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Sexual arousal disorders
“Man survives earthquakes, experiences the horrors of illness, and all of
the tortures of the sou...
Sexuality and sexual behaviour
Reproduction is a fundamental biological function,
that guarantees the survival of the spe...
Sexuality and sexual behaviour
Humans are not sexually static reproductively-driven
mammals.
Unlike most animal species,...
History
First attempt at describing and classifying sexual
disorders began with Richard von Krafft-Ebing
and his Psychop...
Prior to
1950
late
1950s
psychoanalytical concepts guided clinicians
in understanding and treatment of sexual
problems
...
In
1966
Masters and Johnson.
described the physiology of phases of
sexual functioning, and
later highlighted the delet...
The
neo-
Masters
and
Johnson
era
heralded by the publication of
Helen Singer Kaplan's book,
The New Sex Therapy.
Integr...
The
mid-
1980s
current psychobiological era.
This period is distinguished by the
medicalization of treatment approaches...
Components of sexuality
Sexual identity: is a pattern of patient’s biological
sexual characteristics
Gender identity: in...
Modelling the human sexual response cycle
Models have been constructed of the normal
sequence of changes during sexual ar...
The EPOR model
formulated by Masters and Johnson
four-phase linear, sequential, and incremental model
of the human sexua...
Modifying the EPOR model into the DEOR model
currently accepted model
Robinson concluded convincingly that the P phase wa...
EPOR replaced by the desire, excitation, orgasmic,
and resolution phase (DEOR) model.
Sexual desire that appears to be s...
(a) the original EPOR model of Masters and Johnson
(b) the DEOR model of Kaplan
(c) the proposed modification with desire ...
Phase I: Desire
Psychological phase
Characterised by sexual fantasies & conscious
desire to have sexual activity.
Can b...
Phase II: Excitement
Brought on by psychological stimulation (fantasy
or presence of love object), physiological
(strokin...
Phase III: Orgasm
Consists of peaking sexual pleasure, with release of sexual
tension, & rhythmic contraction of perineal...
Phase IV: Resolution
Consists of disgorgement of blood from genitalia, which
brings body back to its resting position.
I...
The sexual response cycle
organ Excitement phase
mental Several mins-hrs, heightened excitement before orgasm, 30sec-3min
skin Inconsistent Sexual f...
organ Excitement phase
Mental Several mins-hrs, heightened excitement before orgasm
30sec-3min
Skin Just before orgasm, in...
Sexual
stimulation
Nitric oxide synthesized in nerve
and vascular tissue of penis/clitoris
Nitric oxide activates guanylat...
Neuroanatomy: Central
Cortical: orbitofrontal (sexual emotions), left
anterior cingulate (hormone control and sexual
arou...
Brainstem: nucleus paragigantocellularis, other
serotonergic nuclei
exert inhibitory and excitatory control over spinal s...
Neuroanatomy: Peripheral
Parasympathetic
Pelvic splanchnic
nerves
Roots S2, S3, S4
Reflex impulses
Synergy for erection
...
Neurochemistry
Dopamine: increases libido and sexual activity
Acetylcholine: important for erection
Norepinephrine: ere...
Neurochemistry
Prostaglandins: penile erection
Nitric oxide: penile erection, ? female genital
response
Vasoactive inte...
Endocrinology
Testosterone: libido in both genders In men, stress
is inversely correlated with testosterone blood
concen...
A more simple classification
Pleasure inhibitors, or sexual dysfunctions – disorders
occurring in the context of a “norma...
Sexual dysfunctions:
following the response cycle
Disorders of desire
Disorders of arousal (excitement)
Disorders of or...
Sexual dysfunctions:
outside the cycle
Sexual pain disorders – dyspareunia and vaginismus
Sexual dysfunction, NOS:
Compu...
SEXUAL AROUSAL DISORDERS:
DSM IV TR:
1. Female sexual arousal disorders
2.Male erectile disorder
ICD-10:
Failure of genita...
DSM-IV-TR Diagnoses
DSM-IV-TR specifies three criteria for each sexual
dysfunction.
The first criterion describes the ps...
DSMIV- TR gives the clinician additional latitude for
deciding when a person who meets the first criterion
qualifies for ...
MALE ERECTILE DISORDER/ ERECTILE
DYSFUNCTION/ IMPOTENCE.
DSM IV TR:
A.Persistent or recurrent inability to attain, or main...
Specify type: Life long type
: Acquired type.
Specify type: Generalized type
: Situational type.
Specify: Due to Psycho...
ICD-10 F52.2 Failure of Genital
Response
In men, the principal problem is erectile dysfunction.
In women, the principal ...
ICD-10:
A. General criteria must be met-
G1- subject is unable to participate in a sexual
relationship as he/she would wis...
B. Erection sufficient for intercourse fails to when it is
attempted. Dysfunction takes one of the following form-
1. Full...
Erectile dysfunction
Erectile dysfunction is defined as the consistent
inability to achieve and or maintain an erection of...
Pathophysiology
Normal erection – delicate balance
between vasoconstriction & vasorelaxation
of corporal smooth muscle.
...
Aetiology
1)Psychological causes:
-Performance anxiety,
-Relationship conflicts/loss of attraction
-Sexual inhibition, Gu...
2)Vascular:
i)Atherosclerosis:
Penis has more vascular smooth muscle than any other
organ in the body.Atherosclerosis occ...
3)Endocrinological causes:
DM, Dysfunction of the pituitary-adrenal-testis axis,
Hyperthyroidism, Myxedema ,Hyperprolacti...
others
Renal and urological disorders
Peyronie's disease, CKD, Hydrocele & varicocele
Hepatic disorders
Cirrhosis (usual...
Neurogenic etiology
Neurological disorders
Multiple sclerosis, Tumours, CVA,
Encephalitis, Dementia,Transverse myelitis
P...
Surgery or trauma
Neurological: head trauma/surgery, spinal cord
trauma/surgery, Retroperitoneal lymphnode
dissection.
V...
