This document defines various types of sexual dysfunction including impotence, sterility, infertility and defines their causes. It discusses the examination process for evaluating sexual dysfunction in males and females. It outlines numerous psychological, developmental, medical, injury and environmental factors that can cause impotence or sterility. The document also describes different sterilization methods and their classifications as well as some medicolegal aspects of sterilization.

1. IMPOTENCE
AND
STERILITY
Forensic Medicine
S. Ayisha Mufsira
III BNYS
GYNMC
Chennai-106

2. DEFINITIONS

3. Impotence
Inability to perform sexual
intercourse and achieve
gratification

4. Impotence Quode Hanc
(Quod)
A male impotent with one particular
female and not with other

5. Fertility
Ability to procreate

6. Sterility
Inability to procreate

7. Infertility
Inability to conceive after 1 year
of unprotected and regular
intercourse

8. Sexual Dysfunction
Impairment in desire for gratification or
in the ability to achieve gratification

9. Frigidity
Inability to initiate or maintain
sexual arousal pattern

10. Erectile dysfunction
Inability to develop and
maintain an erection

11. Premature Ejaculation
Ejaculation occurs immediately
before or immediately after
penetration

12. Legal Issues

13. CIVIL
CRIMINAL
• Adultery
• Rape
• Unnatural offences
• Nullity of marriage
• Divorce
• Adultery
• Paternity and legitimacy
• Adoption
• Assault or accident

14. Examination
Medical

15. Examination
done only when asked by
Court
Police officer (not below the rank
of sub inspector)

16. History taking
Habits
Sexual history

17. Habits
Smoking
Alcohol
Drugs - cannabis
Diabetes - peripheral neuropathy
Trauma - head and spinal injury
STD - syphilis - tertiary stage - poster
column of spinal cord
HTN - ganglion blocking drugs
Occupation- lead handling - neuropathy

18. Sexual history
Sexual development
Marital state
No. Of children
Sexual deviation

19. Examination in

20. Test the Sensation of
I. Penis
II. Testes
III. Epididymis
IV. Cord

21. Palpation Per Rectum
I. Prostate gland
II. Seminal vesicle

22. Penis
o Flaccid
o Length= 8.5cm - 10.5cm;
o Erect: 15cm
o Axis: 16-36 deg
Bulbocavernosus reflex Test (To test nerve sensation): Squeeze glans → Anal contraction

23. Laboratory Investigation
• Semen analysis
• Tests for systemic diseases
• Serum testosterone, LH and prolactin

24. Examination in

25. Evaluate
o Hair distribution
o Clitoris size
o Bartholin glands
o Labia majora and minora

26. Inspection
• Vagina: Mucosa → Oestrogen deficiency/ infection
• Bimanual examination

27. Laboratory Investigation
• Cervix - Pap test and cultures for STD
• Postcoital test - Sims Huhner test - number of sperms, its
motility

28. Other Investigations
 HysteroSalpingoGraphy
 USG
 Hysterosonogram
 MRI

29. AETIOLOGY

30. Psychological
→ Emotional disturbance
→ Fear of (1st night or honeymoon)
impotence
→ Disgust of sexual act
→ Dislike of partner
→ Depression / anxiety
→ Excessive passion
→ Overindulgence
→ Quoad hoc
MALE

31. Age
→ Poor physical development of penis
→ Spermatozoa absent before puberty
→ Aged - low libido
MALE

32. Developmental defects and
acquired abnormalities
→ Penis - absent / non development / partial amputation
→ External genitalia malformation
• Intersexuality
• Hypospadiasis (urethral opening on underside of penis)
• Epispadiasis ( failure of urethra to tubularise; opening on
upperpart)
• Double penis
• Penis adherent to scrotum
• Retrograde ejaculation
• Klinefelter syndrome (47XXY)
• Cryptorchidism (faulty descending of testes into scrotum
from abdomen)
MALE

33. Local diseases
→ Large hernias
→ Elephantiasis
→ Hydrocele
→ Phimosis (tight foreskin; inability to retract the foreskin)
→ Paraphimosis ( foreskin is retracted behind glans but can't be returned to
original position)
→ Adherent prepuce
→ Gonorrhea / Syphilis Sore glans Cancer / Sarcoma
→ TB
→ Cauda equina (bundle of spinal nerves and nerve rootlets consisting of L2-5,
S1- 5,C nerves)
→ Spina bifida (incomplete closing of spine and spinal cord)
→ Exposure to X-rays
MALE

