[e-mail]

1
???????? ?????? ????

• ???? ??? ??? ????
• ??? ???? ???? ???? ????????
• ???????? ?????
• ???? ??????????? ? ????? ??????
• azin_at_royaninstitute.org

2

• ???? ???? ???????? ?????? ???? ?? ?? ????? ?????
  ?? ???? ???? ???? ?? ????? ??? ????? ???.
• ?? ??? ????? ??????? ???? ???? ??? ???
• ?????? ???? ?? ??? ????? (Lifelong)
• ?????? ??????? (Acquired)
• ?????? ?? ??? ????? ? ?? ?? ??? ?????
  (Generalized)
• ?????? ?? ??? ??????? ? ?? ?? ???? ?????
  (Situational)
• ?????? ????? ?? ????? ???? ?????? (Due to
  Psychological Factors)
• ?????? ????? ?? ?????? ?? ????? (Due to Combined
  Factors)

3

• ??? ??????? ?? ?? ??????? ??? ?? ??? ?? ????? ???
  ??????? ? ????? ????? ?? ???? ????? ???? ????.
• ????? ???????? ??????? ? ????? (?? ??? ?????
  ????? ????) ????? ?????? ?? ???????? ???????? ???
  ?? ???? ?? ??? (????? ?????? ??? ?? ????? ?? ???
  ??? ????).
• ?? ?????? ???????? ???????? ??????? ????????? ???
  ?????? ???? ? ????? ????? ????? ??????? ?? ????
  ???? ???? ? ?? ????? ??? ?? ?? ???. (????? ??? ??
  ?????? ???? ?????.)

4
???? ???? ???????? ?????? ???? ?? ???? DSM IV TR

• ???????? ??? ???? (Sexual Desire Disorders )
• ?????? ??? ???? ?????????? (Hypoactive Sexual
  Desire Disorder )
• ?????? ?????? (??????) ???? (Sexual Aversion
  Disorder )
• ???????? ?????????? (?????) ???? (Sexual Arousal
  Disorders )
• ?????? ?????????? ???? ?? ???? (Female Sexual
  Arousal Disorder )
• ?????? ???? ?? ????? (Male Erectile Disorder )
• ???????? ?????? (Orgasmic Disorders )
• ?????? ?????? ?? ???? (Female Orgasmic Disorder)
• ?????? ?????? ?? ????? (Male Orgasmic Disorder)
• ????? ??? ?? ???? (Premature Ejaculation)

5
???? ???? ???????? ?????? ???? ?? ???? DSM IV TR

• ???????? ??? ???? (Sexual Pain Disorders )
• ?????? ?????? (Dyspareunia)
• ???????? (Vaginismus)
• ???????? ???? ????? ?? ????? ??? ?????
• (Sexual Dysfunction Due to General Medical
  Condition)
• ???????? ???? ????? ?? ???? ????
• (Substance Induced Sexual Dysfunction)
• ???????? ???? ???? ???? ????
• (Sexual Dysfunction Not Otherwise Specified)

6
???????? ??? ???? (Sexual Desire Disorders )

• ?? ???? ????? ????? ?????? ?????? ????? Sexual
  desire ?? ??? ?? ????. ?????
• ?????? (libido)? ????? (interest)? ???? (urge)?
  ?????? (appetite)? ??? (lust)? ????? (instinct)
• ??? ???? ?? (low sexual desire) ??? ??? ??
  ??????? ??? ?? ?????? ???? (sexual apathy)? ?????
  ?? ????? ???? (sexual malaise)? ?? ??????? ????
  (sexual anorexia) ????? ?? ???.