Recreational drugs
i) Nicotine, Alcohol.
ii)Cannabis
iii)Amphetamines: vasoconstriction of genital tissue.
 Increases ...
Drugs
Accounts for 25%
Thiazide diuretics are the most common cause of ED.
i)Diuretics: Thiazides, Spironolactone(anti-...
iv)H-2 antagonists: Cimetidine,Ranitidine (anti-
androgen activity).
v)Hormones:
Estrogens,Progesterone,Corticosteroids,...
Psychotropics and sexual
dysfunction
Antipsychotics: lack of libido, ED
Mood stabilizers: rare
Tricyclics: retrograde e...
i) Aging: ED is 4times higher im men in 60s than in
40s.
ii)Arsenic poisoning- alteration in K-gated pump,
plumbism, herbi...
Clinical evaluation
1)History
2)Physical exmination.
3)Psychological assessment.
4)Tests
History
The first step in the management- sexual, medical,
and psychosocial history.
A sensitive topic, and the clinicia...
questionnaires:
IIEF –International Index of Erectile Function.
SHIM -Sexual Health Inventory for Men.
Arizona Sexual Exp...
Organic causes – characterized by an insidious &
consistent change in rigidity or inability to sustain
morning, coital,or...
Physical examination
A physical examination is necessary for every patient,
with particular emphasis on the genitourinary...
Psychological assessment
The main diagnostic feature of psychogenic ED vs
selective ED.
The man is able to produce rigid...
Tests
1)Nocturnal Penile Tumecsence(NPT)
Useful in distinguishing psychogenic ED from
Organic.
Erections occur during REM...
 There are 2 methods:
i)Snap-Gauge band:Velcro band fitted around the penis.
Shotrcomings: lack of information regarding ...
2)Vascular studies:
i)Intra –cavernous vaso-active drug injection:
A positive test – rigid erectile response(unable to
b...
iii) Arteriography & Dynamic Cavernosometry or
Cavernosography(DICC):
Used to detect failure of veno-occlusive mechanism....
3)Neurological studies:
i)Bulbo-cavernous reflex latency:
The physician squeezes the glans of the
penis,which immediately...
iii)Penile Biothesiometry:
A small electro-magnetic test probe
is placed on the right & left of the
shaft and on the glan...
4)Endocrinological studies:
Testosterone,prolactin,FSH,LH,GH.
5)Other tests:
Fasting glucose & lipid profile,
PSA,psycho...
PLISSIT: a simple model for
routine practice (Annon)
P – permission
LI – limited information
SS – specific suggestion
...
PLISSIT: a simple model for
routine practice
Treatment
1)Psychotherapy
2) Non-pharmacological methods
3)Vacuum devices
4)Pharmacotherapy: topical, injectales, oral...
Management: psychotherapies
Dual sex therapy developed by Masters & Johnson
(Sensate Focus)
Behavioural therapy (assumes...
Nonpharmacologic Treatment Options
Lifestyle changes:
• Reduce fat and cholesterol in diet
• Decrease or limit alcohol con...
Vacuum devices:
Can be used by almost all patients with ED.
These devices exert a negative pressure on the
penis, which ...
Pharmacotherapy
1) Prostaglandin delivery systems: intra-cavernosal
: intraurethral
2) Transdermal delivery.
3) Other int...
Intra cavernosal PGE1
Caverject: injectable form of Alprostadil.
Administration:
i)reconstitution of the powder of the d...
Side-effects:
Pain, Prolonged use- corporal fibrosis.
Priapism.
Containdications:
Known hypersensitivity to the drug.
...
Intra urethral PGE1
Alprostadil administered using MUSE(Medicated
Urethral System for Erection)
It is rapidly absorbed f...
Transdermal delivery
Minimizes systemic exposure & tissue traumatization.
Administration of vaso-active substances(PGE1)...
PDE5 Inhibitors
Mechanism of Action:
• PDE inhibitor and increases the cGMP that promotes
and sustains smooth muscle relax...
Mechanism of Action of
PDE5 Inhibitors
.. SM
DRUG SILDENAFIL VARDENAF
IL
TADALAFIL
RELEASED IN MARCH 1998 APRIL 2003 FEBRUARY
2003
ONSET OF
ACTION
30 min 25-45min 30mi...
Medication
(Yohimbine, Yocon, Erex, Yohimex)
• Alpha 2 andrenoreceptor antagonist
• Dose: 5.4 mg TID
• Results: ~20% (same...
Medication
Trazodone(Desyrel)
• Anti-depressant associated with priapism
• Mechanism of action not fully understood
• Not ...
Medication
Apomorphine (Spontane)
• Dopaminergic mechanism with hypothalamic activity
• Sublingual administration
• 64% to...
Medication
Phentolamine (Vasomax)
• Alpha-blocker
• Relaxes smooth muscle tissue
• 40% efficacy in mild organic ED
• Side ...
Surgery
1)Venous leakage:
2 approaches are adopted:
i) ligation of all veins draining to the penis i.e deep
dorsal,cavern...
PENILE PROTHESIS
2 types:
i)Semi-rigid rods
Consists of 2 rod-like cylinders that are implanted
into the corpora cavernos...
Penile prosthesis
Penile prosthesis has
highest satisfaction ~93%
 Infection rate: ~2% virgin
& 4% diabetic
Malfunction...
An innovative drug-delivery system –
nanoparticles encapsulating NO or prescription
drugs – shows promise for topical tre...
Treatment of antidepressant-
induced sexual disorders
Drug holidays
Switching – mirtazapine, bupropion, nefazodone
Psyc...
FEMALE SEXUAL AROUSAL DISORDERS:
DSM IV TR:
A.Persistent or recurrent inability to attain, or
maintain until completion of...
ICD-10:
A.General criteria must be met-
G1- subject is unable to participate in a sexual
relationship as he would wish
G2-...
B. There is failure of genital response, experienced as
failure of vaginal lubrication, together with
inadequate tumescenc...
Women with excitement phase dysfunction often have
orgasmic problems as well.
May be associated with dyspareunia or lack...
