Diagnosis of Sexual neuropathy
Sexual neuropathy Diagnosis: Book Excerpts
Diagnostic Tests for Sexual neuropathy: Online Medical Books
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IMPOTENCE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a history of alcohol or drug ingestion? A host of antihypertensive drugs, including the beta-blockers, may cause impotence. In addition, tricyclic drugs, nicotine, and alcohol intoxication may cause impotence.
- Is there loss of secondary sex characteristics? These findings suggest Fröhlich's syndrome,
Klinefelter's syndrome, and other congenital disorders.
- Are there abnormalities on urologic examination? Various conditions such as Peyronie's disease, atrophied testes, prostatitis, and Leriche's syndrome may be found on urologic examination.
- Are there abnormalities on the neurologic examination? Neurologic examination may reveal diabetic neuropathy, spinal cord tumor, multiple sclerosis, and other neurologic disorders.
DIAGNOSTIC WORKUP
A thorough psychiatric and sexual history is necessary before undertaking expensive laboratory tests. It is wise to interview the spouse or sexual partner also because the symptom may be exaggerated by the patient. Do not hesitate to order a drug screen. Routine tests include a CBC and differential count, a urinalysis, a urine culture and colony count, a chemistry panel, VDRL test, thyroid profile, serum testosterone, and gonadotrophin assay. A referral to a urologist is probably wise at this point. He will work up the patient further with a nocturnal tumescent study, Doppler ultrasonography, and penile blood pressure studies. In addition, he may want to do a cystoscopy. It may be wise to perform a postage stamp test before referral for a formal tumescence study.
Nerve conduction velocity studies and EMGs may be needed to rule out diabetic neuropathy. MRI of the spine, cystometric studies, and SSEP studies will help to rule out multiple sclerosis and other spinal cord lesions. A sacral reflex latency time may be very helpful in diagnosing sacral nerve injury. A spinal tap may help rule out central nervous system lues. Angiography may be needed to exclude a Leriche's syndrome.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
IMPOTENCE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A careful examination of the external genitalia, the prostate, and secondary sex characteristics is essential. The laboratory workup may include a glucose tolerance test, blood testosterone and cortisol levels, thyroid function studies, a spinal tap, a skull x-ray, and a chromosomal analysis. A nocturnal penile tumescence study is performed to rule out organic causes. If the physical examination is normal, it may be wise to administer psychometric tests or to refer the patient to a psychiatrist before doing an extensive endocrine and neurologic workup. A sympathetic physician may be able to find the supratentorial cause and cure it with a few long discussions with the patient. A female physician may have more success in this area than a male.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Impotence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination in a systematic way, moving from less sensitive to more sensitive matters. Begin with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What’s the age and health status of his sexual partner? Is he feeling stress or pressure from his partner to conceive a child? Find out about past marriages, if any, and ask him why he thinks they ended. If you can do so discreetly, ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have type 2 diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient’s impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about alcohol intake, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What’s its current status? Make your questions specific, but remember that he may have difficulty discussing sexual problems or may not understand the physiology involved.
The following sample questions may yield helpful data: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Ask the patient to rate the quality of a typical erection on a scale of 0 to 10, with 0 being completely flaccid and 10 being completely erect. Using the same scale, also ask him to rate his ability to ejaculate during sexual activity, with 0 being never and 10 being always.
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient’s sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient’s vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Introduction: Sexual Disorders:
Sexual history
(Professional Guide to Diseases (Eighth Edition))
Careful assessment helps identify the cause of a sexual problem as psychological or physical. A sexual history provides the basis for prevention, diagnosis, and treatment.
❑ Ensure privacy, as for physical assessment. Allow sufficient time so that the patient doesn’t feel rushed.
❑ Approach a sexual history objectively. Remember, sexual health is relative; avoid making assumptions or judgments about the patient’s sexual activities.
❑ After listening to the patient, determine his level of sexual understanding and phrase your questions in language that he can understand. Avoid technical terms.
❑ Begin with the least threatening questions. Usually, a menstrual or urologic history helps lead into a sexual history.
