sexual dysfunctions as per icd-11 new classification. disorders and their management as per standard clinical practice guidelines.

2. Sexual dysfunctions
• For several months (DSM-5 – 6M, ICD-11 – Several months)
• Clinically significant distress
• Occurs frequently although maybe absent on some occasions (ICD – 11,
DSM-5 – 75-100% times )
• Not better explained by non-sexual mental disorder or severe relationship
distress or other significant stressors and not attributable to medication or
substance
• Specifiers
• Lifelong or Acquired:
• Specify whether: Generalized: Situational:
• Mild, Moderate, Severe (only DSM – 5)

3. Hypoactive sexual desire dysfunction
• Reduced or absent spontaneous desire (sexual thoughts or fantasies)
• Reduced or absent responsive desire to erotic cues and stimulation
or
• Inability to sustain desire or interest in sexual activity once initiated
• Any one of the 3 criteria is required
• To assess for presence of ED or PME that may contribute to the loss of
interest
• Individual differences in preference of initiation should be taken into
account

4. Female Sexual Interest/ Arousal Disorder
• Characterized by absence or marked reduction in response to sexual
stimulation in women, as manifested by any of the following:
• 1) Absence or marked reduction in genital response, including vulvovaginal
lubrication, engorgement of the genitalia, and sensitivity of the genitalia;
• 2) Absence or marked reduction in non-genital responses such as hardening
of the nipples, flushing of the skin, increased heart rate, increased blood
pressure, and increased respiration rate;
• 3) Absence or marked reduction in feelings of sexual arousal (sexual
excitement and sexual pleasure) from any type of sexual stimulation.
DSM-5 also mentioned reduced/absent sexual or erotic thoughts or fantasies

5. Male Erectile Dysfunction
• Inability or marked reduction in the ability in men to attain or sustain
a penile erection of sufficient duration or rigidity to allow for sexual
activity
• Majority of male treated for sexual dysfunction complaints of this
problem
• May have low self-esteem, low self-confidence and sense of lack of
masculinity
• Decreased satisfaction and desire are common in the partner

7. Female Orgasmic Disorder
• Recurrent delay in, or absence of orgasm after a normal sexual
excitement phase that a clinician judges to be adequate in focus,
intensity, and duration
• In most cases, complaint is reported by the woman herself
• Causes- fears of impregnation, rejection , injury to vagina; hostility
toward men; poor body image, guilt about sexual impulses .
• Nonorgasmic women may be otherwise symptom free or may
experience frustration in a variety of ways.

8. Male early ejaculation
• Ejaculation that occurs prior to or within a very short duration of the
initiation of vaginal penetration or other relevant sexual stimulation,
with no or little perceived control over ejaculation
• DSM-5 mentions the time to be less than 1 minute following vaginal
penetration in case of lifelong problem
• Men report lack of control over delaying ejaculation

9. Male delayed ejaculation
• Inability to achieve ejaculation or an excessive or increased latency of
ejaculation, despite adequate sexual stimulation and the desire to
ejaculate
• Patient or the partner might feel exhausted during intercourse and
feel the partner to be less desirable

10. Sexual pain-penetration disorder
• Characterized by at least one of the following:
• 1) marked and persistent or recurrent difficulties with penetration, including
due to involuntary tightening or tautness of the pelvic floor muscles during
attempted penetration;
• 2) marked and persistent or recurrent vulvovaginal or pelvic pain during
penetration;
• 3) marked and persistent or recurrent fear or anxiety about vulvovaginal or
pelvic pain in anticipation of, during, or as a result of penetration
Avoidance behaviour seen

11. Assessment
• Assessment of type of sexual dysfunction, factors associated with or
contributing to sexual dysfunction and factors maintaining the sexual
dysfunction
• Detailed history taking (sexual, medical and psychosocial), focused
physical examination, laboratory tests (routine and specific) and
consultation with appropriate specialists

12. History taking
• Anticipate the embarrassment of patient and acknowledge that it
could be difficult talking about such issues
• Attention to be given to features distinguishing psychogenic from
organic
• Assess “timetable of life.”
• Past and present partner relationship
• Relationship between the couple with respect to nonsexual factors
• Substance and medication history

