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Male Sexual Dysfunction

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  • 1. Male Sexual Dysfunction
  • 2. Male Sexual Response Cycle
    • Arousal
    • Plateau
    • Orgasm
    • Resolution
    • Refractory Period
    Arousal Resolution Refractory Orgasm Plateau
  • 3. Stage One - Arousal
    • Vasocongestion contributes to erection of the penis. 
    • The inner diameter of the urethra doubles.  The scrotum pulls toward the body.
    • Muscular tension increases in the body.  Heart rate and blood pressure increase.
  • 4. Stage Two - Plateau
    • Not much change in the penis, but it is less likely for a man to lose his erection if distracted during plateau phase than during excitement.
    • The testes increase in size by 50 percent or more and are elevated toward the body.
    • Muscular tension heightens and involuntary body movements may increase as orgasm approaches.  Heart rate increases to between 100-175 beats per minute.
  • 5. Stage Three - Orgasm
    • Actual climax and ejaculation are preceded by a distinct inner sensation that orgasm is imminent (ejaculatory inevitability).  Just after this the man senses that ejaculation cannot be stopped.
    • The most noticeable change in the penis during orgasm is the ejaculation of semen, even though orgasm and ejaculation are separate functions and may not occur at the exact same time.  The muscles at the base of the penis and around the anus contract rhythmically.
    • Men often have strong involuntary muscle contractions through the body during orgasm and can also have involuntary pelvic thrusting.  The hands and feet show spastic contractions and the entire body may arch backward or contract.
  • 6. Stage Four - Resolution
    • Immediately following ejaculation, the male body begins to return to its prearousal state.  About 50% of the erection is lost immediately, and the remainder of the erection is lost over a longer period of time.
    • Muscular tension usually is fully relaxed within five minutes after orgasm, and the man feels relaxed and drowsy.
    • Resolution is a gradual process that may take as long as two hours.
  • 7. Stage Five - Refractory Period
    • During resolution, most males experience a period of time in which they cannot be re-stimulated to ejaculation or even maintain an erection.
    • On average, men in their late thirties cannot be ready for more for about 30 minutes or longer.
    • Not many men beyond their teen years are able to have more than one orgasm during sexual encounters.
    • Most men feel sexually satisfied with one orgasm.
  • 8. Prevalence of MSD
    • Between 10-52% of men at some point in their lives will experience some type of sexual dysfunction.  One recent study in the Journal of American Medical Association (1999) found sexual dysfunction common in 31% of men age 18 to 59.
  • 9. Diagnostic Questions
    • Onset
      • Primary
      • Secondary
    • Context
      • Global
      • Situational
    • Contributing Factors
      • Physiological
      • Mechanical
      • Psychological
  • 10. The Big Three in MSD
    • Erectile Dysfunction
    • Premature Ejaculation
    • Retarded Ejaculation
      • The penis may be the most honest parts of the male anatomy.
  • 11. Phases in Disorder
    • Desire
    • Arousal
    • Orgasm
  • 12. Desire Disorders
    • Hyperactive Sexual Desire
    • Hypoactive Sexual Desire
    • Sexual Aversion
  • 13. Hyperactive Sexual Desire
    • Deregulation or lack of control over sexual motivation
    • Have sex frequently, often having several orgasms each day
    • Often preoccupied with sexual feelings and/or thoughts to the extent that this interferes with their functioning at work, and/or creates problems in their relationships.
    • Compulsive sexual behavior, inadequate control of sexual impulses and intense, and spontaneous sexual desire.
    • Kaplan
  • 14. Hypoactive Sexual Desire Definition
    • Deficiency or absence of sexual fantasies and desire for sexual activity.
    • Must cause marked distress or interpersonal difficulty.
    • Not better accounted for by an Axis I disorder, substances, or a general medical condition.
  • 15. Hypoactive Sexual Desire Causes
    • Stress, Anxiety
    • Medications
    • Drugs
    • Alcohol
    • Depression
    • Hormonal Imbalances
    • Relational Factors
    • Sexual Arousal Disorder
    • Endocrine Diseases
      • Cushing’s Syndrome
      • Hypothyroidism
    • Diabetes
    • Systemic Diseases
      • Chronic Renal Failure
      • Testicular Atrophy
    • Chronic Pain
  • 16. 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.
  • 17. Hypoactive Sexual Desire Case Formulation Hormones: Testosterone / Estrogen History of sexual activity Aschematic Sexual Self View Few positive romantic relationships / sexual encounters Low Desire Protective: Partner Factors Hormone Supplements Cognitive Restructuring
  • 18. Sexual Aversion Definition
    • Aversion to and active avoidance of genital sexual contact with a sex partner.
    • Must cause marked distress or interpersonal difficulty.
    • Not better accounted for by an Axis I disorder, substances, or a general medical condition.
  • 19. Sexual Aversion Causes
    • Sexual trauma
      • incest, sexual abuse, or rape
    • Repressive family atmosphere
    • Rigid religious training
    • Pain during first attempts at intercourse
  • 20. 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.
