sexual dysfunction

2. • Introduction
• Factors affecting sexuality
• Benefits of sexuality
• Definition of sexual dysfunction
• Sexual Response cycle
• Disorder of Sexual response cycle
• Evaluation
• Paraphilias
• Conclusion

3. SEXUAL DYSFUNCTION

4. Introduction
• Sexual activity is a basic human right and an
integral part of life
• Problems related to sexual function may affect
the sense of personal satisfaction, reduce the
quality of life (QoL) and therefore have a
negative impact on the health of the person

5. Introduction
• Sexual dysfunctions are not uncommon in clinical
practice.
• Discussing these issues are embarrassing for the
individuals, and this compounded if the clinician
is also uncomfortable.
• The essential feature is inhibition in one or more
of the phases of the sexual cycle.

6. Introduction
• These disorders are diagnosed only when they are a
major part of the clinical picture.
• These disorders are frequently associated with other
mental disorders such as depression, anxiety,
personality disorders and schizophrenia.
• With the exception of premature ejaculation and
anorgasmia, in many cases it may be diagnosed in
conjunction with another psychiatric disorder; in other
cases, however, it is one of many signs or symptoms of
the psychiatric disorder.

7. Introduction
Sexuality determined by:
• Anatomy
• Physiology
• Psychology
• Culture
• Relationship
• Developmental experience
Virginia Sadock (2000)

8. Sexuality
Neurologic,
vascular and
endocrine
systems
Family,
societal and
religious
beliefs
Aging, health
status and
personal
experience

9. BENEFITS OF SEXUALITY
• Sex as exercise burns calories to produce
health benefits.
• Sex also relieves stress.
• Boosts the immune system with higher levels
of immunoglobulin A.
• Improves cardiovascular health.
• Increases self-esteem.

10. BENEFITS OF SEXUALITY
• Improves intimacy.
• Reduces pain by production of the hormone
oxytocin.
• Reduces the risk of prostate cancer
• Strengthens pelvic muscles and urinary
bladder control
• Promotes good sleep.
• Sex also improves the sense of smell.

11. Sexual dysfunction
• Difficulties that occur during the sexual response cycle
that prevent the individual from experiencing
satisfaction from sexual activity.
• Clinical conditions characterized by abnormalities of
sexual desire and psycho-physiological modifications of
the sexual response cycle, causing considerable distress
and interpersonal difficulties
• Lifelong (primary) or acquired (secondary)
Situational or generalized

12. EPIDEMIOLOGY
PROBLEM A MALE FEMALE
Reduced libido 30% 40%
Arousal difficulties 50% 60%
Reaching orgasm too soon 15% 10%
Failure to have orgasm 2% 35%
Dyspaurenia 5% 15%

13. AETIOLOGICAL FACTORS
• PSYCHOLOGICAL
 Relationship problems
 Life stressors
 Anxiety/ depression
 Low self esteem
 Sexual performance anxiety
 Excessive self monitoring
 Feeling of guilt about sex
 Lack of knowledge about sexuality
 Previous significant negative sexual experiences

14. AETIOLOGICAL FACTORS
• ENVIRONMENTAL
 Fear of interruption
 Physical discomfort
• PHYSICAL
 Use of drugs or alcohol
 Medication side effects
 Medical disorders
 Pain or discomfort due to illness
 Feeling tired
 Recent childbirth

15. AETIOLOGICAL FACTORS
• FACTORS RELATED TO THE PARTNER
Sexual attractiveness (gender, physical
characteristics)
Evidence of disinterest
Constant criticism
Inconsideration
Inability to cope with difficulties
Sexual inexperience /poor technique
Preference for sexual activities that are
unappealing to the partner.

16. AETIOLOGICAL FACTORS
EFFECTS OF MEDICATION
Antihypertensive agents
 Diuretics, b blockers, alpha blockers
Antidepressants
 TCA 10- 30%), SSRI(30-60%)MAOI
Mood stabilizers
 Lithium (10-30%)
Anxiolytics and hypnotics
 Benzodiazepines
Antipsychotics (40-71%)
Hormonal agents
 Anabolic steroids, corticosteroids, estrogens

17. Sexual Response cycle
• This is a sequence of physical and emotional
phases that occur when an individual
becomes aroused or engages in sexually
stimulating activities.
• Penile-vaginal intercourse
• Masturbation
• Manual stimulation

18. Models of sexual response cycle
• Masters & Johnson EPOR
• Kaplan DAOR
• Whipple & Brash-McGreer S S S R
• Basson's M K E

