Male Sexual Dysfunction

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Male Sexual Dysfunction
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Computer Sex
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• More Computer Sex

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Male Sexual Response Cycle

• Arousal
• Plateau
• Orgasm
• Resolution
• Refractory Period

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Stage One - Arousal

• Vasocongestion contributes to erection of the
  penis. 
• The inner diameter of the urethra doubles.  The
  scrotum pulls toward the body.
• Muscular tension increases in the body.  Heart
  rate and blood pressure increase.

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Stage Two - Plateau

• Not much change in the penis, but it is less
  likely for a man to lose his erection if
  distracted during plateau phase than during
  excitement.
• The testes increase in size by 50 percent or more
  and are elevated toward the body.
• Muscular tension heightens and involuntary body
  movements may increase as orgasm approaches. 
  Heart rate increases to between 100-175 beats per
  minute.

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Stage Three - Orgasm

• Actual climax and ejaculation are preceded by a
  distinct inner sensation that orgasm is imminent
  (ejaculatory inevitability).  Just after this the
  man senses that ejaculation cannot be stopped.
• The most noticeable change in the penis during
  orgasm is the ejaculation of semen, even though
  orgasm and ejaculation are separate functions and
  may not occur at the exact same time.  The
  muscles at the base of the penis and around the
  anus contract rhythmically.
• Men often have strong involuntary muscle
  contractions through the body during orgasm and
  can also have involuntary pelvic thrusting.  The
  hands and feet show spastic contractions and the
  entire body may arch backward or contract.

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Stage Four - Resolution

• Immediately following ejaculation, the male body
  begins to return to its prearousal state.  About
  50 of the erection is lost immediately, and the
  remainder of the erection is lost over a longer
  period of time.
• Muscular tension usually is fully relaxed within
  five minutes after orgasm, and the man feels
  relaxed and drowsy.
• Resolution is a gradual process that may take as
  long as two hours.

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Stage Five - Refractory Period

• During resolution, most males experience a period
  of time in which they cannot be re-stimulated to
  ejaculation or even maintain an erection.
• On average, men in their late thirties cannot be
  ready for more for about 30 minutes or longer.
• Not many men beyond their teen years are able to
  have more than one orgasm during sexual
  encounters.
• Most men feel sexually satisfied with one orgasm.

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Prevalence of MSD

• Between 10-52 of men at some point in their
  lives will experience some type of sexual
  dysfunction.  One recent study in the Journal of
  American Medical Association (1999) found sexual
  dysfunction common in 31 of men age 18 to 59.

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Diagnostic Questions

• Onset
• Primary
• Secondary
• Context
• Global
• Situational
• Contributing Factors
• Physiological
• Mechanical
• Psychological

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The Big Three in MSD

• Erectile Dysfunction
• Premature Ejaculation
• Retarded Ejaculation

• The penis may be the most honest parts of the
  male anatomy.

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Phases in Disorder

• Desire
• Arousal
• Orgasm

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Desire Disorders

• Hyperactive Sexual Desire
• Hypoactive Sexual Desire
• Sexual Aversion

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Hyperactive Sexual Desire

• Deregulation or lack of control over sexual
  motivation
• Have sex frequently, often having several orgasms
  each day
• Often preoccupied with sexual feelings and/or
  thoughts to the extent that this interferes with
  their functioning at work, and/or creates
  problems in their relationships.
• Compulsive sexual behavior, inadequate control of
  sexual impulses and intense, and spontaneous
  sexual desire.
• Kaplan

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Hypoactive Sexual Desire Definition

• Deficiency or absence of sexual fantasies and
  desire for sexual activity.
• Must cause marked distress or interpersonal
  difficulty.
• Not better accounted for by an Axis I disorder,
  substances, or a general medical condition.