Masters & johnson found normally responsive women to
desire sex premenstrually.
Another set of dysfunctional women found...
Causes of female sexual arousal
disorder
Classified as:
1)Psychological domain.
2)Physical domain.
Psychological factor...
ii) Individual factors:
Stress & fatigability.
Over-exposure to pornography &
style media which is thought to lead to poor...
Physical factors: 30-80% of the cases.
Circulatory & neurological disorders are the most
likely causes of sexual dysfunc...
iv)Recreational drugs: alcohol,smoking.
v)Medications:
Anti-depressants, Anti-psychotics, Sedatives,
Anti-hypertensives, O...
Role of Male Circumsicion
The `valve' mechanism of foreskin of uncircumcised
penis is thought to retain the natural lubr...
Persistent sexual arousal syndrome
in women
Infrequent,
distressing and perplexing not only because of its
mysterious on...
Interventions
1)PsychologicalTreatment
Education about anatomy,
Physiology and expectations.
couples therapy.
Masters &...
2)Lubricants:
Helps in vaginal dryness & the resulting dyspareunia.
3)Pharmacotherapy:
i)Sildenafil:
Dose: 50-100mg/day.
F...
4)Hormonal:
Providing exogenous source of hormones ameliorate
vasomotor symptoms in menopausal women.
Women with vagina...
5)Clitoris Vacuum therapy:
A small ,handheld device ,connected by a tubing to a
small ,soft plastic cup, that is placed ...
6)Others:
i)Topical vasodilators: PGE1- increases genital arousal.
ii)Dopamine agonists – increases sexual interest, orga...
CONCLUSION:
Sexual arousal disorders are quite common & very
distressing both in men & women but appears to
be high in men...
Thank u
Men look for youthfulness and physical attractiveness, smooth
complexion, optimum stature, and good physique, and ...
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sexual-arousal-disorders

  1. 1. Sexual arousal disorders “Man survives earthquakes, experiences the horrors of illness, and all of the tortures of the soul. But the most tormenting tragedy of all time is, and will be, the tragedy of the bedroom.” - Tolstoy. Presented by Dr Pavan Kumar K Chaired by Dr Denzil A Pinto
  2. 2. Sexuality and sexual behaviour Reproduction is a fundamental biological function, that guarantees the survival of the species. Due to its evolutionary advantages, most complex life-forms have evolved methods of sexual reproduction, which involves the combination of genetic material from parents of two different genders.
  3. 3. Sexuality and sexual behaviour Humans are not sexually static reproductively-driven mammals. Unlike most animal species, human sexuality is associated with gratification (pleasure), and not just reproduction. Sexual behavior is richly multidetermined. Human sexuality is shaped not only by biology, but by social, cultural, interpersonal, and psychological constraints.
  4. 4. History First attempt at describing and classifying sexual disorders began with Richard von Krafft-Ebing and his Psychopathia Sexualis(1898), which influenced medical and legal practice for more than 3- quarters of a century. Seminal contributions of Havelock Ellis and Albert Kinsey (sexual behavior in human male and female)
  5. 5. Prior to 1950 late 1950s psychoanalytical concepts guided clinicians in understanding and treatment of sexual problems Sexual symptoms were linked to unresolved, unconscious conflicts occurring during specific developmental periods. behavioural perspective gained ascendancy; sexual problems were understood to be learned (conditioned)
  6. 6. In 1966 Masters and Johnson. described the physiology of phases of sexual functioning, and later highlighted the deleterious influence of performance anxiety, the impact of relationship factors, and the significance of biological factors on the development of sexual dysfunctions. Their work foreshadowed the later integration of medical and psychological interventions.
  7. 7. The neo- Masters and Johnson era heralded by the publication of Helen Singer Kaplan's book, The New Sex Therapy. Integrated psychoanalytical theory with Masters & Johnson's cognitive-behavioral understanding of sexual dysfunction. Distinguishing between recent and remote etiological causations, she recommended behavioral approaches for the former and reserved traditional psychodynamic methods for the latter.
  8. 8. The mid- 1980s current psychobiological era. This period is distinguished by the medicalization of treatment approaches, primarily for male sexual dysfunction. Scientific investigations of cellular chemistry have elucidated the pathophysiology of male sexual arousal problems and have led to the introduction of new oral treatments, such as sildenafil.
  9. 9. Components of sexuality Sexual identity: is a pattern of patient’s biological sexual characteristics Gender identity: individual sense of maleness/ femaleness, from infinite clues derived from experiences with family members, peers, teachers & cultural phenomenon. Established by age of 2 or 3 yrs. Sexual orientation: describes the object of person’s sexual impulses. Heterosexual, homosexual, or bisexual. Sexual behaviour: includes desire, fantasies, pursuit of partners, auto-erotic activities & activities engaged in to express & gratify sexual needs.
  10. 10. Modelling the human sexual response cycle Models have been constructed of the normal sequence of changes during sexual arousal and coitus. The first models described a simple sequence of increasing arousal and excitement culminating in rapid discharge by orgasm, displayed graphically as an ascent, peak, and then descent.
  11. 11. The EPOR model formulated by Masters and Johnson four-phase linear, sequential, and incremental model of the human sexual response cycle excitation (E) phase (stimuli from somatogenic or psychogenic sources raise sexual tensions), plateau (P) phase (sexual tensions intensified), orgasmic (O) phase (involuntary pleasurable climax), and finally resolution (R) phase (dissipation of sexual tensions).
  12. 12. Modifying the EPOR model into the DEOR model currently accepted model Robinson concluded convincingly that the P phase was simply the final stage of the E phase. Helen Kaplan, proposed that before the E phase there should be a ‘desire phase' (D phase). came from her work with women who professed to have no desire to be sexually aroused, even by their usual partners.
  13. 13. EPOR replaced by the desire, excitation, orgasmic, and resolution phase (DEOR) model. Sexual desire that appears to be spontaneous should obviously be placed at the beginning of the model but what of sexual desire created when the person is sexually aroused by another?