7

• ?? ??? ????? ??????? ???? ?????
• ??? ???? ????? (?????) ?????
• ??? ??? ?? ? ??? ????? ?? ????? ????? ?????
• ?? ??? ??????? ???? ????? ?????? ????? ?? ??????
  ????? ?? ???? ??? ????? ???? ????? ?? ??????
  ????? ????? ??? ?? ?????.
• ??? ??? ???? ?? ????? ? ???? ?? ???? ??? ? ????
  ????? ????
• ????? ??? ??????? ??? ?? ??? (?? ??? ??? ? ????
  ???? ?????) ???? ?? ??? ???? ?? ???? ?? ?? ??
  ???.
• ??? ??? ???? ?? ????? ???? (????? ? ???????)
  ?????? ???? ?? ??? ? ?? ????? ???? (????? ???) ?
  ?? ?? ???
• ??? ??? ???? ?? ?? ??? ????? ?????? ????? ?????
  ??? ???? ??? ????? ??? ????? ????? ?????? ???? ??
  ???.

8

• ?????? ??? ???? ?????????? (Hypoactive Sexual
  Desire Disorder)
• ????? ? ?? ????? ??? ? ?? ????? ????? ?? ??????
  ????
• ????? ?? ???? ??? ????? ? ?? ?????? ?? ??????
  ????? ???? ?? ?????? ???? ??? ?? ? ??????? ?????
  ???? ?? ???? ??????? ???.
• ?????? ???? ????? ??????? ? ?????? ???? ?? ?????
  ??? ???? ?? ???.
• ?????? ?????? ???? ?? ?????? ????? ?? Axis I (???
  ?????? ???? ????) ???? ????? ?????.
• ???? ?? ????? ?????????? ?????? ???? ???? (??
  ???? ????) ? ?? ?? ????? ????? ????? ?????.

9

• ?????? ?????? (??????) ???? (Sexual Aversion
  Disorder)
• ?????? ???? ???? ?? ????? ???? ?? ?????? (??
  ??????? ??????) ???? ???? ?????? ?? ?? ???? ????
  ? ?????? ?? ??
• ?????? ???? ????? ??????? ? ?? ?????? ???? ??
  ????? ??? ???? ?? ???.
• ?????? ?????? ???? ?? ?????? ????? ?? Axis I (???
  ?????? ???? ????) ???? ????? ?????.

10

• ?????? ??? ?? ???? ??? ?????? ???. ??? ?? ?? ??
  ???? ???? ?? ?? ????? ???? ?? ????.
• ????? ??? ???? ?? 10 ?? 15 ???? ?? ???? (??
  ??????? ?????) ????? ??? ???. ?? ?????? ?????
  ???? ?? 20 ???? ????? ??? ???. ()
• ????? ????? ??? ???? ?? ?? ????? ?? ????? ????? ?
  ???? ????? ?? ???? ???? ?? ???.
• ?? ??? ????? ???? ????? ?? ?? ????? ????? ?????
  ????? ???? ????? ??? ??? ???? ??? ?? ???? ??
  ????? ?????? ???? ???? ????? ?????. (????? ??? ??
  ?????)
• ????? ??? ???? ?? ????? ?? ??? ????? ????? ??????
  ? ?? ??????? ????. ()

11

• ??????? ?? ????? ???? (Abstinence) ?? ??? ??????
  ??? ?? ????? ?? ???? ????? ??? ???? ????????.
• ????? ??? ???? ???? ??? ???? ????? ???? ?? ????
  ???? ???? ? ?? ????? ?? ?? ???? ??? ????? ??? ??
  ??.
• ???? ??? ???? ?? ????? ?????? ?????? ???. ????
  ???? ? ?? ????? ?????? ?? ??? ????? ?? ????? ??
  ???? ??? ???? ????????
• ??? ????????
• ?????? ?? ??? ????
• ??????? ????? ?? ??? ?? ????? ???? ????
• ????? ???? ??? ????
• ???? ?? ???? ???? ?????
• ????? ??? ??? ???? ?? ???? ?????

12

• ????? ?? ??? ???? ??????? ????? ?? ???? ??? ???
  ?????? ???? ???? ????? 3 ??? ?? ??? ?????? ?????
  ???? ??? ???? ?? ??? ????? ? ????? ????? ???? ???
  ??? ?? ?? ??? ???? ??? ?? ??? ???? ??? ???? ????
  ?? ???? ?? ???? ????. ??????? ???? ?? ?? ????
  ???? ???? ????? ????
• ????? ???? ????? ? ??? ???? ?? ??
• ????? ????? ???? ???? ???? ????? ??????? ???? ???
  ??? ????.
• ??? ???? ?? ????? ?? ???? ?????? ??? ?????? ???.
  ??? ???? ???? ??? ????? ?????? ?? ? ???? ???? ??
  ??? ???? ??? ????? ????? ????? ?????.