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Hypoactive Sexual Desire Causes

• Stress, Anxiety
• Medications
• Drugs
• Alcohol
• Depression
• Hormonal Imbalances
• Relational Factors
• Sexual Arousal Disorder

• Endocrine Diseases
• Cushings Syndrome
• Hypothyroidism
• Diabetes
• Systemic Diseases
• Chronic Renal Failure
• Testicular Atrophy
• Chronic Pain

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Hypoactive Sexual Desire Treatment

• Treatment must be individualized to the factors
  that may be inhibiting sexual interest.
• Many couples will need relationship enhancement
  work or marital therapy prior to focusing
  directly on enhancing sexual activity.

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Hypoactive Sexual Desire Case Formulation
Hormones Testosterone / Estrogen
History of sexual activity
Hormone Supplements
Aschematic Sexual Self View
Cognitive Restructuring
Protective Partner Factors
Few positive romantic relationships / sexual
encounters
Low Desire
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Sexual Aversion Definition

• Aversion to and active avoidance of genital
  sexual contact with a sex partner.
• Must cause marked distress or interpersonal
  difficulty.
• Not better accounted for by an Axis I disorder,
  substances, or a general medical condition.

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Sexual Aversion Causes

• Sexual trauma
• incest, sexual abuse, or rape
• Repressive family atmosphere
• Rigid religious training
• Pain during first attempts at intercourse

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Sexual Aversion Treatment

• Couples counseling may help resolve discord in a
  relationship.
• Psychotherapy may be needed for people who have
  experienced sexual trauma.
• Behavioral therapy in which a person is gradually
  exposed to sexual activity, beginning with
  nonthreatening activities and progressing to full
  sexual expression, may also be effective.
• Drugs may help relieve panic attacks associated
  with sexual activity.

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Sexual Aversion Disorder Case Formulation
Negative Sexual Self-Schema
Traumatic Event (e.g. rape)
Cognitive Restructuring
Relaxation Training
Sexual Anxiety / Fear Response
Avoidance
Low arousal / sexual satisfaction
Exposure
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Arousal Disorders

• Erectile Dysfunction
• Erectile Dyspareunia

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Erectile Dysfunction Definition

• Inability to attain or to maintain an adequate
  erection until the completion of sexual activity
• Must cause marked distress or interpersonal
  difficulty.
• Not better accounted for by an Axis I disorder,
  substances, or a general medical condition.

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Erectile Dysfunction

• 20 of males over 50 experience significant
  erectile dysfunction
• 52 of men between 40 and 70 report some degree
  of erectile difficulty
• Between 18 and 30 million American men affected
  by erectile dysfunction
• 85 of men with erectile dysfunction do not seek
  help

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Erectile Dysfunction Causes

• Depression
• Job loss
• Diabetes or other disorders impacting circulation
• Hypertension
• Medications
• Obesity
• Smoking and tobacco products
• Alcohol
• Age
• Rigid training
• Guilt
• Unreasonable expectations

• Fear
• Rejection
• Not able to satisfy wife
• Being compared to other men
• Losing erection
• Inability to ejaculate
• Ridicule
• Poor physical fitness
• Autosexuality
• Passive wife
• Sagging vagina
• Nagging
• Feminine dominance
• Unfavorable weather
• Burnt toast

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Erectile DysfunctionMay Disguise

• Paraphilic problem
• Homosexual orientation
• Gender identity disorder
• Lack of desire towards partner
• Immorality
• Adultery
• Pornography

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Erectile Dysfunction Treatments

• First Line
• Medications
• Excitatory sidenafil
• Inhibitory Alpha-1/2 blockers
• Vacuum Constriction Devices
• Therapy
• Cognitive correct thought distortions
• Behavioral sensate focus training
• CMASH
• Second Line
• Intraurethral Suppositories
• Injection Therapy
• Third Line
• Penile prosthesis
• Semi-rigid
• Inflatable

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Center for Marital and Sexual Health (CMASH)

