Sexual Dysfunctions

Sexual dysfunctions are real and these can be treated as well. So lets learn about this dysfunction.

1. Sexual Dysfunctions Dr. Dikshya Upreti Dept. of Psychiatry National Medical College Teaching Hospital

2. Content (Objectives of the presentation ) Introduction Types of sexual dysfunctions Related treatment Common myths

3. Introduction Sexual dysfunction can be defined by disturbance in the subjective sense of pleasure or desire usually associated with sex, or by the objective performance. Sexual dysfunctions are an inability to respond to sexual stimulation, or the experience of pain during the sexual act. Kaplan and Sadock’s Comprehensive textbook of psychiatry, 10 th Edition

4. According to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), sexual dysfunction refers to a person’s inability “to participate in a sexual relationship as he or she would wish.” F52

5. DSM-5, sexual dysfunctions include: A. Desire, interest, and arousal disorders Male hypoactive sexual desire disorder Female sexual interest/arousal disorder Erectile disorder B. Orgasmic disorder Female orgasmic disorder Delayed ejaculation Premature (early) ejaculation C. Sexual pain disorders Genito-pelvic pain/penetration disorder Sexual dysfunction due to a general medical condition Substance/medication induced sexual dysfunction Other specified sexual dysfunction G. Unspecified sexual dysfunction

6. Male Hypoactive Sexual Desire Disorder Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The symptoms in criterion A have persisted for a minimum duration of approximately 6 months. The symptoms in criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

7. Male Hypoactive Sexual Desire Disorder Prevalence: Greatest at the younger and older ends of the age spectrum 6 % of men ages 18 to 24 40 % of men ages 66 to 74 Only 2 percent of men ages 26 to 44

8. Female Sexual Interest/Arousal Disorder Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following: Absent/reduced interest in sexual activity 2. Absent/reduced sexual/erotic thoughts or fantasies. 3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate.

9. Female Sexual Interest/Arousal Disorder 4. Absent/reduced sexual excitement/pleasure during sexual activity 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual). 6. Absent/reduced genital or non genital sensations during sexual activity B. The symptoms in criterion A have persisted for a minimum duration of approximately 6 months.

10. Male Erectile Disorder Historically called impotence However, men with this dysfunction frequently suffer with the feelings of powerlessness, helplessness, and resultant low self-esteem. A man with lifelong male erectile disorder has never been able to obtain an erection sufficient for insertion.

11. DSM-5 criteria of male erectile disorder At least one of the three following symptoms must be experienced on the occasions of sexual activity: Marked difficulty in obtaining an erection during sexual activity. 2. Marked difficulty in maintaining an erection until the completion of sexual activity. 3. Marked decrease in erectile rigidity.

12. Prevalence of male erectile disorder: Lifelong male erectile disorder is rare About 20% of men fear erectile problems on their first sexual experience It occurs in about 1 percent of men under age 35. 2% of men younger than age 40-50 years complain of frequent problems with erections 13-21% of men 40-80 years complain of occasional problem with erection 40%-50% of men older than 60-70 years may have significant problems with erections.

13. Female orgasmic disorder/Inhibited female orgasm /anorgasmia Presence of either of the following symptoms and experienced on almost all or all (approximately 75%-100%) occasions of sexual activity: Marked delay in, marked infrequency of, or absence of orgasm. Markedly reduced intensity of orgasmic sensations. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

14. Prevalence rates: 10% to 42%, depending on multiple factors (e.g., age, culture, duration, and severity of symptoms) Approximately 10% of women do not experience orgasm throughout their lifetime.

15. Delayed Ejaculation Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity, and without the individual desiring delay: Marked delay in ejaculation. 2. Marked infrequency or absence of ejaculation. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

16. Prevalence It is the least common male sexual complaint. Only 75% of men report always ejaculating during sexual activity, and less than 1% of men will complain of problems with reaching ejaculation.

17. Early Ejaculation A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it. B. The symptom in Criterion A must have been present for at least 6 months and must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity.

18. DSM-5 defines the disorder as mild, moderate and severe: Mild: If ejaculation occurs within approximately 30 seconds to 1 minute of vaginal penetration Moderate if ejaculation occurs within approximately 15 to 30 seconds of vaginal penetration Severe when ejaculation occurs at the start of sexual activity or within approximately 15 seconds of vaginal penetration.

19. Sexual pain disorders Genito-Pelvic Pain/Penetration Disorder: Persistent or recurrent difficulties with one (or more) of the following: 1. Vaginal penetration during intercourse. 2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts. 3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration. 4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

20. The prevalence of genito -pelvic pain/penetration disorder is unknown. However, approximately 15% of women report recurrent pain during intercourse.