19. Masters and Johnson's Four-Phase
Model

20. Sexual Response cycle
• DESIRE is defined by an interest in being
sexual and in having sexual relations by
oneself or with an appropriate partner.
• AROUSAL it refers to physiological, cognitive
and affective changes that serve to prepare an
individual for sexual activity (penile
tumescence and erection, vaginal lubrication,
expansion and swelling of the vulva)

21. Sexual Response cycle
• ORGASM refers to climatic phase with release
of sexual tension and rhythmic contraction of
the perineal muscles and reproductive organs.
• RESOLUTION is the sense of muscular
relaxation and general wellbeing

22. Current model of the female sexual
response cycle.

23. Phase 1:
Excitement
• Muscle tension increases
• Heart rate
• Breasts become fuller and Nipples
become hardened or erect
• Blood flow to the genitals increases
•Swelling of the woman's
clitoris and labia minora (inner
lips)
•Erection of the man's penis
•The man's testicles swell, his
scrotum tightens
•Vaginal lubrication begins

24. Phase 2: Plateau
• Both males and females experience powerful
surges of sexual excitement or pleasure
• The changes begun in phase 1 are intensified
• Breathing, heart rate, and blood pressure
• Muscle tension and spasm increases
• The man's testicles are withdrawn up into the
scrotum
• The vagina continues to swell from
increased blood flow

25. Phase 3: Orgasm
• The orgasm is the climax of the sexual response
cycle
• Involuntary muscle contractions begin
• In women, the muscles of the vagina and uterus
undergo rhythmic contractions
• In men, rhythmic contractions of the muscles at the
base of the penis result in the ejaculation of semen
• Blood pressure, heart rate, and breathing are at
their highest rates
• Muscles in the feet spasm

26. Phase 3: Orgasm

27. Phase 4:
Resolution
• The body slowly
returns to its normal
level of functioning
• Swelled and erect
body parts return to
their previous size and
color
• General sense of
well-being,
enhanced intimacy,
often, fatigue

28. Sexual Dysfunction
Male
• Desire
• Arousal
• Orgasmic
Female
• Sexual Interest/Arousal
Disorder
• Orgasmic disorder
• Genito-Pelvic
Pain/Penetration Disorder
Desire; arousal; orgasm; sexual pain with personal
distress being a criterion for dysfunction

29. Sexual desire disorder
Hypoactive sexual desire
disorder
• It is characterized by a
persistent or recurrent
deficiency or absence of
sexual fantasies and
desire for sexual
activities
Sexual aversion
disorder
• Persistent or recurrent
extreme aversion to,
and avoidance of all
sexual contacts with a
sexual partner

30. Arousal disorder
Female sexual arousal
disorder
• Persistent or recurrent
partial or complete failure
to attain or maintain the
lubrication swelling
response
Male Erectile disorder
• Persistent or recurrent
inability to attain or
maintain an erection to
perform the sex act

31. Orgasmic disorders
• This is characterized by the persistent or
recurrent delay in, or absence of orgasm
following a normal sexual excitement phase.
Either by coitus or masturbation
• Primary
• Secondary

32. Female Orgasmic disorders
• Only 50% of women experience orgasm during
adolescence
• 95% of women older than 35yrs have achieved
orgasm
• 46 % of women encounter difficulty in
reaching orgasm

33. Male Orgasmic disorders
• Disorders of ejaculation are the most common
sexual dysfunctions experienced by men
• Early ejaculation before or shortly after
penetrating the vagina (premature
ejaculation)
• Ejaculation into the bladder (retrograde
ejaculation)
• Inability to ejaculate (anejaculation)

34. Sex Pain Disorders
• Superficial and deep
• Superficial pain: occurs with attempted
penetration.
• Deep pain: related to thrusting.
• The involuntary contraction of the muscles of
the outer one third of the vagina, is often
related to sexual phobias or past abuse or
trauma

35. EVALUATION
• Evaluation of sexual complaints may be
limited by
 time constraints
Physician or patient discomfort
Difficulty with diagnosis
Lack of available referral services
 limited treatment options.

36. EVALUATION
• Both partners should be interviewed separately
and then together.
• An empathic, non judgmental, understanding
• Acknowledge the difficulty in talking about it
• Start with general issues before moving to
specific issues
• Be aware of sexual myths.
• Reassure that sexual problems are common and
mostly treatable `

37. A focused history
• Status of current relationships and sexual
activity
• Family and personal beliefs about sexuality
• Sexual trauma or abuse
• Medical and surgical history
• Medication use over-the-counter medications
and herbal supplements;
• Alcohol, tobacco, and illicit drug use
• Menstrual and reproductive

38. Physical examination
• A complete examination, including a focused
examination, can identify pathology
• Physical examination focuses on mental
status; blood pressure and peripheral pulse
measurements; and musculoskeletal, thyroid,
breast, and neurologic abnormalities.
• Pelvic examination

