SEXUAL DYSFUNCTION

Sexual Dysfunction

The number of patients attending a doctor with acknowledged sexual dysfunction will
depend on the cultural background of the patients and the perceived attitude of the
doctor. Many patients present with gynecological symptoms even when their problems
are psychosocial or psychosexual. If the doctor is not aware of this, patients may be
inappropriately managed.

• Not all doctors have the time or ability to deal with sexual problems in depth but
a sympathetic approach will help to resolve many problems. In other more complex
cases, referral to a psychosexual counselor will be appropriate.

• Psychosexual therapy requires good rapport between the therapist and the patient
or couple and this may take time to achieve. Such therapy can be very time
consuming and progress may be slow.

• An understanding of both male and female sexual function and dysfunction is
necessary when providing counseling to the patient or to the couple.

• The gynecologist must be aware of the concerns regarding sexual function of a
patient who is advised to undergo surgical treatment - particularly vaginal surgery.
Adequate explanation must be given to the patient who may not express her
concerns directly.

Male sexual dysfunction
Normal male coital function requires arousal through mental, visual or tactile stimulation, erection (a parasympathetic function), penetration, ejaculation (a sympathetic function) and resolution.

Low sex drive and failure of arousal
• Congenitally diminished testicular function (as in Klinefelter's syndrome). Treatment with testosterone is likely to be beneficial if circulating levels are low.

• Psychiatric problems such as anxiety, depression and stress.

• Psychosocial and psychosexual problems due to marital disharmony or to latent or
overt homosexuality. Counseling may be beneficial.

• Medications such as sedatives, tranquillizers and hypotensive drugs can reduce sex
drive.

Impotence
• Congenital neurological problems such as spina bifida.

• Acquired neurological problems due to traumatic spinal tract damage or to a tumor.

Psychiatric problems are commonly related to anxiety, depression or stress, or may
follow an industrial or road traffic accident which leads to compensation orientated
sexual dysfunction.

• Psychosocial and psychosexual maladjustment or malorientation.

• Medical disorders, e.g. diabetes, hyperprolactinaemia, myxedema or liver failure.

• Drugs such as alcohol and psychotropic, anticholinergic and hypotensive medications. It is important to warn patients that sexual dysfunction is a possible side-effect of certain drugs.

• Psychoemotional problems following vasectomy.

• Disorders of the urogenital tract such as infection or Peyronie's disease. In Peyronie's disease a fibrous plaque develops between the fascia and the tunica albuginea of the corpora cavernosa causing angulation of the penis and pain on erection.

Management
• Appropriate counseling and treatment of medical problems or alteration of drug
therapy.

• In a few patients surgical implantation of a penile prosthesis may be helpful.

Ejaculatory problems
• Congenital abnormalities such as hypospadias or phimosis.

• May be due to drugs which affect neurological control.

• Premature ejaculation is a common problem which can sometimes be treated effectively by squeezing the glans penis gently when the desire to ejaculate is felt, until
the desire disappears. This process is repeated up to five times before ejaculation
is allowed to occur. Treatment with clomipramine (25-75 mg a day) may also be
helpful.

• Ejaculatory incompetence may occur with anxiety and stress.

• Retrograde ejaculation can occur, particularly after prostatectomy. Ejaculation with
a full bladder may overcome the problem.

Female sexual dysfunction
Normal female sexual arousal occurs more through mental and tactile stimulation than
by visual stimulation. During arousal lubricating secretions are produced. Intercourse
can be pleasurable in the absence of orgasm which does not occur in all women.

Local problems
• An imperforate hymen or vaginal atresia will prevent penetration.

• Superficial or deep dyspareunia may lead to apareunia.

Dyspareunia may be due to failure of arousal.

• Superficial dyspareunia may be due to infection such as candidiasis or trichomoniasis, or to atrophic vaginitis, or may occur following surgery such as an episiotomy or posterior repair.

• Deep dyspareunia may be due to pelvic inflammatory disease or endometriosis.

General problems
• Libido may be reduced by general debilitation or by oestrogen lack as in hypogonado- trophic hypogonadism, gonadal failure or hyperprolactinaemia.

• Drugs do not affect sexual function in women as much as in men, but libido may
be reduced by oral contraception, phenothiazines and drugs of addiction in some
women.

• Psychiatric problems such as anxiety, depression and psychosis commonly cause
sexual dysfunction and require appropriate management and treatment.

• Psychosexual problems are a common cause and common result of marital dishar-
mony. Management includes counseling of both partners often over a period of
weeks or months.

History
• Obtaining a good history from a patient with sexual dysfunction is an art.

• A sympathetic unhurried, uncritical approach is essential.

Examination
• Thorough general and pelvic examination to exclude organic problems.

• The woman's response to pelvic examination may be a helpful indicator of the
nature of the problem.

Management
• Depends on the problem.

• Local and general medical problems should be treated appropriately.

• Referral to a psychosexual counselor or psychiatrist may be required.