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1. Libido Reward Motivation Interest Sexual arousal Mental fatigue Serotonergic projections Inhibitory on DA Inhibition of spinal reflex Anorgasmia Sexual Desire & Reward Circuits Dopaminergic projections Positive

2. PSYCHOSEXUAL FACTORS SEXUALITY – 4 INTERRELATED FACTORS SEXUAL IDENTITY GENDER IDENTITY GENDER ROLE SEXUAL ORIENTATION

3. Sexual Response Cycle 4 PHASES IN BOTH MALE & FEMALE DESIRE PHASE EXCITEMENT PHASE ORGASMIC PHASE RESOLUTION PHASE ONLY MEN HAVE REFRACTORY PERIOD

4. PHYSIOLOGY OF THE SEXUAL RESPONSE Each phase shows age changes. Excitation : Men: fastest 16-20 years, then slow decline Middle Age: very noticeable, need direct stimulation Old Age: need lots of direct stimulation Women: slower in teens, early 20s faster 30’s on Plateau : Men: capacity for longer with age Women: same, but never a big problem

5. PHYSIOLOGY OF THE SEXUAL RESPONSE Orgasmic : Men: intensity lessens from mid- to late 20s Middle Age: really noticeable ejaculate less volume, less forceful Resolution : Refractory period increases

6. PHYSIOLOGY OF THE SEXUAL RESPONSE Resolution: Men: longer refractory periods, 24 hrs. midlife, longer in old age. Women: no refractory periods ever.

7. TAKING A SEXUAL HISTORY

8. Male and Female prevalence rates of sexual dysfunctional/problems 3% 10% 10% 15% 20% 25% 27% 33% 0% 5% 10% 15% 20% 25% 30% 35% Male dyspareunia Male orgasm problems Male erectile problems Female dyspareunia Female arousal problems Female orgasm problems Premature ejaculation Female hypoactive sexual desire

9. Introduction Sexual dysfunction is defined as a disturbance in the person’s ability to respond sexually or to experience sexual pleasure. There are 10 categories(DSM- V ) Male hypoactive sexual desire disorder Female sexual interest /arousal disorder Erectile disorder Female o rgasmic disorder Delayed ejaculation Premature ejaculation Genito-pelvic pain/penetration disorder Substance/medication induced sexual dysfunction Other specified sexual dysfunction Unspecified sexual dysfunction

10. MALE HYPOACTIVE SEXUAL DISORDER Deficiency/ absence of sexual fantasies and desire for sexual activity for minimum of 6 months Prevalence high at younger & older ends of age spectrum Presence of desire depends on following factors -Biological drive -Adequate self esteem -Previous good experiences with sex -Appropriate partner availability -Good relationship in nonsexual areas with partner Chronic stress , depression and anxiety may result in lack of desire.

11. FEMALE SEXUAL INTEREST/AROUSAL DISORDER Includes a decrease of erotic feelings/thoughts or fantasies, decreased impulse to initiate sex, decreased receptivity to partner’s overtures, inability to respond to partner stimulation, fore minimum of 6 months Hormonal patterns may contribute to responsiveness Alterations in testosterone , estrogen , prolactin and thyroxine are implicated.

12. MALE ERECTILE DISORDER Difficulty in obtaining/maintaining erections, decrease in erectile rigidity, for 6 months causing significant distress. -It can be lifelong or acquired, generalized or situational -It can be organic or psychological. Morning erections,good erections with masturbation or with partners other than usual one indicate negligibility of an organic cause. Freud’s Madonna putana complex- men with conficting feelings of affection and desire can function only with whom they see as degraded. Freud’s Punitive superego – inability to trust , feeling inadequate/undesirable as partner.

13. ORGASMIC DISORDERS Female orgasmic disorder- recurrent and persistant inhibition of female orgasm. Manifest as absence or delay of orgasm after normal excitement phase. Two types- Lifelong and acquired Overall prevalence 30% Psychological factors – Fears of impregnation, rejection by partner,poor body image , guilt about sexual impulses, prolonged marital discord. May also present otherwise symptom free or with pelvic complaints , increased tension, irritability and fatigue.

14. DELAYED EJACULATION Achieves ejaculation during coitus with great difficulty Life long and acquired types Life long type indicates severe psychopathology. May have h/o rigid and puritanical background, perceiving sex as sinful, difficulty with closeness beyond sex. H/o attention deficit disorder can aggravate the condition Acquired type reflects interpersonal difficulties. More common among men with OCD than others. Other causes- Physiological, medical conditions like parkinsons , drugs like antihypertensives and antidepressants. All these cases diagnosed as medically or pharmacologically induced sexual dysfunction.

15. EARLY EJACULATION Orgasm and ejaculation occurs before they wish to. DSM-5 refers only to vaginal penetration and defines severity according to time. MILD- Ejaculation in 30s to 1 min of vaginal penetration, MODERATE- Ejaculation in 15 to 30s , SEVERE- Ejaculation within 15s. Early ejaculation is the chief complaint in about 40% cases treated for sexual disorders. Can be physiologically predisposed to climax quickly due shorter nerve latency time. Some may have psychogenic or behaviourally conditioned cause.

