Sexual dysfunctions are real and these can be treated as well. So lets learn about this dysfunction.

1. SEXUAL
DYSFUNCTIONS
Dr. Dikshya Upreti
Dept. of Psychiatry
National Medical College Teaching Hospital

2. Content (Objectives of the
presentation)
■ Introduction
■ Types of sexual dysfunctions
■ Related treatment
■ Common myths

3. Introduction
■ Sexual dysfunction can be defined by disturbance in the subjective
sense of pleasure or desire usually associated with sex, or by the
objective performance.
■ Sexual dysfunctions are an inability to respond to sexual
stimulation, or the experience of pain during the sexual act.
Kaplan and Sadock’s Comprehensive textbook of psychiatry, 10th Edition

4. ■ According to the 10th revision of the International Statistical
Classification of Diseases and Related Health Problems (ICD-10),
sexual dysfunction refers to a person’s inability “to participate in a
sexual relationship as he or she would wish.”
■ F52

5. DSM-5, sexual dysfunctions include:
A. Desire, interest, and arousal
disorders
1. Male hypoactive sexual desire
disorder
2. Female sexual interest/arousal
disorder
3. Erectile disorder
B. Orgasmic disorder
1. Female orgasmic disorder
2. Delayed ejaculation
3. Premature (early) ejaculation
C. Sexual pain disorders
1. Genito-pelvic pain/penetration
disorder
D. Sexual dysfunction due to a
general medical condition
E. Substance/medication induced
sexual dysfunction
F. Other specified sexual dysfunction
G. Unspecified sexual dysfunction

6. Male Hypoactive Sexual Desire Disorder
A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or
fantasies and desire for sexual activity.
B. The symptoms in criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in criterion A cause clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress or other
significant stressors and is not attributable to the effects of a
substance/medication or another medical condition.

7. Male Hypoactive Sexual Desire
Disorder
Prevalence:
■ Greatest at the younger and older ends of the age spectrum
■ 6 % of men ages 18 to 24
■ 40 % of men ages 66 to 74
■ Only 2 percent of men ages 26 to 44

8. Female Sexual Interest/Arousal Disorder
A. Lack of, or significantly reduced, sexual interest/arousal, as
manifested by at least three of the following:
1. Absent/reduced interest in sexual activity
2. Absent/reduced sexual/erotic thoughts or fantasies.
3. No/reduced initiation of sexual activity, and typically
unreceptive to a partner’s attempts to initiate.

9. Female Sexual Interest/Arousal Disorder
4. Absent/reduced sexual excitement/pleasure during sexual activity
5. Absent/reduced sexual interest/arousal in response to any internal or
external sexual/erotic cues (e.g., written, verbal, visual).
6. Absent/reduced genital or non genital sensations during sexual
activity
B. The symptoms in criterion A have persisted for a minimum duration of
approximately 6 months.

10. Male Erectile Disorder
■ Historically called impotence
■ However, men with this dysfunction frequently suffer with the
feelings of powerlessness, helplessness, and resultant low self-
esteem.
■ A man with lifelong male erectile disorder has never been able to
obtain an erection sufficient for insertion.

11. DSM-5 criteria of male erectile disorder
A. At least one of the three following symptoms must be experienced on
the occasions of sexual activity:
1. Marked difficulty in obtaining an erection during sexual activity.
2. Marked difficulty in maintaining an erection until the completion of
sexual activity.
3. Marked decrease in erectile rigidity.

12. Prevalence of male erectile disorder:
■ Lifelong male erectile disorder is rare
■ About 20% of men fear erectile problems on their first sexual experience
■ It occurs in about 1 percent of men under age 35.
■ 2% of men younger than age 40-50 years complain of frequent problems
with erections
■ 13-21% of men 40-80 years complain of occasional problem with erection
■ 40%-50% of men older than 60-70 years may have significant problems
with erections.

13. Female orgasmic disorder/Inhibited female
orgasm /anorgasmia
A. Presence of either of the following symptoms and experienced on
almost all or all (approximately 75%-100%) occasions of sexual
activity:
1. Marked delay in, marked infrequency of, or absence of orgasm.
2. Markedly reduced intensity of orgasmic sensations.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.

14. Prevalence rates:
■ 10% to 42%, depending on multiple factors (e.g., age, culture,
duration, and severity of symptoms)
■ Approximately 10% of women do not experience orgasm
throughout their lifetime.

15. Delayed Ejaculation
A. Either of the following symptoms must be experienced on almost all or
all occasions (approximately 75%-100%) of partnered sexual activity,
and without the individual desiring delay:
1. Marked delay in ejaculation.
2. Marked infrequency or absence of ejaculation.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.

16. Prevalence
■ It is the least common male sexual complaint.
■ Only 75% of men report always ejaculating during sexual activity,
and less than 1% of men will complain of problems with reaching
ejaculation.

17. Early Ejaculation
A. A persistent or recurrent pattern of ejaculation occurring during
partnered sexual activity within approximately 1 minute following
vaginal penetration and before the individual wishes it.
B. The symptom in Criterion A must have been present for at least 6
months and must be experienced on almost all or all (approximately 75%-
100%) occasions of sexual activity.

