 Axis I disorders The syndromes listed are correlated with the sexual  physiological response, which is divided into the...
DSM-IV-TR Phases of the Sexual Response Cycle     and Associated Sexual Dysfunctions1. Desire: Distinct from any identifi...
DSM-IV-TR Phases of the Sexual Response Cycle     and Associated Sexual Dysfunctions2. Excitement: Subjective sense of se...
DSM-IV-TR Phases of the Sexual Response Cycle     and Associated Sexual Dysfunctions3. Orgasm: Peaking of sexual pleasure...
DSM-IV-TR Phases of the Sexual Response Cycle     and Associated Sexual Dysfunctions4. Resolution: A sense of general rel...
 The essential feature of the sexual dysfunctions is inhibition in  one or more of the phases, including disturbance in t...
 Sexual disorders can lead to or result from relational problems, and patients invariably develop an increasing fear of f...
Sexual Dysfunction Not Correlated with Phases of           the Sexual Response Cycle  Category                            ...
 In DSM-IV-TR, a sexual dysfunction is defined as a disturbance  in the sexual response cycle or as pain with sexual inte...
 Sexual dysfunctions can be symptomatic of biological  (biogenic) problems or intrapsychic or interpersonal  (psychogenic...
1. SEXUAL DESIRE DISORDERS two classes1. hypoactive sexual desire disorder,    characterized by a deficiency or absence ...
 Patients with desire problems often use inhibition of desire  defensively, to protect against unconscious fears about se...
 Equally,women may suffer from unresolved developmental conflicts that inhibit desire. Lack of desire can also result fr...
DSM-IV-TR Diagnostic Criteria for Hypoactive Sexual Desire DisorderA.Persistently or recurrently deficient (or absent) sex...
DSM-IV-TR Diagnostic Criteria for Sexual Aversion DisorderA.Persistent or recurrent extreme aversion to, and avoidance of,...
 Abstinence from sex for a prolonged period sometimes results in  suppression of sexual impulses. Loss of desire may als...
2. SEXUAL AROUSAL DISORDERS The sexual arousal disorders are divided by DSM-IV-  TR into…. female sexual arousal disorde...
Female Sexual Arousal Disorder The DSM-III-R defines female sexual arousal disorder in    terms of the physiological arou...
DSM-IV-TR Diagnostic Criteria for Female Sexual Arousal DisorderA.Persistent or recurrent inability to attain, or to maint...
Male Erectile Disorder Male erectile disorder is also called erectile dysfunction and impotence. Impotence is the chief ...
DSM-IV-TR Diagnostic Criteria for Male Erectile DisorderA.Persistent or recurrent inability to attain, or to maintain unti...
3. ORGASM DISORDERS
Female Orgasmic Disorder Also called inhibited female orgasm or anorgasmia defined as the recurrent or persistent inhibi...
 lifelong female orgasmic disorder    has never experienced orgasm by any kind of stimulation. acquired orgasmic disord...
 Some women equate orgasm with loss of control or with  aggressive, destructive, or violent impulses; their fear of  thes...
DSM-IV-TR Diagnostic Criteria for Female Orgasmic DisorderA.Persistent or recurrent delay in, or absence of, orgasm follow...
Male Orgasmic Disorder Also called inhibited orgasm or retarded ejaculation, a man achieves ejaculation during coitus wi...
 Lifelong  male orgasmic         disorder    indicates    severe  psychopathology.   A man may come from a rigid, purita...
DSM-IV-TR Diagnostic Criteria for Male Orgasmic DisorderA.Persistent or recurrent delay in, or absence of, orgasm followin...
Premature Ejaculation
 In premature ejaculation, men persistently or recurrently  achieve orgasm and ejaculation before they wish to. No defin...
 Some researchers divide men who experience premature ejaculation into   two groups:1.   those who are physiologically pr...
DSM-IV-TR Diagnostic Criteria for Premature EjaculationA.Persistent or recurrent ejaculation with minimal sexual stimulati...
4. SEXUAL PAIN DISORDERS
Dyspareunia Recurrent or persistent genital pain occurring in either men or women before, during, or after intercourse. ...
 Dyspareunia can also occur in men, but it is uncommon and is usually associated with an organic condition, such as herpe...
DSM-IV-TR Diagnostic Criteria for DyspareuniaA.Recurrent or persistent genital pain associated with sexual intercourse ine...
Vaginismus an involuntary muscle constriction of the outer third of the vagina  that interferes with penile insertion and...
DSM-IV-TR Diagnostic Criteria for VaginismusA.Recurrent or persistent involuntary spasm of the musculature of the outer th...
5. SEXUAL DYSFUNCTION DUE TO AGENERAL MEDICAL CONDITION
DSM-IV-TR Diagnostic Criteria for Sexual Dysfunction Due to a General MedicalA.Clinically significant sexual dysfunction t...
Male Erectile Disorder Due to aGeneral Medical Condition Side effects of medication can impair male sexual functioning in...
 Other diagnostic tests that delineate organic bases for  impotence include    glucose tolerance tests,    plasma hormo...
Diseases and Other Medical Conditions Implicated in Male Erectile DisorderInfectious and parasitic diseases  Elephantiasis...
Diseases and Other Medical Conditions Implicated in Male Erectile DisorderNutritional disorders  Malnutrition  Vitamin def...
Diseases and Other Medical Conditions Implicated in Male Erectile DisorderPharmacological factors Alcohol and other depend...
Dyspareunia Due to a GeneralMedical Condition Organic abnormalities leading to dyspareunia and vaginismus  include ….   ...
 Two conditions not readily apparent                   on   physical examination that produce dyspareunia are   Vulvar v...
Hypoactive Sexual Desire DisorderDue to a General Medical Condition Sexual desire commonly decreases after major illness ...
Neurophysiology of Sexual Dysfunction              DA     5-HT      NE       ACh            Clinical CorrelationErection  ...
Other Male Sexual Dysfunction Dueto a General Medical Condition When another dysfunctional feature is predominant (e.g., ...
 Male orgasmic disorder must also be differentiated  from retrograde ejaculation, in which ejaculation  occurs but the se...
Other Female Sexual DysfunctionDue to a General Medical Condition Some medical conditions (specifically, endocrine diseas...
Some Antipsychotic Drugs Implemented in Inhibited Female OrgasmTricyclic antidepressants Imipramine (Tofranil) Clomipramin...