• Gender Identity
• Object Choice
• Intention
• Sexual Desire
• Arousal
• Orgasm

• All these in context contribute to a sexual
  equilibrium in the relationship, whether it is a
  healthy one or dysfunctional one

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Erectile Dysfunction Case Formulation
Organic Factors / Medication Side Effects
Low Sexual Experience
Protective Factors Positive emotions, love
Medical Treatments
Non-demand Pleasuring
Anxiety
Dysfunctional Attentional Processes
Inhibited Parasympathetic Activity
Sensate Focus
Psychoeducation
Low Arousal
Negative Expectations
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Viagra (Sildenafil)
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Viagra Side Effects

• Headache
• Flushing
• Dyspepsia
• Consult a doctor if on Nitroglycerine for
  possible cardiac effects

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Viagra Contraindicators

• A clear reason for recent onset of erectile
  dysfunction
• Severe marital discord
• Performance anxiety is the cause
• The client does not like to use medications
• Althof

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Conclusions on Erectile Dysfunction

• We must also attempt to address relapse issues
• Not everyone can be helped
• Helping a man attain an erection by medical means
  may do more harm than good relationally
• 44-91 success rate
• 20-50 discontinue therapy

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Erectile Dyspareunia

• Peyronies disease/Penile Induration
• Severe curvature of penis caused by scarring in
  the tunica. Treated through surgery or
  anti-scarring and anti-inflammatory drugs. Also
  may cause pain during or prevent intromission.
• Balanitis
• inflammation of the foreskin
• Balanoposthtis
• inflammation of prepuce and glans
• Frenular tethering
• scarring of frenulum results in loss of
  elasticity
• Paraphimosis
• opening of foreskin too small
• Chordee
• congentical curvature of the penis
• Neurologic damage

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Ejaculatory Disorders

• Premature Ejaculation
• Retarded Ejaculation
• Ejaculatory Incompetence
• Retrograde Ejaculation
• Ejaculatory Dyspareunia

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Premature Ejaculation

• Possibly the top complaint from men about sexual
  dysfunction
• In a study by Kinsey in 1948, 75 of men were
  found to ejaculate within 2 minutes.
• We have no empirical way to diagnose thisit is
  very subjective.
• Possibly universal for first sexual encounters
• Can lead to feelings of shame, guilt or
  inadequacy as a man
• 30 of men report they are not satisfied with
  their ability to control orgasm.
• Rapid orgasm seen as a problem for men and a
  sought after attribute for women.
• Women report men ejaculate prematurely 80 to 100
  percent of the time, while men report it at 10 to
  20 percent of the time.

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Premature Ejaculation Definition

• Onset of orgasm and ejaculation with minimal
  sexual stimulation before, on, or shortly after
  penetration and before the person wishes it.
• Must cause marked distress or interpersonal
  difficulty.
• Not better accounted for by an Axis I disorder,
  substances, or a general medical condition.

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Premature Ejaculation Causes

• Anxiety
• Performance pressure
• Novelty of experience or partner
• Interpersonal difficulties
• Conditioned to be quick
• Possible biological differences in men

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Premature Ejaculation Treatments

• Any one of millions of untested folklore remedies
  (which may have harmful side effects)
• SSRI/Antidepressants
• Therapy
• Cognitive Dispel myths
• Behavioral Desensitization (Squeeze Technique)
• Kegel Exercises

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Premature Ejaculation Case Formulation
Low Sexual Experiences
High Arousal Sensitivity
History Rewarding Speedy Circumstances
learned response
Premature Ejaculation
Pause squeeze Technique
Anxiety
Often disappears with age / experience
Avoidance
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Retarded Ejaculation Definition

• Delay in or absence of orgasm following a normal
  sexual excitement phase.
• Must cause marked distress or interpersonal
  difficulty.
• Not better accounted for by an Axis I disorder,
  substances, or a general medical condition.

