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Sexual arousal disorders

Man survives earthquakes, experiences the horrors of illness, and all of the tortures of the soul. But the most tormenting tragedy of all time is, and will be, the tragedy of the bedroom. - Tolstoy.

Presented by Dr Pavan Kumar K Chaired by Dr Denzil A Pinto

Sexuality and sexual behaviour


Reproduction is a fundamental biological function,

that guarantees the survival of the species. Due to its evolutionary advantages, most complex lifeforms have evolved methods of sexual reproduction, which involves the combination of genetic material from parents of two different genders.

Sexuality and sexual behaviour


Humans are not sexually static reproductively-driven

mammals. Unlike most animal species, human sexuality is associated with gratification (pleasure), and not just reproduction. Sexual behavior is richly multidetermined. Human sexuality is shaped not only by biology, but by social, cultural, interpersonal, and psychological constraints.

History
First attempt at describing and classifying sexual

disorders began with Richard von Krafft-Ebing and his Psychopathia Sexualis(1898), which influenced medical and legal practice for more than 3-quarters of a century. Seminal contributions of Havelock Ellis and Albert Kinsey (sexual behavior in human male and female)

Prior to

psychoanalytical concepts guided clinicians

1950

in understanding and treatment of sexual problems Sexual symptoms were linked to unresolved, unconscious conflicts occurring during specific developmental periods.
behavioural perspective gained

late

1950s

ascendancy; sexual problems were understood to be learned (conditioned) anxiety responses.

In

Masters and Johnson.


described the physiology of phases of

1966

sexual functioning, and later highlighted the deleterious influence of performance anxiety, the impact of relationship factors, and the significance of biological factors on the development of sexual dysfunctions. Their work foreshadowed the later integration of medical and psychological interventions.

The neo-

heralded by the publication of

Masters and Johnson era

Helen Singer Kaplan's book, The New Sex Therapy. Integrated psychoanalytical theory with Masters & Johnson's cognitive-behavioral understanding of sexual dysfunction. Distinguishing between recent and remote etiological causations, she recommended behavioral approaches for the former and reserved traditional psychodynamic methods for the latter.

The

current psychobiological era.


This period is distinguished by the

mid1980s

medicalization of treatment approaches, primarily for male sexual dysfunction. Scientific investigations of cellular chemistry have elucidated the pathophysiology of male sexual arousal problems and have led to the introduction of new oral treatments, such as sildenafil.

Components of sexuality
Sexual identity: is a pattern of patients biological

sexual characteristics Gender identity: individual sense of maleness/ femaleness, from infinite clues derived from experiences with family members, peers, teachers & cultural phenomenon. Established by age of 2 or 3 yrs. Sexual orientation: describes the object of persons sexual impulses. Heterosexual, homosexual, or bisexual. Sexual behaviour: includes desire, fantasies, pursuit of partners, auto-erotic activities & activities engaged in to express & gratify sexual needs.

Modelling the human sexual response cycle


Models have been constructed of the normal sequence

of changes during sexual arousal and coitus. The first models described a simple sequence of increasing arousal and excitement culminating in rapid discharge by orgasm, displayed graphically as an ascent, peak, and then descent.

The EPOR model


formulated by Masters and Johnson
four-phase linear, sequential, and incremental model

of the human sexual response cycle excitation (E) phase (stimuli from somatogenic or psychogenic sources raise sexual tensions), plateau (P) phase (sexual tensions intensified), orgasmic (O) phase (involuntary pleasurable climax), and finally resolution (R) phase (dissipation of sexual tensions).

Modifying the EPOR model into the DEOR model currently accepted model
Robinson concluded convincingly that the P phase was

simply the final stage of the E phase. Helen Kaplan, proposed that before the E phase there should be a desire phase' (D phase). came from her work with women who professed to have no desire to be sexually aroused, even by their usual partners.

EPOR replaced by the desire, excitation, orgasmic, and

resolution phase (DEOR) model. Sexual desire that appears to be spontaneous should obviously be placed at the beginning of the model but what of sexual desire created when the person is sexually aroused by another?