6. SUBSTANCE-INDUCED SEXUAL DYSFUNCTION The diagnosis of substance-induced sexual dysfunction is used when     evidence o...
 In   small doses, many substances enhance sexual  performance by decreasing inhibition or anxiety or by  causing a tempo...
DSM-IV-TR Diagnostic Criteria for Substance-Induced Sexual DysfunctionA.Clinically significant sexual dysfunction that res...
Pharmacological Agents Implicatedin Sex Dysfunction Almost every pharmacological agent, particularly those used in  psych...
Diagnostic Issues with Sex and Some Antipsychotic DrugsDifferential diagnosis of Problem after drug therapy started or dru...
Antipsychotic Drugs impair erection and ejaculation, in which the seminal  fluid backs up into the bladder rather than be...
Lithium may reduce hypersexuality,Sympathomimetics Libido is increased; however, with prolonged use, men  may experience...
Anticholinergics produce dryness of the mucous membranes (including those  of the vagina) and impotence. However, amanta...
Alcohol women reporting increased libido after drinking small  amounts of alcohol. In men, that produces signs of femini...
7. SEXUAL DYSFUNCTION NOTOTHERWISE SPECIFIED     DSM-IV-TR Diagnostic Criteria for Sexual Dysfunction Not                 ...
Female Premature Orgasm no separate category of premature orgasm for women is included in DSM-IV-TR. A case of multiple ...
Masturbatory Pain Organic causes should always be ruled out;    a small vaginal tear    early Peyronies disease Should...
TREATMENT Classic psychodynamic theory holds that sexual inadequacy has its roots in early developmental conflicts, and t...
Dual-Sex Therapy treatment is based on a concept that the couple must be treated when a dysfunctional person is in a rela...
 The keystone of the program is the roundtable session in which a male and female therapy team clarifies, discusses, and ...
 Psychotherapy sessions follow each new exercise period, and problems and satisfactions, both sexual and in other areas o...
Specific Techniques and Exercises In cases of vaginismus, a woman is advised to dilate her vaginal  opening with her fing...
 A man with a sexual desire disorder or male erectile disorder is sometimes told to masturbate to prove that full erectio...
 In cases of lifelong female orgasmic disorder, the woman is  directed to masturbate, sometimes using a vibrator. The sh...
Hypnotherapy Hypnotherapists focus specifically on the anxiety-producing situation- that is, the sexual    interaction  th...
 Patients are also taught relaxation techniques to use on themselves before sexual relations. With   these methods to al...
Behavior Therapy Using traditional techniques, therapists set up a hierarchy of anxiety-  provoking situations, ranging f...
Group Therapy A therapy group provides a  strong support system for a  patient who feels ashamed,  anxious, or guilty abo...
 Groups for the treatment of sexual disorders can be organized in  several ways. Members may all share the same problem,...
Analytically Oriented Sex Therapy One of the most effective treatment modalities is the use of sex  therapy integrated wi...
Pharmacotherapy The major new medications to treat sexual dysfunction  are…..    sildenafil (Viagra) and its congeners; ...
sildenafil (Viagra) and its congeners   drug takes effect about 1 hour after ingestion, and its effect    can last up to ...
 Alprostadil may be administered by direct injection into the  corpora cavernosa or by intraurethral insertion of a pelle...
Mechanical Treatment Approaches In male patients with arteriosclerosis (especially of the distal  aorta, known as Leriche...
Vacuum Pump mechanical devices that patients without vascular  disease can use to obtain erections.   The blood drawn in...
Surgical TreatmentMale Prostheses penile prosthetic devices The two main types of prostheses are(1) a semirigid rod pros...
Abnormal sexuality and sexual disfunction
Abnormal sexuality and sexual disfunction
Abnormal sexuality and sexual disfunction
Abnormal sexuality and sexual disfunction
Abnormal sexuality and sexual disfunction
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Abnormal sexuality and sexual disfunction

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Abnormal sexuality and sexual disfunction

  1. 1.  Axis I disorders The syndromes listed are correlated with the sexual physiological response, which is divided into the four phases
  2. 2. DSM-IV-TR Phases of the Sexual Response Cycle and Associated Sexual Dysfunctions1. Desire: Distinct from any identified solely through physiology and reflects the patients motivations, drives, and personality; characterized by sexual fantasies and the desire to have sex Hypoactive sexual desire disorder; sexual aversion disorder; hypoactive sexual desire disorder due to a general medical condition (male or female); substance-induced sexual dysfunction with impaired desire
  3. 3. DSM-IV-TR Phases of the Sexual Response Cycle and Associated Sexual Dysfunctions2. Excitement: Subjective sense of sexual pleasure and accompanying physiological changes; all physiological responses noted in Masters and Johnsons excitement and plateau phases are combined in this phase Female sexual arousal disorder; male erectile disorder (may also occur in stages 3 and 4); male erectile disorder due to a general medical condition; dyspareunia due to a general medical condition (male or female); substance-induced sexual dysfunction with impaired arousal
  4. 4. DSM-IV-TR Phases of the Sexual Response Cycle and Associated Sexual Dysfunctions3. Orgasm: Peaking of sexual pleasure, with release of sexual tension and rhythmic contraction of the perineal muscles and pelvic reproductive organs Female orgasmic disorder; male orgasmic disorder; premature ejaculation; other sexual dysfunction due to a general medical condition (male or female); substance-induced sexual dysfunction with impaired orgasm
  5. 5. DSM-IV-TR Phases of the Sexual Response Cycle and Associated Sexual Dysfunctions4. Resolution: A sense of general relaxation, well-being, and muscle relaxation; men are refractory to orgasm for a period of time that increases with age, whereas women can have multiple orgasms without a refractory period Postcoital dysphoria; postcoital headache
  6. 6.  The essential feature of the sexual dysfunctions is inhibition in one or more of the phases, including disturbance in the subjective sense of pleasure or desire or in the objective performance. Either type of disturbance can occur alone or in combination. Sexual dysfunctions are diagnoses only when they are a major part of the clinical picture. They can be lifelong or acquired, generalized or situational, and result from psychological factors, physiological factors, or combined factors. 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
  7. 7.  Sexual disorders can lead to or result from relational problems, and patients invariably develop an increasing fear of failure and self-consciousness about their sexual performance. Sexual dysfunctions are frequently associated with other mental disorders, such as depressive disorders, anxiety disorders, personality disorders, and schizophrenia. In many instances, a sexual dysfunction may be diagnosed in conjunction with another psychiatric disorder; in other cases, however, it is only one of many signs or symptoms of the psychiatric disorder
  8. 8. Sexual Dysfunction Not Correlated with Phases of the Sexual Response Cycle Category DysfunctionsSexual pain Vaginismus (female) Dyspareunia (female and male)disorders 1.Sexual dysfunctions not otherwise specified. Examples: No erotic sensation despite normal physiological response to sexualOther stimulation (e.g., orgasmic anhedonia) 2.Female analogue of premature ejaculation 3.Genital pain occurring during masturbation
  9. 9.  In DSM-IV-TR, a sexual dysfunction is defined as a disturbance in the sexual response cycle or as pain with sexual intercourse. Seven major categories of sexual dysfunction are listed in DSM- IV-TR:1. sexual desire disorders,2. sexual arousal disorders,3. orgasm disorders,4. sexual pain disorders,5. sexual dysfunction caused by a general medical condition,6. substance-induced sexual dysfunction, and7. sexual dysfunction not otherwise specified.