❑ Inquire about what the patient accepts as normal sexual behavior. Ask about sexual needs and priorities and whether the patient can discuss them with a sex partner.
❑ Assess risk behavior concerning selection of sex partners and specific sexual practices.
❑ Ask about possible homosexual activity, which can influence the risk and treatment of some STDs.
❑ Ask the female patient if she has adequate lubrication during intercourse and if she has ever experienced orgasm or pain with sexual contact. Ask the male patient if he has ever had difficulties with erection or ejaculation.
❑ Ask about current or past contraceptive practices.
❑ Try to use the history therapeutically by encouraging the patient to express anxiety. Such fears may be alleviated simply by providing factual information and answering questions.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Impotence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination in a systematic way, moving from less sensitive to more sensitive matters. Begin with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What’s the age and health status of his sexual partner? Find out about past marriages, if any, and ask him why he thinks they ended. If you can do so discreetly, ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have type 2 diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient’s impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about intake of alcohol, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What’s its current status? Make your questions specific, but remember that many patients have difficulty discussing sexual problems, and many don’t understand the physiology involved.
The following sample questions may yield helpful data: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Ask the patient to rate the quality of a typical erection on a scale of 0 to 10, with 0 being completely flaccid and 10 being completely erect. Using the same scale, also ask him to rate his ability to ejaculate during sexual activity, with 0 being never and 10 being always.
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient’s sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient’s vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Impotence:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Basic history. Although written questionnaires may elicit sexual dysfunction, most patients prefer to communicate such issues in the privacy of verbal communication with their primary care provider. For the initial inquiry, simply ask: “Are you sexually active?” For sexual dysfunction evaluation, gender orientation is not relevant to diagnosis or therapy, so that whether the patient is homosexual, heterosexual, or bisexual has no distinct bearing on the diagnostic or therapeutic direction. For persons who are not sexually active, next determine whether this is a matter of choice or an obstacle that prevents sexual activity (e.g., lack of partner, ED, physical disorder).
For persons who are sexually active, a series of follow-up questions will uncover most relevant psychosexual pathology. Begin with: “How would you rate your sex life on a scale of 1 to 10?” If the response is 10, sexual dysfunction is decidedly unlikely. However, most individuals respond, “Oh, about a 7.” Follow with, “What would have to be different to change your sex life from a 7 to a 10?” This forced-choice inquiry often produces responses which directly indicate problematic underlying issues: “Well, if I could just get a good erection.” “If my erection could last more than 30 seconds.” “If my partner didn’t always pick a fight with me and then expect to have sex.”
For impotent men, their response is usually direct and simple, indicating an inability to get or maintain an erection. Follow-up questions should determine the duration and nature of onset. Absence of morning erections should be sought, as this typifies organic impotence. Men who are much more likely to have psychogenic ED are those who report sudden, complete loss of sexual function, or “circumstantial” impotence, for example, (a) good function with one partner, but not another; (b) good erections with masturbation but not with interactive sex; (c) good morning erections, but not at times of interactive sex; or (d) overt anxiety or relationship conflict. Because organic ED generally leads to psychological consequences, many patients suffer a combination of psychogenic and organic impotence.
B. Inquiry about libido is a crucial diagnostic point for testosterone deficiency. Testosterone is necessary for libido, but not erections. Men who present with good libido have only a remote possibility of having testosterone deficiency.
C. A medication history should be taken for all men complaining of impotence, recalling that most medication-induced impotence is evident by the temporal relationship between onset of impotence and medication initiation. On the other hand, agents such as thiazides can produce impotence after months of use. Similarly, some antidepressants can produce sexual dysfunction either early or after weeks of therapy. The relationship of medications to impotence can often be clarified by a drug holiday.