  14. 14. (a) the original EPOR model of Masters and Johnson (b) the DEOR model of Kaplan (c) the proposed modification with desire phase 1 (before initiation of the excitation phase and desire phase 2 during excitation phase) and (d) with added courtship behaviour
  15. 15. Phase I: Desire Psychological phase Characterised by sexual fantasies & conscious desire to have sexual activity. Can be biologically driven or result from a wish to bond sexually with a particular partner. Dysfunction: hypoactive sexual desire disorder, sexual aversion disorder, hypoactive sexual desire disorder due to general medical condition (man/ woman), substance induced sexual dysfunction with impaired arousal.
  16. 16. Phase II: Excitement Brought on by psychological stimulation (fantasy or presence of love object), physiological (stroking/ kissing) or combination. Consists of subjective sense of pleasure & objective signs of sexual excitement. Dysfunction: female sexual arousal disorders, male erectile disorders, male erectile disorder due to general medical condition, substance induced
  17. 17. Phase III: Orgasm Consists of peaking sexual pleasure, with release of sexual tension, & rhythmic contraction of perineal muscles & pelvic reproductive organ. Lasts for 3-15sec Dysfunction: female & male orgasmic disorders, premature ejaculation
  18. 18. Phase IV: Resolution Consists of disgorgement of blood from genitalia, which brings body back to its resting position. If orgasm occurs resolution is rapid, if not may take 2-6hrs & be associated with irritability & discomfort. Through orgasm it is characterised by sense of well being, general relaxation, muscular relaxation. Men have refractory period (mins-hrs), they can’t be stimulated to further orgasm. This does not exist in females. Dysfunction: postcoital dysphoria, postcoital headache.
  19. 19. The sexual response cycle
  20. 20. organ Excitement phase mental Several mins-hrs, heightened excitement before orgasm, 30sec-3min skin Inconsistent Sexual flush, maculopapular rash on abdomen spreads to ant chest wall, face& neck & include shoulders & forearm breasts Nipple erection (2/3rd ), venous congestion & areolar enlargement, size increases by 1/4th clitoris Enlargement in diameter of glans & shaft, just before orgasm shaft retracts into prepuce Labia majora Nullipara- elevate & flatten against perineum Multipara- congestion & edema Labia minora Size increase 2-3 times normal, change to pink, red, deep red before orgasm vagina Colour change to dark purple, transudate appears 10-30 sec after arousal, elongation & ballooning, lower third constricts before orgasm uterus Ascends into false pelvis, labor like contractions begin in heightened excitement just before orgasm others Myotonia Mucoid secretion from bartholin’s gland during heightened excitement Cervix swells slightly & is passively elevated with uterus
  21. 21. organ Excitement phase Mental Several mins-hrs, heightened excitement before orgasm 30sec-3min Skin Just before orgasm, inconsistent Sexual flush, maculopapular rash on abdomen spreads to ant chest wall, face& neck & include shoulders & forearm Penis Erection in 10-30 sec caused by vasocongestion in erectile bodies of corpus cavernosa of shaft, loss of erection may occur with introduction of asexual stimulus ( loud noise), with heightened excitement size og glans & diameter of penile shaft increase further Scrotum & testes Tightening & lifting of scrotal sac & elevation of testes, 50% increase in size of testes over unstimulated state & flattening against perineum, signalling impending ejaculation Cowper’s gland 2-3 drops of mucoid fluid that contain viable sperm are secreted during heightened excitement. other Breasts- inconsistent nipple erection Myotonia- semispastic contractions of facisl, abdominal & intercostal muscles Tachycardia- upto 175 beats/min BP- rises to 20-80mm systolic & 10-40 diastolic Respiration - increased
  22. 22. Sexual stimulation Nitric oxide synthesized in nerve and vascular tissue of penis/clitoris Nitric oxide activates guanylate cyclase GTP  cGMP cGMP relaxes smooth muscles of corpus cavernosum and arterioles in penile/clitoral tissue Vasocongestion of penile/clitoral tissues
  23. 23. Neuroanatomy: Central Cortical: orbitofrontal (sexual emotions), left anterior cingulate (hormone control and sexual arousal) Subcortical: right caudate (sexual activity) Limbic: Hippocampus, amygdala, septum, medial preoptic area, fimbria, anterior thalamic nuclei, mammillary bodies (Chemical or electrical stimulation elicited penile erection)
  24. 24. Brainstem: nucleus paragigantocellularis, other serotonergic nuclei exert inhibitory and excitatory control over spinal sexual reflexes projects directly to pelvic efferent neurons in the lumbosacral spinal cord, apparently causing them to secrete serotonin, which is known to inhibit orgasms Spinal cord: receives sensory inputs; reflex centre in lumbosacral area. sexual arousal and climax are ultimately organized at the spinal level.
  25. 25. Neuroanatomy: Peripheral Parasympathetic Pelvic splanchnic nerves Roots S2, S3, S4 Reflex impulses Synergy for erection Sympathetic Hypogastric plexus Psychological impulses Ejaculation Orgasm
  26. 26. Neurochemistry Dopamine: increases libido and sexual activity Acetylcholine: important for erection Norepinephrine: erection, ejaculation, orgasm Serotonin: complex role. produced in the upper pons and midbrain is presumed to have an inhibitory effect on sexual function. Oxytocin: orgasm, reinforce pleasurable activities
  27. 27. Neurochemistry Prostaglandins: penile erection Nitric oxide: penile erection, ? female genital response Vasoactive intestinal polypeptide: arousal in both men and women
  28. 28. Endocrinology Testosterone: libido in both genders In men, stress is inversely correlated with testosterone blood concentration. Other factors, such as sleep, mood, and lifestyle, influence circulating levels of the hormone. Oxytocin: enhances sexual activity and levels in both sex increase during orgasm Oestrogen: maintains the integrity of the female genital tract GnRH (LHRH): pulsatile release Others: prolactin, thyroid hormones, adrenal steroids
  29. 29. A more simple classification Pleasure inhibitors, or sexual dysfunctions – disorders occurring in the context of a “normal” sexual response or behaviour. Pleasure facilitators, or paraphilias – in which deviations from normal erotic stimuli and activities are obligatory for sexual arousal and response.