16. GENITO-PELVIC PAIN/PENETRATION DISORDER According to DSM5 , one or more of the following complaints are implicated- difficulty having intercourse, genito pelvic pain, fear of pain or penetration, tension of pelvic floor muscles. Somatic causes must be ruled out. Dyspareunia can occur in immediate postpartum but temporary, in postmenopausal woman due to hormonal physiological changes in vagina. Dyspareunia uncommon in men – usually with underlying organic cause ( peyronie , prostatitis, gonorrheal and herpetic infections)

17. SEXUAL DYSFUNCTION DUE TO GENERAL MEDICAL CONDITION Male erectile disorder due to- diabetes mellitus , endocrine disease , vascular disease , trauma involving pelvis and spinal cord, radical surgeries, pharmacological effects of medications including psychotropics and anti hypertensive drugs. Various physiological tests- nocturnal penile tumescence with strain gauge, penile plethysmography or us doppler flow meter to assess blood flow in internal pudendal artery, measuring pudendal nerve latency time. Other tests include GTT, hormone assays, LFT, TFT,Cystometric examinations. Invasive tests penile arteriography, infusion cavernography , radioactive xenon penography are reserved only for vascular reconstructive procedures .

18. A good history taking is very crucial- can avoid costly diagnostic procedures . Dyspareunia in female can be due to pelvic pathology, various forms of vaginitis and cervicitis, scarring due to surgeries and episiotomy , endometriosis and some dermatological conditions such as lichen sclerosis. Medical conditions in women especially diabetes, hypothyroid, primary hyper prolactinemia can affect ability to have orgasms. Drugs like SSRI’s, MAOI’s, and antihypertensives also interfere with the same. Chronic conditions, serious illnesses and major surgeries may lead to reduce in sexual desire and arousal in both sexes.

19. SUBSTANCE INDUCED SEXUAL DYSFUNCTION Specified substances include alcohol, amphetamines, cocaine, opioids, sedative hypnotics, anxiolytics and others. Abused recreational substances , in small doses , seems to enhance sexual performance by decreasing inhibition and anxiety but with continued use cause impairment . Evidence of substance intoxication or withdrawal apparent from history , examination or lab findings with sexual dysfunction predominant in clinical picture which occurs soon after significant substance intoxication or withdrawal aids in diagnosis.

20. PHARMACOLOGICAL AGENTS IMPLICATED IN DYSFUNCTION ANTIPSYCHOTICS- Most are dopamine antagonists with blocking of adrenergic and cholinergic receptors, lead to adverse sexual effects. Chlorpromazine and trifluoperazine are potent anticholinergics. Some cause retrograde ejaculation and rarely priapism. ANTIDEPRESSANT DRUGS- Tricyclics and tetracyclics have anticholinergic action causing adverse effect. Desipramine is one with fewest effects. Venlafaxine and SSRI’s causing rise in serotonin levels lead to lowering of sex drive. Reversal achieved with cyprohepatadine , antihistamine with antiserotonergic effects . MAOI’s cause impaired erection, delayed or retrograde ejaculation, vaginal dryness and inhibited orgasm.

21. As depression itself associated with decreased libido, varying levels of sexual dysfunction and anhedonia are part of disease process. In such cases some pts report improved sexual functioning with antidepressant medications as depression improves. This makes evaluation of sexual side effects difficult. LITHIUM- may reduce hyper sexuality in manic state, by dopamine antigonist activity. ADRENERGIC RECEPTOR ANTAGONISTS- Used in treatment of hypertension, angina and certain arrythmias diminish tonic sympathetic ouflow causing impotence.

22. ANTICHOLINERGICS- like amantadine and benzatropine produce dryness of mucous membranes and erectile disorder. Amantadine however may reverse SSRI induced orgasmic dysfunction through dopaminergic effect. ANTIHISTAMINES- Diphenhydramine has anticholinergic activity inhibit sexual function. Cyprohepatadine with its potent serotonin antagonist activity help treat adverse effects by serotonergy of SSRI’s ANTIANXIETY AGENTS BZD’s- diminish anxiety by decreasing plasma ephinephrine concentration and hence improve sexual function in persons inhibited by anxiety. ALCOHOL- supress CNS activity and produce erectile disorders. Also has a direct gonadal effect reducing testosterone levels in men.

23. OPIOIDS- heroin cause erectile failure and decreased libido. HALLUCINOGENS- LSD, phencyclidine, psilocybin, mescaline- some report enhanced sexual experience but others experience anxiety , delirium and psychosis which clearly interferes with sexual function. CANNABIS- Prolonged use depressed testosterone levels. BARBITURATES &SIMILARLY ACTING DRUGS- No direct effect on sex organs , may enhance sexual responsiveness if sexually unresponsive due to anxiety.

24. Unspecified sexual dysfunction Those that do not fall under that are discussed above but cause distress and interference with sexual connection and pleasure are listed here Compulsive sexual behaviour Persistent genital arousal disorder Postcoital dysphoria Unconsummated marriage Body image problems Don Juanism Nymphomania Fantasies Postcoital headache Orgasmic anhedonia Female premature ejaculatiom Masturbatory pain

25. TYPES: Primary: Primary premature ejaculation generally applies to men who have had the condition since the earliest age of sexual maturity. Secondary: Secondary PE, on the other hand, refers to men who have previously had acceptable level of ejaculatory control AETIOLOGY Psychological Biological

26. PSYCHOLOGICAL sexual inexperience Anxiety and rush during early sexual experiences poor understanding of sexual responses infrequent sexual intercourse relationship problems Emotional disturbances Traumatic experiences in childhood Guilt Anxiety Performance fear