  10. 10.  Sexual dysfunctions can be symptomatic of biological (biogenic) problems or intrapsychic or interpersonal (psychogenic) conflicts or a combination of these factors. Sexual function can be adversely affected by stress of any kind, by emotional disorders, or by ignorance of sexual function and physiology
  11. 11. 1. SEXUAL DESIRE DISORDERS two classes1. hypoactive sexual desire disorder,  characterized by a deficiency or absence of sexual fantasies and desire for sexual activity; and  more common  more common among women than among men2. sexual aversion disorder,  characterized by an aversion to, and avoidance of, genital sexual contact with a sexual partner or by masturbation
  12. 12.  Patients with desire problems often use inhibition of desire defensively, to protect against unconscious fears about sex. Sigmund Freud conceptualized low sexual desire as the result of inhibition during the phallic psychosexual phase of development and of unresolved oedipal conflicts. Some men, fixated at the phallic state of development, are fearful of the vagina and believe that they will be castrated if they approach it. Freud called this concept vagina dentata; because men unconsciously believe that the vagina has teeth, they avoid contact with the female genitalia.
  13. 13.  Equally,women may suffer from unresolved developmental conflicts that inhibit desire. Lack of desire can also result from chronic stress, anxiety, or depression.
  14. 14. DSM-IV-TR Diagnostic Criteria for Hypoactive Sexual Desire DisorderA.Persistently or recurrently deficient (or absent) sexual fantasies and desirefor sexual activity. The judgment of deficiency or absence is made by the clinician,taking into account factors that affect sexual functioning, such as age and the contextof the persons life.B.The disturbance causes marked distress or interpersonal difficulty.C.The sexual dysfunction is not better accounted for by another Axis I disorder (exceptanother sexual dysfunction) and is not due exclusively to the direct physiologicaleffects of a substance (e.g., a drug of abuse, a medication) or a general medicalcondition.Specify type: Lifelong type Acquired typeSpecify type: Generalized type Situational typeSpecify: Due to psychological factors Due to combined factors
  15. 15. DSM-IV-TR Diagnostic Criteria for Sexual Aversion DisorderA.Persistent or recurrent extreme aversion to, and avoidance of, all (or almostall) genital sexual contact with a sexual partner.B.The disturbance causes marked distress or interpersonal difficulty.C.The sexual dysfunction is not better accounted for by another Axis I disorder(except another sexual dysfunction).Specify type: Lifelong type Acquired typeSpecify type: Situational type Generalized typeSpecify: Due to psychological factors Due to combined factors
  16. 16.  Abstinence from sex for a prolonged period sometimes results in suppression of sexual impulses. Loss of desire may also be an expression of hostility to a partner or the sign of a deteriorating relationship. The presence of desire depends on several factors:  biological drive,  adequate self-esteem,  the ability to accept oneself as a sexual person,  previous good experiences with sex,  the availability of an appropriate partner, and  a good relationship in nonsexual areas with a partner. Damage to, or absence of, any of these factors can diminish desire.
  17. 17. 2. SEXUAL AROUSAL DISORDERS The sexual arousal disorders are divided by DSM-IV- TR into…. female sexual arousal disorder,  the persistent or recurrent partial or complete failure to attain or maintain the lubrication-swelling response of sexual excitement until the completion of the sexual act. male erectile disorder,  the recurrent and persistent partial or complete failure to attain or maintain an erection to perform the sex act.
  18. 18. Female Sexual Arousal Disorder The DSM-III-R defines female sexual arousal disorder in terms of the physiological arousal response. A woman complaining of lack of arousal may lubricate vaginally, but may not experience a subjective sense of excitement. Other women report feeling the greatest sexual excitement immediately after the menses or at the time of ovulation. Alterations in testosterone, estrogen, prolactin, and thyroxin levels have been implicated in female sexual arousal disorder. Also, medications with antihistaminic or anticholinergic properties cause a decrease in vaginal lubrication.
  19. 19. DSM-IV-TR Diagnostic Criteria for Female Sexual Arousal DisorderA.Persistent or recurrent inability to attain, or to maintain until completionof the sexual activity, an adequate lubrication-swelling response of sexualexcitement.B.The disturbance causes marked distress or interpersonal difficulty.C.The sexual dysfunction is not better accounted for by another Axis I disorder(except another sexual dysfunction) and is not due exclusively to the directphysiological effects of a substance (e.g., a drug of abuse, a medication) or ageneral medical condition.Specify type: Lifelong type Acquired typeSpecify type: Generalized type Situational typeSpecify: Due to psychological factors Due to combined factors
  20. 20. Male Erectile Disorder Male erectile disorder is also called erectile dysfunction and impotence. Impotence is the chief complaint of more than 50 percent of all men treated for sexual disorders All men over 40, have a fear of impotence, reflects the masculine fear of loss of virility with advancing age lifelong male erectile disorder  has never been able to obtain an erection sufficient for vaginal insertion.  Rare  incidence increases with age acquired male erectile disorder,  a man has successfully achieved vaginal penetration at some time in his sexual life but is later unable to do so.  reported in 10 to 20 percent of all men situational male erectile disorder,  a man is able to have coitus in certain circumstances but not in others; for example, he may function effectively with a prostitute but be impotent with his wife.