  • 21. Sexual Aversion Disorder Case Formulation Negative Sexual Self-Schema Traumatic Event (e.g. rape) Sexual Anxiety / Fear Response Avoidance Low arousal / sexual satisfaction Cognitive Restructuring Relaxation Training Exposure
  • 22. Arousal Disorders
    • Erectile Dysfunction
    • Erectile Dyspareunia
  • 23. Erectile Dysfunction Definition
    • Inability to attain or to maintain an adequate erection until the completion of sexual activity
    • Must cause marked distress or interpersonal difficulty.
    • Not better accounted for by an Axis I disorder, substances, or a general medical condition.
  • 24. Erectile Dysfunction
    • 20% of males over 50 experience significant erectile dysfunction
    • 52% of men between 40 and 70 report some degree of erectile difficulty
    • Between 18 and 30 million American men affected by erectile dysfunction
    • 85% of men with erectile dysfunction do not seek help
  • 25. Erectile Dysfunction Causes
    • Depression
    • Job loss
    • Diabetes or other disorders impacting circulation
    • Hypertension
    • Medications
    • Obesity
    • Smoking and tobacco products
    • Alcohol
    • Age
    • Rigid training
    • Guilt
    • Unreasonable expectations
    • Fear
      • Rejection
      • Not able to satisfy wife
      • Being compared to other men
      • Losing erection
      • Inability to ejaculate
    • Ridicule
    • Poor physical fitness
    • Autosexuality
    • Passive wife
    • Sagging vagina
    • Nagging
    • Feminine dominance
    • Unfavorable weather
    • Burnt toast
  • 26. Erectile Dysfunction May Disguise
    • Paraphilic problem
    • Homosexual orientation
    • Gender identity disorder
    • Lack of desire towards partner
    • Immorality
      • Adultery
      • Pornography
  • 27. Erectile Dysfunction Treatments
    • First Line
      • Medications
        • Excitatory – sidenafil
        • Inhibitory – Alpha-1/2 blockers
      • Vacuum Constriction Devices
      • Therapy
        • Cognitive – correct thought distortions
        • Behavioral – sensate focus training
        • CMASH
    • Second Line
      • Intraurethral Suppositories
      • Injection Therapy
    • Third Line
      • Penile prosthesis
        • Semi-rigid
        • Inflatable
  • 28. Center for Marital and Sexual Health (CMASH)
    • Gender Identity
    • Object Choice
    • Intention
    • Sexual Desire
    • Arousal
    • Orgasm
    • All these in context contribute to a sexual equilibrium in the relationship, whether it is a healthy one or dysfunctional one
  • 29. Erectile Dysfunction Case Formulation Organic Factors / Medication Side Effects Low Sexual Experience Anxiety Inhibited Parasympathetic Activity Low Arousal Dysfunctional Attentional Processes Protective Factors: Positive emotions, love Negative Expectations Medical Treatments Sensate Focus Psychoeducation Non-demand Pleasuring
  • 30. Viagra (Sildenafil)
  • 31. Viagra Side Effects
    • Headache
    • Flushing
    • Dyspepsia
    • Consult a doctor if on Nitroglycerine for possible cardiac effects
  • 32. Viagra Contraindicators
    • A clear reason for recent onset of erectile dysfunction
    • Severe marital discord
    • Performance anxiety is the cause
    • The client does not like to use medications
    • Althof
  • 33. Conclusions on Erectile Dysfunction
    • We must also attempt to address relapse issues
    • Not everyone can be helped
    • Helping a man attain an erection by medical means may do more harm than good relationally
    • 44-91% success rate
    • 20-50% discontinue therapy
  • 34. Erectile Dyspareunia
    • Peyronie’s disease/Penile Induration
      • Severe curvature of penis caused by scarring in the tunica. Treated through surgery or anti-scarring and anti-inflammatory drugs. Also may cause pain during or prevent intromission.
    • Balanitis
      • inflammation of the foreskin
    • Balanoposthtis
      • inflammation of prepuce and glans
    • Frenular tethering
      • scarring of frenulum results in loss of elasticity
    • Paraphimosis
      • opening of foreskin too small
    • Chordee
      • congentical curvature of the penis
    • Neurologic damage
  • 35. Ejaculatory Disorders
    • Premature Ejaculation
    • Retarded Ejaculation
    • Ejaculatory Incompetence
    • Retrograde Ejaculation
    • Ejaculatory Dyspareunia
  • 36. Premature Ejaculation
    • Possibly the top complaint from men about sexual dysfunction
    • In a study by Kinsey in 1948, 75% of men were found to ejaculate within 2 minutes.
    • We have no empirical way to diagnose this…it is very subjective.
    • Possibly universal for first sexual encounters
    • Can lead to feelings of shame, guilt or inadequacy as a man
    • 30% of men report they are not satisfied with their ability to control orgasm.
    • Rapid orgasm seen as a problem for men and a sought after attribute for women.
    • Women report men ejaculate prematurely 80 to 100 percent of the time, while men report it at 10 to 20 percent of the time.
  • 37. Premature Ejaculation Definition
    • Onset of orgasm and ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.
    • Must cause marked distress or interpersonal difficulty.
    • Not better accounted for by an Axis I disorder, substances, or a general medical condition.