34. General diseases
→ Temporary Impotence - regained during convalescence
• Anemia
• Diabetes
• Pulmonary
• TB
• Chronic nephritis
• Endocrine diseases
• Excessive masturbation
• Hemi / paraplegia
• Locomotor ataxia
• Disseminated(Multiple) sclerosis (Autoimmune affecting
protective covering of nerves)
• Neurasthenia
→Satyriasis - Excessive sexual desire may also be seen
MALE

35. Injuries
→ Fracture of spine at L4,5
→ Fracture of pelvis
→ Fracture of penis
MALE

36. Chronic poisoning
→ Lead
→ Arsenic
→ Pesticides
→ Aphrodisiac
MALE

37. Medications
→ Antidepressants
→ Antipsychotics
→ Antiulcer - cimetidine
→ Cholesterol lowering agents
→ Finasteride (Rx. benign prostate hyperplasia)
MALE

38. Behavioural factors
→ Overweight
→ Alcoholism
→ Tight fitting underwear
MALE

39. Addiction
→ Cannabis
→ Heroin
→ Morphine
→ Heavy Smoking
MALE

40. Psychological
 Vaginismus (spasmodic contraction of vagina due to
hyperesthesia; a classical eg. of psychosomatic illness)
due to fear, pain, disgust or apprehension
 Frigidity due to dislike of partner, neurological,
hypothyroidism, sedatives/depressants, menopause
FEMALE

41. Age
 No effect on potency
 Fertile from puberty to menopause
 Aged - Kraurosis vulvae, infertility
FEMALE

42. Developmental defects and
acquired abnormalities
• Absent vagina/uterus/ovaries/fallopian tubes
• Occlusion of vagina
• Adhesion of labia
• Imperforate hymen
• Turner’s syndrome
• Vaginal injury/infection
FEMALE

43. Local diseases
• Gonorrhoea
• Vaginal hyperesthesia
• Uterine or bladder prolapse
• Tumors - vagina/vulva
• Elephantiasis
• Ovarian diseases
• Fallopian tube obstruction
• Rectovaginal fistula
• Perineum rupture
• Menstrual disorders
• Leucorrhoea / acid v. Secretions
• PID
• Cysts - ovary, bartholin
FEMALE

44. General diseases
 Sterility but no impotency
 Physiologic sexual dysfunction due to impaired
neurovascular tone to clitoris and vagina
FEMALE

45. Chronic poisoning
• Lead
• Arsenic
FEMALE

46. Environmental factors and
addiction
 Occupational exposures to heat /
lead/microwave and X-ray radiation
 Alcohol/opium
FEMALE

47. Medications
 Chemotherapy
 Cessation of OCP
FEMALE

48. STERILIZATION
A procedure to make a male or female sterile
without interfering potency

49. Classification
DIRECT
VOLUNTARY
•Therapeutic
•Contraceptive
•Eugenics
INDIRECT
COMPULSARY
•Mentally/Physi
cally defective
•Punishment to
criminals
ACCIDENTAL
Unintended
result of an
opera for
preserving life
or health
Intended to
make the
person
operated
upon sterile
By an
order of
the state
By married
persons with
consent
Injury to
testes or
drug or
poison

50. Methods
PERMANENT
Vasectomy
Chemical sclerosing agents (ethanol, HCHO, AgNO3)
Tubectomy
Hysteroscopy using electro coagulation/ cauterization
Laparotomy / minilaparotomy
Laparoscopy using clips

51. TEMPORARY
Natural contraception
• Rhythm method
• Coitus interruptus
• Breastfeeding
Barrier contraceptives
• Spermicidal agents/diaphragm
• Condoms
IUD
• Copper T200/ CuT380A
• Multiload 250/375
• Progestasert
• Lippes loop
Steroidal contraception
• OCP
• Injectable steroids
• Implants

52. MEDICOLEGAL
ASPECTS

53. No absolute guarantee to sterility after vasectomy. Additional protection
needed.
Failure of contraceptive measure in male may lead to suspicion of wife
Tubectomy overall failure rate 0.7%
Written consent from both husband and wife
Sterilization desirable only above 30yrs having 2 children (1 male)
Healthy couples should not be permanently sterilized without any issue
It is not unlawful to sterilize under therapeutic and eugenic grounds