  21. 21. DSM-IV-TR Diagnostic Criteria for Male Erectile DisorderA.Persistent or recurrent inability to attain, or to maintain until completion ofthe sexual activity, an adequate erection.B.The disturbance causes marked distress or interpersonal difficulty.C.The erectile dysfunction is not better accounted for by another Axis I disorder(other than a sexual dysfunction) and is not due exclusively to the directphysiological effects of a substance (e.g., a drug of abuse, a medication) or a generalmedical condition.Specify type: Lifelong type Acquired typeSpecify type: Generalized type Situational typeSpecify: Due to psychological factors Due to combined factors
  22. 22. 3. ORGASM DISORDERS
  23. 23. Female Orgasmic Disorder Also called inhibited female orgasm or anorgasmia defined as the recurrent or persistent inhibition of female orgasm, as manifested by the 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 short, a womans inability to achieve orgasm by masturbation or coitus . Women who can achieve orgasm by one of these methods are not necessarily categorized as anorgasmic, although some sexual inhibition may be postulated.
  24. 24.  lifelong female orgasmic disorder  has never experienced orgasm by any kind of stimulation. acquired orgasmic disorder  has previously experienced at least one orgasm, regardless of the circumstances or means of stimulation, whether by masturbation or while dreaming during sleep. Numerous psychological factors are associated with female orgasmic disorder.  fears of impregnation,  rejection by a sex partner,  damage to the vagina  hostility toward men  feelings of guilt about sexual impulses.
  25. 25.  Some women equate orgasm with loss of control or with aggressive, destructive, or violent impulses; their fear of these impulses may be expressed through inhibition of excitement or orgasm. Cultural expectations and social restrictions on women are also relevant. Many women have grown up to believe that sexual pleasure is not a natural entitlement for so-called decent women. Nonorgasmic women may be otherwise symptom free or may experience frustration in a variety of ways; they may have such pelvic complaints as lower abdominal pain, itching, and vaginal discharge, as well as increased tension, irritability, and fatigue
  26. 26. DSM-IV-TR Diagnostic Criteria for Female Orgasmic DisorderA.Persistent or recurrent delay in, or absence of, orgasm following a normal sexualexcitement phase. Women exhibit wide variability in the type or intensity of stimulationthat triggers orgasm. The diagnosis of female orgasmic disorder should be based on theclinicians judgment that the womans orgasmic capacity is less than would be reasonablefor her age, sexual experience, and the adequacy of sexual stimulation she receives.B.The disturbance causes marked distress or interpersonal difficulty.C.The orgasmic dysfunction is not better accounted for by another Axis I disorder (exceptanother sexual dysfunction) and is not due exclusively to the direct physiological effects ofa substance (e.g., a drug of abuse, a medication) or a general medical condition.Specify type: Lifelong type Acquired typeSpecify type: Generalized type Situational typeSpecify: Due to psychological factors Due to combined factors
  27. 27. Male Orgasmic Disorder Also called inhibited orgasm or retarded ejaculation, a man achieves ejaculation during coitus with great difficulty. lifelong orgasmic disorder  has never been able to ejaculate during coitus. acquired orgasmic disorder  it develops after previously normal functioning. Some researchers think that orgasm and ejaculation should be differentiated, especially in the case of men who ejaculate but complain of a decreased or absent subjective sense of pleasure during the orgasmic experience (orgasmic anhedonia).
  28. 28.  Lifelong male orgasmic disorder indicates severe psychopathology.  A man may come from a rigid, puritanical background;  he may perceive sex as sinful and the genitals as dirty; and  he may have conscious or unconscious incest wishes and guilt. The disorder may be a mans way of coping with real or fantasized changes in a relationship, such as  plans for pregnancy about which the man is ambivalent,  the loss of sexual attraction to the partner,  demands by the partner for greater commitment as expressed by sexual performance. In some men, the inability to ejaculate reflects unexpressed hostility toward a woman.
  29. 29. DSM-IV-TR Diagnostic Criteria for Male Orgasmic DisorderA.Persistent or recurrent delay in, or absence of, orgasm following a normalsexual excitement phase during sexual activity that the clinician, taking intoaccount the persons age, judges to be adequate in focus, intensity, and duration.B.The disturbance causes marked distress or interpersonal difficulty.C.The orgasmic dysfunction is not better accounted for by another Axis I disorder(except another sexual dysfunction) and is not due exclusively to the directphysiological effects of a substance (e.g., a drug of abuse, a medication) or a generalmedical condition.Specify type: Lifelong type Acquired typeSpecify type: Generalized type Situational typeSpecify: Due to psychological factors Due to combined factors
  30. 30. Premature Ejaculation
  31. 31.  In premature ejaculation, men persistently or recurrently achieve orgasm and ejaculation before they wish to. No definite timeframe exists within which to define the dysfunction; the diagnosis is made when a man regularly ejaculates before or immediately after entering the vagina. man a premature ejaculator if he could not control ejaculation sufficiently long enough during intravaginal containment to satisfy his partner in at least half their episodes of coitus. This definition assumes that the female partner is capable of an orgasmic response.
  32. 32.  Some researchers divide men who experience premature ejaculation into two groups:1. those who are physiologically predisposed to climax quickly because of shorter nerve latency time and2. those with a psychogenic or behaviorally conditioned cause. Difficulty in ejaculatory control can be associated  with anxiety regarding the sex act,  with unconscious fears about the vagina, or  with negative cultural conditioning. Men whose early sexual contacts occurred largely with prostitutes who demanded that the sex act proceed quickly or whose sexual contacts took place in situations in which discovery would be embarrassing (e.g., in the back seat of a car or in the parental home) might have been conditioned to achieve orgasm rapidly. With young, inexperienced men, who are more likely to have the problem, it may resolve in time.
  33. 33. DSM-IV-TR Diagnostic Criteria for Premature EjaculationA.Persistent or recurrent ejaculation with minimal sexual stimulation before, on,or shortly after penetration and before the person wishes it. The clinician musttake into account factors that affect duration of the excitement phase, such as age,novelty of the sexual partner or situation, and recent frequency of sexual activity.B.The disturbance causes marked distress or interpersonal difficulty.C.The premature ejaculation is not due exclusively to the direct effects of a substance(e.g., withdrawal from opioids).Specify type: Lifelong type Acquired typeSpecify type: Generalized type Situational typeSpecify: Due to psychological factors Due to combined factors
  34. 34. 4. SEXUAL PAIN DISORDERS
  35. 35. Dyspareunia Recurrent or persistent genital pain occurring in either men or women before, during, or after intercourse. Much more common in women than in men, dyspareunia is related to, and often coincides with, vaginismus. Repeated episodes of vaginismus can lead to dyspareunia and vice versa; in either case, somatic causes must be ruled out. If a partner proceeds with intercourse regardless of a womans state of readiness, the condition is aggravated.
