Week 5 - Sexual Disorders in Men Diagnosis and Treatment Flashcards
Sexual dysfunctions in men
- Male hypoactive sexual desire disorder
- Erectile disorder
- Delayed ejaculation
- Premature ejaculation
Other specified sexual dysfunctions
- Sexual aversion
- Hyperactive sexual desire
Unspecified sexual dysfunction
Body dysmorphic disorder (genital related)
Male hypoactive sexual desire disorder
- Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity
- The assessments of this must take account of factors such as age and lifestyle
Prevalance MHSD
Periodically
* 0-6% (18 -24 years)
* 41% (66-74 years)
Longer than 6 months
* 1.8% (16-44 years)
A sexual response requires
- Adequate sexual stimulus
- Genital response, subjective experience of arousal
- Situational factors (context, opportunities, motivation)
- Physiological sensitivity (androgenic hormones, neurotransmitters etc.)
Production of testosterone
Testosterone is produced in the leydig cells of the testes and the adrenal glans
Production is regulated from the pituitary gland by:
* LH
* FSH
Why is testosterone important
- A minimum of testosterone is needed in order to function sexually
- Testosterone makes the system ready for sexual activity
- Lower levels are found in 1% of men aged between 20 and 40, but in 20% of over-65
What to do to make a diagnosis
Physical examination and lab tests
* “Lifestyle” (alcohol and drugs)
Individual history (anamnesis), focussing on
* Asking about psychiatric co-morbidity
* Negative sexual experiences
* Interest in sexual stimuli
Potential treatment
- Testosterone supplements
- Sex counselling
- Combination
Sex counselling
- Lifestyle changes: loss weight and exercise
- Break the pattern of avoidance behavior
* Look for positive sexual cues
* “Sensate focus” couple exercises: sex therapy technique (introduced by the Masters and Johnson team) refocusing the participants on their own sensory perceptions and sensuality, instead of goal-oriented behavior focused on the genitals and penetrative sex - Cognitive restructuring (rational emotive therapy)
- Couple therapy: for example, communication exercises, communicate about what you like sexually
Erectile disorder
- Marked difficulty in obtaining an erection during sexual activity
- Marked difficulty in maintaining an erection
- Marked decrease in rigidity
Prevalence ED
18-80 years around 6%
* 2% of men younger than 40 years
* 40-50% older than 60-70 years
* 27% among MSM group
Biological, medical and lifestyle risk factors
- Trauma
- Pelvic surgery
- Neurological diseases
- Hormonal diseases
- Alcohol, drugs use
- age
- Cardiovascular diseases
- Hyperlipidemia
- Diabetes mellitus
- Side effect of medication
- Smoking
Is an erectile disorder an arousal disorder
- Sexual arousal has a genital component (the erection) but also a subjective component (pleasure, pleasure, relaxation, self-esteem, intimacy) that may be at stake and require attentio
- Sexual arousal cannot be separated from sexual desire, as both can reinforce each other in a context of preconscious and explicit rewarding stimulation
Social/cultural and relational factors in ED
- “Erotophobia”: learned negative attitudes towards sexuality
- Traditional (religious) believes (sex myths)
- Poor interpersonal relationship, lack of communication
Psychological factors
- Temporary “normal” episode related to a period of stress
- Psychopathology
- Negative cognitive schemas
- Fear of failure
Organic vs psychogenic cause
Ask for:
* “spontaneous” erections
* Erectile failure during masturbation
* Morning erections
OR
* NPT measurement
Psychophysiological research on fear of failure, performance pressure and sexual arousal
Men with erectile disorders:
* Negative affect in relation to sexuality
* Underreporting of the level of sexual arousal
* Reduced perception of control in relation to sexual arousal
* Distracted by performance-related stimuli
* Increased anxiety inhibits sexual arousal
Conclusion of research on ED
- The (selective) attention of men with erectile problems focuses on performance-related, task-irrelevant and therefore non-sexual cognitions (“attention bias”