  30. 30. Sexual dysfunctions: following the response cycle Disorders of desire Disorders of arousal (excitement) Disorders of orgasm (Though disorders of resolution exist, they have not been considered in the nosology)
  31. 31. Sexual dysfunctions: outside the cycle Sexual pain disorders – dyspareunia and vaginismus Sexual dysfunction, NOS: Compulsive sexual behaviour (addiction) Postcoital dysphoria, Postcoital headache Nymphomania / satyriasis Distress over sexual orientation Orgasmic anhedonia If they are attributable entirely to a general medical condition, substance use, or adverse effects of medication, then sexual dysfunction due to a general medical condition or substance-induced sexual dysfunction is diagnosed.
  32. 32. SEXUAL AROUSAL DISORDERS: DSM IV TR: 1. Female sexual arousal disorders 2.Male erectile disorder ICD-10: Failure of genital response
  33. 33. DSM-IV-TR Diagnoses DSM-IV-TR specifies three criteria for each sexual dysfunction. The first criterion describes the psycho-physiologic impairment; for example, absence of sexual desire, arousal, or orgasm. The second requires that the patient have marked distress or interpersonal difficulty as a result, while The third asks the clinician to ascertain that some other Axis I diagnosis, medical illness, medication, or substances of abuse does not best explain the problem.
  34. 34. DSMIV- TR gives the clinician additional latitude for deciding when a person who meets the first criterion qualifies for a disorder. The doctor is asked to consider the effects of the individual’s age, experience, ethnicity and cultural background, the degree of subjective distress, adequacy of sexual stimulation, and symptom frequency.
  35. 35. MALE ERECTILE DISORDER/ ERECTILE DYSFUNCTION/ IMPOTENCE. DSM IV TR: A.Persistent or recurrent inability to attain, or maintain until completion of sexual activity, an adequate erection B.Disturbance causes marked distress or interpersonal difficulty. C.Not better accounted for by another axis I disorder not due to direct physiological affect of drug or general medical condition.
  36. 36. Specify type: Life long type : Acquired type. Specify type: Generalized type : Situational type. Specify: Due to Psychological factors : Due to combined factors.
  37. 37. ICD-10 F52.2 Failure of Genital Response In men, the principal problem is erectile dysfunction. In women, the principal problem is vaginal dryness or failure of lubrication. Includes: Female sexual arousal disorder : Male erectile disorder : Psychogenic Impotence.
  38. 38. ICD-10: A. General criteria must be met- G1- subject is unable to participate in a sexual relationship as he/she would wish G2- dysfunction occurs frequently but may be absent on some occasions. G3- The dysfunction has been present for at least 6 months. G4- The dysfunction not entirely attributable to any of the other mental & behavioural disorders, physical disorders, drug treatment.
  39. 39. B. Erection sufficient for intercourse fails to when it is attempted. Dysfunction takes one of the following form- 1. Full erection occurs during the early stages of love making but disappears or declines when intercourse is attempted (before ejaculation if it occurs) 2. Erection does occur but only at times when intercourse is not being considered 3. Partial erection, insufficient for intercourse occurs but not full erection 4. No penile tumescence occurs at all.
  40. 40. Erectile dysfunction Erectile dysfunction is defined as the consistent inability to achieve and or maintain an erection of the penis sufficient for satisfactory sexual activity. Epidemiology: 2-4% at 35yrs & 77% at 80yrs ( Kinsey) The chief complaint of men below 35 & 50% of all men treated for sexual disorders is erectile dysfunction.
  41. 41. Pathophysiology Normal erection – delicate balance between vasoconstriction & vasorelaxation of corporal smooth muscle. If a critical level of relaxation is not achieved, there will be incomplete resistance to the outflow of blood from the corpora & a spectrum of penile tumescence will range from flaccidity to near but not complete erection. ED due to incomplete corporal smooth muscle relaxation- veno-occlusive dysfunction.
  42. 42. Aetiology 1)Psychological causes: -Performance anxiety, -Relationship conflicts/loss of attraction -Sexual inhibition, Guilt -Widower’s syndrome. -Conflicts over sexual preference -Sexual abuse in childhood -Depression, Fear of pregnancy or STDs .
  43. 43. 2)Vascular: i)Atherosclerosis: Penis has more vascular smooth muscle than any other organ in the body.Atherosclerosis occurs here early. ED may be a reflection of vascular disease elsewhere prior to it becoming clinically evident. ii) CAD & CVAs, iii)Hypertension, cardiac failure iv)Dyslipidaemia. HDL-Cholesterol: inverse relation. v)Peripheral vascular disease,
  44. 44. 3)Endocrinological causes: DM, Dysfunction of the pituitary-adrenal-testis axis, Hyperthyroidism, Myxedema ,Hyperprolactinemia, Hypogonadism, Low GH, Acromegaly, Addison's disease DIABETES AND ERECTILE DYSFUNCTION Psychogenic: Anxiety. Neurogenic : Loss of sensory & autonomic nerves. Arterial: Small vessel disease. Venous: Cavernous myopathy, endothelial dysfunction.
  45. 45. others Renal and urological disorders Peyronie's disease, CKD, Hydrocele & varicocele Hepatic disorders Cirrhosis (usually associated with alcohol dependence) Pulmonary disorders - Respiratory failure Infectious and parasitic diseases Elephantiasis, Mumps Genetic disorders - Klinefelter's syndrome Congenital penile vascular and structural abnormalities (Epispadias)
  46. 46. Neurogenic etiology Neurological disorders Multiple sclerosis, Tumours, CVA, Encephalitis, Dementia,Transverse myelitis Parkinson's disease, Temporal lobe epilepsy, Traumatic and neoplastic spinal cord diseases, ALS Peripheral neuropathy, General paresis,Tabes dorsalis, Disc herniation
  47. 47. Surgery or trauma Neurological: head trauma/surgery, spinal cord trauma/surgery, Retroperitoneal lymphnode dissection. Vascular: Aorto-iliac bypass, Aorto-femoral bypass. Gastro-intestinal: Abdomino-perineal resection, Proctocolectomy. Pelvis: trauma, irradiation, pelvic lympahadenectomy. Urological : prostatectomy.