  36. 36.  Dyspareunia can also occur in men, but it is uncommon and is usually associated with an organic condition, such as herpes, prostatitis, or Peyronies disease, which consists of sclerotic plaques on the penis that cause penile curvature. Chronic pelvic pain is a common complaint in women with a history of rape or childhood sexual abuse.
  37. 37. DSM-IV-TR Diagnostic Criteria for DyspareuniaA.Recurrent or persistent genital pain associated with sexual intercourse ineither a male or a female.B.The disturbance causes marked distress or interpersonal difficulty.C.The disturbance is not caused exclusively by vaginismus or lack of lubrication,is not better accounted for by another Axis I disorder (except another sexualdysfunction), and is not due exclusively to the direct physiological effects of asubstance (e.g., a drug of abuse, a medication) or a general medical condition.Specify type: Lifelong type Acquired typeSpecify type: Generalized type Situational typeSpecify: Due to psychological factors Due to combined factors
  38. 38. Vaginismus an involuntary muscle constriction of the outer third of the vagina that interferes with penile insertion and intercourse. It most often afflicts highly educated women and those in high socioeconomic groups. Women with vaginismus may consciously wish to have coitus, but unconsciously wish to keep a penis from entering their bodies.  A sexual trauma, such as rape,  women with psychosexual conflicts may perceive the penis as a weapon.  pain or the anticipation of pain at the first coital experience causes vaginismus.  strict religious upbringing in which sex is associated with sin  problems in dyadic relationships; if women feel emotionally abused by their partners
  39. 39. DSM-IV-TR Diagnostic Criteria for VaginismusA.Recurrent or persistent involuntary spasm of the musculature of the outer third ofthe vagina that interferes with sexual intercourse.B.The disturbance causes marked distress or interpersonal difficulty.C.The disturbance is not better accounted for by another Axis I disorder (e.g.,somatization disorder) and is not due exclusively to the direct physiological effectsof a general medical condition.Specify type: Lifelong type Acquired typeSpecify type: Generalized type Situational typeSpecify: Due to psychological factors Due to combined factors
  40. 40. 5. SEXUAL DYSFUNCTION DUE TO AGENERAL MEDICAL CONDITION
  41. 41. DSM-IV-TR Diagnostic Criteria for Sexual Dysfunction Due to a General MedicalA.Clinically significant sexual dysfunction that results in marked distress or interpersonaldifficulty predominates in the clinical picture.B.There is evidence from the history, physical examination, or laboratory findings that the sexualdysfunction is fully explained by the direct physiological effects of a general medicalcondition.C.The disturbance is not better accounted for by another mental disorder (e.g., major depressivedisorder).Select, code and term based on the predominant sexual dysfunction: Female hypoactive sexual desire disorder due to…[indicate the general medical condition]: ifdeficient or absent sexual desire is the predominant feature Male hypoactive sexual desire disorder due to…[indicate the general medical condition]: ifdeficient or absent sexual desire is the predominant feature Male erectile disorder due to…[indicate the general medical condition]: if male erectiledysfunction is the predominant feature Female dyspareunia due to…[indicate the general medical condition]: if pain associated withintercourse is the predominant feature Male dyspareunia due to…[indicate the general medical condition]: if pain associated withintercourse is the predominant feature Other female sexual dysfunction due to…[indicate the general medical condition]: if someother feature is predominant (e.g., orgasmic disorder) or no feature predominates Other male sexual dysfunction due to…[indicate the general medical condition]: if some otherfeature is predominant (e.g., orgasmic disorder) or no feature predominatesCoding note: Include the name of the general medical condition on Axis I, e.g., male erectiledisorder due to diabetes mellitus; also code the general medical condition on Axis III.
  42. 42. Male Erectile Disorder Due to aGeneral Medical Condition Side effects of medication can impair male sexual functioning in a variety of ways. Castration (removal of the testes) does not always lead to sexual dysfunction, because erection may still occur. A reflex arc, fired when the inner thigh is stimulated, passes through the sacral cord erectile center to account for the phenomenon. A number of procedures, benign and invasive, are used to help differentiate organically caused impotence from functional impotence. The procedures include  monitoring nocturnal penile tumescence  measuring blood pressure in the penis in the internal pudendal artery; and  measuring pudendal nerve latency time.
  43. 43.  Other diagnostic tests that delineate organic bases for impotence include  glucose tolerance tests,  plasma hormone assays,  liver and thyroid function tests,  prolactin and follicle-stimulating hormone (FHS) determinations, and  cystometric examinations. Invasive diagnostic studies include  penile arteriography,  infusion cavernosonography, and  radioactive xenon penography.
  44. 44. Diseases and Other Medical Conditions Implicated in Male Erectile DisorderInfectious and parasitic diseases Elephantiasis MumpsCardiovascular diseasea Atherosclerotic disease Aortic aneurysm Leriches syndrome Cardiac failureRenal and urological disorders Peyronies disease Hepatic disorders Chronic renal failure Cirrhosis (usually associated with alcohol Hydrocele and varicocele dependence) Pulmonary disorders Respiratory failure Genetics Klinefelters syndrome Congenital penile vascular and structural abnormalities
  45. 45. Diseases and Other Medical Conditions Implicated in Male Erectile DisorderNutritional disorders Malnutrition Vitamin deficiencies Neurological disorders Obesity Multiple sclerosisEndocrine disordersa Transverse myelitis Diabetes mellitus Parkinsons disease Dysfunction of the Temporal lobe epilepsypituitary-adrenal-testis axis Traumatic and neoplastic spinal cord diseasesa Acromegaly Central nervous system tumor Addisons disease Amyotrophic lateral sclerosis Chromophobe adenoma Peripheral neuropathy Adrenal neoplasia General paresis Myxedema Tabes dorsalis Hyperthyroidism
  46. 46. Diseases and Other Medical Conditions Implicated in Male Erectile DisorderPharmacological factors Alcohol and other dependence-inducing substances (heroin, methadone,morphine, cocaine, amphetamines, and barbiturates) Prescribed drugs (psychotropic drugs, antihypertensive drugs, estrogens,and antiandrogens)Poisoning Lead (plumbism) HerbicidesSurgical proceduresa Perineal prostatectomy Abdominal-perineal colon resection Sympathectomy (frequently interferes with ejaculation) Aortoiliac surgery Radical cystectomy Retroperitoneal lymphadenectomyMiscellaneous Radiation therapy Pelvic fracture Any severe systemic disease or debilitating condition
  47. 47. Dyspareunia Due to a GeneralMedical Condition Organic abnormalities leading to dyspareunia and vaginismus include ….  irritated or infected hymenal remnants,  episiotomy scars,  Bartholins gland infection,  various forms of vaginitis and cervicitis, and  endometriosis. Postcoital pain has been reported by women with myomata and endometriosis and is attributed to the uterine contractions during orgasm. Postmenopausal women may have dyspareunia resulting from thinning of the vaginal mucosa and reduced lubrication.