(a) the original EPOR model of Masters and Johnson (b) the DEOR model of Kaplan (c) the proposed modification with desire phase 1 (before initiation of the excitation phase and desire phase 2 during excitation phase) and (d) with added courtship behaviour

Phase I: Desire
Psychological phase

Characterised by sexual fantasies & conscious desire to have sexual activity.


Can be biologically driven or result from a wish to

bond sexually with a particular partner. Dysfunction: hypoactive sexual desire disorder, sexual aversion disorder, hypoactive sexual desire disorder due to general medical condition (man/ woman), substance induced sexual dysfunction with impaired arousal.

Phase II: Excitement


Brought on by psychological stimulation (fantasy

or presence of love object), physiological (stroking/ kissing) or combination. Consists of subjective sense of pleasure & objective signs of sexual excitement. Dysfunction: female sexual arousal disorders, male erectile disorders, male erectile disorder due to general medical condition, substance induced

Phase III: Orgasm


Consists of peaking sexual pleasure, with release of sexual

tension, & rhythmic contraction of perineal muscles & pelvic reproductive organ. Lasts for 3-15sec Dysfunction: female & male orgasmic disorders, premature ejaculation

Phase IV: Resolution


Consists of disgorgement of blood from genitalia, which

brings body back to its resting position. If orgasm occurs resolution is rapid, if not may take 2-6hrs & be associated with irritability & discomfort. Through orgasm it is characterised by sense of well being, general relaxation, muscular relaxation. Men have refractory period (mins-hrs), they cant be stimulated to further orgasm. This does not exist in females. Dysfunction: postcoital dysphoria, postcoital headache.

The sexual response cycle

organ mental skin breasts

Excitement phase Several mins-hrs, heightened excitement before orgasm, 30sec-3min Inconsistent Sexual flush, maculopapular rash on abdomen spreads to ant chest wall, face& neck & include shoulders & forearm Nipple erection (2/3rd), venous congestion & areolar enlargement, size increases by 1/4th

clitoris

Enlargement in diameter of glans & shaft, just before orgasm shaft retracts into prepuce

Labia majora Nullipara- elevate & flatten against perineum Multipara- congestion & edema Labia minora vagina uterus others Size increase 2-3 times normal, change to pink, red, deep red before orgasm Colour change to dark purple, transudate appears 10-30 sec after arousal, elongation & ballooning, lower third constricts before orgasm Ascends into false pelvis, labor like contractions begin in heightened excitement just before orgasm Myotonia Mucoid secretion from bartholins gland during heightened excitement Cervix swells slightly & is passively elevated with uterus

organ Mental Skin

Excitement phase Several mins-hrs, heightened excitement before orgasm 30sec-3min Just before orgasm, inconsistent Sexual flush, maculopapular rash on abdomen spreads to ant chest wall, face& neck & include shoulders & forearm Erection in 10-30 sec caused by vasocongestion in erectile bodies of corpus cavernosa of shaft, loss of erection may occur with introduction of asexual stimulus ( loud noise), with heightened excitement size og glans & diameter of penile shaft increase further Tightening & lifting of scrotal sac & elevation of testes, 50% increase in size of testes over unstimulated state & flattening against perineum, signalling impending ejaculation 2-3 drops of mucoid fluid that contain viable sperm are secreted during heightened excitement. Breasts- inconsistent nipple erection Myotonia- semispastic contractions of facisl, abdominal & intercostal muscles Tachycardia- upto 175 beats/min BP- rises to 20-80mm systolic & 10-40 diastolic Respiration - increased

Penis

Scrotum & testes

Cowpers gland other

Nitric Oxide & Penile/Clitoral Tumescence


Sexual stimulation Nitric oxide synthesized in nerve and vascular tissue of penis/clitoris
Nitric oxide activates guanylate cyclase GTP cGMP

cGMP relaxes smooth muscles of corpus cavernosum and arterioles in penile/clitoral tissue Vasocongestion of penile/clitoral tissues

Neuroanatomy: Central
Cortical: orbitofrontal (sexual emotions), left anterior cingulate (hormone control and sexual

arousal) Subcortical: right caudate (sexual activity) Limbic: Hippocampus, amygdala, septum, medial preoptic area, fimbria, anterior thalamic nuclei, mammillary bodies (Chemical or electrical stimulation elicited penile erection)

Brainstem: nucleus paragigantocellularis, other

serotonergic nuclei exert inhibitory and excitatory control over spinal sexual reflexes projects directly to pelvic efferent neurons in the lumbosacral spinal cord, apparently causing them to secrete serotonin, which is known to inhibit orgasms Spinal cord: receives sensory inputs; reflex centre in lumbosacral area. sexual arousal and climax are ultimately organized at the spinal level.

