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OJHAS Vol. 8, Issue 2: (2009
Apr-Jun) |
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Etiology and Management of Sexual
Dysfunction :: Sexual Dysfunction: Part II |
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Anil Kumar Mysore Nagaraj,
Senior Resident, Dept of Psychiatry, Mysore Medical College &
Research Institute, Mysore - 570001, India,
Nagesh Brahmavar Pai,
Clinical
Associate Professor, Graduate School of Medicine, University of Wollongong, Australia,
Raveesh Bevinahalli Nanjegowda,
Associate Professor, Dept of Psychiatry, Mysore Medical College
& Research Institute, Mysore - 570001, India,
Rajendra Rajagopal,
Assistant
Professor, Dept of Psychiatry, Mysore Medical College & Research
Institute, Mysore - 570001, India,
Narendra Kumar Muthugaduru
Shivarudrappa,
Senior Resident, Psychiatry, Mysore Medical College
& Research Institute, Mysore - 570001, India
Nayeema Siddika,
Junior
Resident, Dept of Psychiatry, Mysore Medical College & Research
Institute, Mysore - 570001, India. |
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Address For Correspondence |
Senior Resident,
Dept of Psychiatry,
Mysore Medical College &
Research Institute,
Mysore - 570001, India
E-mail:
nagarajakm24@gmail.com |
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Anil Kumar MN, Pai NB, Raveesh BN, Rajagopal R, Shivarudrappa NKM,
Siddika N. Etiology and Management of Sexual Dysfunction. Online J Health Allied Scs.
2009;8(2):1 |
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Submitted: Jun 10, 2009; Accepted:
Jun 22, 2009; Published: Sep 8, 2009 |
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| Abstract: |
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Sexual dysfunction is the impairment
or disruption of any of the three phases of normal sexual functioning,
including loss of libido, impairment of physiological arousal and loss,
delay or alteration of orgasm. Each one of these can be affected by
an orchestra of factors like senility, medical and surgical illnesses,
medications and drugs of abuse. Non-pharmacological therapy is the main
stay in the treatment of sexual dysfunction and drugs are used as adjuncts
for a quicker and better result. Management in many of the cases depends
on the primary cause. Here is a review of the major etiological factors
of sexual dysfunction and its management.
Key Words: Sexual dysfunction,
Erectile dysfunction, Premature ejaculation, Impaired libido
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Sex is a multifaceted activity.
Though essentially it is meant for procreation, it has also been a source
of pleasure, a natural relaxant, it confirms one’s gender, bolsters
one’s self esteem and sense of attractiveness for mutually satisfying
intimacy and relationship.(1) An adult’s sexuality has seven components-
gender identity, orientation, intention (what one wants to do with a
partner’s body and have done with one’s body during sexual behavior),
desire, arousal, orgasm and emotional satisfaction. The first three
components constitute our sexual identity, second three comprise our
sexual function and the seventh is based on our personal reflection
on the first six. Impairment in any one of these areas comprises
sexual dysfunction.(2) However, as the disorders due to first three
components are identity difficulties, they can better be grouped into
sexual perversions or sexual behavior disorders (gender identity disorder,
homosexuality, paraphilia) rather than sexual dysfunction. Further,
they rarely consult a doctor for treatment of this behaviour as majority
of them are comfortable about their sexual behavior. Thus the sexual
dysfunction can be defined as the impairment or disruption of any of
the three phases of normal sexual functioning, including loss of libido,
impairment of physiological arousal and loss, delay or alteration of
orgasm.(3) As sexuality derives self-discovery, attachment, pleasure
and self-esteem, all these are lost in a person with sexual dysfunction,
thus causing a severe psychological trauma to the extent of severe depression,
which can eventually lead to suicidal deaths if not appropriately treated.
A successful treatment depends on a thorough evaluation to recognize
the etiology of sexual dysfunction. In many of the cases adequate treatment
of the primary causative factor will resolve sexual dysfunction. The
following section presents a classification of sexual dysfunction based
on the etiological factors.