27. BIOLOGICAL Penile hypersensitivity -reach ejaculatory threshold rapidly -lower ejaculatory threshold Hyper excitability of the ejaculatory reflux -faster emission and ejaculation phase -faster bulbocavernosis reflex Low Serotonin (5HT)transmission in the central nervous system. - hyposensitivity of the 5-HT2c receptors - hypersensitivity of the 5HT1a receptors

28. BIOLOGICAL contd : Diabetes Hyperthyroidism Local infections -Prostatitis -Infections of urethra or bladder - Balanitis - Vulvovaginitis - orchitis

29. HISTORY Primary or secondary Duration Any general medical illness Early sexual experiences Peer relationships Work pressure General attitude towards sex Nature of upbringing Likeability of the partner Quality and duration of erections -nocturnal -masturbation Estimated IELT Remissions and exacerbations Any coexisting erectile dysfunction

30. Intra vaginal ejaculatory latency time( ielt ) IELT is defined as the time between the start of vaginal intromission and the start of intravaginal ejaculation In normal men , the IELTs range from 2 to 10 minutes 5-7% climax before vaginal penetration 90% with PE have IELT<60sec.

31. WORKUP Serotonin levels serum testosterone (free and total) level prolactin level. hypothalamic-pituitary-gonadal axis melatonin levels carbon monoxide and nitric oxide (mediators of male sexual function).

32. Ejaculatory incompetence Inability to ejaculate during sexual intercourse Delayed/absent ejaculation No difficulty in getting and maintaining erection but ejaculation does not occur inside the vagina CAUSES Homosexual man having heterosexual intercourse Female partner is no longer sexually attractive to the man Female partner not ready for sex Female partner projecting an antisexual image Female hairstyles,i.e . hair in curlers,face covered in cold creams, unwashed body

33. RETROGRADE EJACULATION The seminal fluid is ejected into the bladder instead of being propelled out through the urethral meatus MECHANISM During ejaculation the pelvic floor muscles undergo rhythmic contractions resulting in compression of urethra and closure of bladder neck inturn causing antegrade propulsion of semen In RE, the bladder neck closure does not occur, so the deposited semen in posterior urethra enters the bladder

34. Causes 1. Bladder neck incompetence Congenital Congenital malformation of posterior urethra Posterior urethral valves/polyps Utricular cysts Exstrophy or hemitrigone Acquired Transurethral prostatectomy Retropubic prostatectomy Bladder neck surgery Trauma (pelvic fracture), spinal injury

35. Causes 2. Neurogenic -Surgical injuries Lumbar sympathectomy Retroperitoneal lymphadenectomy Aortoiliac surgery Abdomino peritoneal resection -Neuropathies Diabetes mellitus Multiple sclerosis -Spinal cord lesions

36. 3. Pharmacological Alpha adrenergic blockers: phenoxybenzamine , prazosin Peripheral sympatholytics : guanethidine Ganglion blockers: hexamethonium Antipsychotics: chlorpromazine, haloperidol, clomipramine, MAOI 4. Mechanical obstruction Urethral stricture Meatal stenosis Urethral valves Urethrocoele 5. Idiopathic

37. DIAGNOSIS Post masturbation urine sample shows presence of spermatozoa or fructose. PAINFUL EJACULATION Physiological Unpleasant hyperaesthesia of glans penis after ejaculation Intense burning in urethra following ejaculation Infections Bladder, prostate, seminal vesicles, urethra Stricture of urethra due to scarring following infection

38. Dry ejaculation The person cannot ejaculate but would have an orgasm CAUSES: Drugs : phenothiazines , TCA, MAOI, Lithium, amphetamines. Antihypertensives : methyldopa, clonidine, guanethidine . Diabetes Autonomic neuropathies Myelopathies Spinal trauma Multiple sclerosis

39. DIAGNOSIS Differentiate from retrograde ejaculation Post masturbation urine sample REDUCED EJACULATION Ageing Infections ORGASMIC DYSFUNCTIONS Orgasm is defined as a sensation resulting from a sudden release of accumulated sexual tension in the form of sudden rhythmic muscular contractions in the pelvic region or elsewhere in the body. Goal of sexual activity

40. CAUSES Primary anorgasmia Psychological depression performance anxiety Painful orgasm with desipramine treatment Drugs antidepressants antihypertensives Diseases diabetes, multiple sclerosis, carcinomas Parkinsons disease, Huntington’s chorea

41. Trauma injury to spinal cord, head injury Pelvic surgey prostate surgery, other pelvic surgeries SEXUAL PAIN DISORDER Recurrent or persistent genital pain occurring in male/female before during or after intercourse r/o local factors HSV Prostatitis Peyronies disease Psoriasis, LP, lichen sclerosis vulval squamous cell carcinoma

42. Not otherwise specified Orgasmic anhedonia : decreased/ absent subjective pleasure despite normal physiological response to sexual stimulus and ejaculation. Post coital headache : vascular muscular contraction psychogenic Masturbation pain : small vaginal tear Peyronies disease

43. HISTORY H/O drug intake H/O trauma (spinal cord injury) H/O prior surgeries (pelvic surgery) H/S/O chronic diseases(DM, HTN,) H/O Smoking, alcoholism H/S/O thyroid , pituitary or adrenal disease H/O early morning erection , nocturnal emissions Psychological history Sexual history