  • 38. Premature Ejaculation Causes
    • Anxiety
    • Performance pressure
    • Novelty of experience or partner
    • Interpersonal difficulties
    • Conditioned to be quick
    • Possible biological differences in men
  • 39. Premature Ejaculation Treatments
    • Any one of millions of untested folklore remedies (which may have harmful side effects)
    • SSRI/Antidepressants
    • Therapy
      • Cognitive – Dispel myths
      • Behavioral – Desensitization (Squeeze Technique)
    • Kegel Exercises
  • 40. Premature Ejaculation Case Formulation Low Sexual Experiences High Arousal Sensitivity History: Rewarding Speedy Circumstances Premature Ejaculation Anxiety Avoidance learned response Often disappears with age / experience Pause – squeeze Technique
  • 41. Retarded Ejaculation Definition
    • Delay in or absence of orgasm following a normal sexual excitement phase.
    • Must cause marked distress or interpersonal difficulty.
    • Not better accounted for by an Axis I disorder, substances, or a general medical condition.
  • 42. Retarded Ejaculation Considerations
    • Relatively rare
    • The man is physically able to have an orgasm and ejaculate, just not during intercourse.
    • May be a means of malingering
    • Considered by some to be an arousal disorder in that the man is never aroused enough to achieve orgasm
    • Often the erection is maintained even when not aroused
  • 43. Retarded Ejaculation Causes
    • Damage to nerves in penis or nerves transmitting signals to the brain lessening sensation in the penis
    • Partner relational issues
      • repulsed by partner
      • using a lack of orgasm to punish partner
      • being too focused on pleasing the partner
    • Performance Anxiety
    • Arousal Deficit
    • Autosexuality
    • Lack of personal responsibility for own pleasure
  • 44. Retarded Ejaculation Treatments
    • Increase pressure to perform (could be too relaxed)
    • Coutnerbypassing
      • Control sexual content
      • Woman verbalizes her worries about her partner’s impatience, which are validated
      • Focus attention on self
  • 45. Retarded Ejaculation Case Formulation Medical Condition Desire / Arousal Deficits Negative Affect / Self-schema Low relationship satisfaction No Orgasm Anxiety Negative Expectations Cognitive Restructuring Relaxation Sensate Focus
  • 46. Ejaculatory Incompetence Definition
    • Consistent inability to reach orgasm no matter the duration or type of stimulation.
  • 47. Ejaculatory Incompetence Causes
    • Neurologic diseases
    • Traumatic injury
    • Complication of surgery
    • The nerves responsible for the signal for ejaculation are most commonly injured after spinal trauma resulting in paraplegia or quadriplegia, major bowel or vascular surgery, or surgery for testicular cancer.
  • 48. Ejaculatory Incompetence Treatments
    • If the goal is to produce ejaculation for impregnation, a reflex ejaculation can be produced if the level of injury is not too severe by using a vibrator with a designated frequency and wave amplitude. If injury is too severe, the prostate can be electrically stimulated to ejaculate.
  • 49. Retrograde Ejaculation Definition
    • Upon ejaculation all or part of the semen travels backward into the bladder due to the sphincter at the bladder neck not closing.
    • This does not effect sexual functioning or pleasure unless it is psychologically troubling to not see any semen (in severe cases).
  • 50. Retrograde Ejaculation Causes
    • Surgical damage to the muscle of the bladder neck, or to the nerves that control this muscle
      • Prostatectomy
      • Surgery on the bladder neck
      • Extensive pelvic surgery, especially to treat cancer of the testicles, colon, or rectum
      • Staging surgery for cancer in the pelvis or lower abdomen
      • Certain types of surgery on the discs and vertebrae of the lower spine
    • Nerve damage caused by medical illness
    • Side effects of medication
      • Amitriptyline (Elavil)
      • Amoxapine (Asendin)
      • Chlorpromazine (Thorazine)
      • Thioridazine (Mellaril)
      • Guanethidine (Ismelin)
      • Reserpine (Serpasil)
  • 51. Retrograde Ejaculation Treatments
    • Alter medications that cause it
    • If it is a mild muscle or nerve problem, drugs proscribed to improve muscle tone at the bladder neck
      • Pseudoephedrine
      • Imipramine (Tofranil)
    • In cases of severe nerve damage, a fertility specialist may collect sperm from the bladder and use washed sperm for an assisted fertilization procedure.
  • 52. Ejaculatory Dyspareunia
    • Prostatitis
      • Chronic or acute infection of the prostate often caused by bacteria entering the urethra. Treated with antibiotics.
    • Urethritis
      • Chronic or acute infection of the urethra often caused by bacteria entering the urethra. Treated with antibiotics.
    • Neurologic damage
    • Medications (antidepressants)
      • Amoxapine, imipramine, and clomipramine
  • 53. Conclusion
    • It is uncommon to find one factor that is causing 100% of the problem.
    • It is uncommon to find one solution that will fix 100% of the problem.
    • Often, physical, relational, and psychological factors are all involved in causing and being impacted by male sexual dysfunction.
    • Male Sexual Dysfunction is more common than presented.