  48. 48. Recreational drugs i) Nicotine, Alcohol. ii)Cannabis iii)Amphetamines: vasoconstriction of genital tissue.  Increases libido ,Erectile failure;  prolonged erection (up to 18 hours!)  iv)Ecstacy: Erection: impaired in 40% v) other dependence-inducing substances (heroin, methadone, morphine, cocaine, barbiturates)
  49. 49. Drugs Accounts for 25% Thiazide diuretics are the most common cause of ED. i)Diuretics: Thiazides, Spironolactone(anti-androgen activity). ii)Anti-hypertensives: CCBs, methyldopa,clonidine,beta-blockers. - act directly at the corporal level or indirectly by decreasing the systemic B.P. iii)Cardiac: Digoxin(Na-K ATPase blockade),clofibrate.
  50. 50. iv)H-2 antagonists: Cimetidine,Ranitidine (anti- androgen activity). v)Hormones: Estrogens,Progesterone,Corticosteroids, Cyproterone acetate,5-alpha reductase inhibitors,LHRH agonists. vi) Cytotoxic drugs: Cyclophosphamide, Methotrexate.(by causing hypogonadism). vii)Others:Anticholinergics,Anti-convulsants
  51. 51. Psychotropics and sexual dysfunction Antipsychotics: lack of libido, ED Mood stabilizers: rare Tricyclics: retrograde ejaculation, ED, orgasmic difficulties SSRIs: lack of libido, arousal disorders, delayed ejaculation Benzodiazepines: not clear Anticholinergics: failure of vaginal lubrication, ED
  52. 52. i) Aging: ED is 4times higher im men in 60s than in 40s. ii)Arsenic poisoning- alteration in K-gated pump, plumbism, herbicides iii)haematological: sickle cell anaemia,leukaemia. iv)nutritional : malnutrition, zinc deficiency. v)Bicycling: A study done in 2002 found that the No. of hours on a bike &/or pressure on the penis from the saddle of an upright bicycle is directly related to ED.
  53. 53. Clinical evaluation 1)History 2)Physical exmination. 3)Psychological assessment. 4)Tests
  54. 54. History The first step in the management- sexual, medical, and psychosocial history. A sensitive topic, and the clinician must be sensitive to the patient's comfort level. Taking the history provides an opportunity for the physician to initiate patient and partner education about ED and its treatments and to facilitate communication.  It also allows the physician to establish a rapport with the couple, which assists in treatment
  55. 55. questionnaires: IIEF –International Index of Erectile Function. SHIM -Sexual Health Inventory for Men. Arizona Sexual Experience Scale, Brief Sexual Function Questionnaire, Changes in Sexual Functioning Questionnaire, Derogatis Sexual Function Inventory, Rush Sexual Inventory.
  56. 56. Organic causes – characterized by an insidious & consistent change in rigidity or inability to sustain morning, coital,or mastubatory-related erections. Also enquire about: penile sensation, penile curvature, altered libido, partner’s sexual function & others psychological factors. Obtain information about current medications, any history of pelvic surgery, trauma, prior prostate surgery, or radiation to the prostate.  substance use should be documented.
  57. 57. Physical examination A physical examination is necessary for every patient, with particular emphasis on the genitourinary, vascular, and neurologic systems. The physical examination may corroborate history findings and reveal unsuspected physical findings, such as penile plaques, small testes, evidence of possible prostate cancer, prostate infections, or hypertension, thyroid dysfunction,serious cardiovascular pathology,end-stage kidney disease. All peripheral pulses should be measured.
  58. 58. Psychological assessment The main diagnostic feature of psychogenic ED vs selective ED. The man is able to produce rigid, long-lasting erections during the night or early mornings, with certain partners, in response to magazines or videos, but not while attempting intercourse with his wife. Underlying relationship problems are the cause and they must be addressed.
  59. 59. Tests 1)Nocturnal Penile Tumecsence(NPT) Useful in distinguishing psychogenic ED from Organic. Erections occur during REM sleep. A band is placed around the penis. Patient is asked to wear it on 2-3 successive nights. Sleep can be monitored by polysomnography
  60. 60.  There are 2 methods: i)Snap-Gauge band:Velcro band fitted around the penis. Shotrcomings: lack of information regarding partial rigidity, No.of erections & duration of erections. ii) Rigi scan:Home- monitoring device, capable of continuously monitoring penile circumference & rigidity. Logging unit- strapped to the patient’s thigh& 2 loops placed around the base &tip of the penis just behind the corona.
  61. 61. 2)Vascular studies: i)Intra –cavernous vaso-active drug injection: A positive test – rigid erectile response(unable to bend) ,that appears within 10mins after the intracavernous injection(of 20mcg of PGE1 or papaverine)& lasts for 30mins. A positive response indicates- functional origin. Limited use ii) Duplex ultrasound of penile arteries: Measurements are compared between flaccid & pharmacological erect penis. Color doppler can also be used.
  62. 62. iii) Arteriography & Dynamic Cavernosometry or Cavernosography(DICC): Used to detect failure of veno-occlusive mechanism. Cavernosography using radiographic contrast enables the detection of potential leakage into all penile venous drainage systems.  iv)Penile angiogram  v)Digital subtraction angiography  vi)Magnetic Resonance Angiography
  63. 63. 3)Neurological studies: i)Bulbo-cavernous reflex latency: The physician squeezes the glans of the penis,which immediately causes the anus to contract, if the nerve function is normal. The latency between sqeeze & contraction is measured by observing the anal spincter or feeling it with a gloved finger inserted past the anus. ii) Nerve conduction Studies
  64. 64. iii)Penile Biothesiometry: A small electro-magnetic test probe is placed on the right & left of the shaft and on the glans. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence.