Neuroanatomy: Peripheral
Parasympathetic Sympathetic

Pelvic splanchnic nerves Roots S2, S3, S4 Reflex impulses Synergy for erection

Hypogastric plexus Psychological impulses Ejaculation Orgasm

Neurochemistry
Dopamine: increases libido and sexual activity Acetylcholine: important for erection

Norepinephrine: erection, ejaculation, orgasm


Serotonin: complex role. produced in the upper pons

and midbrain is presumed to have an inhibitory effect on sexual function. Oxytocin: orgasm, reinforce pleasurable activities

Neurochemistry
Prostaglandins: penile erection Nitric oxide: penile erection, ? female genital

response Vasoactive intestinal polypeptide: arousal in both men and women

Endocrinology
Testosterone: libido in both genders In men, stress is inversely correlated with testosterone blood

concentration. Other factors, such as sleep, mood, and lifestyle, influence circulating levels of the hormone. Oxytocin: enhances sexual activity and levels in both sex increase during orgasm Oestrogen: maintains the integrity of the female genital tract GnRH (LHRH): pulsatile release Others: prolactin, thyroid hormones, adrenal steroids

A more simple classification


Pleasure inhibitors, or sexual dysfunctions disorders

occurring in the context of a normal sexual response or behaviour.


Pleasure facilitators, or paraphilias in which

deviations from normal erotic stimuli and activities are obligatory for sexual arousal and response.

Sexual dysfunctions: following the response cycle


Disorders of desire

Disorders of arousal (excitement) Disorders of orgasm

(Though disorders of resolution exist, they have not been considered in the nosology)

Sexual dysfunctions: outside the cycle


Sexual pain disorders dyspareunia and vaginismus

Sexual dysfunction, NOS:

Compulsive sexual behaviour (addiction) Postcoital dysphoria, Postcoital headache Nymphomania / satyriasis Distress over sexual orientation Orgasmic anhedonia If they are attributable entirely to a general medical condition, substance use, or adverse effects of medication, then sexual dysfunction due to a general medical condition or substance-induced sexual dysfunction is diagnosed.

SEXUAL AROUSAL DISORDERS: DSM IV TR: 1. Female sexual arousal disorders 2. Male erectile disorder
ICD-10: Failure of genital response

DSM-IV-TR Diagnoses
DSM-IV-TR specifies three criteria for each sexual

dysfunction. The first criterion describes the psycho-physiologic impairment; for example, absence of sexual desire, arousal, or orgasm. The second requires that the patient have marked distress or interpersonal difficulty as a result, while The third asks the clinician to ascertain that some other Axis I diagnosis, medical illness, medication, or substances of abuse does not best explain the problem.

DSMIV- TR gives the clinician additional latitude for

deciding when a person who meets the first criterion qualifies for a disorder. The doctor is asked to consider the effects of the individuals age, experience, ethnicity and cultural background, the degree of subjective distress, adequacy of sexual stimulation, and symptom frequency.

MALE ERECTILE DISORDER/ ERECTILE DYSFUNCTION/ IMPOTENCE.


DSM IV TR: A. Persistent or recurrent inability to attain, or maintain until completion of sexual activity, an adequate erection B. Disturbance causes marked distress or interpersonal difficulty. C. Not better accounted for by another axis I disorder not due to direct physiological affect of drug or general medical condition.

Specify type: Life long type

: Acquired type. Specify type: Generalized type : Situational type. Specify: Due to Psychological factors : Due to combined factors.

ICD-10 F52.2 Failure of Genital Response


In men, the principal problem is erectile dysfunction.
In women, the principal problem is vaginal dryness or

failure of lubrication. Includes: Female sexual arousal disorder : Male erectile disorder : Psychogenic Impotence.