39. Laboratory evaluation
• Rarely helpful in guiding the diagnosis or
treatment of sexual dysfunction
• Fbc
• Fbs
• Lipid profile
• Hormonal assay
• Thyroid function test

40. Treatment
• Complicated by the lack of a single causative
factor
• Limited proven treatment options
• Physician unfamiliarity with available
treatments
• Patient education and therapy are the
foundation of treatment

41. Treatment
• Advice, information and reassurance
• Treat underlying cause
• Psychological (behavioral techniques, sex
therapy)
• Drug treatment (phosphodiestarase type 5
inhibitors) sildenafil
• Others (vacuum device, dilators)

42. SEX THERAPY
• It is a form of behavioral therapy .It owes much to the
work of Master and Johnson (1966) ‘sensate focus’
I. The partners are treated together
II. They are helped to communicate better about their
relationship
III. They receive lecture about the anatomy and physiology
of sexual intercourse
IV. They complete a series of graded tasks
It was found to be effective in the treatment of orgasmic
dysfunction in women, and erectile dysfunction in men

43. PATIENT EDUCATION
• Many women consider normal sexual function
to be the traditional desire-arousal-orgasm
process.
• Women may be reassured that normal sexual
functioning is widely variable
• Education about normal anatomy is another
important component in addressing sexual
concerns.

44. HYPOACTIVE SEXUAL DESIRE DISORDER
Female
• Non pharmacologic
treatment is aimed at
education, and treatment
of contributing factors.
• Therapy emphasizes
lifestyle changes such as
stress management,
adequate rest, and regular
exercise
• Pharmacologic treatment is
limited
Male
• Counseling
• Behavioral therapies
• Supplemental
testosterone

45. EXCESSIVE SEXUAL DESIRE
• Referred to as
nymphomania (in women)
or satyriasis (in men)
• Usually seen in late
teenage/ late adulthood .
• It is seen in mania, early
stages of dementia, learning
disability, brain injury or
side effects of medications
(androgens, dopamine
agonist,methamphetamine)
• Treatment is directed at the
primary problem
• Psychological; psychotherapy,
group therapy, couples and
family therapy.
• Medications; antidepressants
(SSRI), Anti androgens, LHRH,
mood stabilizers, naltrexone.
• Support /self help groups

46. SEXUAL AVERSION AND LACK OF
SEXUAL ENJOYMENT
• Strong negative feelings that
produces sufficient fear or
anxiety that sexual activity is
avoided
• Whereas in lack of sexual
enjoyment there is lack of
appropriate pleasure despite
normal sexual responses and
orgasm (commoner in women)
• It is related to complex
psychosocial factors, often
previous traumatic sexual
relationship
• TREATMENT
• Skilled experienced
therapist; Establishing
reasons for seeking help
may clarify sensible
outcome goals

47. FEMALE SEXUAL AROUSAL DISORDER
• It manifests as reduced vaginal lubrication.
• It may be due to inadequate foreplay, lack of
sexual interest, anxiety, or low estrogen levels
(typically related to menopause).
• It has no effective treatment.
• Although yohimbine (alpha antagonist), PDE 5
inhibitors are sometimes tried

48. MALE ERECTILE DISORDER
(failure of genital response)
• It is the inability to develop or sustain
an erection long enough for
satisfactory coitus.
• It may be primary or secondary
• It may be situational or total
• More common in older men
• Primary; low sex drive, anxiety about
performance, previous negative
sexual experiences
• Secondary; reduced sexual interest in
middle aged and elderly, loss of
interest in partner, anxiety,
depression, organic disease and its
treatment, alcohol, stress and
fatigue.
• MANAGEMENT
• Physical assessment to exclude
organic cause
• Measurement Penile tumescence and
blood flow using ultrasound
• General education and self help
exercises
• PDE 5 inhibitors are effective in 70%
of cases (Tsertsvadze et al 2009); side
effects such as headache, flushing,
dyspepsia and nasal congestion
• It has supplanted earlier Rx such as
intracavernosal injection, vacuum
devices and surgical implantation

49. FEMALE ORGASMIC DYSFUNCTION
• It is the most common sexual
complaint in women.
• Experience of orgasm is delayed or
does not occur at all, despite normal
sexual arousal and excitement.
• Primary vs secondary; situational vs
total
• It may be due to normal variation in
sexual drive, poor sexual technique,
lack of affection, tiredness,
depression, gynaecological problems,
sexual abuse, effects of medication
TREATMENT
• Education and behavioral method
can help the woman and her partner
to increase arousal and thus orgasm
• Sex therapy (sensate focus), kegels
pelvic floor exercises, use of sexual
fantasy and directed masturbation