13. Physical Examination
• Ensure privacy, confidentiality & comfortability and convey it to the
patient
• Detailed assessment of gonadal function, vascular competence,
neurological integrity, and genital organ normalcy
• Focussed examination based on history

14. • Assessment of Knowledge and Attitude towards sex

15. Goal of Assessment
• Does patient/couple actually have sexual dysfunction?
• Whether the dysfunction is primarily psychogenic or primarily organic?
• If the dysfunction has organic etiology, then is there a psychological overlay too?
• If there are more than one dysfunction, then which is the primary?
• Does patient has any comorbid psychiatric disorder?
• If subject has a psychiatric disorder, then is the sexual dysfunction secondary to it?
• If subject has a psychiatric disorder, then how severe it is?
• Is there a marital discord between the couple, which needs to be addressed?
• What is the motivation of the patient/couple to seek treatment?
• What is the level of psychological sophistication?

16. Management
• Principles – Formulation, Balancing the partners, Treatment options,
Selection of treatment
• General Non-pharmacological measures: Education about sexuality &
Relaxation exercises
• Specific Non-pharmacological management of Sexual Dysfunction -
Homework assignment for the couple - non-genital sensate focus,
genital sensate focus and vaginal containment

17. Common Sexual Myths

21. Home work assignments for Single Male with Erectile
Dysfunction

22. Specific Non Pharmacological treatment for
erectile dysfunction
• Men with erectile dysfunction often have difficulty attending to erotic
stimuli, especially when an erection develops, tending instead to
think about the quality of their erection or whether they will be able
to maintain it
• To specifically encourage the man to focus his attention on the
pleasurable sensations he experiences during the partner's genital
caressing (the use of a lotion can often heighten these sensations),
areas of his partner's body that he finds arousing, and the pleasure of
witnessing his partner's sexual arousal

23. Management
• Biological Treatments
• Pharmacotherapy
• PDE-5 inhibitors
• Sildenafil
• effect about 1 hour after ingestion, and its effect can last up to 4 hours.
• S/E- headaches, flushing, and dyspepsia.
• Vardenafil ,Tadalafil
• Other agents
• Oral phentolamine and apomorphine
• injectable and transurethral forms of alprostadil( PGE-1 analogue)

24. • Available data also suggests the safety of some of these PDE-5
inhibitors in patients with erectile dysfunction associated with
diabetes mellitus, spinal cord injury, chronic renal failure, Parkinson's
disease, antidepressant use and following radical prostatectomy

25. • Trazodone: One of the earliest drugs used in erectile dysfunction -
antagonistic effect on 5HT2C receptors and may also have adrenoceptor
antagonistic action.
• Yohimbine: α2-adrenergic blocker. Before introduction of sildenafil,
yohimbine was the most widely used oral medication for management of
erectile dysfunction.
• Apomorphine: Apomorphine is a dopamine agonist (D1 & D2 receptors)
and its sublingual form (Apo-SL) is a new central initiator of erection and
has been found to be effective in various types of erectile dysfunction.
Recent studies show that sublingual apomorphine has a safe cardiovascular
profile and thus making it a new treatment option for patients with
concomitant disease including cardiovascular disease and diabetes
mellitus.

26. • Phentolamine: competitive inhibitor of α- adrenergic receptor. Has
been suggested as an alternative to treatment of erectile dysfunction
in patients with cardiac illness.
• L-arginine: L-arginine is the precursor of Nitric Oxide (NO) and has
been shown to improve erections in 40% of patients.

27. • Androgen - useful for erectile dysfunction in men with severe
hypogonadism
• Injection – IM , 1-2 times /week
• Implants – every 3-6 months
• Gel, Patch – Daily use, Expensive
• S/E- Increased risk of Prostate CA, Regular S. PSA check

28. Vasoactive Intracavernosal Injections
• phentolamine mesylate, papavarine, vasoactive intestinal peptide
(VIP), forskolin and alprostadil
• Phentolamine mesylate - increasing cAMP and decreasing
intracellular Ca2+ and also possibly via nitric oxide synthase (NOS)
activation
• Papavarine - increasing cAMP thus decreasing intracellular smooth
muscle. It is used in papavarine (20-80 mg) induced penile erection
(PIPE) test to distinguish between psychogenic and organic ED

29. Intraurethral therapy
• Medicated urethral system for erection (MUSE), which contains 500-
1000 mg of alprostadil, has shown success rates varying from 43-69%
in efficacy studies. It has advantages that it can be self-administered
and has little systemic and local side effects.