An understanding
of sexual functioning begins with the phases of the sexual response
cycle.(4) Human sexual response in generally divided into four phases
(i) Desire, (ii) Arousal, (iii) Orgasm & (iv) Resolution.(5) Kaplan's triphasic model of sexual response conceptualizes desire, arousal and
orgasm as three distinct and sequential phases(6) and has been chosen
as a model for studying sexual dysfunction as there are no known disorders
recognized in the resolution phase. In each of the phases of desire,
arousal and orgasm there are various causes that impair the sexual performance.
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Factors
affecting sexual performance: |
i) Age:
A review of
the literature suggests that in men there is a decrease in the frequency
of sexual behavior, to a lesser extent a diminution in sexual interest
and an increased prevalence of sexual dysfunction associated with aging.(7) However identification of the natural biologic changes that mediate
sexual function in the aged is confounded by the effects of chronic
medical illnesses and drugs in this age group.
In a cross-sectional
study in healthy men aged 45-75 years, significant decreases in sexual
desire, arousal and activity was documented but no age differences in
sexual pleasure and satisfaction. A proportion of subjects in the oldest
age group, however, had regular intercourse in the presence of marked
decrements in erectile capacity as measured by nocturnal penile tumescence.
Healthy aging men had a decrease in bioavailable testosterone (bT) and
an increase in Leutinising Hormone (LH).(8) Aging is associated with
a decrease in gonadal function but the evidence that androgen deficiency
contributes to the decrease in sexual desire and activity in older men
is not compelling. Changes in central receptor site sensitivity may
contribute to the age related decreases in sexual function.(9)
Epidemiologic
data have demonstrated a significant diminution in coital and orgasmic
frequencies and an increase in the incidence of sexual problems in post
menopausal women. Estrogen deficiency is primarily responsible for the
decrease in pelvic vasocongestion, atrophy of vaginal epithelium and
diminished vaginal lubrication. However, even in women androgens are
more important for sustaining sexual desire.(10)
ii) Psychiatric
disorders:
Crisp has presented
a rough assessment of the presence of sexual deterioration in a group
of 375 consecutive new psychiatric outpatients. He found that people
with endogenous depression, alcoholism, or the presence of anxious or
sad moods or tension were significantly more likely to report a reduction
of sexual activity since the onset of their problem, where as those
with conversion disorder, obsessional neurosis or paranoid psychosis
were significantly less likely to do so.(11) Some of the studies focused
on common psychiatric illness are given below.
- Depression: Depression remains an important
associated factor for sexual dysfunction. Studies have revealed that
in untreated depression, reduced libido is seen in 40-74%, arousal /
erectile dysfunction in 16-50% and orgasmic dysfunction in 15-22%.(12)
- Schizophrenia: Changes
in behaviour, emotional reactions and thought processes that manifest
the schizophrenic states are often so gross and so pervading that it
would be surprising if sexual repercussions do not occur. Studies have
shown that majority of untreated schizophrenics have reduced desire
for sex, more in females as compared to males, though arousal and ejaculatory
functions remain intact. They have diminished fantasy, and schizophrenic
men often limit their sexual activity to masturbation.(13)
- Anxiety disorders: Aksaray
and colleagues compared sexual dysfunction among 23 patients of Obsessive
Compulsive Disorder (OCD) and 26 patients of Generalized Anxiety Disorder
(GAD). All were untreated female patients. They were assessed for orgasm,
vaginismus, avoidance and nonsensuality. Overall, 39% of OCD patients
had sexual dysfunction as compared to 19% in GAD.(14) Another study
reported a wide range of sexual dysfunction in the patients of social
phobia. About 33% of males had reduced desire, premature ejaculation
and retarded ejaculation where as 10% had erectile dysfunction. Among
females 42% complained of dyspareunia, and 46% had reduced desire. Thus
all anxiety disorders seem to be associated with some kind of sexual
dysfunction, but generalization of prevalence rate needs further studies.(15)
Other psychiatric illnesses like substance
use disorders and post-traumatic stress disorder are also known to be associated with sexual dysfunction.