ICD-10:
A. General criteria must be met-

G1- subject is unable to participate in a sexual relationship as he/she would wish G2- dysfunction occurs frequently but may be absent on some occasions. G3- The dysfunction has been present for at least 6 months. G4- The dysfunction not entirely attributable to any of the other mental & behavioural disorders, physical disorders, drug treatment.

B. Erection sufficient for intercourse fails to when it is attempted. Dysfunction takes one of the following form1. Full erection occurs during the early stages of love making but disappears or declines when intercourse is attempted (before ejaculation if it occurs) 2. Erection does occur but only at times when intercourse is not being considered 3. Partial erection, insufficient for intercourse occurs but not full erection 4. No penile tumescence occurs at all.

Erectile dysfunction
Erectile dysfunction is defined as the consistent inability to achieve and or maintain an erection of the penis sufficient for satisfactory sexual activity.

Epidemiology: 2-4% at 35yrs & 77% at 80yrs ( Kinsey) The chief complaint of men below 35 & 50% of all men treated for sexual disorders is erectile dysfunction.

Pathophysiology
Normal erection delicate balance

between vasoconstriction & vasorelaxation of corporal smooth muscle. If a critical level of relaxation is not achieved, there will be incomplete resistance to the outflow of blood from the corpora & a spectrum of penile tumescence will range from flaccidity to near but not complete erection. ED due to incomplete corporal smooth muscle relaxation- veno-occlusive dysfunction.

Aetiology
1)Psychological causes:

-Performance anxiety, -Relationship conflicts/loss of attraction -Sexual inhibition, Guilt -Widowers syndrome. -Conflicts over sexual preference -Sexual abuse in childhood -Depression, Fear of pregnancy or STDs .

2)Vascular:

i)Atherosclerosis: Penis has more vascular smooth muscle than any other organ in the body.Atherosclerosis occurs here early. ED may be a reflection of vascular disease elsewhere prior to it becoming clinically evident. ii) CAD & CVAs, iii)Hypertension, cardiac failure iv)Dyslipidaemia. HDL-Cholesterol: inverse relation. v)Peripheral vascular disease,

3)Endocrinological causes: DM, Dysfunction of the pituitary-adrenal-testis axis, Hyperthyroidism, Myxedema ,Hyperprolactinemia, Hypogonadism, Low GH, Acromegaly, Addison's disease
DIABETES AND ERECTILE DYSFUNCTION Psychogenic: Anxiety. Neurogenic : Loss of sensory & autonomic nerves. Arterial: Small vessel disease. Venous: Cavernous myopathy, endothelial dysfunction.

others
Renal and urological disorders

Peyronie's disease, CKD, Hydrocele & varicocele Hepatic disorders Cirrhosis (usually associated with alcohol dependence) Pulmonary disorders - Respiratory failure Infectious and parasitic diseases Elephantiasis, Mumps Genetic disorders - Klinefelter's syndrome Congenital penile vascular and structural abnormalities (Epispadias)

Neurogenic etiology
Neurological disorders

Multiple sclerosis, Tumours, CVA, Encephalitis, Dementia,Transverse myelitis Parkinson's disease, Temporal lobe epilepsy, Traumatic and neoplastic spinal cord diseases, ALS Peripheral neuropathy, General paresis,Tabes dorsalis, Disc herniation

Surgery or trauma
Neurological: head trauma/surgery, spinal cord

trauma/surgery, Retroperitoneal lymphnode dissection. Vascular: Aorto-iliac bypass, Aorto-femoral bypass. Gastro-intestinal: Abdomino-perineal resection, Proctocolectomy. Pelvis: trauma, irradiation, pelvic lympahadenectomy. Urological : prostatectomy.