18. DSM-5 defines the disorder as mild, moderate and severe:
1. Mild: If ejaculation occurs within approximately 30 seconds to 1 minute of
vaginal penetration
2. Moderate if ejaculation occurs within approximately 15 to 30 seconds of
vaginal penetration
3. Severe when ejaculation occurs at the start of sexual activity or within
approximately 15 seconds of vaginal penetration.

19. Sexual pain disorders
Genito-Pelvic Pain/Penetration Disorder:
A. Persistent or recurrent difficulties with one (or more) of the
following:
1. Vaginal penetration during intercourse.
2. Marked vulvovaginal or pelvic pain during vaginal intercourse or
penetration attempts.
3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation
of, during, or as a result of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor muscles during
attempted vaginal penetration.

20. ■ The prevalence of genito-pelvic pain/penetration disorder is
unknown.
■ However, approximately 15% of women report recurrent pain
during intercourse.

21. Sexual dysfunction due to a general
medical condition
Male Erectile Disorder Due to a General Medical Condition:
■ 20 to 50 percent of men with erectile disorder have an organic
basis for the disorder.
■ A physiologic etiology is more likely in men older than 50
■ The most likely cause in men older than age 60

22. Diseases and other medical conditions
implicated in erectile dysfunction
Infectious
1. Parasitic diseases
2. Elephantiasis Mumps
Cardiovascular disease
1. Atherosclerotic disease
2. Aortic aneurysm
3. Cardiac failure
Renal and urological
disorders
1. Peyronie’s disease
2. Chronic renal failure
3. Hydrocele and varicocele
4. Hepatic disorders
5. Cirrhosis

23. Pulmonary disorders
1. Respiratory failure
2. Genetic disorders
3. Klinefelter syndrome
4. Congenital penile vascular
and structural abnormalities
Nutritional disorders
1. Malnutrition Vitamin
deficiencies
Endocrine disorders
■ Diabetes mellitus
■ Dysfunction of the pituitary–
adrenal–testis axis
■ Acromegaly
■ Addison disease
■ Adenoma Adrenal neoplasia
■ Myxedema Hyperthyroidism

24. Neurological disorders
1. Multiple sclerosis
2. Transverse myelitis
3. Parkinson disease
4. Temporal lobe epilepsy
5. Traumatic and neoplastic spinal
cord diseases
6. Central nervous system tumor
7. Amyotrophic lateral sclerosis
8. Peripheral neuropathy
9. General paresis
Surgical procedures
1. Perineal prostatectomy
2. Abdominal–perineal colon
resection
3. Sympathectomy (frequently
interferes with ejaculation)
4. Aortoiliac surgery Radical
cystectomy
5. Retroperitoneal
lymphadenectomy
Others
1. Poisoning Lead (plumbism)
2. Herbicides

25. Dyspareunia Due to a General
Medical Condition
■ An estimated 30 percent of all surgical procedures on the female
genital area result in temporary dyspareunia.
■ 30 to 40 percent have pelvic pathology.

26. Organic abnormalities leading to dyspareunia and vaginismus
includes:
1. Irritated or infected hymenal remnants
2. Episiotomy scars
3. Bartholin’s gland infection
4. Various forms of vaginitis and cervicitis
5. Endometriosis, and adenomyosis
■ Postmenopausal women may have dyspareunia resulting from thinning
of the vaginal mucosa and reduced lubrication.

27. Male Hypoactive Sexual Desire Disorder and
Female Interest/Arousal Disorder Due 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:
1. Mastectomy
2. Ileostomy
3. Hysterectomy
4. Prostatectomy

28. Substance/Medication-Induced Sexual
Dysfunction
■ Distressing sexual dysfunction occurs soon after significant substance
intoxication or withdrawal, or after exposure to a medication or a
change in medication use.
■ Specified substances include:
1. Alcohol
2. Amphetamines or related substances
3. Cocaine, opioids
4. Sedatives, hypnotics, or anxiolytics, and other or unknown substances

29. Some Pharmacological Agents
Implicated in Male Sexual
Dysfunctions
Drug Impairs Erection Impairs ejaculation
Cyclic drugs
Imipramine
Protriptyline
Clomipramine
Amitriptyline
+
+
+
+
+
+
+
+
Monoamine oxidase
inhibitors
Phenelzine
Pargyline
Isocarboxazid
+
-
-
+
+
+
Others
Lithium
Amphetamines
Fluoxetine
+
+
-
+
+

30. Some Pharmacological Agents
Implicated in Male Sexual
Dysfunctions
Drug Impairs Erection Impairs ejaculation
Antipsychotics
Fluphenazine
Thioridazine
Trifluoperazine
Reserpine
Haloperidol
+
+
-
+
-
+
+
+
+
Antianxiety
Chlordiazepoxide - +
Antihypertensive drugs
Clonidine
Methyldopa
Spironolactone
Hydrochlorothiazide
+
+
+
+
+
-
-
Commonly abused substances
Alcohol
Barbiturate
Cannabis
Cocaine
Heroine
Methadone
Morphine
+
+
+
+
+
+
+
+
+
-
+
+
-
+

