more complex distally. The pseudostratified epithelium vasal lining is composed of basal cells and three types of tall, thin columnar cells (Hoffer, 1976; Paniagua et al. The columnar cells, extending from the epithelial base to the lumen, include principal cells, pencil cells, and mitochondria-rich cells. Principal cells are the most frequent columnar cell type in the proximal vas deferens, whereas pencil cells and mitochondria-rich cells increase in density distally. The thickness of the total muscle layer gradually decreases along the length of the vas deferens. This complex cytoarchitecture strongly suggests that the vas deferens is more than simply a passive conduit for sperm transport. Vas Deferens Function Sperm Transport Sperm transport through the vas deferens is influenced by several physiologic processes. Finally, fluid within the vas deferens can be propelled into the urethra by strong peristaltic contractions elicited either by electrical stimulation of the hypogastric nerve (Bruschini et al. This suggests that immediately before emission, with sympathetic stimulation, sperm is rapidly transported from the distal epididymis through the vas deferens to the ejaculatory duct. This rapid transport is consistent with the vas deferens having the highest muscle-tolumen ratio (approximately 10: 1) of any hollow viscus in the body. Sperm reserves in the vas deferens have been estimated at approximately 130 million, suggesting that a significant proportion of human ejaculated sperm is stored in the vas deferens (Amann and Howards, 1980). In addition, vasal sperm quality, as assessed from fertile men at the time of vasectomy, is very similar to that of the ejaculate, with 71% motility and 91% viability (Bachtell et al. In the rabbit, it has been shown that during sexual rest, epididymal sperm are transported through the vas deferens and leak into the urethra in small amounts (Prins and Zaneveld, 1979, 1980a, 1980b). This suggests that the vas deferens is involved in ridding the epididymis of excess, stored sperm. On sexual stimulation, rabbit sperm are transported through the vas deferens similar to humans. After sexual stimulation, however, the vas deferens contents are propelled proximally toward the epididymis because the distal vas deferens contracts with greater amplitude, frequency, and duration than the proximal segment (Prins and Zaneveld, 1980a). Notably, with prolonged sexual rest, excess epididymal sperm are once again transported distally, supporting the idea that the vas deferens is important for sperm transport and for maintenance of epididymal sperm reserves. Male Reproductive Physiology 1407 the blood supply to the seminal vesicle arises from the internal iliac artery and inferior vesicular artery through the prostatovesicular branch (Clegg, 1955). The prostatovesicular artery can also arise from the superior vesicular artery or from the pudendal artery. Most commonly, the prostatovesicular artery has anterior and posterior branches that supply the respective surfaces of the seminal vesicle. The lymphatic drainage of the seminal vesicle is through the internal iliac lymph nodes. The seminal vesicles are innervated through sympathetic nerves from the superior lumbar and hypogastric nerves. Ejaculatory Ducts the ejaculatory ducts are paired, collagenous, tubular structures that commence at the junction of the vas deferens and seminal vesicle, course through the prostate, and empty into the prostatic urethra at the verumontanum. Histologically, the ejaculatory ducts are a continuation of the seminal vesicle, except that the outer circular muscle layer does not extend into the ducts (Nguyen et al. There are three distinct anatomic regions to the ejaculatory duct: the proximal, extraprostatic portion; the middle intraprostatic segment; and a short distal segment incorporating the lateral aspect of the verumontanum in the urethra (Nguyen et al.

Schulze W: Structural principles underlying the spermatogenic process in man and a non-human primate (Macaca cynomolgus) definition du cholesterol total cheap crestor generic. Steinberger E: Molecular mechanisms concerned with hormonal effects on the seminiferous tubule and endocrine relationships at puberty in the male cholesterol definition food buy crestor cheap. Suzuki F, Nagano T: Development of tight junctions in caput epididymal epithelium of mouse, Dev Biol 63:321, 1978. Despite these differences, attention from health policy leadership and local, national, and supranational entities toward addressing this issue has remained scant. Efforts to reduce gender inequality in health are desperately needed and require a substantial adjustment in multiple facets of life, including workplace safety, global peace, sociology, psychology, and lifestyle. Gender Longevity Gap Human longevity continues to increase on a global scale (Fries, 1980; Oeppen and Vaupel, 2002). Emphasis on perinatal care, labor and delivery, childhood vaccinations, smoking cessation, and healthier lifestyles in terms of diet and exercise have made a true impact on extending human life span around the world (Mathers and Loncar, 2006; Oeppen and Vaupel, 2002). Interestingly, one peculiar statistic seems to stand out from the general progress: the gap in longevity between male and female humans. The gap exists across the globe and across all strata of industrial development; eastern Europe demonstrates the largest gap, approximately 7 years. Even in sub-Saharan Africa, the region with the shortest life expectancy in the world, men are living on average 5. In addition to the discrepancy present in current statistics, trends recorded over the past 50 years do not demonstrate a narrowing of the longevity gap. Thus, although the average longevity of men and women is improving, it tends to be improving more among women than among men (Klenk et al. Explanation of the Poorer Health of Men In most societies men possess more power, opportunity, and wealth than women; yet these privileges do not seem to translate into an advantage or parity between the genders in regard to health and comorbidity. A series of factors have been identified that place men at higher risk of death and disease. These include increased exposure to physical and environmental harm in the workplace, propensity for risk-taking behaviors, and masculinity-defined norms of health behavior that may negatively affect acute and chronic illness-related outcomes. Propensity for Risk-Taking Behavior Men are more likely to engage in risk-taking behaviors than women. This has been demonstrated across cultures and is a recognized world-wide phenomenon (Byrnes et al. Hazardous pursuits such as alcohol use, smoking, and risky sexual practices are more prevalent among men (Creighton and Oliffe, 2010; Dolan, 2011; Stergiou-Kita et al. As expected, ratios of drinking rates between males and females were greater than 1. Other studies have demonstrated similar findings (Balabanova and McKee, 1999; Hao et al.