13

• ???????? ????? ????? ???? ?? ???? ??? ???? (???
  ???? ???? ?? ????)
• ?????? ???? ?? ???? ???? ????????? ?? ????
• ?? ????? ??????? ???? ?? ? ?? ???? ?? ????/
  ?????? ???? ?? ?? ??? ??/ cryptorchism ??????/
  ???????/ ????????/ ????????/ ????????? ???/
  ?????? ???? ?? ??????/ ?????? ??????? ? ??
  ???????????/ ?????? ??????
• ?? ???? ??????? ?????? ??????/ ???????????/
  ???????????? ? ?? ?????? ??/ ????????/ ??????
  ??????/ ???? ??????? ?? ???????
• ????? ???? ? ?? ????? ?? ????????????????
• ????? ???????/ ????????????/ ????? ????/ ???????/
  ??????/ ???? ????? ????????
• ?????? ?? ????????? ?? ??? ???? ??? ?? ?????
  ????? ???????? ?? ????? ?? ??? ?????? ??????
  ??????? ???????? ? ?? ??? ???? ?? ?????????? ??
  ???? ??? ????? ??????? ?? ??? ?????? ??? ? ??
  ??????? (?????/ ????????? ?...)? ???????????
  ??????? ? STIs
• ????? ????? ???? ?? ??? ???? ? ?? ????? ???? ??
  ????? ?????? ?? ????? ???? ?? ???? ????? ???
  ?????? ??? ?????? ??? ???? ???? ????? ???????
  ????? ???????? ??? ????? ?...

14

• ???????? ???????? ?? ?? ?????? ??? ???? ?? ????
  ????
• ??????? ?????????
• ?? ????? ???????? ?????????? ? ???? ???? ???????
  ???? ?????? ??? ???????????? ?????????? ? ???
  ??????
• ??????? ????? ? ????
• Sedative/hypnotics ?? ??? ???? ? ????/ ?? ????
  ????? ??????????? ??? ?????????? ??
• ?????? ??? ??????? ?????? ? ...
• ?? ??????? ?? (SSRIs ? ?? ???? ?? ??? ?????? ?
  ???????????)
• ????????? ?? ?? ???? ????????? ? ?????????? (??
  ?????? ??? ?????????)
• ??????? ???? (???? ??????? ?? ??????? ???
  ??????????????? ???? ????? ????????/ ?????????? ?
  ????? ???????)
• ???? ?????? ?????????? ???????????
  ?????????????????

15

• ??????? ????? ??????? ????? ?? ????? ??? ????
• ???? ?? ????? ??? ????? (?? ???? ?????? ?? ?????)
• ?????? ?????
• ????? ?????? (?? ????? ???? ???? ??? ????? ?????
  ? ?? ???? ?????? ????.)
• ??? ?? ??????
• ??? ? ?? ?????? ???? ????? ????? ?? ?? ?????
  ????? ???? ?? ????? ? ?? ????????
• ????? ???? ?? (Widowers syndrome)
• ????? ??? ???? ???? ?? ???? ????
• Madonna/Prostitute Syndrome