30. Topical therapy (Transdermal delivery)
• Soft Enhanced Percutaneous Absorption (SEPA) + prostaglandin-E1
• Testosterone Gel - applied daily to the abdomen, back, thighs or
upper arms

31. Vacuum constriction devices
• work by exerting a negative pressure on the penis, which results in an
increase in corporeal blood flow and erection
• A constriction ring placed around the base of the penis prolongs the
erection by decreasing corporeal drainage
• Overall success rate with VCD has been reported to be around 90%,
with more than 80% of patients continuing with the device

32. Penile Prosthesis
• various forms of penile prosthesis, i.e., semi-rigid rod prosthesis
consists of two rod like cylinders that are implanted into corpora
cavernosum, mechanical rods (Dura II), malleable rods and inflatable
penile prosthesis (Unitary, two-piece, and three-piece devices).
• Usually 3 piece inflatable penile prosthesis is preferred as it leads to
more natural erections

33. Reconstructive surgery
• penile venous ligation or embolization - for venous leakage
• Arterial revascularization - young men with pure arteriogenic erectile
dysfunction

34. Pre Mature Ejaculation
• Stop-start technique - man lying on his back and focusing his attention
fully on the sensation provided by the partner's stimulation of his penis.
When he feels himself becoming highly aroused he is to indicate this to
her in pre-arranged manner at which point she need to stop caressing
and allow his arousal to subside. After a short delay this procedure is
repeated twice more, following which the woman stimulates her partner
to ejaculation.
• squeeze technique - When the man indicates he is becoming highly
aroused his partner should apply a firm squeeze to his penis for about
15-20 seconds. During applying the pressure, the forefinger and middle
finger are placed over the base of the glans and shaft of the penis, on the
upper surface of the penis, with the thumb placed at the base of the
undersurface of the glans. This inhibits the ejaculatory reflex

36. Dhat syndrome

37. Female sexual Dysfunction
• Vaginismus - Helping the woman develop more positive attitudes
towards her genitals- Pelvic muscle exercises- Vaginal penetration-
Vaginal containment- Movements during containment
• Dyspareunia - sex education and teaching sensate focus- may be
helpful for the couple to avoid deep penetration positions (such as
vaginal entry from the rear) and to assume positions in which the
woman is in control of the depth of penetration (woman on top) or in
which penetration is not too deep (side by side or ‘spoons’ position)
• Arousal disorder- Sensate focusing, CBT, systematic desensitization,
individual and couples therapy, directed masturbation and
communication skills have been tried in arousal disorders with
moderate results

38. • Desire disorders- individual/couples therapy and medical/
psychological treatment
• flibanserin has been approved for the management of hypoactive
sexual desire disorder in premenopausal women. The recommended
dose is 100 mg per day at bed time

39. Termination of treatment
• Prepare for termination from the start of treatment: The
patient/couple should be told about the likely duration of therapy at
the beginning of the treatment. Setting the time frame will encourage
the patient/couple to work on the homework assignments.
• Towards the end of treatment extend the intervals between sessions:
The intervals between the last two to three sessions need to be
extended to two to three weeks.

40. • Prepare for relapse: The therapist need to prepare the couple for relapse.
About three-fourth of men will experience recurrence of their problem
following treatment. Hence, treatment also needs to assist men to cope
well with relapse. Most recurrences occur in a temporal pattern (i.e., will
occur more at certain times than at others) and usually improve naturally
or with self-initiated restart of treatment techniques. The understanding
that relapses are normal expected helps to reduce the anxiety and sense of
failure that may otherwise prolong erectile difficulties.
• Follow-up assessments: Follow-up assignments help the therapist to
evaluate the short-term effectiveness of treatment.

41. Conclusion