  48. 48.  Two conditions not readily apparent on physical examination that produce dyspareunia are  Vulvar vestibulitis  may present with chronic vulvar pain  interstitial cystitis  produces pain most intensely following orgasm Dyspareunia can also occur in men, but it is uncommon and is usually associated with an organic condition, such as Peyronies disease, which consists of sclerotic plaques on the penis that cause penile curvature.
  49. 49. Hypoactive Sexual Desire DisorderDue to a General Medical Condition Sexual desire commonly decreases after major illness or surgery, particularly when the body image is affected after such procedures as mastectomy, ileostomy, hysterectomy, and prostatectomy. Illnesses that deplete a persons energy, chronic conditions that require physical and psychological adaptation, and serious illnesses that can cause a person to become depressed can all markedly lessen sexual desire in both men and women. Drugs that depress the central nervous system (CNS) or decrease testosterone production can decrease desire.
  50. 50. Neurophysiology of Sexual Dysfunction DA 5-HT NE ACh Clinical CorrelationErection Antipsychotics may lead to erectile dysfunction (DA block): DA agonists α may lead to enhanced erection and   M β libido; priapism with trazodone (α1 block); β-blockers may lead to impotenceEjaculation α1 Blockers (tricyclic drugs, MAOls,and orgasm  α1  thioridazine) may lead to impaired ± M ejaculation; 5-HT agents may inhibit orgasmfacilities;inhibits or decreases;± some; minimal.ACh, acetylcholine; DA dopamine; 5-HT serotonin; M, modulates; NE, norepinephrine;
  51. 51. Other Male Sexual Dysfunction Dueto a General Medical Condition When another dysfunctional feature is predominant (e.g., orgasmic disorder) or when no feature predominates, the category other male sexual dysfunction due to a general medical condition is used. Male orgasmic disorder can have physiological causes  can occur after surgery on the genitourinary tract, such as prostatectomy.  may also be associated with Parkinsons disease and other neurological disorders involving the lumbar or sacral sections of the spinal cord.  The antihypertensive drug guanethidine monosulfate (Ismelin), methyldopa (Aldomet), the phenothiazines,  the tricyclic drugs,  the selective serotonin reuptake inhibitors (SSRIs),
  52. 52.  Male orgasmic disorder must also be differentiated from retrograde ejaculation, in which ejaculation occurs but the seminal fluid passes backward into the bladder. Retrograde ejaculation always has an organic cause. It can develop after genitourinary surgery and is also associated with medications that have anticholinergic adverse effects, such as the phenothiazines, especially thioridazine (Mellaril).
  53. 53. Other Female Sexual DysfunctionDue to a General Medical Condition Some medical conditions (specifically, endocrine diseases such as hypothyroidism, diabetes mellitus, and primary hyperprolactinemia) can affect a womans ability to have orgasms. Several drugs also affect some womens capacity to have orgasms.  Antihypertensive medications,  CNS stimulants,  tricyclic drugs,  SSRIs, and,  monoamine oxidase inhibitors (MAOIs)
  54. 54. Some Antipsychotic Drugs Implemented in Inhibited Female OrgasmTricyclic antidepressants Imipramine (Tofranil) Clomipramine (Anafranil) Nortriptyline (Aventyl)Monoamine oxidase inhibitors Tranylcypromine (Parnate) Phenelzine (Nardil) Isocarboxazid (Marplan)Dopamine receptor antagonists Thioridazine (Mellaril) Trifluoperazine (Stelazine)Selective serotonergic receptor inhibitors Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Fluvoxamine (Luvox) Citalopram (Celexa)
  55. 55. 6. SUBSTANCE-INDUCED SEXUAL DYSFUNCTION The diagnosis of substance-induced sexual dysfunction is used when evidence of substance intoxication or withdrawal is apparent from the history, physical examination, or laboratory findings. Distressing sexual dysfunction occurs within a month of significant substance intoxication or withdrawal. Specified substances include alcohol, amphetamines or related substances, cocaine, opioids, sedatives, hypnotics, or anxiolytics, and other or unknown substances Men usually go through two stages:1. an experience of prolonged erection without ejaculation, then2. a gradual loss of erectile capability.
  56. 56.  In small doses, many substances enhance sexual performance by decreasing inhibition or anxiety or by causing a temporary elation of mood. With continued use, however, erectile engorgement and orgasmic and ejaculatory capacities become impaired. The abuse of sedatives, anxiolytics, hypnotics, and particularly opiates and opioids nearly always depresses desire. Alcohol, cocaine, amphetamine may foster the initiation of sexual activity by removing inhibition, but it also impairs performance. users initially have feelings of increased energy and may become sexually active but ultimately, dysfunction occurs.
  57. 57. DSM-IV-TR Diagnostic Criteria for Substance-Induced Sexual DysfunctionA.Clinically significant sexual dysfunction that results in marked distress or interpersonal difficultypredominates in the clinical picture.B.There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunctionis fully explained by substance use as manifested by either (1) or (2): A. the symptoms in Criterion A developed during, or within a month of, substance intoxication B. medication use is etiologically related to the disturbanceC.The disturbance is not better accounted for by a sexual dysfunction that is not substance induced. Evidencethat the symptoms are better accounted for by a sexual dysfunction that is not substance induced mightinclude the following: the symptoms precede the onset of the substance use or dependence (or medicationuse); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation ofintoxication, or are substantially in excess of what would be expected given the type or amount of thesubstance used or the duration of use; or there is other evidence that suggests the existence of anindependent non–substance-induced sexual dysfunction (e.g., a history of recurrent non–substance-related episodes).Note: This diagnosis should be made instead of a diagnosis of substance intoxication only when the sexualdysfunction is in excess of that usually associated with the intoxication syndrome and when the dysfunctionis sufficiently severe to warrant independent clinical attention. Code [Specific substance]-induced sexual dysfunction: Alcohol; amphetamine [or amphetamine-likesubstance]; cocaine; opioid; sedative, hypnotic, or anxiolytic; other [or unknown] substance Specify if: With impaired desire With impaired arousal With impaired orgasm With sexual pain Specify if: With onset during intoxication: if the criteria are met for intoxication with the substance and thesymptoms develop during the intoxication syndrome
  58. 58. Pharmacological Agents Implicatedin Sex Dysfunction Almost every pharmacological agent, particularly those used in psychiatry, has been associated with an effect on sexuality. In men, these effects include  decreased sex drive,  erectile failure (impotence),  decreased volume of ejaculate, and  delayed or retrograde ejaculation. In women,  decreased sex drive,  decreased vaginal lubrication,  inhibited or delayed orgasm, and  decreased or absent vaginal contractions may occur. Drugs may also enhance the sexual responses and increase the sex drive, but this is less common than adverse effects.