The 5-year relapse-free survival ranges from 80% to 86% cholesterol medication mayo clinic discount 20mg crestor fast delivery, and cancer-specific survival approaches 100% cholesterol what to eat order 5mg crestor otc. Eighty-four to 100% of patients relapse in the retroperitoneum, and 18% to 24% of patients have bulky retroperitoneal disease and/or distant metastases at the time of recurrence (Aparicio et al. Almost all patients who relapse outside the retroperitoneum are cured with first-line chemotherapy. Surveillance schedules employ assessments every 2 to 4 months in years 1 to 3, every 6 months in years 4 to 7, then annually thereafter. Fifteen percent of relapses occurred after 3 years, so a minimum of 5 years of surveillance is recommended. A concern with one cycle of carboplatin is the potential for inadequate dosing, leading to an increased risk of relapse. In men with tumors larger than 4 cm, the risk of relapse was 19% with surveillance and 9. A German study similarly reported only a 50% reduction in risk of relapse for men with large tumors when one cycle of carboplatin was administered (Dieckmann et al. Overall, the risk of relapse in this study was 5% with one cycle of carboplatin and 1. Thus it is recommended to base 1 cycle of carboplatin dosing on the results of radioisotope renal scans or administer 2 cycles of therapy. For noncompliant patients or those unwilling to accept surveillance, primary radiotherapy or primary chemotherapy with 2 cycles of carboplatin are recommended. It is unclear whether these findings can be safely applied to surveillance for seminoma. To better select patients for active treatment, investigators have endeavored to identify prognostic factors for occult metastasis. In a pooled analysis of 3 large surveillance series from the 1980s, tumor size larger than 4 cm and rete testis invasion were significant predictors of relapse in multivariable analysis (Warde et al. The 5-year relapse rate for patients with 0, 1, and 2 risk factors was 12%, 16%, and 32%, respectively. Twenty-one percent of patients in this cohort had rete testis invasion and tumor size greater than 4 cm. Primary chemotherapy with 1 to 2 cycles of single-agent carboplatin has also been investigated as an alternative to primary radiotherapy with the potential for reduced late toxicity. The rationale for single-agent carboplatin is based on the 65% to 90% reported complete response rates observed among patients with advanced seminoma (Horwich et al. No deaths from seminoma have been observed, and 3- to 5-year relapse-free rates are 91% to 100%. Over a median follow-up of 6 1 2 years, the 5-year relapse-free survival was similar (94. Prophylactic radiation to the left supraclavicular fossa is no longer practiced because less than 3% of patients are likely to benefit (Chung et al. Relapses are cured in almost all cases with first-line chemotherapy, and disease-specific survival approaches 100%. Overall, 83% of patients achieved a serologic and radiographic complete response, and only 1 (1. Overall, the 5-year relapse-free and overall survival was 90% and 95%, respectively. Complete radiographic responses are reported in 70% to 90% of patients, and the 5-year overall is 91% (Gholam et al. Single-agent carboplatin in advanced seminoma is associated with inferior survival compared to cisplatinbased regimens (Bokemeyer et al. After first-line chemotherapy, 58% to 80% of patients have radiologically detectable residual masses (De Santis et al. The histology of residual masses is necrosis and viable malignancy in 90% and 10% of cases, respectively (De Santis et al. Teratoma and malignant transformation are much less of a concern with advanced seminoma. Post-chemotherapy radiotherapy has no role in the management of residual masses (Duchesne et al.