Неврозы – Neuroses

Finding a sex therapist who is qualified, experienced and trained to handle problems like yours is important. We believe that a personal recommendation from a qualified professional is one of the best ways to find someone to help you. Ask the urologist who examined you for physical problems for a recommendation.

Another good source of referral is a university which has a sex therapy clinic, or a program to train sex therapists. Even if the clinic itself is too far away or otherwise inconvenient for you to use, many will provide referrals to graduates or other qualified sex therapists who practice near you.

Paying for Sex Therapy

How much you pay for sex therapy depends on where you live, which therapist you see, the length of treatment and the type of program. Hourly rates may be the same or close to those charged for other types of therapy. Intensive programs may cost $1,500 to $2,000, or substantially more. Some therapists do offer sliding scales based on the client’ s ability to pay, and some university training programs may occasionally offer therapy at reduced prices.

What’ s important is that you understand, up front, how much the therapy will cost. Get an estimate as to the number of sessions. And ask if at any point in the program you decide not to continue—or if the therapist decides you should stop—do you get a partial refund of any money you’ve paid in advance?

Many health insurance policies will not pay for sex therapy, so be sure to check out your coverage in advance.

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If muscle fatigue during sex has become an unwanted presence in your life, you need resistance training. This type of exercise will increase overall muscular strength in your arms, abdomen, back, and legs. To measure the current state of your muscles, get down on the floor and see how many push-ups you can do in a minute. A man in his forties should be able to perform at least twenty. A fifty-year-old should be able to manage fifteen. If you can’t meet these numbers, start performing this classic exercise daily.

To test your midsection strength, see how many crunches you can perform in a minute. Lying on the floor with knees bent, feet flat on the floor, and arms crisscrossed over your chest, curl up until your shoulders come off the floor. Then return to the starting position. I expect a man in his forties to be able to do anywhere from twenty to forty crunches. A fifty-year-old should be able to accomplish at least fifteen in sixty seconds. If these numbers are high for you, add crunches to your daily regimen.

If you really want to build muscle strength, ten to twelve repetitions with light weights for each muscle group two times a week will be very effective. Get a professional to show you what to do to avoid injury.

Remember: regular aerobic exercise, such as walking briskly, running, or swimming laps for twenty minutes or more several times a week can protect against ED development. However, for all of you men who ride a bicycle there is an ED connection that you should be aware of: prolonged sitting on the traditional narrow riding saddle.

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The man currently taking any number of medicines—either prescription or over-the-counter—that give him ED is now able to counteract the negative condition without compromising his health. Research bears this out. Dr. Harin Padma-Nathan, director of the Male Clinic in Santa Monica and an associate professor of urology at the University of Southern California, has had extensive clinical experience with both Vasomax and Viagra. His findings, which relate to men taking antihypertensive medication, are extremely positive. He says, “ED will be much less of an issue for men taking hypertensive drugs.”

One of the pivotal trials with Vasomax suggests it overrides the ED-inducing effects of antihypertensive medications. In the study, men were allowed to continue with their current prescription. When the testing was over, researchers analyzed the data to see if hypertensive medications, a single class of drugs which cause more ED than any other, were still inhibiting sexual function. The results were conclusive: Vasomax was also equally effective in restoring erectile function, whether a man was taking antihypertensive medication or none at all. Vasomax was also effective in men who had mild to moderate dysfunction, whether they were taking medications for other conditions or not.

Dr. David Ferguson, clinical director for the American trials with Vasomax, is even more optimistic about the ability of the drug to override ED-related side effects of medications. He states, “You can improve function while still getting all the benefits of the other medications you are currently taking. In my experience, Vasomax seems to be compatible with all other drugs.”

This has been borne out in cases with my own patients. Gary’s story is an excellent illustration of the restorative powers of the oral intervention in the face of a serious disease. When he first came to see me, the forty-one-year-old advertising executive had dangerously high blood pressure. My immediate concern was that, left unchecked, his hypertension could lead to a heart attack or stroke. Naturally unnerved by the news, Gary was shattered when I informed him that hypertensive medication very often causes ED. His response was a very common one: “Forget it! Why can’t you give me something that will let me live the way I want to? Do you really expect me to give up my sex life?”

I explained to Gary that he had a life-threatening condition but that we could try several different drugs to see which one least affected his sex life. Finally capitulating, he said he would try a prescription. However, when he came back several weeks later, his blood pressure readings were unchanged. Suspecting that he had cut—or even eliminated—his medication, I confronted Gary, asking him if that was the case.

“Okay, you caught me,” he confessed. “I did try the medication— but as soon as I did, I couldn’t get hard anymore. Look, it’s my life and I make the decisions about it, okay?”