  59. 59. Diagnostic Issues with Sex and Some Antipsychotic DrugsDifferential diagnosis of Problem after drug therapy started or drug overdosedrug-induced sexual Problem not situation or partner specificdysfunction Not a lifelong or recurrent problem No obvious nonpharmacological precipitant Dissipates with drug discontinuationAntipsychotic drugs and Perphenazine Chlorpromazineejaculatory problems Trifluoperazine Haloperidol Mesoridazine Thioridazine ChlorprothixeneAntipsychotic drugs and Perphenazine Mesoridazinepriapism Chlorpromazine Thioridazine Fluphenazine Molindone Risperidone Clozapine
  60. 60. Antipsychotic Drugs impair erection and ejaculation, in which the seminal fluid backs up into the bladder rather than being propelled through the penile urethra. Patients still have a pleasurable sensation, but the orgasm is dry. When urinating after orgasm, the urine may be milky white because it contains the ejaculate.Antidepressant Drugs interfere with erection and delay ejaculation.
  61. 61. Lithium may reduce hypersexuality,Sympathomimetics Libido is increased; however, with prolonged use, men may experience a loss of desire and erections.Α Adrenergic and β Adrenergic Receptor Antagonists can cause impotence, decrease the volume of ejaculate, and produce retrograde ejaculation. Changes in libido have been reported in both sexes.
  62. 62. Anticholinergics produce dryness of the mucous membranes (including those of the vagina) and impotence. However, amantadine may reverse SSRI-induced orgasmic dysfunction through its dopaminergic effect.Antihistamines may inhibit sexual functionAntianxiety Agents Because they decrease plasma epinephrine concentrations, they diminish anxiety, and as a result they improve sexual function in persons inhibited by anxiety
  63. 63. Alcohol women reporting increased libido after drinking small amounts of alcohol. In men, that produces signs of feminization (such as gynecomastia as a result of testicular atrophy).Opioids erectile failure and decreased libido.Cannabis may enhance sexual pleasure for some persons.
  64. 64. 7. SEXUAL DYSFUNCTION NOTOTHERWISE SPECIFIED DSM-IV-TR Diagnostic Criteria for Sexual Dysfunction Not Otherwise Specified1.This category includes sexual dysfunctions that do not meet criteria forany specific sexual dysfunction. Examples include: No (or substantiallydiminished) subjective erotic feelings despite otherwise normal arousaland orgasm2.Situations in which the clinician has concluded that a sexual dysfunctionis present but is unable to determine whether it is primary, due to a generalmedical condition, or substance induced
  65. 65. Female Premature Orgasm no separate category of premature orgasm for women is included in DSM-IV-TR. A case of multiple spontaneous orgasms without sexual stimulation was seen in a woman; the cause was an epileptogenic focus in the temporal lobe. Instances have been reported of women taking antidepressants (e.g., fluoxetine and clomipramine) who experience spontaneous orgasm associated with yawning.Postcoital Headache headache immediately after coitus, may last for several hours. It is usually described as throbbing and is localized in the occipital or frontal area.Orgasmic Anhedonia person has no physical sensation of orgasm, even though the physiological component (e.g., ejaculation) remains intact. Organic causes, such as sacral and cephalic lesions that interfere with afferent pathways from the genitalia to the cortex, must be ruled out. Psychiatric causes usually relate to extreme guilt about experiencing sexual pleasure.
  66. 66. Masturbatory Pain Organic causes should always be ruled out;  a small vaginal tear  early Peyronies disease Should differentiated from compulsive masturbation.  Persons may masturbate to the extent that they do physical damage to their genitals and eventually experience pain during subsequent masturbatory acts. autoerotic asphyxiation  The practices involve persons masturbating while hanging by the neck to heighten the erotic sensations and the orgasms intensity through the mechanism of mild hypoxia.  Although the persons intend to release themselves from the noose after orgasm, an estimated 500 to 1,000 persons a year accidentally kill themselves by hanging.
  67. 67. TREATMENT Classic psychodynamic theory holds that sexual inadequacy has its roots in early developmental conflicts, and the sexual disorder is treated as part of a pervasive emotional disturbance. Treatment focuses on the exploration of unconscious conflicts, motivation, fantasy, and various interpersonal difficulties. The addition of behavioral techniques is often necessary to cure the sexual problem.
  68. 68. Dual-Sex Therapy treatment is based on a concept that the couple must be treated when a dysfunctional person is in a relationship. Because both are involved in a sexually distressing situation, both must participate in the therapy program. The sexual problem often reflects other areas of disharmony or misunderstanding in the marriage so that the entire marital relationship is treated, with emphasis on sexual functioning as a part of the relationship.
  69. 69.  The keystone of the program is the roundtable session in which a male and female therapy team clarifies, discusses, and works through problems with the couple. The four-way sessions require active participation by the patients. Therapists and patients discuss the psychological and physiological aspects of sexual functioning, and therapists have an educative attitude.
  70. 70.  Psychotherapy sessions follow each new exercise period, and problems and satisfactions, both sexual and in other areas of the couples lives, are discussed. Specific instructions and the introduction of new exercises geared to the individual couples progress are reviewed in each session. Gradually, the couple gains confidence and learns to communicate, verbally and sexually. Dual-sex therapy is most effective when the sexual dysfunction exists apart from other psychopathology
  71. 71. Specific Techniques and Exercises In cases of vaginismus, a woman is advised to dilate her vaginal opening with her fingers or with size graduated dilators. Dilators are also used to treat cases of dyspareunia. squeeze technique  In cases of premature ejaculation  used to raise the threshold of penile excitability.  In this exercise, the man or the woman stimulates the erect penis until the earliest sensations of impending ejaculation are felt. At this point, the woman forcefully squeezes the coronal ridge of the glans, the erection is diminished, and ejaculation is inhibited. Sex therapy has been most successful in the treatment of premature ejaculation.