21. Sexual dysfunction due to a general medical condition Male Erectile Disorder Due to a General Medical Condition: 20 to 50 percent of men with erectile disorder have an organic basis for the disorder. A physiologic etiology is more likely in men older than 50 The most likely cause in men older than age 60

22. Diseases and other medical conditions implicated in erectile dysfunction Infectious Parasitic diseases Elephantiasis Mumps Cardiovascular disease Atherosclerotic disease Aortic aneurysm Cardiac failure Renal and urological disorders Peyronie’s disease Chronic renal failure Hydrocele and varicocele Hepatic disorders Cirrhosis

23. Pulmonary disorders Respiratory failure Genetic disorders Klinefelter syndrome Congenital penile vascular and structural abnormalities Nutritional disorders Malnutrition Vitamin deficiencies Endocrine disorders Diabetes mellitus Dysfunction of the pituitary–adrenal–testis axis Acromegaly Addison disease Adenoma Adrenal neoplasia Myxedema Hyperthyroidism

24. Neurological disorders Multiple sclerosis Transverse myelitis Parkinson disease Temporal lobe epilepsy Traumatic and neoplastic spinal cord diseases Central nervous system tumor Amyotrophic lateral sclerosis Peripheral neuropathy General paresis Surgical procedures Perineal prostatectomy Abdominal–perineal colon resection Sympathectomy (frequently interferes with ejaculation) Aortoiliac surgery Radical cystectomy Retroperitoneal lymphadenectomy Others Poisoning Lead (plumbism) Herbicides

25. Dyspareunia Due to a General Medical Condition An estimated 30 percent of all surgical procedures on the female genital area result in temporary dyspareunia. 30 to 40 percent have pelvic pathology.

26. Organic abnormalities leading to dyspareunia and vaginismus includes: Irritated or infected hymenal remnants Episiotomy scars Bartholin’s gland infection Various forms of vaginitis and cervicitis Endometriosis, and adenomyosis Postmenopausal women may have dyspareunia resulting from thinning of the vaginal mucosa and reduced lubrication.

27. Male Hypoactive Sexual Desire Disorder and Female Interest/Arousal Disorder Due to a General Medical Condition Sexual desire commonly decreases after major illness or surgery, particularly when the body image is affected after such procedures as: Mastectomy Ileostomy Hysterectomy Prostatectomy

28. Substance/Medication-Induced Sexual Dysfunction Distressing sexual dysfunction occurs soon after significant substance intoxication or withdrawal, or after exposure to a medication or a change in medication use. Specified substances include: Alcohol Amphetamines or related substances Cocaine, opioids Sedatives, hypnotics, or anxiolytics, and other or unknown substances

29. Some Pharmacological Agents Implicated in Male Sexual Dysfunctions Drug Impairs Erection Impairs ejaculation Cyclic drugs Imipramine Protriptyline Clomipramine Amitriptyline + + + + + + + + Monoamine oxidase inhibitors Phenelzine Pargyline Isocarboxazid + - - + + + Others Lithium Amphetamines Fluoxetine + + - + +

30. Some Pharmacological Agents Implicated in Male Sexual Dysfunctions Drug Impairs Erection Impairs ejaculation Antipsychotics Fluphenazine Thioridazine Trifluoperazine Reserpine Haloperidol + + - + - + + + + Antianxiety Chlordiazepoxide - + Antihypertensive drugs Clonidine Methyldopa Spironolactone Hydrochlorothiazide + + + + + - - Commonly abused substances Alcohol Barbiturate Cannabis Cocaine Heroine Methadone Morphine + + + + + + + + + - + + - +

31. The overall propensity of an antipsychotic to cause sexual dysfunction is related to propensity to raise prolactin, i.e. Risperidone  >  Haloperidol  >  Olanzapine  >  Quetiapine  >  Aripiprazole Antipsychotic‐induced sedation and weight gain may reduce sexual desire. Anti-depressant Mirtazapine, Bupropion, Reboxetine are relatively safe compare to SSRI, TCA, SNRI, MAOIs The Maudsley Prescribing Guidelines in Psychiatry 13th Edition

32. TREATMENT Non Pharmacological therapy Pharmacological therapy

33. Dual-Sex Therapy: The methodology was originated and developed by Masters and Johnson. In dual-sex therapy, treatment is based on a concept that the couple must be treated when a dysfunctional person is in a relationship. Because both are involved in a sexually distressing situation, both must participate in the therapy program. Masters and Johnson

34. The four way sessions require active participation by the patients. Therapists and patients discuss the psychological and physiological aspects of sexual functioning, and therapists have an educative attitude. The aim of the therapy is to establish or reestablish communication within the partner unit. Treatment is short term and is behaviorally oriented. The therapists attempt to reflect the situation as they see it, rather than interpret underlying dynamics.