44. PHYSCIAL EXAMINATION Blood pressure Breast examination ( R/O gyanecomastia ) Examine penis (R/O Peyronie’s disease) Determine size and consistency of testes Pubic hair distribution Focused vascular exam - peripheral pulses & penile blood pressure Focused neurologic examination – deep tendon reflexes, bulbocavernosus reflex, visual field defects

45. LAB INVESTIGATIONS Blood sugar, cholesterol & triglyceride Complete blood count Liver function tests, renal function tests Thyroid hormone level Serum prolactin level PSA(IN men above 45 years) Testosterone & LH Levels Buccal smear for karyotyping

46. PENILE TUMESCENCE MONITORING Stamp test Nocturnal penile tumescence Intracavernosal alprostadil test

47. Stamp test Strips of 4 or 5 stamps sufficient to encircle the shaft of penis are given to patient. Before going to sleep, the patient positions the strip and connects the ends with the stamps' own adhesive If the man has a normal nocturnal tumescence response, the stamps separate at one or more of the perforations, resulting in a positive test

48. NPT monitoring - Rigiscan two self-calibrating loops are attached to the penis, one at the tip and the other at the base. This machine is strapped to the thigh or waist of the person. The equipment is attached to a computer, which provides graph, and data  The equipment will measure the blood flow in the organ, size of the organ and hardness at the tip and at the shaft during erection.

49. Intracavernosal injection test. Intracavernosal injection of alprostadil 2- 5 µg – erection in neurogenic ED 10- 20 µg NO erection in vasculogenic ED NORMAL erection in psychogenic ED

50. Other investigations Duplex ultrasound scanning Cavernosography for venous leak Penile brachical index ( normal > 0.7) Penile angiography

51. TREATMENT Non pharmacological Psychotheraphy Oral medications Transurethral pharmacotherapy Intracavernosal pharmacotherapy Vaccume devices Prosthesis

52. Nonpharmacologic Treatment Lifestyle changes: Reduce fat and cholesterol in diet Decrease or limit alcohol consumption Eliminate tobacco use and substance abuse Weight loss if appropriate Regular exercise

53. Simple psychoeducation may lead to rapid improvement in the first few sessions

54. Sensate Focus Master & Johnson (1966) Put ban on intercourse Engage in a series of increasingly sexual activities Remove pressure to perform Return focus to pleasurable sensations Reintroduce the “basics” Derive pleasure from various forms of stimulation

55. Modified Masters& J ohnson theraphy Non-genital massage with feedback Non-genital nude massage with feedback Genital contact massage while nude with feedback Penetration without thrusting Penetration with minimal thrusting Lift ban on intercourse “Do what you like”

56. Oral medications Phosphodiesterase inhibitors Sildenafil Tadalafil Vardanafil Adrenergic receptor antagonist yohimbine phentolamine Dopaminergic agents apomorphine

57. MECHANISM OF ACTION Phosphodiesterase 5 inhibition. This causes increase in cGMP smooth muscle relaxation Penile erection

58. Mechanism of Corpus Cavernosal Smooth Muscle Relaxation and Penile Erection NO = nitric oxide NANC = nonadrenergic-noncholinergic neurons PDE 5 = phosphodiesterase type 5 NANC NO Guanylate cyclase cGMP GMP RELAX GTP PDE 5 Penile erection Endothelial cells Site of PDE5 inhibition

59. Compare the 3 PDE5 Sydney Men’s Health

60. INDICATIONS Psychogenic ED Mild vasculogenic ED Neurogenic ED Side effects from medication(s) patient is already taking

61. Intracavernous Injection Drugs are injected directly in to corpora cavernosa to produce an erection. Drugs Papaverine Alprostadil Moxisylate hydrohloride Phentolamine with VIP

62. Papaverine Opium alkaloid It has a direct relaxing effect on smooth muscle tone via the nonselective inhibition of cyclic nucleotide PDEs, which results in the accumulation of cAMP and cGMP Dosage 5- 20 µg Erection occurs after 15 – 20 minutes Side effect : priapism, subcutaneous hemorrhage , pain, trauma, scar

63. Alprostadil (PGE-1) Prostaglandin E 1 potent smooth muscle relaxant and vasodilator Dosage 10 – 40 µg SIDE EFFECTS – pain, priapism, hematoma, fibrosis.

64. Phentolamine with VIP Phentolamine - α-1 and α-2 adrenoceptor blocker Not effective when used alone since it is short lived. VIP - endogenous peptide dual action – relaxation of cavernosal sm veno -occlusive mechanism DOSAGE – Phentolamine / VIP- 1-2mg/ 25µg SIDE EFFECTS – mild flushing, pain, hematoma

65. Moxisylate hydrohloride Post synaptic α-1 receptor-selective antagonist Cause smooth muscle relaxation Dosage 10 – 20 mg SIDE EFFECTS - dizziness, asthenia

66. Transurethral alprostadil Mechanism of Action: vasodilator Administration: 125, 250, 500. 1000ug Insert in the urethra Erection occurs 10-15 minutes later Erection lasts 30-45 minutes Results: 10-65% Side effects: Pain, bleeding, priapism (<3%)

67. Vacuum Constriction Device Mechanism of Action: Penis placed in plastic tube Air evacuated from the tube Blood trapped in penis with constricting ring

68. Erection limited to 30 minutes Results: 80%-90% Contraindications: bleeding disorders, sickle cell disease, anticoagulation Complications: coolness, petechiae , numbness, pain with ejaculation High drop out rate

69. Penile Prosthesis Indications: Patients who have failed other therapies Peyronie’s disease Severe vasculogenic disease TYPES Inflateable Malleable