  72. 72.  A man with a sexual desire disorder or male erectile disorder is sometimes told to masturbate to prove that full erection and ejaculation are possible. Male orgasmic disorder is managed initially by extravaginal ejaculation and then by gradual vaginal entry after stimulation to a point near ejaculation. Most importantly, the early exercises forbid ejaculation to remove the pressure to climax and allow the man to immerse himself in sexual pleasuring.
  73. 73.  In cases of lifelong female orgasmic disorder, the woman is directed to masturbate, sometimes using a vibrator. The shaft of the clitoris is the masturbatory site most preferred by women, and orgasm depends on adequate clitoral stimulation. An area on the anterior wall of the vagina has been identified in some women as a site of sexual excitation, known as the G-spot; but reports of an ejaculatory phenomenon at orgasm in women following the stimulation of the G-spot have not been satisfactorily verified.
  74. 74. Hypnotherapy Hypnotherapists focus specifically on the anxiety-producing situation- that is, the sexual interaction that results in dysfunction. The successful use of hypnosis enables patients to gain control over the symptom that has been lowering self-esteem and disrupting psychological homeostasis. The focus of treatment is on symptom removal and attitude alteration. The patient is instructed in developing alternative means of dealing with the anxiety-provoking situation, the sexual encounter.
  75. 75.  Patients are also taught relaxation techniques to use on themselves before sexual relations. With these methods to alleviate anxiety, the physiological responses to sexual stimulation can readily result in pleasurable excitation and discharge. Psychological impediments to vaginal lubrication, erection, and orgasms are removed, and normal sexual functioning ensues.
  76. 76. Behavior Therapy Using traditional techniques, therapists set up a hierarchy of anxiety- provoking situations, ranging from least threatening (e.g., the thought of kissing) to most threatening (the thought of penile penetration). The behavior therapist enables the patient to master the anxiety through a standard program of systematic desensitization, which is designed to inhibit the learned anxious response by encouraging behaviors antithetical to anxiety. The patient first deals with the least anxiety-producing situation in fantasy and progresses by steps to the most anxiety-producing situation. Medication, hypnosis, and special training in deep muscle relaxation are sometimes used to help with the initial mastery of anxiety. Assertiveness training is helpful in teaching patients to express sexual needs openly and without fear.
  77. 77. Group Therapy A therapy group provides a strong support system for a patient who feels ashamed, anxious, or guilty about a particular sexual problem. It is a useful forum in which to counteract sexual myths, correct misconceptions, and provide accurate information about sexual anatomy, physiology, and varieties of behavior.
  78. 78.  Groups for the treatment of sexual disorders can be organized in several ways. Members may all share the same problem, such as premature ejaculation; members may all be of the same sex with different sexual problems; or groups may be composed of both men and women who are experiencing a variety of sexual problems. Groups composed of married couples with sexual dysfunctions have also been effective. Such groups are not indicated for couples when one partner is uncooperative, when a patient has a severe depressive disorder or psychosis, when a patient finds explicit sexual audiovisual material repugnant, or when a patient fears or dislikes groups.
  79. 79. Analytically Oriented Sex Therapy One of the most effective treatment modalities is the use of sex therapy integrated with psychodynamic and psychoanalytically oriented psychotherapy. The material and dynamics that emerge in patients in analytically oriented sex therapy are the same as those in psychoanalytic therapy, such as dreams, fear of punishment, aggressive feelings, difficulty trusting a partner, fear of intimacy, oedipal feelings, and fear of genital mutilation. The combined approach of analytically oriented sex therapy is used by the general psychiatrist who carefully judges the optimal timing of sex therapy and the ability of patients to tolerate the directive approach that focuses on their sexual difficulties.
  80. 80. Pharmacotherapy The major new medications to treat sexual dysfunction are…..  sildenafil (Viagra) and its congeners;  oral phentolamine (Vasomax);  alprostadil (Caverject),  an injectable prostaglandin;  and a transurethral alprostadil (MUSE), all used to treat erectile disorder.
  81. 81. sildenafil (Viagra) and its congeners  drug takes effect about 1 hour after ingestion, and its effect can last up to 4 hours  facilitates the inflow of blood to the penis necessary for an erection  in women results in vaginal lubrication, but not in increased desire Pharmacokinetics of the PDE-5 (phosphodiesterase type 5 ) Inhibitors Sildenafil Vardenafil Tadalafil 100 mg 20 mg 20 mgMaximumconcentration 450 ng/mL 20.9 ng/mL 378 ng/mLTime tomaximum 1.0 hours 0.7 hours 2.0 hoursconcentrationHalf-life 4 hours 3.9 hours 17.5 hours
  82. 82.  Alprostadil may be administered by direct injection into the corpora cavernosa or by intraurethral insertion of a pellet through a canula.  The firm erection produced within 2 to 3 minutes after administration of the drug may last as long as 1 hour cream consists of three vasoactive substances-- aminophylline, isosorbide dinitrate, and co-dergocrine mesylate A gel containing alprostadil and an additional ingredient, which temporarily makes the outer layer of the skin more permeable. A cream incorporating alprostadil also has been developed to treat female sexual arousal disorder
  83. 83. Mechanical Treatment Approaches In male patients with arteriosclerosis (especially of the distal aorta, known as Leriches syndrome), the erection may be lost during active pelvic thrusting. The need for increased blood in the gluteal muscles and others served by the ilial or hypogastric arteries takes blood away (steals) from the pudendal artery and, thus, interferes with penile blood flow.• Relief may be obtained by decreasing pelvic thrusting, which is also aided by the womans superior coital position.
  84. 84. Vacuum Pump mechanical devices that patients without vascular disease can use to obtain erections.  The blood drawn into the penis EROS is a small suction cup that fits over the clitoral region and draws blood into the clitoris.
  85. 85. Surgical TreatmentMale Prostheses penile prosthetic devices The two main types of prostheses are(1) a semirigid rod prosthesis thatproduces a permanent erectionthat can be positioned close tothe body for concealment and(2) an inflatable type that isimplanted with its own reservoirand pump for inflation anddeflation.

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