?????? ?? ??? ???? ?? ?????? ?? ????? ??? ????
???.
16

• ??????? ?????? ???? ?? ?????? ??? ????
• ?? ??? ?????? ??? ????? ???? ?????? ????? ?? ????
  ?? ????? ???? ????? ?? ?? ????? ????? ????? ??
  ???? ?? ??? ????? ????? ???? ?? ?????? ?????
  ??????. ????? ????? ???? ?? ?? ??????? ?? ?????
  ???? ???? ???? ??? ???? ????? ? ?????? ??? ??
  ????? ???? ?? ??? ????? ?? ???. (Transition
  activities) ()
• ?? ???? ?? ????? ??? ????? ????? ???? ????? ????
  ?? ?? ???? ???????? ???? ?? ?????? ( ? ?????????
  ???? ?? ?? ??? ?????? ?????? ???? ?? ??? ?
  ??????? ???? ??? ??? ???? ? ...) ?? ?? ???? ????
  ? ???? ?????? ?? ?????? ?? ????? ??????.
• ???? ?? ???????? ???? ???? ?????? ?? ???? ???
  (????? ?????? ?? ??????). ??? ??? ?????? ???? ???
  ?? ??? ???? ???? ?????? ??? ????? ?? ????? ??
  ???? ???? ?? ?? ???.

17

• ????? ??? ????? ???????
• ????? ????? ?????????
• ?????? ????? ? ???? ?????? (????? ????? ????
  ?????? ????)
• Bremekinotide ???????? ?? ?? ????? ???? ???? ???
  ????? ???? ?? ?? ????? ? ???? ?????? ???? ??
  ????? ????? ????????? ?????? ???.
• Clomiphene ? Tamoxifen ?? ?? ?? ??? ????
  ?????????? ? ???? ???? GnRH ???? ?????? ?????????
  ? ?????? ?????? ?? ????. ???? ????? ?? ?????
  ????? ?? ?? ????????? ????? ?? ????? ?????? ???
  ???? ?? ????? ???? ???. ????? ?????? ??? ??
  ????????? ??? ????? ??? ?? ?????? ?? ???.

18
???????? ?????????? (?????) ???? (Sexual Arousal
Disorders)

• ?????? ?????????? ???? ?? ???? (Female Sexual
  Arousal Disorder)
• ??????? ????? ? ?? ????? ?? ??? ? ?? ??? ??? ???/
  ???? ??????? ?? ?????? ???? ?? ????? ?????? ????
• ?????? ???? ????? ??????? ? ?? ????? ?????? ????
  ?? ????? ??? ???? ?? ???.
• ?????? ?????? ???? ?? ?????? ????? ?? Axis I (???
  ?????? ???? ????) ???? ????? ????? ? ???? ??
  ????? ?????????? ?????? ???? ???? (?? ???? ????
  ???? ? ?? ??????? ?? ) ? ?? ?? ????? ????? ?????
  ??? ?????.

19

• ????? ?? ??? ?????????? ????? ???? (lubrication)
  ???? ???? ?? ????? ???? (subjective) ?? ??? ???.
  ???? ??????? ???? ?? ???? ?? ??? ?? ????? ???????
  ????? ?? ?????? ????? ??????.
• ????? ??????? ??????? ?? ???? ???? ??????? ?????
  ?? ??? ????? ?? ?????????? ???? ??? ???? ??? ?
  ??? ????? ?? ???? ????? ?????? ???.
• ?? ??????? ????? ???? ?? ????????? ?? ???? ??????
  ???? ????? ?????????? ???????? ????????? ?
  ???????? ?? ??? ????? ???? ?? ???? ???? ????.
• ???? ??????? ???? ???????? ? ?? ???? ???? ?????
  ?? (?? ???? ????????? ??? ?? ???? ??) ????? ????
  ???? ???? ???? ????.

20

• ??????? ?? ????????? ???? ? ??? ?????? ?????
  ?????? ?? ??? ???? ??? ???? ???? ??? ? ?????
  ????? ???? ? ???????? ??????.
• ??????? ????? (?? ????? ???? ??? ??? ?? ????
  ???????) ?? ???? ??? ???? ???? ??????? ???? ?
  ??????????? ?? ????? ?? ???. (??? ? ???? ?? ????
  ?? ????? ??? ???? ???? ????? ????? ??? ???? ????
  ????? ??????? ????? ?? ????? ????? ???? ???? ????
  ????? ???.)
• ??????? ?? ?? ????????? ????? ?? ??? ???? ???? ?
  ???? ???? ??? ?? ?? ????? ???? ????? ???. (?????
  ?????? ? ????????? ???????????)