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Retarded Ejaculation Considerations

• Relatively rare
• The man is physically able to have an orgasm and
  ejaculate, just not during intercourse.
• May be a means of malingering
• Considered by some to be an arousal disorder in
  that the man is never aroused enough to achieve
  orgasm
• Often the erection is maintained even when not
  aroused

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Retarded Ejaculation Causes

• Damage to nerves in penis or nerves transmitting
  signals to the brain lessening sensation in the
  penis
• Partner relational issues
• repulsed by partner
• using a lack of orgasm to punish partner
• being too focused on pleasing the partner
• Performance Anxiety
• Arousal Deficit
• Autosexuality
• Lack of personal responsibility for own pleasure

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Retarded Ejaculation Treatments

• Increase pressure to perform (could be too
  relaxed)
• Coutnerbypassing
• Control sexual content
• Woman verbalizes her worries about her partners
  impatience, which are validated
• Focus attention on self

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Retarded Ejaculation Case Formulation
Negative Affect / Self-schema
Medical Condition
Desire / Arousal Deficits
Low relationship satisfaction
Cognitive Restructuring
No Orgasm
Sensate Focus
Negative Expectations
Relaxation
Anxiety
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Ejaculatory Incompetence Definition

• Consistent inability to reach orgasm no matter
  the duration or type of stimulation.

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Ejaculatory Incompetence Causes

• Neurologic diseases
• Traumatic injury
• Complication of surgery
• The nerves responsible for the signal for
  ejaculation are most commonly injured after
  spinal trauma resulting in paraplegia or
  quadriplegia, major bowel or vascular surgery, or
  surgery for testicular cancer.

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Ejaculatory Incompetence Treatments

• If the goal is to produce ejaculation for
  impregnation, a reflex ejaculation can be
  produced if the level of injury is not too severe
  by using a vibrator with a designated frequency
  and wave amplitude. If injury is too severe, the
  prostate can be electrically stimulated to
  ejaculate.

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Retrograde Ejaculation Definition

• Upon ejaculation all or part of the semen travels
  backward into the bladder due to the sphincter at
  the bladder neck not closing.
• This does not effect sexual functioning or
  pleasure unless it is psychologically troubling
  to not see any semen (in severe cases).

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Retrograde Ejaculation Causes

• Surgical damage to the muscle of the bladder
  neck, or to the nerves that control this muscle
• Prostatectomy
• Surgery on the bladder neck
• Extensive pelvic surgery, especially to treat
  cancer of the testicles, colon, or rectum
• Staging surgery for cancer in the pelvis or lower
  abdomen
• Certain types of surgery on the discs and
  vertebrae of the lower spine
• Nerve damage caused by medical illness
• Side effects of medication
• Amitriptyline (Elavil)
• Amoxapine (Asendin)
• Chlorpromazine (Thorazine)
• Thioridazine (Mellaril)
• Guanethidine (Ismelin)
• Reserpine (Serpasil)

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Retrograde Ejaculation Treatments

• Alter medications that cause it
• If it is a mild muscle or nerve problem, drugs
  proscribed to improve muscle tone at the bladder
  neck
• Pseudoephedrine
• Imipramine (Tofranil)
• In cases of severe nerve damage, a fertility
  specialist may collect sperm from the bladder and
  use washed sperm for an assisted fertilization
  procedure.

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Ejaculatory Dyspareunia

• Prostatitis
• Chronic or acute infection of the prostate often
  caused by bacteria entering the urethra. Treated
  with antibiotics.
• Urethritis
• Chronic or acute infection of the urethra often
  caused by bacteria entering the urethra. Treated
  with antibiotics.
• Neurologic damage
• Medications (antidepressants)
• Amoxapine, imipramine, and clomipramine

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Conclusion

• It is uncommon to find one factor that is causing
  100 of the problem.
• It is uncommon to find one solution that will fix
  100 of the problem.
• Often, physical, relational, and psychological
  factors are all involved in causing and being
  impacted by male sexual dysfunction.
• Male Sexual Dysfunction is more common than
  presented.