Recreational drugs
i) Nicotine, Alcohol. ii)Cannabis iii)Amphetamines: vasoconstriction of genital tissue. Increases libido ,Erectile failure; prolonged erection (up to 18 hours!) iv)Ecstacy: Erection: impaired in 40%

v) other dependence-inducing substances (heroin, methadone, morphine, cocaine, barbiturates)

Drugs
Accounts for 25%
Thiazide diuretics are the most common cause of ED. i)Diuretics: Thiazides, Spironolactone(anti-androgen

activity). ii)Anti-hypertensives: CCBs, methyldopa,clonidine,beta-blockers. - act directly at the corporal level or indirectly by decreasing the systemic B.P. iii)Cardiac: Digoxin(Na-K ATPase blockade),clofibrate.

iv)H-2 antagonists: Cimetidine,Ranitidine (anti-

androgen activity). v)Hormones: Estrogens,Progesterone,Corticosteroids, Cyproterone acetate,5-alpha reductase inhibitors,LHRH agonists. vi) Cytotoxic drugs: Cyclophosphamide, Methotrexate.(by causing hypogonadism). vii)Others:Anticholinergics,Anti-convulsants

Psychotropics and sexual dysfunction


Antipsychotics: lack of libido, ED

Mood stabilizers: rare


Tricyclics: retrograde ejaculation, ED, orgasmic

difficulties SSRIs: lack of libido, arousal disorders, delayed ejaculation Benzodiazepines: not clear Anticholinergics: failure of vaginal lubrication, ED

i) Aging: ED is 4times higher im men in 60s than in 40s. ii)Arsenic poisoning- alteration in K-gated pump, plumbism, herbicides iii)haematological: sickle cell anaemia,leukaemia. iv)nutritional : malnutrition, zinc deficiency. v)Bicycling: A study done in 2002 found that the No. of hours on a bike &/or pressure on the penis from the saddle of an upright bicycle is directly related to ED.

Clinical evaluation
1)History
2)Physical exmination. 3)Psychological assessment. 4)Tests

History
The first step in the management- sexual, medical,

and psychosocial history. A sensitive topic, and the clinician must be sensitive to the patient's comfort level. Taking the history provides an opportunity for the physician to initiate patient and partner education about ED and its treatments and to facilitate communication. It also allows the physician to establish a rapport with the couple, which assists in treatment

questionnaires:

IIEF International Index of Erectile Function. SHIM -Sexual Health Inventory for Men. Arizona Sexual Experience Scale, Brief Sexual Function Questionnaire, Changes in Sexual Functioning Questionnaire, Derogatis Sexual Function Inventory, Rush Sexual Inventory.

Organic causes characterized by an insidious &

consistent change in rigidity or inability to sustain morning, coital,or mastubatory-related erections. Also enquire about: penile sensation, penile curvature, altered libido, partners sexual function & others psychological factors. Obtain information about current medications, any history of pelvic surgery, trauma, prior prostate surgery, or radiation to the prostate. substance use should be documented.

Physical examination
A physical examination is necessary for every patient,

with particular emphasis on the genitourinary, vascular, and neurologic systems. The physical examination may corroborate history findings and reveal unsuspected physical findings, such as penile plaques, small testes, evidence of possible prostate cancer, prostate infections, or hypertension, thyroid dysfunction,serious cardiovascular pathology,end-stage kidney disease. All peripheral pulses should be measured.

Psychological assessment
The main diagnostic feature of psychogenic ED vs

selective ED. The man is able to produce rigid, long-lasting erections during the night or early mornings, with certain partners, in response to magazines or videos, but not while attempting intercourse with his wife. Underlying relationship problems are the cause and they must be addressed.

Tests
1)Nocturnal Penile Tumecsence(NPT)

Useful in distinguishing psychogenic ED from Organic. Erections occur during REM sleep. A band is placed around the penis. Patient is asked to wear it on 2-3 successive nights. Sleep can be monitored by polysomnography

There are 2 methods:

i)Snap-Gauge band:Velcro band fitted around the penis. Shotrcomings: lack of information regarding partial rigidity, No.of erections & duration of erections. ii) Rigi scan:Home- monitoring device, capable of continuously monitoring penile circumference & rigidity. Logging unit- strapped to the patients thigh& 2 loops placed around the base &tip of the penis just behind the corona.