Thus whatever the psychiatric diagnosis is, any psychopathology, at
least in some patients is known to affect sexual function, especially
the desire. Mania which is known by the term ‘happiness psychosis’
also affects desire, but in the opposite direction.(16)
iii) Medical/Surgical
disorders:
The list of
medical and surgical conditions causing sexual dysfunction is exhaustive
(Table 1). The Diagnostic and Statistical Manual of Mental Disorders-
fourth edition- text revision (DSM-IV-TR) has classified sexual dysfunction
due to general medical conditions into seven categories.
- Female Hypoactive
Sexual Desire Disorder Due to a General Medical Condition
- Male Hypoactive
Sexual Desire Disorder Due to a General Medical Condition
- Male Erectile Disorder
Due to a General Medical Condition
- Female Dyspareunia
Due to a General Medical Condition
- Male Dyspareunia
Due to a General Medical Condition
- Other Male Sexual
Dysfunction Due to a General Medical Condition
- Other Female Sexual
Dysfunction Due to a General Medical Condition
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Table 1: Diseases
and Medical Conditions Implicated in Male Erectile Disorder. (18) |
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Infectious and parasitic
Diseases |
Neurological disorders |
| Elephantiasis |
Multiple
sclerosis |
| Mumps |
Transverse myelitis |
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Cardiovascular disease |
Parkinson’s
disease |
| Atherosclerotic disease |
Temporal
lobe epilepsy |
| Aortic aneurysm |
Traumatic
and neoplastic spinal
cord diseases |
| Leriche’s syndrome |
Central
nervous system tumor |
| Cardiac failure |
Amyotrophic
lateral sclerosis |
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Renal and urological disorders |
Peripheral
neuropathy |
| Peyronie’s disease |
General
paresis |
| Chronic renal failure |
Tabes dorsalis |
| Hydrocele and varicocele |
Pharmacological factors
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Hepatic disorders |
Alcohol and other
dependence-inducing substances (Heroin, methadone, morphine, cocaine, aphetamines, and barbiturates)
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| Cirrhosis (usually associated
with alcohol dependence) |
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Pulmonary disorders |
| Respiratory failure |
Prescribed drugs
(psychotropic drugs, antihypertensive drugs, estrogens, antiandrogens) |
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Genetics |
| Klinefelter’s syndrome |
| Congenital penile vascular
and structural abnormalities |
Poisoning |
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Nutritional disorders |
Lead (plumbism) |
| Malnutrition |
Herbicides |
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Vitamin deficiencies
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Surgical Procedures |
| Obesity |
Perineal prostatectomy |
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Endocrine disorders |
Abdominal- perineal colon resection |
| Diabetes mellitus |
Sympathectomy (frequently interferes
with ejaculation) |
| Dysfunction of the
pituitary-adrenal- testis axis |
Aortoiliac surgery |
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Acromegaly
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Radical cystectomy |
| Addison’s disease |
Retroperitoneal lymphadenectomy |
| Chromophobe adenoma |
Miscellaneous |
| Adrenal neoplasia |
Radiation
therapy |
| Myxedema |
Pelvic
failure |
| Hyperthyroidism |
Any severe
disease or debilitating condition |
In determining
whether the sexual dysfunction is exclusively due to a general medical
condition, the clinician must first establish the presence of a general
medical condition, and then that the sexual dysfunction is etiologically
related to the general medical condition through a physiological mechanism.