  65. 65. 4)Endocrinological studies: Testosterone,prolactin,FSH,LH,GH. 5)Other tests: Fasting glucose & lipid profile, PSA,psychodiagnostic tests.
  66. 66. PLISSIT: a simple model for routine practice (Annon) P – permission LI – limited information SS – specific suggestion IT – intensive therapy
  67. 67. PLISSIT: a simple model for routine practice
  68. 68. Treatment 1)Psychotherapy 2) Non-pharmacological methods 3)Vacuum devices 4)Pharmacotherapy: topical, injectales, oral. 5) Surgery.
  69. 69. Management: psychotherapies Dual sex therapy developed by Masters & Johnson (Sensate Focus) Behavioural therapy (assumes sexual dysfunction as learned maladaptive behaviour) Hypnotherapy Group therapy Psychodynamic therapy Integrated therapy (sex therapy integrated with supportive, psychodynamic, insight oriented psychotherapy)
  70. 70. Nonpharmacologic Treatment Options 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
  71. 71. Vacuum devices: Can be used by almost all patients with ED. These devices exert a negative pressure on the penis, which results in an increase in corporeal blood flow & erection. The time taken to achieve erection -2-30mins.
  72. 72. Pharmacotherapy 1) Prostaglandin delivery systems: intra-cavernosal : intraurethral 2) Transdermal delivery. 3) Other intracavernosal & transdermal drugs 4) Oral therapies
  73. 73. Intra cavernosal PGE1 Caverject: injectable form of Alprostadil. Administration: i)reconstitution of the powder of the drug. ii)The skin over the penis should be pulled taut & the needle & syringe are held at right angles to the penis iii)The drug should be injected directly into one corpus cavernsum,avoiding visible veins;the injection site should be alternated between the cavernosa .
  74. 74. Side-effects: Pain, Prolonged use- corporal fibrosis. Priapism. Containdications: Known hypersensitivity to the drug. Patients with conditions that predispose to priapism. E.g; sicle cell anemia, multiple myeloma, leukemia. Other drugs: i)Moxisylte- selective alpha-1 blocker. ii)Vasoactive intestinal polypeptide.
  75. 75. Intra urethral PGE1 Alprostadil administered using MUSE(Medicated Urethral System for Erection) It is rapidly absorbed from the urethral mucosa. Usual onset of action:20mins & erections last for 30-60min..
  76. 76. Transdermal delivery Minimizes systemic exposure & tissue traumatization. Administration of vaso-active substances(PGE1) across the skin to the penis. Others: Testosterone patches. 1-2 patches containing 2.5-5mg of testosterone applied daily to the abdomen, back thighs or upper arms.
  77. 77. PDE5 Inhibitors Mechanism of Action: • PDE inhibitor and increases the cGMP that promotes and sustains smooth muscle relaxation Indications: • Psychogenic ED • Mild vasculogenic ED • Neurogenic ED • Side effects from medication(s) patient is already taking
  78. 78. Mechanism of Action of PDE5 Inhibitors .. SM
  79. 79. DRUG SILDENAFIL VARDENAF IL TADALAFIL RELEASED IN MARCH 1998 APRIL 2003 FEBRUARY 2003 ONSET OF ACTION 30 min 25-45min 30min DURATION OF ACTION 5hrs 6hrs 36hrs SIDE- EFFECTS Headache , flushing, bluish vision and nasal congestion Headache, flushing and nasal congestion Headache, myalgia, dyspepsia. Backache,nasal congestion CONTRAINDI CATION Nitrates Nitrates Nitrates, Angina, Hypertension,
  80. 80. Medication (Yohimbine, Yocon, Erex, Yohimex) • Alpha 2 andrenoreceptor antagonist • Dose: 5.4 mg TID • Results: ~20% (same as placebo) • Side effects: increase blood pressure, tachycardia, anxiety
  81. 81. Medication Trazodone(Desyrel) • Anti-depressant associated with priapism • Mechanism of action not fully understood • Not FDA approved for ED • Side effects: drowsiness, dry mouth, sedation, priapism
  82. 82. Medication Apomorphine (Spontane) • Dopaminergic mechanism with hypothalamic activity • Sublingual administration • 64% to 67% response rate with ED • Side effects: nausea, sweating, hypotension, yawning • Awaiting FDA approval
  83. 83. Medication Phentolamine (Vasomax) • Alpha-blocker • Relaxes smooth muscle tissue • 40% efficacy in mild organic ED • Side effects: nasal congestion, tachycardia, dizziness, hypotension • Awaiting FDA approval
  84. 84. Surgery 1)Venous leakage: 2 approaches are adopted: i) ligation of all veins draining to the penis i.e deep dorsal,cavernosal & crural veins. ii)ligation & division of the deep dorsal vein. 2)Arterial revascularization. 3)Peyronie’s disease: The Horton – Devine procedure. : The Nesbit procedure.
  85. 85. PENILE PROTHESIS 2 types: i)Semi-rigid rods Consists of 2 rod-like cylinders that are implanted into the corpora cavernosa Types: Malleable & Mechanical rods ii) Inflatable Cylinders. Unitary, Two-piece, Three piece
  86. 86. Penile prosthesis Penile prosthesis has highest satisfaction ~93%  Infection rate: ~2% virgin & 4% diabetic Malfunction rate ~10% at 10years  Surgical Procedure – Requires Anesthesia – Takes approximately 90 min.
  87. 87. An innovative drug-delivery system – nanoparticles encapsulating NO or prescription drugs – shows promise for topical treatment of ED, -Science Daily (Sep. 20, 2009) A study done by Dr.Yoram Vadi in Nov 2009, showed that 75% of men suffering from ED, treated with shock-wave therapy showed a return of erectile functioning.(release of VEGF- stimulates the growth of new blood vessels in the genital area).
