1. SEXUAL DISORDERS Dr. Y R Bhattarai TMU

2. Normal Human Sexual Response Cycle PhaseMaleFemale Excitement phase Sexual flush, Vasocongestion & penile erection, Scrotal tightening & lifting, Nipple erection Sexual flush, Nipple erection, Clitoris enlargement, Transudate secretion from vagina, Uterus ascends into false pelvis Orgasm phase EjaculationContraction of lower vagina Resolution phase Return to baseline

3. Sexual dysfunction disorders Sexual dysfunction disorders may be classified into four categories: Sexual desire disorders Arousal disorders Orgasm disorders Pain disorders

4. Sexual desire disorders Sexual desire disorders or decreased libido are characterized by a lack or absence for some period of time of sexual desire or libido for sexual activity or of sexual fantasies The condition ranges from a general lack of sexual desire to a lack of sexual desire for the current partner. The condition may have started after a period of normal sexual functioning or the person may always have had no/low sexual desire.

5. Disorder of excitement Male erectile disorder (impotence, erectile dysfunction) This disorder is characterized by an inability to have or sustain penile erection till the completion of satisfactory sexual activity. The causes may be psychological and physical. Psychological factors are considered only when biological factors are ruled out.

6. Psychological impotence Usually occurs acutely The early morning erections and erections during REM sleep are usually preserved. -Fear of failure of and performance anxiety. E.g. during honeymoon -Mental disorders : clinical depression, schizophrenia, substance abuse, panic disorder, generalized anxiety disorder, personality disorders or traits, psychological problems, negative feelings, anxiety disorders

7. Psychological impotence …. -Masturbatory anxiety -Interpersonal difficulties between the sexual partners. E.g. marital conflicts. -Fatigue -Fear of STDIs and pregnancy -Environmental factors like privacy

8. Physical causes of male erectile disorder Local: congenital malformations, priapism, mumps, hydrocele, elephantiasis, Peyronie's disease. Endocrine: DM, dysfunction of pituitary-adrenal-testis axis, testicular atrophy(cirrhosis) Neurological: autonomic neuropathy, spinal cord lesions like transverse myelitis, third ventricle tumors, nerve disorders such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, stroke, temporal lobe damage. Cardiological: Leriche syndrome Chronic diseases Alcohol and drugs

9. Physical causes of male erectile disorder Surgery -Radiation therapy, surgery of the colon, prostate, bladder, or rectum may damage the nerves and blood vessels involved in erection. -These nerves course beside the prostate arising from the sacral plexus and can be damaged in prostatic and colo-rectal surgeries. -Damage to the nerve erigentes prevents or delays erection. Ageing

10. Physical causes of male erectile disorder… Lifestyle: alcohol and drugs, obesity, cigarette smoking. -Incidence of impotence is approximately 85 percent higher in male smokers compared to non-smokers. -Smoking is a key cause of erectile dysfunction. -Smoking causes impotence because it promotes arterial narrowing

11. Drugs affecting on sexual cycle Desire: methyldopa, propanolol, spironolactone, steroids, estrogens Erection: Spironolactone, SSRIs, Trazodone (causes priapism), Propanolol, TCA and MAO inhibitors Ejaculation: delayed by SSRIs, thioridazine and lithium.

12. Treatment Individual psychotherapy to address issues with patient such as feelings, guilt, poor self esteem, homosexual impulses etc. Couple therapy may be indicated if due to marital conflict. Behavior therapy -Relaxation training: Jacobson’s progressive relaxation technique. -Systemic desensitization for anxiety -Biofeedback mechanism Masters’ and Johnson’s technique Oral drug therapy

13. Masters’ and Johnson technique Most popular and successful methods of treatment for psychosexual dysfunction. Both the partners are treated together by a male and a female therapists. Goal of the treatment is symptom removal using simple behavioral techniques. Some common steps: detail history, round table discussion, behavior modification steps depending on the type of psychosexual dysfunction.

14. Some Techniques of Master & Johnson Sensate focus technique: used for the treatment of impotence. The main aim is to discover on body (excluding genital area) areas where manipulation leads to sexual arousal. Squeeze technique: used in premature ejaculation. The female partner is asked to manually squeeze the penis on the coronal ridge when the male partner experiences ejaculatory inevitability to delay the ejaculation.

15. Drug therapy Treatment of underlying psychiatric disorder Low dosage benzodiazepine to relive anxiety PME is treated with TCA like clomipramine and SSRIs like fluoxetine. Impotence is treated with yohimbine

16. Drug for Erectile dysfunction Drug for Erectile dysfunction Erectile dysfunction is treated with Sildenafil citrate, the competitive and selective inhibitor of cGMP thus enhancing the relaxation of cavernosal smooth muscles and increase the arterial flow in the corpora cavernosa. Dosage: 25-100mg one hour before the sexual activity, once a day S/E: headache, flushing, dyspepsia and nasal congestion. Contraindicated with nitrates!

17. MASTURBATION All men and women masturbate Genital self stimulation begins at the age of 15- 199 months but no sexual fantasies present As puberty arrives, sexual interest peaks and masturbation increases Males learn to masturbate earlier than female Adolescents will have sexual fantasies while masturbating Commonly seen among adolescents, married couples and the elderly Excessive only if it interferes with daily functioning and in the marital life.

18. HOMOSEXUALITY Removed from the DSM in 1980 as a mental illness Considered a variant of human sexuality, not a pathologic disorder. Recent studies indicate it may be due to genetic and biologic causes. No differences in the sexual practices from those exhibited by heterosexuals.

19. PARAPHILIAS Paraphilias include sexual disorders related to culturally unusual sexual activity. These disorders are recurrent and sexually arousing Usually focus on humiliation and /or suffering and the use of nonliving objects and involve non consenting partners. Typically occur for more than 6 months. Risk factors : affects men more than women. Peak incidence: between the ages of 15 and 25.

20. Types of Paraphilias SADISM It is enjoyment of sexual pleasure when inflicting pain on one’s sexual partner. E.g. by beating and by biting. MASOCHISM It is opposite of sadism. In this individual experiences sexual pleasure when his or her sexual partner inflicts pain on oneself to get peak arousal and gratification.

21. Types of Paraphilias Pedophilia: recurrent urges or arousal toward prepubescent children. This is the most common paraphilia. Transvestic fetishism: the term is applied to the condition where sexual enjoyment is derived from wearing the dresses of opposite sex. This is more common in males.

22. Fetichism or fetishism Recurrent urge or behavior where the patient gets sexual gratification by the non living parts like dress, particularly the under garments or some article of feminine use. Voyeurism (peeping-tom) Recurrent urge or behavior involving the sexual enjoyment by observing an unsuspecting person who is engaging in sexual activity. Types of Paraphilias

23. Exhibitionism Recurrent urge for sexual enjoyment from exposing one’s own genitals especially in front of members of opposite sex. Necrophilia It is a desire for sexual intercourse with a dead bodies. Males are more sufferer from such desire. Frotteurism Usually practiced by a male sex-pervert in a crowded place to derive sexual gratification, even orgasm by rubbing his private part against female’s body. Types of Paraphilias

24. Individual psychotherapy Behavioral techniques, such as aversive conditioning may be indicated in some situations Pharmacotherapy includes antandrogens or SSRIs to help reduce patients sexual drive. Treatment