Although there are no infallible guidelines for determining whether
the relationship between the sexual dysfunction and the general medical
condition is etiological, several considerations provide some guidance
in this area. One consideration is the presence of a temporal association
between the onset, exacerbation, or remission of the general medical
condition and that of the sexual dysfunction. A second consideration
is the presence of features that are atypical of a primary sexual dysfunction
(ex: atypical age at onset or course). Current clinical experience suggests
that sexual dysfunction due to a general medical condition is usually
generalized. The associated physical examination findings, laboratory
findings, and patterns of prevalence or onset reflect the etiological
general medical condition.(17)
iv)
Drugs and sexual dysfunction:
Many pharmacological
agents, particularly those used in psychiatry, have been associated
with an effect on sexuality. In men, these effects include decreased
sex drive, erectile failure, decreased volume of ejaculate, and delayed
or retrograde ejaculation. In women, decreased sex drive, decreased
vaginal lubrication, inhibited or delayed orgasm and decreased or absent
vaginal contractions may occur.(18) The essential feature of substance/drug
induced sexual dysfunction is a clinically significant sexual dysfunction
that results in marked distress or interpersonal difficulty. Depending
on the substance involved, the dysfunction may involve impaired desire,
arousal, orgasm or sexual pain. The dysfunction is judged to be fully
explained by the direct physiological effects of the substance. A substance
induced sexual dysfunction is distinguished from a primary sexual dysfunction
by considering the onset and course. Sexual dysfunction in the form
of decreased sexual interest or arousal can occur with intoxication
or chronic abuse with alcohol, amphetamine, cocaine, opioids, sedatives,
hypnotics, anxiolytics and other unknown substances. Impaired desire,
arousal and orgasmic disorders may also be caused by prescribed medications
including antihypertensives, histamine H2 receptor antagonists, antidepressants,
neuroleptics, antiepileptics and anabolic steroids. Painful orgasm has
been reported with fluphenazine, thioridazine and amoxapine. Priapism
has been reported with chlorpromazine, trazodone and clozapine.(17)
Tables 2 and 3 enlist the drugs that are known to be associated with
sexual dysfunction.
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Table 2: Some Pharmocological
Agents Implicated in male Sexual Dysfunctions(18) |
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Drug |
Impairs erection |
Impairs Ejaculation |
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Cyclic antidepressant drugs |
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Impipramine (Tofranil) |
+
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+ |
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Protriptyline (Vivactil) |
+ |
+
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Desipramine (Pertofrane) |
+ |
+ |
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Clpmipramine (Anafranil) |
+ |
+
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Amitriptyline (Elavil) |
+ |
+ |
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Trazodone (Desyrel) |
- |
- |
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Monoamine
oxidase inhibitors |
| Tranylcypromine (Parnate) |
+ |
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| Phenelzine (Nardil) |
+ |
+ |
| Pargyline (Eutonyl) |
- |
+ |
| Isocarboxazid (Marplan) |
- |
+ |
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Other
mood- active drugs |
| Lithium (Eskalith) |
+ |
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| Amphetamines |
+ |
+ |
| Fluoxetine (Prozac) |
- |
+ |
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Antipsychotics |
| Fluphenazine (Prolixin) |
+ |
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| Thioridazine (Mellaril) |
+
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+ |
| Chlorprothixene (Taractan) |
- |
+ |
| Mesoridazine (Serentil) |
- |
+ |
| Perphenazine (Trilafon) |
- |
+ |
| Trifluoperazine (Stelazine) |
- |
+ |
| Reserpine (Serpasil) |
+ |
+ |
| Haloperidol (Haldol) |
- |
+ |
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Antianxiety
Agent |
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Chlordiazepoxide (Librium) |
- |
+ |
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Antihypertensive
drugs |
| Clonidine (Catapres) |
+ |
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| Methyldopa (Alphadopa) |
+ |
+ |
| Spironolalactone (Aldactone) |
+ |
- |
| Hydro chlorothiazide |
+ |
- |
| Guanethidine (Ismelin) |
+ |
+ |
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Commonly
abused substances |
| Alcohol |
+ |
+ |
| Barbiturates |
+ |
+ |
| Cannabis |
+ |
- |
| Cocaine |
+ |
+ |
| Heroin |
+ |
+ |
| Methadone |
+ |
- |
| Morphine |
+ |
+ |
|
Miscellaneous
drugs |
| Antiparkinsonian agents |
+ |
+ |
| Clofibrate (Atromid-S) |
+ |
- |
| Digoxin (Lanoxin) |
+ |
- |
| Glutethimide (Doriden) |
+ |
+ |
| Indomethacin (Indocin) |
+ |
- |
| Phentolamine (Regitine) |
- |
+ |
|
Propranodol (Inderal) |
+ |
- |
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Table 3: Some Psychotropic Drugs
Implicated in Inhibited Female Orgasm (16) |
| Tricyclic antidepressants |
Dopamine receptor antagonists |
| Imipramine (Tofranil) |
Thioridazine (Mellaril) |
| Clomipramine (Anafranil) |
Trifluperazine (Stelazine) |
| Nortriptyline (Aventyl) |
Selective serotonergic receptor inhibitors |
| Monoamine oxidase inhibitors |
Fluoxetine (Prozac), Paroxetine (Paxil) |
| Tranylcypromine (Parnate) |
Sertraline (Zoloft) |
| Phenelzine (Nardil) |
Fluvoxamine (Luvox) |
| Iso carboxazid (Marplan) |
Citalopram (Celexa) |
v)
Primary Sexual Dysfunction:
Sexual
response is a psychosomatic process; and both psychological and somatic
processes are usually involved in the causation of sexual dysfunction.