31.  The overall propensity of an antipsychotic to cause sexual dysfunction
is related to propensity to raise prolactin,
i.e.
Risperidone > Haloperidol > Olanzapine > Quetiapine > Aripiprazole
 Antipsychotic‐induced sedation and weight gain may reduce sexual
desire.
 Anti-depressant Mirtazapine, Bupropion, Reboxetine are relatively
safe compare to SSRI, TCA, SNRI, MAOIs
The Maudsley Prescribing Guidelines in Psychiatry 13th Edition

32. TREATMENT
■ Non Pharmacological therapy
■ Pharmacological therapy

33. ■ Dual-Sex Therapy:
 The methodology was originated and developed by Masters and Johnson.
 In 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.
Masters and Johnson

34. ■ 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.
■ The aim of the therapy is to establish or reestablish communication within
the partner unit.
■ Treatment is short term and is behaviorally oriented.
■ The therapists attempt to reflect the situation as they see it, rather than
interpret underlying dynamics.

35. Specific Techniques and Exercises
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. Sometimes,
treatment is coordinated with specially trained physiotherapists who work
with the patients to help them relax their perineal muscles.

36. Specific Techniques and Exercises
Premature ejaculation:
 An exercise known as the squeeze technique is used to raise the
threshold of penile excitability.

37. Stop–start technique:
 Developed by James H. Semans, in which the woman stops all stimulation
of the penis when the man first senses an impending ejaculation.
 No squeeze is used.
In cases of lifelong female orgasmic disorder, the woman is directed to
masturbate, sometimes using a vibrator.

38. Behavior Therapy
■ Behavioral approaches were initially designed for the treatment of
phobias but are now used to treat other problems as well.
■ Behavior therapists assume that sexual dysfunction is learned
maladaptive behavior, which causes patients to be fearful of sexual
interaction.
■ Therapists set up a hierarchy of anxiety provoking situations, ranging
from least threatening (e.g., the thought of kissing) to most threatening
(e.g., the thought of penile penetration).

39. Mindfulness
■ Mindfulness is a cognitive technique that has been helpful in the
treatment of sexual dysfunction.
■ The patient is directed to focus on the moment and maintain an
awareness of sensations—visual, tactile, auditory, and olfactory—that
he or she experiences in the moment.
■ The aim is to distract the patient from watching him or herself and
center the person on the sensations that lead to arousal and/or
orgasm.

40. 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.
■ 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.

41. Biological Treatments
Biological treatments, includes:
1. Pharmacotherapy
2. Surgery
3. Mechanical devices

42. Investigation:
■ Penile Doppler Ultrasound is a procedure that is used to predict
the response of your erectile dysfunction (ED) to vasodilation
medications that enhance blood flow to the penis.

43. Pharmacotherapy:
1. Sildenafil (viagra) and its congeners
2. Oral phentolamine; alprostadil
3. Injectable medications; papaverine, prostaglandin E1,
phentolamine, or some combination of these
4. Transurethral alprostadil.
Sildenafil
100mg
Vardenafil
20mg
Tadalafil
20mg
Maximum
Concentrati
on
450ng/ml 20.0ng/ml 378ng/ml
Time to
max
concentrati
on
1.0 hours 0.7 hours 2.0 hours
Half-life 4 hours 3.9 hours 17.5 hours

44. Hormone therapy
■ Androgens increase the sex drive in women and in men with low
testosterone concentrations.
■ Clomiphene and tamoxifen are both antiestrogens, and both
stimulate gonadotropin-releasing hormone (GnRH) secretion and
increase testosterone concentrations, thereby increasing libido.

45. Vacuum pumps:
 These are mechanical devices that patients without vascular
disease can use to obtain erections.
 The blood drawn into the penis following the creation of the vacuum
is kept there by a ring placed around the base of the penis.

46. Shockwave therapy is administered with a wand-like device placed
near different areas of the penis. The device along parts of your penis
for about 15 minutes while it emits gentle pulses. No anesthesia is
needed. The pulses trigger improved blood flow and tissue remodeling
in the penis.
Surgical Treatment:
Inflatable Penis Prosthesis and vascular surgery
Shockwave therapy Inflatable Penis

47. Sexual-Dysfunction Myths
1. Sexual dysfunction is only a problem for older men.
2. Erectile dysfunction is the only sexual problem that can be reliably
treated.
3. Dysfunction is a result of a man no longer finding his partner sexy.
4. Sexual dysfunction cannot be prevented.
5. Treating a man’s sexual problems doesn’t require his partner’s
input.

48. Thank you

49. References:
1. Kaplan and Sadock’s Synopsis of Psychiatry, 11th Edition
2. Kaplan and Sadock’s Comprehensive textbook of psychiatry, 10th
Edition
3. Diagnostic and Statistical Manual of Mental Disorders (DSM–5)
4. The Maudsley Prescribing Guidelines in Psychiatry 13th Edition