  88. 88. Treatment of antidepressant- induced sexual disorders Drug holidays Switching – mirtazapine, bupropion, nefazodone Psychological interventions Sildenafil Others – dopamine agonists, cyproheptadine, amantadine, buspirone
  89. 89. FEMALE SEXUAL AROUSAL DISORDERS: DSM IV TR: A.Persistent or recurrent inability to attain, or maintain until completion of sexual activity, an adequate lubrication swelling response. B.Disturbance causes marked distress or interpersonal difficulty. C.Not better accounted for by another axis I disorder not due to direct physiological affect of drug or general medical condition. Specify: lifelong/ acquired type, generalised/ situational, due to psychological factors or combined factors.
  90. 90. ICD-10: A.General criteria must be met- G1- subject is unable to participate in a sexual relationship as he would wish G2- dysfunction occurs frequently but may be absent on some occasions. G3- The dysfunction has been present for at least 6 months. G4- The dysfunction not entirely attributable to any of the other mental & behavioural disorders, physical disorders, drug treatment.
  91. 91. B. There is failure of genital response, experienced as failure of vaginal lubrication, together with inadequate tumescence of the labia. Dysfunction takes place one of the following forms: 1. General: lubrication fails in all relevant circumstances 2. Lubrication may occur initially but fails to persist for long enough to allow comfortable penile entry. 3. Situational: lubrication occurs only in some situations (with one partner not another, during masturbation, when vaginal intercourse is being contemplated.
  92. 92. Women with excitement phase dysfunction often have orgasmic problems as well. May be associated with dyspareunia or lack of desire. Studies shown 14-16% women having chronic lubrication difficulties & 23% with intermittent problems. Postmenopausal- 44% Less research on physiological components of dysfunction in women than men
  93. 93. Masters & johnson found normally responsive women to desire sex premenstrually. Another set of dysfunctional women found felt the greatest sexual excitement at the time of ovulation Evidence indicates dysfunctional women are less aware of physiological responses in their bodies, like vasocongestion during arousal.
  94. 94. Causes of female sexual arousal disorder Classified as: 1)Psychological domain. 2)Physical domain. Psychological factors: i)Impact of events during childhood and adolescence. - studies have shown some probative links between chidhood sexual abuse & sexual dysfunction in later life.
  95. 95. ii) Individual factors: Stress & fatigability. Over-exposure to pornography & style media which is thought to lead to poor body image, self- consciousness and lowered self esteem. - Psychiatric disorders like depression, anxiety, OCD, PTSD. iii)Relationship factors:
  96. 96. Physical factors: 30-80% of the cases. Circulatory & neurological disorders are the most likely causes of sexual dysfunction. i)Circulatory: HTN, CAD. Damage to blood vessels decreases blood flow damage to nerves in pelvic area diminishes arousal. ii)General medical condition: Diabetes, Anaemia. iii)Hormonal: Low level of sex hormones , due to aging(menopause) Thyroid dysfunction, disorders of adrenal gland etc.
  97. 97. iv)Recreational drugs: alcohol,smoking. v)Medications: Anti-depressants, Anti-psychotics, Sedatives, Anti-hypertensives, OCPs & Other hormone containing pills. vi)Post baby coolness: Extreme loss of lidido after childbirth.
  98. 98. Role of Male Circumsicion The `valve' mechanism of foreskin of uncircumcised penis is thought to retain the natural lubrication provided by the female because the bunched up foreskin acts to block the lubrication escaping from the vagina, which results in dryness.
  99. 99. Persistent sexual arousal syndrome in women Infrequent, distressing and perplexing not only because of its mysterious onset, but also because of the feelings of shame and discomfort that accompany the phenomenon. persistent feelings of vaginal congestion and other physical signs of sexual arousal in the absence of any awareness of sexual desire provoking or accompanying this arousal or persisting for hours after attaining orgasm.
  100. 100. Interventions 1)PsychologicalTreatment Education about anatomy, Physiology and expectations. couples therapy. Masters & Johnson-sensate focus. progressive levels of touching, starting with non-sexual, sexual and sexual intercourse. CBT: uses thought records to capture the cognitions that accompany emotions.
  101. 101. 2)Lubricants: Helps in vaginal dryness & the resulting dyspareunia. 3)Pharmacotherapy: i)Sildenafil: Dose: 50-100mg/day. Found to be superior to placebo in effects of arousal. ii)The Non- SSRI: Bupropion Especially in those with SSRI induced dysfunction. Dose: 300-400mg/day
  102. 102. 4)Hormonal: Providing exogenous source of hormones ameliorate vasomotor symptoms in menopausal women. Women with vaginal atrophy & donot wish to take systemic therapy – topical estrogen creams.  Transdermal delivery: Natural progestin containing creams combined with estrogen. Tibolone: Synthetic steroid sex hormone.Superior to HRT.
  103. 103. 5)Clitoris Vacuum therapy: A small ,handheld device ,connected by a tubing to a small ,soft plastic cup, that is placed over the clitoris. When gentle vacuum is created , blood flow to the genitalia causes genital engorgement, increased vaginal lubrication & enhanced ability to achieve orgasm. May be used prior to having intercourse or 3-4times a week to rehabilitate sexual responses.
  104. 104. 6)Others: i)Topical vasodilators: PGE1- increases genital arousal. ii)Dopamine agonists – increases sexual interest, orgasm & improves patient-partner sexual satisfaction. 7) Alternative medicine: Natural estrogens such as soya products. Belladona ,ginkgo biloba etc. Prognosis: Generally once a woman seeks the appropriate help they are quite likely to find a way to resolve their problem.
  105. 105. CONCLUSION: Sexual arousal disorders are quite common & very distressing both in men & women but appears to be high in men causing distress to both partners & causing interpersonal problems. Hence early detection & treatment should be our goal as successive episodes are reinforcing and cause anticipatory anxiety perpetuating the problem. Arousal disorders are usually not diagnosed or treated in women as they rarely seek treatment.
  106. 106. Thank u Men look for youthfulness and physical attractiveness, smooth complexion, optimum stature, and good physique, and they value virginity and chastity. Partner variety is highly desired. Women, look for high-quality mates with abundant resources and emotional and financial status and security.

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