2)Vascular studies: i)Intra cavernous vaso-active drug injection:

A positive test rigid erectile response(unable to bend) ,that appears within 10mins after the intracavernous injection(of 20mcg of PGE1 or papaverine)& lasts for 30mins. A positive response indicates- functional origin. Limited use ii) Duplex ultrasound of penile arteries: Measurements are compared between flaccid & pharmacological erect penis. Color doppler can also be used.

iii) Arteriography & Dynamic Cavernosometry or

Cavernosography(DICC): Used to detect failure of veno-occlusive mechanism. Cavernosography using radiographic contrast enables the detection of potential leakage into all penile venous drainage systems. iv)Penile angiogram v)Digital subtraction angiography vi)Magnetic Resonance Angiography

3)Neurological studies:

i)Bulbo-cavernous reflex latency: The physician squeezes the glans of the penis,which immediately causes the anus to contract, if the nerve function is normal. The latency between sqeeze & contraction is measured by observing the anal spincter or feeling it with a gloved finger inserted past the anus. ii) Nerve conduction Studies

iii)Penile Biothesiometry:

A small electro-magnetic test probe is placed on the right & left of the shaft and on the glans. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence.

4)Endocrinological studies:

Testosterone,prolactin,FSH,LH,GH.
5)Other tests:

Fasting glucose & lipid profile, PSA,psychodiagnostic tests.

PLISSIT: a simple model for routine practice (Annon)


P permission

LI limited information
SS specific suggestion IT intensive therapy

PLISSIT: a simple model for routine practice

Treatment
1)Psychotherapy
2) Non-pharmacological methods 3)Vacuum devices 4)Pharmacotherapy: topical, injectales, oral. 5) Surgery.

Management: psychotherapies
Dual sex therapy developed by Masters & Johnson

(Sensate Focus) Behavioural therapy (assumes sexual dysfunction as


learned maladaptive behaviour)

Hypnotherapy Group therapy Psychodynamic therapy Integrated therapy (sex therapy integrated with supportive, psychodynamic, insight oriented psychotherapy)

Nonpharmacologic Treatment Options


Lifestyle changes: Reduce fat and cholesterol in diet Decrease or limit alcohol consumption Eliminate tobacco use and substance abuse Weight loss if appropriate Regular exercise

Vacuum devices:
Can be used by almost all patients with ED.
These devices exert a negative pressure on the penis,

which results in an increase in corporeal blood flow & erection. The time taken to achieve erection -2-30mins.

Pharmacotherapy
1) Prostaglandin delivery systems: intra-cavernosal

: intraurethral 2) Transdermal delivery. 3) Other intracavernosal & transdermal drugs 4) Oral therapies

Intra cavernosal PGE1


Caverject: injectable form of Alprostadil. Administration:

i)reconstitution of the powder of the drug. ii)The skin over the penis should be pulled taut & the needle & syringe are held at right angles to the penis iii)The drug should be injected directly into one corpus cavernsum,avoiding visible veins;the injection site should be alternated between the cavernosa .

Side-effects: Pain, Prolonged use- corporal fibrosis. Priapism. Containdications: Known hypersensitivity to the drug. Patients with conditions that predispose to priapism. E.g; sicle cell anemia, multiple myeloma, leukemia. Other drugs: i)Moxisylte- selective alpha-1 blocker. ii)Vasoactive intestinal polypeptide.

Intra urethral PGE1


Alprostadil administered using MUSE(Medicated

Urethral System for Erection) It is rapidly absorbed from the urethral mucosa. Usual onset of action:20mins & erections last for 30-60min..

Transdermal delivery
Minimizes systemic exposure & tissue traumatization.
Administration of vaso-active substances(PGE1) across

the skin to the penis. Others: Testosterone patches. 1-2 patches containing 2.5-5mg of testosterone applied daily to the abdomen, back thighs or upper arms.

PDE5 Inhibitors
Mechanism of Action: PDE inhibitor and increases the cGMP that promotes and sustains smooth muscle relaxation Indications: Psychogenic ED Mild vasculogenic ED Neurogenic ED Side effects from medication(s) patient is already taking

Mechanism of Action of PDE5 Inhibitors

SM

DRUG RELEASED IN ONSET OF ACTION

SILDENAFIL MARCH 1998 30 min

VARDENAF TADALAFIL IL APRIL 2003 25-45min 6hrs Headache, flushing and nasal congestion Nitrates FEBRUARY 2003 30min 36hrs Headache, myalgia, dyspepsia. Backache,nasal congestion Nitrates, Angina, Hypertension,