Wherever it is possible to identify an unequivocal psychogenic etiology,
it is appropriate to categorize the condition as primary (psychogenic)
sexual dysfunction. This is classified under ‘Sexual dysfunction,
not caused by organic disorder or disease’ in chapter F52 of ICD10.(19) In DSM-IV-TR it is termed ‘sexual dysfunctions’ and is classified
under the chapter ‘Sexual and Gender Identity Disorders.(17) The
difference in nosological status of both major classificatory systems
is represented in table 4 and brief delineating criteria as per DSM-IV-TR
is given in Table 5.
Table 4: Nosological
status of sexual dysfunction
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ICD-10 |
DSM-IV-TR |
- Lack or loss of sexual desire
- Sexual aversion and lack
of sexual enjoyment
- Sexual aversion
- Lack of sexual enjoyment
- Failure of genital response
- Orgasmic dysfunction
- Premature ejaculation
- Non-organic
vaginismus
- Non organic dyspareunia
- Excessive sexual drive
- Other sexual dysfunction,
not caused by organic disorder and disease
- Unspecified sexual dysfunction
- Not listed (under F10)
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- Hypoactive sexual desire
- Sexual aversion disorder
- Female arousal disorder
and male erectile disorder
- Female orgasmic disorder
- Male orgasmic disorder
- Premature ejaculation
- Vaginismus
- Dyspareunia
- Not listed
- Sexual dysfunction not otherwise
specified
- Not listed
- Substance induced sexual
dysfunction
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Table 5: Delineating Criteria Of 12 Sexual Dysfunction Diagnoses.(2)
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Sexual
Desire Disorders
Hypoactive Sexual Desire
Disorder: Persistently or recurrently
deficient (or absent) Sexual fantasies and desire for sexual activity.
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Sexual Arousal Disorders
Female sexual
arousal disorder: Persistent or
recurrent inability to attain, or to maintain until completion of the sexual
activity, an adequate lubrication-swelling response of sexual excitement.
Male
erectile disorder: Persistent
or recurrent inability to attain or to maintain until completion of
the sexual activity, an adequate erection
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Orgasmic Disorders
Female orgasmic disorders: Persistent
or recurrent delay in, or absence of, orgasm after a normal sexual excitement
phase
Male
orgasmic disorder: Persistent
or recurrent delay in, or absence of ,orgasm after a normal sexual excitement
phase during sexual activity
Premature
ejaculation: Persistent
or recurrent ejaculation with minimal sexual stimulation before , on,
or shortly after penetration and before the person wishes it
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Sexual Pain Disorders
Dyspareunia:
Recurrent or
persistent genital pain associated with sexual intercourse on either
a male or a female
Vaginismus:
Recurrent or
persistent; Involuntary
spasm of the musculature of the outer third of the vagina that interferes
with sexual intercourse.
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Sexual aversion Disorder
Extreme aversion to, and avoidance
of all (or almost all) genital sexual contact with a sexual partner.