I told Gary that in my view it wasn’t okay, and that compromising his health in such a dangerous fashion was something I could not condone. Having reached a stalemate, Gary left my office, telling me he wasn’t planning to start taking his medicine again.

But later, after I became involved in the Vasomax trials, one of the first men I thought of was Gary. When I called him, he admitted that he was worried about his health. He still had erections, but he’d experienced some problems over the past year, he said. And then there was the untreated hypertension. He said he felt that he was a time bomb that could explode at any moment.

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The introduction of erection pills has opened the door to the pharmacological enhancement of sexual pleasure. We all know that the human reproductive system is no longer reliant solely on nature to make the decision about when, and if, pregnancy should take place. Vasectomies and birth control pills are commonplace features of our lives. New technology has stretched the years in which a woman can have a baby. Today, even post-menopausal women can have children.

By altering the procreative destinies of men and women—as they wish them to be—sex is most often about pleasure. Therefore, how can the medical establishment deny humans the right to the most exciting and fulfilling sex, including entirely restored erectile function? And, for those with “healthy” function, who is to say that it shouldn’t be enhanced any further?

With the approach of rapidly evolving medical technology and newer medications, is it right to prescribe drugs for a person who isn’t sick? If we look at what is demanded by healthy people, the answer is a definitive yes. We are living in an era in which the public is receptive to custom-tailored pharmacological interventions that not only fight disease but also raise and maintain the quality of their lives. Our century has been marked by the nationwide use of vaccines that prevent serious illnesses in otherwise healthy people. Standardized vaccinations and injections have rendered a number of life-threatening diseases, including measles, diphtheria, polio, tetanus’, typhoid fever, and even different types of hepatitis powerless.

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Of course, psychologically caused erection problems aren’t confined to basically unhappy relationships. Sometimes a good relationship can get sidetracked by the man becoming too concerned with his abilities as a lover. He gets so involved with giving his partner an orgasm that he doesn’t feel his own pleasure. And he can lose his erection as a result of this preoccupation.

Henry, for example, always took great pride in his ability to satisfy a woman and “give” her an orgasm. As Henry got into his 40′s, he noticed that on occasion, his erections took longer to appear. This is a normal result of aging, but Henry didn’t look at it that way. He saw it as a personal defeat, as a sign that his powers were waning, His new wife, Anne, didn’t have orgasms every time they made love, but she told Henry she didn’t feel deprived by this, saying “I don’t keep score.” But Henry took his wife’s occasional lack of orgasm as yet another sign that his skills as a lover were on the decline. He agonized over this state of affairs. One night, Henry lost his erection while making love. He became terribly upset and decided he needed medical attention. As it turned out, Henry didn’t have an erection problem until he created one in his mind; his overconcem about his adroitness as a lover was the initial stress, and his anxiety about his “failure” was the fuel that kept it going.

It’s important to check out all physical causes of potency problems before attributing the situation to psychological factors. At the same time, we think it’s essential not to ignore the psychological impact that physically caused erection problems can have, especially if they are allowed to continue untreated for a long time. Simon, for example, became severely depressed when he could no longer get an erection. His condition was due to a problem with his blood-flow system. After a complete workup and evaluation, Simon decided to have a penile implant. Several weeks after the surgery, he recovered his potency and his wife was very pleased. Simon, however, remained somewhat depressed, although he insisted that he was satisfied with the implant. But the memory of his lack of erection seemed to dog him. “He doesn’t realize that he’s not impotent anymore,” his wife remarked. For this middle-aged man, the lack of erection signified a great loss of self; after his problem was corrected, he remained unhappy for several months. It took a long time for him to let go of his feelings of loss and resume normal living.

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Some diseases of the respiratory system, such as allergies, may continue to bother you as you grow older. Antihistamines are effective for burning eyes, itching nose, or mucous drip that often occurs with allergies. Although these drugs may improve the symptoms, they may also cause excessive drowsiness and mental confusion and should not be taken if you are about to drive, and never when you drink alcohol. Preparations such as terfenadine and astemizole cause less drowsiness.

Bronchodilators relieve the wheezing and the shortness of breath that accompany acute and chronic bronchitis or asthma. An infection of the bronchi or lungs aggravates these symptoms. Bronchodilators widen the bronchi and allow more air to reach the lungs. However, they sometimes lead to an excessively fast heartbeat, mental confusion, nausea, and vomiting. Usually an adjustment of dosage will alleviate these side effects.