35. Specific Techniques and Exercises Vaginismus: A woman is advised to dilate her vaginal opening with her fingers or with size-graduated dilators. Dilators are also used to treat cases of dyspareunia. Sometimes, treatment is coordinated with specially trained physiotherapists who work with the patients to help them relax their perineal muscles.

36. Specific Techniques and Exercises Premature ejaculation: An exercise known as the squeeze technique is used to raise the threshold of penile excitability.

37. Stop–start technique: Developed by James H. Semans , in which the woman stops all stimulation of the penis when the man first senses an impending ejaculation. No squeeze is used. In cases of lifelong female orgasmic disorder , the woman is directed to masturbate, sometimes using a vibrator.

38. Behavior Therapy Behavioral approaches were initially designed for the treatment of phobias but are now used to treat other problems as well. Behavior therapists assume that sexual dysfunction is learned maladaptive behavior, which causes patients to be fearful of sexual interaction. Therapists set up a hierarchy of anxiety provoking situations, ranging from least threatening (e.g., the thought of kissing) to most threatening (e.g., the thought of penile penetration).

39. Mindfulness Mindfulness is a cognitive technique that has been helpful in the treatment of sexual dysfunction. The patient is directed to focus on the moment and maintain an awareness of sensations—visual, tactile, auditory, and olfactory—that he or she experiences in the moment. The aim is to distract the patient from watching him or herself and center the person on the sensations that lead to arousal and/or orgasm.

40. Group Therapy A therapy group provides a strong support system for a patient who feels ashamed, anxious, or guilty about a particular sexual problem. It is a useful forum in which to counteract sexual myths, correct misconceptions, and provide accurate information about sexual anatomy, physiology, and varieties of behavior. Members may all share the same problem, such as premature ejaculation; members may all be of the same sex with different sexual problems; or groups may be composed of both men and women who are experiencing a variety of sexual problems.

41. Biological Treatments Biological treatments, includes: Pharmacotherapy Surgery Mechanical devices

42. Investigation: Penile Doppler Ultrasound is a procedure that is used to predict the response of your  erectile dysfunction (ED)  to vasodilation medications that enhance blood flow to the penis.

43. Pharmacotherapy: Sildenafil ( viagra ) and its congeners Oral phentolamine; alprostadil Injectable medications; papaverine, prostaglandin E1, phentolamine, or some combination of these Transurethral alprostadil. Sildenafil 100mg Vardenafil 20mg Tadalafil 20mg Maximum Concentration 450ng/ml 20.0ng/ml 378ng/ml Time to max concentration 1.0 hours 0.7 hours 2.0 hours Half-life 4 hours 3.9 hours 17.5 hours

44. Hormone therapy Androgens increase the sex drive in women and in men with low testosterone concentrations. Clomiphene and tamoxifen are both antiestrogens, and both stimulate gonadotropin-releasing hormone (GnRH) secretion and increase testosterone concentrations, thereby increasing libido.

45. Vacuum pumps: These are mechanical devices that patients without vascular disease can use to obtain erections. The blood drawn into the penis following the creation of the vacuum is kept there by a ring placed around the base of the penis .

46. Shockwave therapy  is administered with a wand-like device placed near different areas of the penis. The device along parts of your penis for about 15 minutes while it emits gentle pulses. No anesthesia is needed. The pulses trigger improved blood flow and tissue remodeling in the penis. Surgical Treatment: Inflatable Penis Prosthesi s and vascular surgery Shockwave therapy  Inflatable Penis Prosthesi s

47. Sexual-Dysfunction Myths Sexual dysfunction is only a problem for older men. Erectile dysfunction is the only sexual problem that can be reliably treated. Dysfunction is a result of a man no longer finding his partner sexy. Sexual dysfunction cannot be prevented. Treating a man’s sexual problems doesn’t require his partner’s input.

48. Thank you

49. References: Kaplan and Sadock’s Synopsis of Psychiatry, 11 th Edition Kaplan and Sadock’s Comprehensive textbook of psychiatry, 10 th Edition Diagnostic and Statistical Manual of Mental Disorders (DSM–5) The Maudsley Prescribing Guidelines in Psychiatry 13th Edition