DURATION OF 5hrs ACTION SIDE- EFFECTS Headache , flushing, bluish vision and nasal congestion CONTRAINDI CATION Nitrates

Medication
(Yohimbine, Yocon, Erex, Yohimex)
Alpha 2 andrenoreceptor antagonist

Dose: 5.4 mg TID


Results: ~20% (same as placebo) Side effects: increase blood pressure, tachycardia,

anxiety

Medication Trazodone(Desyrel)
Anti-depressant associated with priapism

Mechanism of action not fully understood


Not FDA approved for ED Side effects: drowsiness, dry mouth, sedation,

priapism

Medication Apomorphine (Spontane)


Dopaminergic mechanism with hypothalamic activity

Sublingual administration
64% to 67% response rate with ED Side effects: nausea, sweating, hypotension, yawning

Awaiting FDA approval

Medication Phentolamine (Vasomax)


Alpha-blocker

Relaxes smooth muscle tissue


40% efficacy in mild organic ED Side effects: nasal congestion, tachycardia, dizziness,

hypotension Awaiting FDA approval

Surgery
1)Venous leakage:

2 approaches are adopted: i) ligation of all veins draining to the penis i.e deep dorsal,cavernosal & crural veins. ii)ligation & division of the deep dorsal vein. 2)Arterial revascularization. 3)Peyronies disease: The Horton Devine procedure. : The Nesbit procedure.

PENILE PROTHESIS
2 types:

i)Semi-rigid rods Consists of 2 rod-like cylinders that are implanted into the corpora cavernosa Types: Malleable & Mechanical rods ii) Inflatable Cylinders. Unitary, Two-piece, Three piece

Penile prosthesis
Penile prosthesis has

highest satisfaction ~93% Infection rate: ~2% virgin & 4% diabetic Malfunction rate ~10% at 10years Surgical Procedure Requires Anesthesia Takes approximately 90 min.

An innovative drug-delivery system

nanoparticles encapsulating NO or prescription drugs shows promise for topical treatment of ED, -Science Daily (Sep. 20, 2009) A study done by Dr.Yoram Vadi in Nov 2009, showed that 75% of men suffering from ED, treated with shock-wave therapy showed a return of erectile functioning.(release of VEGF- stimulates the growth of new blood vessels in the genital area).

Treatment of antidepressantinduced sexual disorders


Drug holidays

Switching mirtazapine, bupropion, nefazodone


Psychological interventions Sildenafil

Others dopamine agonists, cyproheptadine,

amantadine, buspirone

FEMALE SEXUAL AROUSAL DISORDERS: DSM IV TR: A. Persistent or recurrent inability to attain, or maintain until completion of sexual activity, an adequate lubrication swelling response. B. Disturbance causes marked distress or interpersonal difficulty. C. Not better accounted for by another axis I disorder not due to direct physiological affect of drug or general medical condition. Specify: lifelong/ acquired type, generalised/ situational, due to psychological factors or combined factors.

ICD-10: A. General criteria must be metG1- subject is unable to participate in a sexual relationship as he would wish G2- dysfunction occurs frequently but may be absent on some occasions. G3- The dysfunction has been present for at least 6 months. G4- The dysfunction not entirely attributable to any of the other mental & behavioural disorders, physical disorders, drug treatment.

B. There is failure of genital response, experienced as

failure of vaginal lubrication, together with inadequate tumescence of the labia. Dysfunction takes place one of the following forms: 1. General: lubrication fails in all relevant circumstances 2. Lubrication may occur initially but fails to persist for long enough to allow comfortable penile entry. 3. Situational: lubrication occurs only in some situations (with one partner not another, during masturbation, when vaginal intercourse is being contemplated.

Women with excitement phase dysfunction often have

orgasmic problems as well. May be associated with dyspareunia or lack of desire. Studies shown 14-16% women having chronic lubrication difficulties & 23% with intermittent problems. Postmenopausal- 44% Less research on physiological components of dysfunction in women than men

Masters & johnson found normally responsive women to

desire sex premenstrually. Another set of dysfunctional women found felt the greatest sexual excitement at the time of ovulation Evidence indicates dysfunctional women are less aware of physiological responses in their bodies, like vasocongestion during arousal.