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Sexual
Dysfunction Due to a General Medical Condition Any of the above mentioned
diagnoses must be judged to be exclusively due to the direct physiological
effects of a medical condition.
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Substance- Induced Sexual
Dysfunction A sexual
dysfunction that is fully explained by substance use in that it
develops within a month of substance intoxication
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Sexual Dysfunction not
otherwise Specified For problems
that do not meet the categories just described
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There are
few systematic epidemiological data regarding the prevalence of the
various sexual dysfunctions, and those show extremely wide variability,
probably reflecting differences in assessments methods, definitions
used and characteristics of sample populations. The most comprehensive
survey to date, conducted on a representative sample of the U.S. population
between ages 18 and 59 suggests the following prevalence estimates for
various sexual complaints: 3% for male dyspareunia, 15% for female dyspareunia,
10% for male orgasm problems, 25% for female orgasm problems, 33% for
female hypoactive sexual desire, 27% for premature ejaculation, 20%
for female arousal problems and 10% for male erectile difficulties.
However, male erectile problems increase in prevalence after the age
50. Estimates of prevalence rates for sexual aversion, vaginismus, sexual
dysfunction due to a general medical condition, and substance induced
sexual dysfunctions are not available.(17)
The treatment
of sexual disorders has evolved significantly since the 1970s, when
Masters and Johnson focused the attention of the psychiatric community
on sexual disorders. In many of the cases, successful treatment of the
primary physical/psychiatric disorder will remit the associated sexual
dysfunction. (18) A thorough history is the fundamental tool to etiologically
evaluate sexual dysfunction, which further guides towards appropriate
treatment. The aims of assessment are to –
- Define the nature
of sexual problems and what changes are desired.
- Obtain the information
which allows formulating a tentative explanation of the causes of the
problem in terms of predisposing, precipitating and maintaining factors.
- Assessment into
medical disorders/medication that commonly lead to sexual dysfunction.
- Thorough genitourinary
examination including relevant laboratory studies like serum prolactin
levels.
- Assess what type
of therapeutic intervention is indicated on the basis of this formulation.
(20)
Treatment
of impaired sexual desire: Historically,
attempts to treat hypoactive sexual desire disorder typically followed
the sex therapy prototype developed by Masters and Johnson in 1970s.
However, recently researchers and practitioners have begun to explore
concomitant psychotherapies.(21) Some of them are-
- Group therapy in
conjunction with orgasm consistency training, which consists of directed
masturbation, sensate focus exercises, male self-control and the timing
of male orgasm.(22)
- A comprehensive
program of multimodal cognitive behavioural approach which entails sexual
intimacy exercises, sensate focus, communication skills training, emotional
skills training, reinforcement training, cognitive restructuring, sexual
fantasy training and couple sex group therapy.(23)
- Multistage treatment
approach.(24)
- Affectual awareness
training: to identify negative emotions through techniques such as list
making, role-playing and imagery.
- Insight and understanding:
to educate couples about their feelings using variety of strategies
like Gestalt therapy and Transactional analysis.
- Cognitive and systematic
therapies are included to provide coping mechanisms as well as to resolve
underlying relational problem.
- Behavioural therapy
is aimed at initially improving non-sexual affectionate behavior with
an eventual goal of introducing mutually acceptable sexual behavior.
Managing
erectile dysfunction:
Masters
& Johnson approach: This therapy proceeds in three stages. The
first stage is called ‘non-genital sensate focus’ which aims to
provide the couple with an opportunity to establish closeness and physical
intimacy but no genital stimulation. This is followed by stage II known
as ‘Genital
sensate focus’ where stimulation of the genitals is allowed. Final
stage is called ‘Vaginal containment’ in which couples eventually
engage in intercourse. However, it has been reported that this technique
has not been effective in all cases of erectile dysfunction.(25)
Cognitive
strategies: These are based on reinforcement of certain common
realities about sexuality. One such approach is acceptance of occasional
erectile problems as a normal variation and treating it as a lapse and
not a relapse. Another concept is to experience sexuality as “pleasuring
play eroticism” i.e. not to be distracted by performance demands and
viewing intercourse as natural continuation of erotic flow and not as
pass-fail test. Yet another strategy is to view the partner as an intimate
friend rather than as a demanding critic for whom he has to perform.(26)
Behavioural
strategies: This involves establishment of sensual and erotic scenarios,
which acts as transition if arousal does not result in intercourse.