An important class of drugs in this family is theophylline, which can be taken as pills, syrup, injection, or suppository. It is often prescribed in combination with the beta-stimulators, a group of medications that mimic the effects of adrenaline. Among them are isoproterenol, salbutamol, orciprenaline, and terbutaline. They can be taken as pills or inhaled four or five times a day. The preparations preferred for use in older people have less stimulatory effect on the heart than adrenaline itself.

For severe respiratory problems, cortisone may be required. Many serious side effects are caused by cortisone when taken orally or by injection, and its prolonged use should be avoided. A type of cortisone has been developed that can be inhaled, which reduces the usual side effects. A number of these preparations, such as beclomethasone dipro-pionate, can be taken through an inhaler four or five times daily, often in conjunction with other bronchodilators. New and effective preparations for the control of asthma become available each year.

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Neurological presentations

Many patients develop neuropsychiatry manifestations including cognitive and memory impairment, personality change and mental slowness progressing to mutism, incontinence and paraplagia. The virus is neurotropic causing dementia of presenile type (AIDS-dementia complex).

Myelopathy may present as ataxia.

Peripheral neuropathy is characterised by symmetrical glove and stocking sensory loss associated with muscle pain and weakness.

Choroidoretinitis due to CMV or HIV infection may result in progressive visual loss.

In some cases, central nervous system disease is related to opportunistic infection such as toxoplasmosis, cryptococcosis or HSV or to primary lymphoma of the brain.

Neoplastic presentations

Kaposi’s sarcoma (KS) is characterised by painless red-purple lesions on any part of the body including palms, soles, gastrointestinal tract and lymph nodes. KS is more common in homosexual men (up to 25%) than in other patients.

Extranodal B-cell lymphoma including brain lymphoma is reported with increased frequency in patients with HIV infection

Pyrexia of unknown origin

MAI infection becomes disseminated in ADDS patients and may present with fever, pancytopacnia and hepatitis. Kaposi’s sarcoma and lymphoma may present as pyrexia of unknown origin.

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Cardiovascular syphilis and neurosyphilis

Prednisolone 20 mg twice daily for two days prior to commencement of penicillin is recommended for patients with cardiovascular or neurosyphilis.

Aqueous procaine penicillin G 1.5 g daily intramuscularly with probenecid 500 mg four times daily by mouth for 21 days may be used for patients with cardiovascular syphilis and for patients with neurosyphilis managed as outpatients.

For patients with neurosyphilis treated as inpatients, intravenous benzylpenicillin G 4 g at four hourly intervals with probenecid 500 mg four times daily by mouth for 10 days may be used.

Asymptomatic patients with positive CSF findings should be treated as having neurosyphilis.

Patients with neurosyphilis should be referred for specialist advice. Benzathine penicillin should not be used for the treatment of neurosyphilis because an adequate level of penicillin in the CSF is not achieved. However, if the CSF examination is negative, benzathine penicillin G 1.8 g intramuscularly at 7 day intervals for 3 doses may be used for the treatment of cardiovascular or gummatous disease in patients unable to comply with daily injections.

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Infection may ascend from endocervix to the upper genital tract causing endometritis, salpingitis and pelvic inflammatory disease. Late sequelae include tubo-ovarian abscess and peri-hepatitis (Fitz-Hugh-Curtis syndrome).

Urethritis in females may cause dysuria and frequency without much discharge and be misdiagnosed as cystitis.

Infection of one or both Bartholin’s glands just inside the vulva may result in local pain, swelling and tenderness.

Anorectal infection secondary to genital infection is common in females. Anal sex may result in anorectal infection in both males and females. Anorectal infection may be asymptomatic or may present as a mucopurulent anal discharge and anal discomfort, including discomfort on defaecation.

Oral sex may result in oropharyngeal infection which may be asymptomatic or present as sore throat or pain on swallowing.

Conjunctivitis may occur in neonates as a result of transmission from an infected mother during parturition. Gonococcal conjunctivitis may occur as a local outbreak in older children or adults due to close contact or autoinoculation in communities with high carrier rates of gonorrhoea and poor hygiene standards.

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The physical examination should include oral, genital and anal examination. In female patients, a vaginal speculum should always be used to visualise the cervix and bimanual pelvic examination should be done. In patients with anorectal symptoms and in homosexual men, proctoscopy should be done to exclude anal canal pathology.

Patients must be treated with the same consideration as other patients. The examination should be carried out in privacy without interruption. Appropriate instruments should be used with gentleness and skill.

Laboratory investigations are directed at:

confirmation of the existence of disease; and

identification of the causative organism or organisms.

Patients should be told what investigations are being done and why they are considered necessary.

The investigations to be undertaken will be determined by the presentation and clinical findings, test results and the differential diagnosis

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