Causes of female sexual arousal disorder


Classified as: 1)Psychological domain. 2)Physical domain.

Psychological factors: i)Impact of events during childhood and adolescence. - studies have shown some probative links between chidhood sexual abuse & sexual dysfunction in later life.

ii) Individual factors: Stress & fatigability. Over-exposure to pornography & style media which is thought to lead to poor body image, self- consciousness and lowered self esteem. - Psychiatric disorders like depression, anxiety, OCD, PTSD.
iii)Relationship factors:

Physical factors: 30-80% of the cases.


Circulatory & neurological disorders are the most

likely causes of sexual dysfunction. i)Circulatory: HTN, CAD. Damage to blood vessels decreases blood flow damage to nerves in pelvic area diminishes arousal. ii)General medical condition: Diabetes, Anaemia. iii)Hormonal: Low level of sex hormones , due to aging(menopause) Thyroid dysfunction, disorders of adrenal gland etc.

iv)Recreational drugs: alcohol,smoking.


v)Medications: Anti-depressants, Anti-psychotics, Sedatives, Anti-hypertensives, OCPs & Other hormone containing pills. vi)Post baby coolness: Extreme loss of lidido after childbirth.

Role of Male Circumsicion


The `valve' mechanism of foreskin of uncircumcised

penis is thought to retain the natural lubrication provided by the female because the bunched up foreskin acts to block the lubrication escaping from the vagina, which results in dryness.

Persistent sexual arousal syndrome in women


Infrequent,
distressing and perplexing not only because of its

mysterious onset, but also because of the feelings of shame and discomfort that accompany the phenomenon. persistent feelings of vaginal congestion and other physical signs of sexual arousal in the absence of any awareness of sexual desire provoking or accompanying this arousal or persisting for hours after attaining orgasm.

Interventions
1)PsychologicalTreatment Education about anatomy, Physiology and expectations. couples therapy. Masters & Johnson-sensate focus. progressive levels of touching, starting with non-sexual, sexual and sexual intercourse. CBT: uses thought records to capture the cognitions that accompany emotions.

2)Lubricants: Helps in vaginal dryness & the resulting dyspareunia. 3)Pharmacotherapy: i)Sildenafil: Dose: 50-100mg/day. Found to be superior to placebo in effects of arousal. ii)The Non- SSRI: Bupropion Especially in those with SSRI induced dysfunction. Dose: 300-400mg/day

4)Hormonal:
Providing exogenous source of hormones ameliorate

vasomotor symptoms in menopausal women. Women with vaginal atrophy & donot wish to take systemic therapy topical estrogen creams. Transdermal delivery: Natural progestin containing creams combined with estrogen. Tibolone: Synthetic steroid sex hormone.Superior to HRT.

5)Clitoris Vacuum therapy: A small ,handheld device ,connected by a tubing to a

small ,soft plastic cup, that is placed over the clitoris. When gentle vacuum is created , blood flow to the genitalia causes genital engorgement, increased vaginal lubrication & enhanced ability to achieve orgasm. May be used prior to having intercourse or 3-4times a week to rehabilitate sexual responses.

6)Others:

i)Topical vasodilators: PGE1- increases genital arousal. ii)Dopamine agonists increases sexual interest, orgasm & improves patient-partner sexual satisfaction. 7) Alternative medicine: Natural estrogens such as soya products. Belladona ,ginkgo biloba etc. Prognosis: Generally once a woman seeks the appropriate help they are quite likely to find a way to resolve their problem.

CONCLUSION: Sexual arousal disorders are quite common & very distressing both in men & women but appears to be high in men causing distress to both partners & causing interpersonal problems. Hence early detection & treatment should be our goal as successive episodes are reinforcing and cause anticipatory anxiety perpetuating the problem. Arousal disorders are usually not diagnosed or treated in women as they rarely seek treatment.

Thank u

Men look for youthfulness and physical attractiveness, smooth complexion, optimum stature, and good physique, and they value virginity and chastity. Partner variety is highly desired.

Women, look for high-quality mates with abundant resources and emotional and financial status and security.

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