Sensual scenarios are pleasure oriented ways of bonding, involving and
satisfying both people e.g. being playful and sharing intimacy, lying
together and talking. Erotic scenarios
are non-intercourse ways of experiencing arousal and orgasm. Ex: mutual
oral and manual stimulation. Another helpful approach is
to empower the medicated member of the couple to engage in sexual activity
with an understanding that he or she can stop the process at any time.
Permission to stop, if the intimacy is not experienced as pleasurable,
may paradoxically reduce performance anxiety and allow for greater enjoyment.
The clinician can suggest that sexual activity can take place during
the part of the day when patient feels best and most capable rather
than being deferred to late night, when physical and/or emotional exhaustion
might pose a further impediment to success.(26)
Pharmacological methods (16,18,26): Several
drugs have been found to be useful for erectile dysfunction. However
the major drawbacks in many of them is that they cannot be used on a
regular basis and they are not curative
- Nitric oxide enhancers
– Sildenafil, vardenafil and tadalafil available as tablets, facilitate
penile erection as well as vaginal lubrication within one hour of ingestion.
They act by inhibiting phosphodiestrase-5. They are effective in both
men and women.
- Phentolamine - It
is an orally effective opioid compound, can be useful in mild erectile
dysfunction, though not FDA approved. It reduces sympathetic tone and
relaxes corporeal smooth muscle.
- Alprostadil –
Available as injectable and transurethral form. It contains prostaglandin
E1 which is a powerful vasodilator. A firm erection is produced within
2-3 min after intracavernosal injection or intraurethral insertion of
a pellet and lasts for about 1 hour.
- Locally applied
cream containing a mixture of three vasoactive substances aminophylline,
isosorbide dinitrate and co-dergocrine mesylate is found to be effective
in two small trials. A cream incorporating alprostadil also has been
developed to treat female sexual arousal disorder.
- Trazodone is useful
due to its adverse effect of preapism, which is utilized for erectile
dysfunction.
- Hormone therapy
with testosterone or GnRH and aphrodisiac herbal compounds like yohimbine
(alpha adrenergic antagonist), ginseng, Mucuna pruriens, Withania somnifera
are also found to be effective when taken for a period of few days to
weeks.
Surgical approaches (16,18):
- Male prosthetic
devices: A semirigid rod prosthesis provides permanent erection while the inflatable type can be deflated after use.
- Vacuum pumps: These
are mechanical devices for patients without vascular disease. Vacuum is created by a ring placed around the base of penis that draws
blood and maintains erection. EROS is a similar device for clitoral
erection in women.
Other approaches:
- Watchful waiting
(27)
- Drug holiday (28,29)
- Switching to alternative
drugs (30)
- Minimizing use of
other medication known to cause ED
- Alcohol & smoking
cessation
- Maintaining tight
glycemic control in diabetics
- Regular exercise
is found to maintain optimum level of testosterone
Managing
premature ejaculation (PE):
i) Traditional
techniques
- Squeeze Technique: It is used to raise the threshold of penile excitability. Man/woman
stimulates the erect penis until the earliest sensations of impending
ejaculation are felt. At this point the woman forcefully squeezes the
coronal ridge of the glans, the erection is diminished and ejaculation
is inhibited.(25)
- Start – Stop Technique : This variant of squeeze technique was developed by James H. Semans.