70. Two-Piece Inflatable Prosthesis Small inflation pump provides comfort and ease Fast and easy one-step deflation procedure Better conceal ability when flaccid than with malleable or self contained devices

71. Malleable Prosthesis Easy for patient and partner to use Few mechanical parts Same-day surgery usually possible Least expensive type of prosthesis

72. Malleable Penile Implant 85

73. Advantages: Low-morbidity Low-mortality surgery Low complication rates High success rates High satisfaction rate – 87% High partner satisfaction rate

74. Androgen Replacement Therapy Indications: hypogonadism (<285ng/dl) Testosterone enanthate and cipionate (t1/2 = 4.5 d) 200 mg injection dosed every 14 to 21 days 100 mg every week minimizes troughs Testosterone proprionate (t1/2 = 0.8 d) must inject every 2-3 days

75. Transdermal Patches Androderm 5 mg/d, applied to back, abdomen, etc High rate of skin irritation AndroGel ® Most physiologic application method Testosterone gel 1% Recommended starting dose: 5 g / day to deliver 5 mg testosterone Can be titrated up to 10 g per day

76. others Vascular surgical procedures Arterial revascularization Venous ligation. Repair of penile structural abnormalities and augmentation phalloplasty .

77. ED treatment algorithm Sydney Men’s Health Ist line – lifestyle changes, hormone issues 2 nd line – oral medication, counselling 3 rd line – penile injections, vacuum devices 4 th line – implants, vascular surgery

78. Hypoactive Sexual Desire Treatment Treatment must be individualized to the factors that may be inhibiting sexual interest. Many couples will need relationship enhancement work or marital therapy prior to focusing directly on enhancing sexual activity. Cognitive-behavioral therapy Testosterone for those with low levels

79. Sexual Aversion Treatment Couples counseling may help resolve discord in a relationship. Psychotherapy may be needed for people who have experienced sexual trauma. Behavioral therapy in which a person is gradually exposed to sexual activity, beginning with nonthreatening activities and progressing to full sexual expression, may also be effective. Drugs may help relieve panic attacks associated with sexual activity.

80. Premature Ejaculation Treatment Psychotheraphy Condoms Local anaesthetics Pharmacotheraphy Penile flexible rings

81. PSYCHOTHERAPHY Simple counselling Couple theraphy Individual theraphy Group theraphy

82. Simple counseling Ignorance , unjustified guilt, anxiety and misunderstanding can cause premature ejaculation Simple reassurance and counseling should be given offering knowledge about normal sexual behavior .

83. Couple therapy Both partners are counseled simultaneously. Stresses good communication between partners Problems are discussed with both partners and behavioral assignments are set.

84. Behavioral Techniques Stop-and-start method (Semans,1957) Involves stimulation of penis until sensation of “premonitory to ejaculation” Stimulation stopped, until sensation ceases, then reapplied

85. Masters & Johnson “Squeeze Technique” (1970) When man feels ejaculatory sensation, he/partner squeeze the ridge of the penis with two fingers and his thumb below the head of his penis and holds firmly (approx. 10 seconds or until partially loses erection) Used before penetration or during intercourse (withdrawal of penis) Technique can be used multiple times during a single sexual encounter Then graduates to intercourse without motion & full intercourse

86. INDIVIDUAL THERAPHY Mostly educational theraphy Simple counselling done in extensive way Patient is encouraged to produce his own explanation of the problem Then the therapist either accepts or rejects it. GROUP THERAPHY Treating people in group dispel myths quickly Proves the individual patient that he is not the only person suffering this problem Gives confidence and increases self-esteem. DISADVANTAGE – Confidentiality is compromised

87. CONDOMS Hypersensitivity of glans or penile skin is believed to cause premature ejaculation in some people In this group use of condom may be useful. LOCAL ANAESTHETICS Lignocaine spray is available in pressurised containers Each spray delivers about 7.7mg of lignocaine Applied to glans and shaft 10 minutes before intercourse Period of maximum effects varies between persons.

88. PHARMACOTHERAPHY Tricyclic antidepressants Selective serotonin reuptake inhibitors(SSRI) TREATMENT MODALITY regular treatment episodic treatment

89. CLOMIPRAMINE Tricyclic antidepressant DOSAGE – 10 – 50 mg Taken 4-6 hrs before intended sexual intercourse SIDE EFFECTS- dry mouth, sedation, blurred vision, constipation, difficulty in micturition, tachycardia, tremor, increased weight gain.

90. SERTALINE Selective serotonin reuptake inhibitors(SSRI) DOSAGE : 50 – 150 mg Taken 4-6 hrs before intended sexual intercourse SIDE EFFECTS- less sedative, GI side effects- nausea , vomiting & diarrhea

91. Other drugs used Combinations of amitriptyline and perphenazine (10-50mg/2-4mg) ALPROSTADIL (PGE 1) This is helpful in premature ejaculation since it keeps the erection in spite of ejaculation.

92. FLEXIBLE RINGS Rubber rings are made according to circumference of base of penis in flaccid state 2 rings are provided I ring is applied when erection is achieved during foreplay If patient looses rigidity after vaginal entry then he can use the second ring.