- This selective attention increases when the pressure to perform increases, causing a decrease in attention to sexually arousing stimuli and a decrease in sexual arousal (“confirmation bias”
Treatment options ED
- Medication
- “Injection” therapy
- Penile prosthesis
- Sex counseling
Sex counseling ED
- Formulate attainable goals and the focus of therapy is to reduce “performance anxiety” and to improve (attention to) sexual arousal
- Prohibition of intercourse
- Psychosexual education
- Relaxation training (progressive relaxation and relaxation of the pelvic floor muscles)
- Sensate focus exercises
- Non-genital and genital touching
- Communication about sex
- Step-by-step introduction to sexual intercourse
- Cognitive interventions: Rational Emotive Therapy
Delayed ejaculation
- Marked delay in ejaculation
- Infrequency or absence of ejaculation
- on 75-100% of occasions
Caused DE
- Physical (neurological diseases like spinal cord injury)
- Psychogenic
Other ethological factors DE
- Less knowledge about high levels of sexual arousal
- Absence of adequate sexual stimuli
- Need of strong genital stimulation
- Inhibition of sexual arousal due to
- Performance anxiety and selective attention
- Anticipation of failure
- Avoidance of sexual activities because they offer low reward
- Lack of self-focused attention
- “Unconscious” motives and / or fears
Treatment of anorgasmia
Aim: “increase and focus on sexual arousal”
* Clear goals
* Prohibition to ejaculate during intercourse
* Masturbation training
* Look for sexual cues/stimuli
* (Guided) fantasy exercises
* Use of vibration
* Involving the partner
* Step-by-step plan towards orgasm during intercourse
Premature ejaculation
Etiology unknown
Ejaculation within 1 minute and before the individual wishes it
Criteria:
* Mild: IELT 30 seconds to 1 minute after pentration
* Moderate: IELT 15-30 seconds after penetration
* Severe: IELT 15 seconds after penetration
Pharmacological treatment
Antidepressants (SSRI’s) “off-label”
* Paroxetine, clomipramine, sertraline
Dapoxetine
Local anesthetic creams “off-label”
Sex therapy PE
- Discuss goals / expectations (realistic)
- Prohibition of intercourse
- Pelvic floor muscle relaxation exercises (as an ejaculation control technique)
- Stop-start exercises (alone and with partner), manually (with and without lubricant), step-by-step during intercourse
- Cognitive interventions (RET)
- Communication about sex with partne
Substance/psychiatric medication-induced sexual dysfunction
Antidepressants (SSRIs, tricyclics, MAO inhibitors)
* 25-80%
Antipsychotics
* >50% report sexual problems as side effect
Use of cocaine, methamphetamine, alcohol, MDA, GHB (“chem-sex) usually increase in disinhibition, but induce sexual dysfunction
Heroin use
* 60-70% report sexual problems as side effect
Factors related to Hyperactive Sexual Desire
- Alcohol / drug abuse (methamphetamine and cocaine) “Chem sex”
- Manic episode in a bipolar disorder
- Neurobiological (e.g. Alzheimer’s)
- Obsessive-compulsive behavior pattern
- High co-morbidity with paraphilia’s
- Side effect of dopaminergic anti-Parkinsonsdisease medication
HSD treatment
Self-help groups
Self-esteem building therapy
Medication
* SSRIs
* Anti-androgens
CBT
Sexual aversion disorder
Persistent or recurrent extreme aversion for, and avoidance of, all or almost all genital sexual contact with a partne
Inhibition of sexual desire due to
* Negative sexual experience
* Negative views about sexuality
* Negative sensations during sexual activities
Satisfaction with penis size
- The distribution in terms of importance attached to penis length and girth is almost the same for both women and men (about 20%)
- Both sexes think that men regard penis size as more important than men themselves say
- There is no correlation between penis size and sexual satisfaction (men and women)
Treatment penis size
Self-help devices, supplements, ointments, patches, and physical methods like pumping, and traction (Don’t try them at home
Surgery: “penis enlargement”
CBT
