Prepare the patient for screening tests for hormonal irregularities and for Doppler studies of penile blood pressure to rule out vascular insufficiency. Other tests include voiding studies, nerve conduction tests, evaluation of nocturnal penile tumescence, and psychological screening.

Treatment of psychogenic impotence may involve counseling for the patient and his sexual partner; treatment of organic impotence focuses on reversing the cause, if possible. Other forms of treatment include surgical revascularization, drug-induced erection, surgical repair of a venous leak, and penile prostheses.

Patient Counseling

Discuss with the patient the importance of keeping follow-up appointments and maintaining therapy for underlying medical disorders. Encourage him to talk openly about his needs, desires, fears, and anxieties, and correct any misconceptions he may have. Urge him to discuss his feelings with his partner as well as what role both of them want sexual activity to play in their lives.

Geriatric Pointers

Most people erroneously believe that sexual performance normally declines with age and that elderly people are incapable of or aren’t interested in sex or that they can’t find elderly partners who are interested in sex. Organic disease must be ruled out in elderly people who suffer from sexual dysfunction before counseling to improve sexual performance can start.

REFERENCES

Hatzimouratidis, K., Amar, E., Eardley, I., Giuliano, F., Hatzichristou, D., Montorsi, F., … Wespes, E. (2010). Guidelines on male sexual dysfunction: Erectile dysfunction and premature ejaculation. European Urology, 57, 804–814.

Ruige, J. B., Mahmoud, A. M., De Bacquer, D., & Kaufman, J. M. (2011). Endogenous testosterone and cardiovascular disease in healthy men: A meta-analysis. Heart, 97, 870–875.

Insomnia

Insomnia is the inability to fall asleep, remain asleep, or feel refreshed by sleep. Acute and transient during periods of stress, insomnia may become chronic, causing constant fatigue, extreme anxiety as bedtime approaches, and psychiatric disorders. This common complaint is experienced occasionally by about 25% of Americans and chronically by another 10%.

Physiologic causes of insomnia include jet lag, arguing, and lack of exercise. Pathophysiologic causes range from medical and psychiatric disorders to pain, adverse effects of a drug, and idiopathic factors. Complaints of insomnia are subjective and require close investigation; for example, the patient may mistakenly attribute his fatigue from an organic cause, such as anemia, to insomnia.

History and Physical Examination

Take a thorough sleep and health history. Find out when the patient’s insomnia began and the circumstances surrounding it. Is the patient trying to stop using a sedative? Does he take a central nervous system (CNS) stimulant, such as an amphetamine, pseudoephedrine, a theophylline derivative, phenylpropanolamine, cocaine, or a drug that contains caffeine, or does he drink caffeinated beverages?

Find out if the patient has a chronic or acute condition, the effects of which may be disturbing his sleep, particularly cardiac or respiratory disease or painful or pruritic conditions. Ask if he has an endocrine or neurologic disorder, or a history of drug or alcohol abuse. Is he a frequent traveler who suffers from jet lag? Does he use his legs a lot during the day and then feel restless at night? Ask about daytime fatigue and regular exercise. Also ask if he commonly finds himself gasping for air, experiencing apnea, or frequently repositioning his body. If possible, consult the patient’s spouse or sleep partner because the patient may be unaware of his own behavior. Ask how many pillows the patient uses to sleep.

Assess the patient’s emotional status, and try to estimate his level of self-esteem. Ask about personal and professional problems and psychological stress. Also ask if he experiences hallucinations and note behavior that may indicate alcohol withdrawal. After reviewing complaints that suggest an undiagnosed disorder, perform a physical examination.

Medical Causes

• Alcohol withdrawal syndrome. Abrupt cessation of alcohol intake after long-term use causes insomnia that may persist for up to 2 years. Other early effects of this acute syndrome include excessive diaphoresis, tachycardia, hypertension, tremors, restlessness, irritability, a headache, nausea, flushing, and nightmares. Progression to delirium tremens produces confusion, disorientation, paranoia, delusions, hallucinations, and seizures.
  
• Generalized anxiety disorder. Anxiety can cause chronic insomnia as well as symptoms of tension, such as fatigue and restlessness; signs of autonomic hyperactivity, such as diaphoresis, dyspepsia, and high resting pulse and respiratory rates; and signs of apprehension.
  
• Mood (affective) disorders. Depression commonly causes chronic insomnia with difficulty falling asleep, waking and being unable to fall back to sleep, or waking early in the morning. Related findings include dysphoria (a primary symptom), decreased appetite with weight loss or increased appetite with weight gain, and psychomotor agitation or retardation. The patient experiences loss of interest in his usual activities, feelings of worthlessness and guilt, fatigue, difficulty concentrating, indecisiveness, and recurrent thoughts of death.
  Manic episodes produce a decreased need for sleep with an elevated mood and irritability. Related findings include increased energy and activity, fast speech, speeding thoughts, inflated self-esteem, easy distractibility, and involvement in high-risk activities such as reckless driving.
  
• Nocturnal myoclonus. With nocturnal myoclonus, a seizure disorder, involuntary and fleeting muscle jerks of the legs occur every 20 to 40 seconds, disturbing sleep.
  
• Sleep apnea syndrome. Apneic periods begin with the onset of sleep, continue for 10 to 90 seconds, and end with a series of gasps and arousal. With central sleep apnea, respiratory movement ceases for the apneic period; with obstructive sleep apnea, upper airway obstruction blocks incoming air, although breathing movements continue. Some patients display both types of apnea. Repeated possibly hundreds of times during the night, this cycle alternates with bradycardia and tachycardia. Associated findings include a morning headache, daytime fatigue, hypertension, ankle edema, and personality changes, such as hostility, paranoia, and agitated depression.
  
• Thyrotoxicosis. Difficulty falling asleep and then sleeping for only a brief period is one of the characteristic symptoms of thyrotoxicosis. Cardiopulmonary features include dyspnea, tachycardia, palpitations, and an atrial or a ventricular gallop. Other findings include weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, hypersensitivity to heat, an enlarged thyroid, and exophthalmos.

Other Causes

• Drugs. Use of, abuse of, or withdrawal from sedatives or hypnotics may produce insomnia. CNS stimulants — including amphetamines, theophylline derivatives, pseudoephedrine, phenylpropanolamine, cocaine, and caffeinated beverages — may also produce insomnia.

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