93. EJACULATORY INCOMPETANCE BEHAVIOURAL THERAPHY manual stimulation of penis by female partner Achieve ejaculation with masturbation Vaginal containment with female superior position as soon as male enters the phase of ejaculatory inevitability Female pelvic thrusting to cause ejaculation inside vagina If ejaculation does not occur partner continues with manual stimulation and tries again DRUG TREATMENT Fluvoxamine 100mg x 3 months

94. RETROGRADE EJACULATION INVESTIGATION Examination of post-masturbation urine sample - presence of fructose & spermatozoa TREATMENT treat the underlying cause control blood sugar in case of DM Change antidepressent medications neurogenic – vibrators with intense stimulation

95. Dry ejaculation INVESTIGATION Examination of post-masturbation urine sample - absence of fructose & spermatozoa TREATMENT stop any offending drug treat underlying organic cause psychotheraphy PAINFUL EJACULATION If physiological – reassurance Treat infections counseling

96. ORGASMIC DYSFUNCTION ANORGASMIA Stop the offending drug Sensate focus treatment kegal’s pubocoygeal exercise Vibrators are helpful in anorgasmia due to spinal cord injury.

97. SEXUAL PAIN DISORDER Treat infections Treat the inflammatory dermatosis Counseling Psychotheraphy Relaxation techniques

98. 111 Wincze & Barlow Model (1997) Medical Evaluation Psychosocial Evaluation Assessment & Integration of Information Medical Indications Minimal Couple Distress One partner Sexual problem One partner Psychological problem Substance Abuse Couple Sex Problems Only Significant Couple Distress Medical Stabilization Individual Sex Therapy Individual Psychotherapy Couple Therapy Substance Abuse Tx Possible Couple Therapy Possible Couple Therapy Possible Couple Therapy Sex Therapy

99. Female Sexual Dysfunction Female sexual Dysfunction

100. Introduction Numerous women suffer from sexual dysfunction; however most of the cases are not reported and it is not known how many women are successfully treated There are differences between male – female sexuality that are pervasive, affecting thoughts and feelings as well as behaviour and hence needs to be addressed separately

101. Basic differences between male and female’s sexuality First, men showed higher levels of sexual desire than women Second, women gained higher than men on general sexual satisfaction Third, women tend to have higher level of sexual satisfaction from non-orgasmic sexual practices Fourth, women’s sexuality tends to be more susceptible and capable of change over time

102. Fear of various kinds are described – fear of being physically hurt by or hurting another fear of being emotionally hurt by or hurting another fear of rejection fear of being out of control fear of size of vagina and penis fear resulting from previous medical problems fear of child birth

103. Treatment Sex education and counseling Desensitisation procedure includes- pelvic floor exercises relaxation guided fantasy graded exposure self- focussing sensate- focussing

104. Graded exposure consists of use of – cotton bud her fingers his fingers Insertion of tampoons vibrators dilators (of increasing diameters placed in vagina for 15mins twice daily) videos to aid process local anesthetic to aid process

105. Sexual desire disorder Hypoactive sexual disorder (frigidity) Absent or diminished feeling of sexual interest or desire, absent sexual thoughts or fantasies Motivations to become sexually aroused are scarce or absent Lack of interest is beyond the normal decrease experienced with increasing age and relationship durations. Prevalence increases with age

106. Sexual aversion disorder Extreme anxiety or disgust at the anticipation of or attempt at any sexual activity Here there is an aversion to and avoidance of all sexual activity with a sexual partner Thought of sexual interaction is associated with negative feeling and causes anxiety

107. Sexual arousal disorder Subjective sexual arousal disorder – absent or diminished feelings of sexual arousal from any type of sexual stimulation however signs of physical response occur Genital sexual arousal disorder – reduced sexual sensations from caressing genitalia; however ,subjective sexual excitement occurs with nongenital sexual stimuli

108. Combined genital and subjective arousal disorder – absent or diminished feelings of sexual arousal from any type of sexual stimuli plus genital sexual stimuli Persistent genital arousal disorder – spontaneous , intrusive ,and unwanted genital arousal in the absence of sexual interest and desire; arousal is unrelieved by orgasm and persists for hours or days.

109. Orgasmic Disorder Despite self report of high sexual arousal or excitement , there is lack of orgasm, ↓ ed intensity of orgasmic sensation marked delay of orgasm from any kind of sexual stimulation Also known as female anorgasmia Either be - primary – never had orgasm secondary- had atleast 1 orgasm

110. Causes of female sexual dysfunction Psychological causes Medical conditions Gynecological causes Medications

111. Psychological causes Stress Sexual performance anxiety/fear Unsatisfactory past sexual experiences Marital/ relationship problems Depression Guilt Past sexual trauma (sexual abuse/molestation) Religious taboos/cultural factors

112. Medical conditions Medical conditions contribute to FSD mainly by – microvascular complications - polyneuropathy They may lead to decreased blood flow to genitalia, causing decreased arousal and delayed orgasm Arthritis may make the intercourse uncomfortable and even painful

113. Medical etiology of FSD include : Endocrine Addison disease,adrenal disorders,cushing syndrome,decreased estrogen and testosterone,diabetes,prolactinoma,thyroid disease Gastrointestinal Irritable bowel syndrome Neurological Childhood trauma,epilepsy,head injuries,multiple sclerosis,neuropathies,parkinson disease,spinal injury,stroke Respiratory COPD Rheumatologic Arthritis ,autoimmune disorders,fibromyalgia Surgical Colostomy, pelvic surgery Urinary Renal failure Vascular CAD, HTN,MI ,pelvic surgery, pelvic trauma,peripheral vascular disease