50. MALE ORGASMIC DISORDER
• It is serious delay in, or
absence of ejaculation.
• Relatively Rare in men
• May be situational or
total
• May be caused by drugs
SSRI, MAOI,
antipsychotics
• TREATMENT
• Reduce performance
anxiety, increasing
arousal and physical
stimulation
• Address triggers and
relationship problems
• Use sensate focus

51. PREMATURE EJACULATION
• This is the inability to
control ejaculation
sufficiently for both
partners to enjoy sexual
interaction.
• More common in younger
than older men.
• It is often caused by fear
of failure
• TREATMENT
• For Psychological causes
;advice and reassurance
• Stop start technique
(semans technique),
squeeze technique,
sensate focus, kegels
exercises
• SSRIs are used

52. NON ORGANIC VAGINISMUS
• It refers to spasm of the
vaginal opening caused by
spasms of the pelvic floor
muscles.
• Usually related to anxiety
or fearful thoughts e.g.
fear of penetration,
previous sexual assault,
fear of sex, fear of
pregnancy and painful
labour
MANAGEMENT
• Physical examination of
the vagina
• Education
• Relaxation techniques
• kegel’s exercise
• Sex therapy techniques

53. NON ORGANIC DYSPAREUNIA
• It refers to pain on intercourse, and
implicitly relates to women, although
it can occur in men
• Pain in men is usually due to physical
factors (urethral infection, STD, tight
foreskin)
• In women, partial penetration may
be due to impaired lubrication, from
scars or from muscle spasms.
• Deep penetration may be caused by
endometriosis, ovarian cyst or
tumors, or pelvic infections
• MANAGEMENT
• Physical examination
• Information about
adequate arousal
• Relaxation techniques
(including kegels exercises)
and ‘positive self talk’

54. PARAPHILIAS
• Recurrent, Intense Sexually Arousing Fantasies,
Sexual Urges, or Behaviors Generally Involving:
– Nonhuman Objects
– Own or Partner’s Suffering or Humiliation
– Children or Other Non-consenting Persons
• Occurring Over a Period of at Least 6 Months
• Lead to Significant Distress or Impairment
– e.g., Are Obligatory, Result in Impairment, Legal or
Relationship Problems

55. PARAPHILIAS
• Exhibitionism
– Intense Sexually Arousing
Fantasies, Urges, or
Behaviors Involving
Exposure of One’s Genitals to
an Unsuspecting Stranger
• Fetishism
– …Involving the Use of
Nonliving Objects
Female Undergarments,
Shoes, Leather
• Frotteurism
– …Involving Touching and Rubbing
Against a Non consenting Person
• Pedophilia
– Intense Sexual Urges, Fantasies,
Behaviors Involving Sexual Activity
With a Prepubescent Child or Children
(Usually 13 or Younger)
– Person is at Least 16 Years and at
Least 5 Years Older Than the Child

56. PARAPHILIAS
• Sexual Masochism
– Intense Sexual Urges, Fantasies,
Behaviors Involving the Act (Real,
Not Simulated) of Being Humiliated,
Bound, Beaten, Made to Suffer
• Sexual Sadism
– …Involving the Psychological or
Physical Suffering of Another
• Transvestic Fetishism
– Intense Sexual Urges, Fantasies,
Behaviors Involving Cross-
Dressing
• Necrophilla
• Urophillia
• Voyerism
• Coprophilla
• Partialism
• Zoophilla

57. The role of a family physician in sexual
dysfunction.
• The Family Physician as a front-line doctor has
a holistic view of his patient
• Manages patients in the context of the family
• Best suited to handle most case of sexual
dysfunction
• Referring patients as appropriate but
maintains a co-coordinating role

58. SUMMARY
• Sexual dysfunction is common in family practice,
which can result from the psychiatric illness,
medication or as a result of drug abuse.
• As clinicians we must strive to explore the sexual
history of our patients, because of the secrecy
associated with such issues patient may not be readily
willing to discuss them.
• Always remember that sexuality is an important aspect
of human existence

59. Conclusion
• Family physicians must assume a proactive
role in the diagnosis and treatment of these
disorders
• Basic treatment strategies, can be successfully
provided by primary care physicians for most
sexual dysfunctions
• Referral can be reserved for patients who do
not respond to therapy.

60. • Letizia Bossini, et alSexual dysfunctions, psychiatric diseases and quality of life: A
review Available from:
https://www.researchgate.net/publication/266945147_Sexual_dysfunctions_psyc
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• S. Mimoun, K. WylieFemale sexual dysfunctions: definitions and classification
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61. THANK YOU