The woman stops all stimulations of the penis when the man first senses
an impending ejaculation. No squeeze is used.(31)
ii) Individual
procedures:
- Physiological
relaxation training: Quiet focus on breathing, body awareness and muscle relaxation is
encouraged. Its purpose is to concentrate on physical sensation and
to ease bodily tension. (32)
- Pubococcygeal
muscle control technique: It capitalizes on the natural ejaculatory inhibiting effect of relaxing
the muscle involved in ejaculation. In this, conscious capacity to relax
pelvic muscles and pubococcygeal muscle relaxation is taught while experiencing sexual arousal.(32)
- Pelvic floor
rehabilitation training: Physiokinesiotherapy
of the pelvic floor, electrostimulation, and biofeedback are the 3 techniques
taught here to provoke contractions of the pelvic floor, strengthening
the muscles and improving self awareness of motor activity.(33)
- Cognitive
and Behavioural pacing techniques (32):
- Cognitive
arousal continuum technique: A thought pacing technique to regulate arousal and inhibit ejaculation
by focusing specifically on varying levels of sexually arousing activities.
Steps are:-
- Identify, observe and distinguish those detailed thoughts (fantasy),
actions, feelings, scenarios and sequences that lead
to individual’s arousal pattern
- Make a hierarchy of them based on the understanding of the individual’s
incremental arousal.
- Thereafter during intercourse, individual is better able to regulate
his level of stimulation by concentrating on items in order to increase
or decrease his level of arousal.
- Sensual
awareness training/Enhancement arousal: PE is said to occur commonly when ones erotic stimuli is outside one’s
own body, ie typically in the sexual partner. Hence the individual is
guided to focus on visual and tactile exploration of his own body. Individual
learns to be familiar with his own physical sensation (awareness) and
then learn to cognitively and behaviouraly
orchestrate his sexual arousal.
iii) Couple
procedures (32):
- Couple sensate focus
pleasuring exercise:
This involves homework sessions with the couple relaxing and gently
pleasuring each other until the man relaxes physiologically and concentrates
on his own physical sensation during gentle stimulation by the partner.
- Partner genital
exploration relaxation exercise: Partners
become more comfortable and relaxing with mutual exploration, observation
and stimulation of each other's own body including genitals.
- Intercourse acclimatization:
After vaginal penetration, the man stops movement and rests while the
penis acclimates to the internal vaginal atmosphere until reaching a
pleasure saturation point.
iv) Medical
management (16,18):
- SSRIs – the adverse
effect of retarded ejaculation is a benefit in PE.
- Thioridazine also
impairs ejaculation, hence used in PE.
- Anxiolytic drugs
(Ex: benzodiazepines) to allay anxiety which is most commonly associated
with PE.
- Treatment of primary
psychiatric illness where PE is secondary to it will many times also
set right PE.
v) Miscellaneous
methods:
- The methods like
watchful waiting (27), drug holiday (28 29), risk factor modification
are all applicable in case of PE too.
- Switching to alternative
drug if PE is drug induced.(30)
- Handling ‘performance
anxiety’ with effective counseling and psychoeducation where that
is the cause of PE.
Managing
Dyspareunia by physical therapy:(34) Treatment
is given through manual or physical means. It includes modalities like
therapeutic exercises to desensitize, stretch and strengthen perineal
soft tissue and pelvic muscles through Kegels exercise, along with other
procedures like relaxation, postural education, and biofeedback. Management
of vaginismus: Recent
researchers have found Cognitive Behaviour Therapy (CBT) useful in the
treatment of vaginismus, especially if it is of psychogenic origin.
(35,36) CBT strategies mainly consist of –
- Sensate focus- to
reduce performance anxiety
- Vaginal dilatation
either with the help of instruments or use of self-finger approach to
desensitize.
- Cognitive restructuring-
to change the dysfunctional thoughts interfering with sexual functioning.
Sexuality
is an integral part of life and sex therapy is an approach to real human
problems. A careful assessment into the cause of sexual dysfunction
is vital for its successful management. Today a multimodal treatment
regimen and an eclectic approach to sexual disorders will result in
a favourable outcome in the great majority of cases. Sex therapy be it for libidinal/erectile/ejaculatory
problem, is an approach to very real human problems based on the belief
that sexuality can be a positive part of life, that relationships can
be rewarding and that emotional and physical intimacy is a desirable
goal.
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