114. Gynecological causes Gynecological causes contribute to physical, psychological difficulties Gynecological surgeries such as hysterectomy or vulvar excision may cause a loss of psychological symbol of femininity and lead to decreased sexuality The hormonal change during pregnancy/postpartum may lead to decrease in sexual activity, desire, and satisfaction, which may be prolonged by lactation

115. Gynecological etiology of FSD External genitalia Bartholin duct cyst, bartholinitis , bartholin abscess, clitoris adhesions, episiotomy scar, dermatological lesions (dermatitis, lichen sclerosis, vulvar cancer,vulvar dystrophy), herpes genitalis Internal genitalia Atrophic change, cancer, chronic pelvic pain syndrome, cystocele / rectocele , endometriosis, pelvic inflammatory disease, uterine prolapse , uterine fibroid,vaginitis

116. Medications likely to cause FSD Antihypertensive Benazepril , clonidine,lisinopril , methydopa , metoprolol , propranolol , reserpine , spironolactone , timolol Antidepressants Amoxapine , bupropion , fluoxetine , imipramine , clomipramine , paroxetine , phenelzine , sertraline , trazodone , venlafaxine Anxiolytics Buspirone , alprazolam,clonazepam,diazepam , lorazepam Illicit and abused drugs Alcohol, amphetamines, amyl nitrate, barbiturates, cocaine, marijuana, ecstacy , morphine, tobacco Miscellaneous Acetazolamide , amiodarone,bromocriptine , cimetidine , danazol , digoxin , diphenhydramine , ethinyl estradiol , medroxprogesterone acetate, gemfibrozil , metronidazole , niacin, phenytoin , ranitidine, phenothiazines , lithium

117. Diagnosis Complete history and physical examination is critical and should include – Sexual orientation Attitude towards sex Past trauma/sexual abuse Relationship problems Substance abuse Medication history Pelvic examination

118. Non-pharmacological therapies Should be the initial treatment for majority as pharmacological therapies are of limited efficacy and have potential side effects Primary focus of the treatment should be to optimize health, well being and interpersonal relationships

119. Laboratory diagnosis Pap smear Baseline hormonal profile including – FSH and LH – primary and secondary hypogonadism ↓ ed estrogen- ↓ ed libido, vaginal dryness, and dyspareunia ↓ edTestosterone /↑ ed prolactin - ↓ ed libido, arousal and tactile sensation

120. Assesment of fsd Female sexual function index (FSFI) It is a brief questionnaire, consisting of 19-item self report measure of female sexual function They include desire(2),arousal(4), lubrication(4),orgasm(3), satisfaction(3), pain (3) The minimum score is 2 and maximum score is 36 A score of 5 or less is predictive of decreased sexual desire in women regardless of menopausal status

121. Other indices : Brief Index of Sexual Functioning for Women (BISF-W) Sexual self efficacy scale for female functioning(SSES-F) Profile of Female Sexual Function (PFSF) Structured Clinical Interview for Gynecologists Caring for Women With Sexual Dysfunction

122. Vaginal photoplethsmograph It is used to asses vaginal blood flow and hence to measure genital sexual arousal in women It consist of a light source and photosensitive light detector The back scattering light is measured in 2 signal- AC-measure of vaginal blood volume DC-VPA-reflects changes in vaginal engorgement with each heart beat

123. Treatment Non-pharmacological Therapies Counseling Non-coital behaviour Kegel exercises Eros-Coital therapy device Pharmacological Therapies Estrogen Progesterone Tibolone Androgen L- arginine Phosphodiesterase inhibitors Alprostadil

124. Counseling Psychological counseling – for psychological causes of FSD Clinical and Educational counseling – normal anatomy and physiologic basis of sexual functioning Couple’s counseling – interpersonal relationship conflict or limited communication

125. Non-coital behaviours include : Sensual massage Sensate focus exercises To reduce anxiety related to sexual performance Master and Johnson technique Includes non genital sensate focus genital sensate focus vaginal containment

126. Kegel exercises Named after Dr Arnold Kegel Developed in 1948 Consists of exercises of the pelvic floor muscles It is a method used for controlling incontinence in women following child birth, in men after prostate surgery The pelvic floor muscles have been proposed to be active in genital arousal and orgasm in both genders, while their hypotonus may impact negatively on these phases of sexual dysfunction

127. Eros-clitoral Therapy Device : US FDA approved It involves inducing specific clitoral erection using vaccum therapy by self erection inducer device For a minimum of 6 week period Safe and effective

128. Pharmacological therapies Used where non-pharmacological therapies have been ineffective Treatment options focus on providing hormonal support and increasing genital blood flow

129. ESTROGEN PROGESTERONE TIBOLONE ANDROGEN L-ARGININE PHOSPHODIASTERASE INHIBITOR ALPROSTADIL

130. 144 Treatment approaches Brief counseling Sex therapy Education Advice Long duration Problem solving efforts proved unsuccessful Caused/ maintained by psychological factors Recent onset Uncomplicated Lack of sex education Treatment Approaches in FSD Sex Therapy + Couples therapy/Family Therapy Significant Interpersonal Issues In

131. Conclusion FSD is a condition of complexity in both diagnosis and treatment Though there is no permanent cure , it can be controlled and improved with treatment Additional research is needed to assess treatment efficacy and establish standard treatment guidelines