Physical examination
Although physical examination is usually not enlightening, general agreement is seen that the genitals should be examined for evidence of overt testicular atrophy, and the penis for Peyronie’s disease. In the latter, inflammatory plaques in the corpora cavernosa produce an area of limited expansile capacity, with subsequent penile deviation on erection which can prevent intromission. A rectal examination to document rectal sensation as well as tone can be complemented by the bulbocavernosus reflex. This reflex is elicited by briskly squeezing the glans penis in one hand while a single digit from the other is in the rectum. A normal examination, indicating an intact reflex arc, is manifest as a rectal contraction in response to the glans squeeze. Prostate examination is pertinent at this point, in the event testosterone therapy is required.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Peripheral Neuropathy:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Diabetes
❑ Alcohol
❑ Vitamin B12 deficiency
❑ Drugs
❑ Carcinomatous
❑ Lead
❑ Guillain-Barré
❑ Tabes dorsalis
❑ Syringomyelia
❑ Polyarteritis nodosa
❑ Amyloidosis
❑ Polymyositis
❑ Pellagra
❑ Arsenic
❑ Porphyria
❑ Wallenberg syndrome
❑ Thalamic lesion
❑ Brown-Sequard syndrome
Diagnostic Approach
Sensory neuropathy symptoms include positive phenomena such as tingling; pins/needles; and burning, cold, or lancinating pain. Physical findings include weakness, fasciculations, atrophy, ataxia, wide-based gait, abnormal sweating, decreased or absent deep tendon reflexes, orthostatic hypotension, hypesthesia surrounded by a zone of hyperesthesia, and vibration or position sense affected before pinprick or temperature sense.
Autonomic neuropathy symptoms include impotence, retrograde ejaculation, diaphoresis, incontinence, urinary retention, constipation, diarrhea, orthostatic dizziness, and flushing. Physical findings include delayed pupillary light response, resting tachycardia, sinus arrhythmia, and orthostatic hypotension.
Sensory loss confined to part of a limb suggests injury to a peripheral nerve, plexus, or spinal root, resulting from trauma, entrapment, or vascular insufficiency. Mononeuropathy multiplex affects multiple nerves over time (e.g., due to diabetes or vasculitis). Polyneuropathy occurs in a stocking-glove distribution starting with the longest nerves, and is due to axonal neuropathy, with a toxic or metabolic origin. Bilaterally symmetrical symptoms are found in polyneuropathy or spinal cord lesions, while unilateral involvement is seen in contralateral disease of the brainstem, thalamus, or cortex.
Injury to large myelinated nerves produces decreased light touch and proprioception with a sensation of “walking on a thick carpet” or imbalance. Injury to medium fibers causes decreased light touch and vibration sense. Injury to small unmyelinated fibers, as occurs in diabetes or amyloidosis, decreases pain and temperature sensation and produces dysesthesias. Disproportionate loss of vibration sense and proprioception compared with pain and temperature sensation occurs with diseases of the dorsal column of the spinal cord (e.g., neurosyphilis, vitamin B 12 deficiency, or multiple sclerosis) and demyelinating polyneuropathy.
Transverse cord lesions produce loss of all modalities below the level of the lesion and a band of hyperalgesia at the level of the lesion. Lateral cord compression is heralded by early sensory changes. Dorsal cord compression affects proprioception and tactile discrimination without pain or temperature loss. Pernicious anemia and tabes dorsalis preferentially affect the dorsal columns.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Impotence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What's the age and health status of his sexual partner? Is he feeling stress or pressure from his partner to conceive a child? Find out about past marriages, if any, and ask him about his sexual experiences with former spouses. Ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient's impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about alcohol intake, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What's its current status? Make your questions specific, but remember that he may have difficulty discussing sexual problems or may not understand the physiology involved.
Other questions that can help yield helpful data include: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient's sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient's vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
IMPOTENCE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A careful examination of the external genitalia, the prostate, and
secondary sex characteristics is essential. The laboratory workup may
include a glucose tolerance test, blood testosterone, free testosterone and
cortisol levels, thyroid function studies, a spinal tap, a skull x-ray, and
a chromosomal analysis. A nocturnal penile tumescence study is performed to
rule out organic causes. If the physical examination is normal, it may be
wise to administer psychometric tests or to refer the patient to a
psychiatrist before doing an extensive endocrine and neurologic workup. A
sympathetic physician may be able to find the supratentorial cause and cure
it with a few long discussions with the patient. A female physician may have
more success in this area than a male.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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