132. DRUGS USED IN MENTAL ILLNESS causing SEXUAL dysfunction

133. Effects of antidepressants on sexual function Treatment - emergent sexual dysfunction reported with all 40% of those taking antidepressants will develop some form of sexual dysfunction (Rothschild, 2000) Decreased Sexual desire/ excitement Diminished or delayed orgasm Loss of sensation in nipples, penis & vagina Decreased nocturnal erections Erection & delayed ejaculation Painful ejaculation Galactorrhoea Hard to separate effects of the depression from medication

134. Effects of First Generation (Typical) Neuroleptics Difficulty in achieving or maintaining erection Ejaculatory difficulties Priapism (isolated incidents) Desire & arousal problems Poor lubrication Diminished orgasm Irregular menstruation/ amenorrhea or menorrhagia Gynaecomastia, Galactorrhoea & breast discomfort in both men and women

135. Effect of Second Generation (Atypical) Neuroleptics Significantly lower incidence of EPS and sexual side-effects (Higgins et al, 2005) Risperidone associated with Galactorrhoea Olanzapine & Clozapine cause fewer sexual side-effects (negligible effect on prolactin levels)

136. Effect of Anticholinergic Drugs Can diminish some side effects Can cause erectile dysfunction Failure of vaginal lubrication

137. The Clinicians Role Informed Consent for treatment Education Support Monitoring Need to be more proactive and feel comfortable introducing the subject Written information should supplement discussion Use of standardized side effect assessment tools

138. Side Effect Assessment Scales Simpson-Angus Scale (Simpson and Angus, 1970) The Abnormal Involuntary Movement Scale (Guy, 1976) The Udvalg for Kliniske Undersogelse Scale ( Lingjaerde et al, 1987) Side Effect Scale/Checklist for Antipsychotic Medication (Bennett et al, 1995) Liverpool University Neuroleptic Side Effect Rating Scale (Day et al, 1995) The Extrapyramidal Symptom Rating Scale (ESRS) ( Chouinard and Margolese , 2005

139. Sexual dysfunction psychiatric co-morbidities

140. The chicken & Egg situation Depression Anxiety Interperso - nal conflict Negative syndrome Sexual Dysfunction Physical illness

141. Medications and Sexual Dysfunction Medications that cause disorders of desire Antipsychotics Barbiturates Phenytoin SSRI’s TCA’s Beta blockers Clonidine Digoxin / Spironolactone Danazol Medications that cause disorders of arousal Anticholinergics Antihistamines Antihypertensives SSRI’s/ MAO inhibitors/ TCA’s Medications that cause orgasmic dysfunction Methyldopa Antipsychotics SSRI,TCA

142. Depression & SD Most common FSD in depression is low sexual desire Loss of libido more in depressed patients compared to non- depressed & is directly proportional to severity of depression. (Beck,1967) People with low desire (No affective illness cross- sectionally ) have double the proportion of life time history of major depression.

143. Anxiety disorders & SD SD in anxiety disorders OCD/Panic had low sexual desire, reduced frequency of sexual intercourse, more aversion to sex. Anxiety in SD Higher levels of psychological distress & dysphoric affect was noted in women with SD Sexually aversive women had high levels of anxiety, difficulty with identity & self acceptance. Anxiety enhances arousal?

144. SSRI induced SD - management SSRI-induced sexual dysfunction may be overcome by lowering doses Switching to an antidepressant with low propensity to cause sexual dysfunction ( bupropion , nefazodone ), Addition of 5HT2 antagonists ( mirtazapine ) Co-administration of 5-phosphodiesterase inhibitors.

145. 8 week Double blind placebo controlled RCT: Sildenafil Treatment of Women With Antidepressant-Associated Sexual Dysfunction Showed significant improvement in sexual function Improved delay in orgasm with sildenafil treatment, which is considered a central feature of SRI-associated sexual dysfunction.

146. Sexual Dysfunction & Psychopathology In a study which looked at sexual functioning and psychopathology it was found that: Higher scores on the PANSS-positive subscale and PANSS-general psychopathology subscale were significantly associated with more difficulty in both sexual arousal and orgasm . Empirical data suggest association with negative symptoms. Drug induced SD may lead to poor adherence & subsequently poor outcome.

147. Schizophrenia Trial of Aripiprazole (STAR) study,2005 APZ OLZ QTN RSPN

148. Antipsychotic induced sexual dysfunction - options Need to balance merits & demerits of the drug Dose reduction Switch to drugs with less sexual side effects. Aripiprazole > Quetiapine > Olanzapine > Risperidone> Typicals Addition of low dose Aripiprazole as Adjuvant Addition of Sildenafil

149. SD & personality disorder Histrionic PD Greater sexual preoccupations Greater orgasmic dysfunction Erotophobic attitude Low self assertiveness Low self esteem Marital dissatisfaction Greater likelihood of extramarital affairs Borderline PD Increased sexual desire & arousability Sensation seeking Better sexual assertiveness Higher self esteem Low marital & sexual satisfaction. Greater likelihood of extramarital affairs ( Hulbert DF, J Sex Marital Ther,1994)

150. Interpersonal Dimension of FSD The effect of interpersonal dimension – F > M More in low desire group Conflict patterns among sexual dysfunction couples: Sexual dysfunction leading to relationship conflict Relationship conflict leading to sexual dysfunction Sexual dysfunction as a protective mechanism from generalized relationship damage Reduced sexual frequency with relationship duration Outcome of sex therapy depends on the involvement of the partner & the resolution of conflicts.