21

• ?????? ???? ?? ????? (Male Erectile Disorder )
• ??????? ????? ?? ????? ???? ??? ? ?? ??? ????
  ???? ?? ????? ?????? ????
• ?????? ???? ????? ??????? ? ?? ????? ?????? ????
  ?? ????? ??? ???? ?? ???.
• ?????? ?? ???? ?? ?????? ????? ?? Axis I (???
  ?????? ???? ????) ???? ????? ????? ? ???? ??
  ????? ?????????? ?????? ???? ???? (?? ???? ????
  ???? ? ?? ??????? ?? ) ? ?? ?? ????? ????? ?????
  ??? ?????.
• ?? ??? ?????? ?? ???? ??????? ???? (Impotence)
  ??? ???? ?? ???. ?? ???? ???? ??? ???? ???? ?? ??
  ???? ??????? ???. ???????? ?? ???? ???? ???? ???
  ????? (frigidity) ???? ???? ???? ???? ???? ????.

22

• ??? ??????? ?? ?? 20- 10 ?? ????? ????? ??? ???
  . ( ?????? ???? ?? ?????? ?? )
• ???????? ????? ?????? (????? ??? ??????? ????????
  ??? ? ...) ??? ?? ??? ?? ???? ??? ?? ??????? ??
  ??? ?? ??? ????? ?? ????? ???? ?? ???? ?????? ??
  ?????? ???. ???? ?? ???? ???? ??? ?? 50 ???? ??
  ?????? ?? ????? ????? ?????? ???? ????? ?? ???
  ??? ?????? ????? ???.

23
(No Transcript)
24

• ????? ????? ??? / ????? / ???????? ? ??? ???????
  ??? ????? ????? ???????? ????? ???? / ????? ?
  ??????? ? ?????? ?? ???? ????? ???? ? ?? ??????
  ????

??? ??????? ? ???? ??????
???
???? ????
???? ??? ????? ? ??????? ???? ?? ???? ????
Erection ?????? ?????? ? ???? ????????? ?
??????? ????? ??? ?? ????? ???? ? ?????? ? ?? ???
??????????? ? ?????? ??????????? ???? ?? ??? ????
??? ??????????? ?? ??? ?????? ????
25
Mechanism of ErectionChemical Pathway
Guanylate cyclase
cGMP
GTP
Penile erection
Relax
GMP
PDE5
cGMP cyclic guanosine monophosphate GTP
guanosine triphosphate PDE5
phosphodiesterase type 5.
26

• ????????
• ????
• ?????? ?????????
• / ???? ?????? (????? SSRIs ? ??????? ?? ???????
  ? ?? ???? ???????????????? ??? ????????? ?? )/
  ?????? ??????? ???????
• ????? ?????????/ ?????? ?????????/ ????? ????/
  ??????? ???? ????/ ??????? ????
• ?????? ????????? ?? ????? ( ???? ???? ??????? ??
  ?? ??? ???? ??? ????? ???. ) (??? ???? ????
  ??????? ???? ???? ?? ????.)
• ?????
• ????? ?? ?????? ?? ??????? ????
• ??? ? ?????? (? ????? ???? ?????) (?? ???? ?????
  Performance anxiety )
• ?????? ?? ????? ??????? ?????/ ??? ()
• ???? ????? Madonna Putana complex
• ???? ?? ????????? ?????? ? ?? ???? ???? ????? ???
  ?????? (????? abuse? ???? ?? ???? ???? ? ...)
• ??? ???? ?????

27

• ?? ?????? ? ?????????? ??????? ??? ???? ??????
  ???? ?????.
• ???? ???? ???????? ?? ????? ???? ?? ?????
  ????????? ? ?? ????? ?? ???? ???? ????? ?? ?? ???
  ???? ??? ????? ???.
• ?? ??? ?????? ??? ???? ? ???? ?????? ?? ?????? ??
  ??? ???? ???? ????? ? ????? ??? ????? ??? ?????
  ?? ????? ????.

28

• ???? ????????? ?????? ?? ???? (ED) ????
• ?????? ??
• ???? ???????
• ????????????
• ????????????
• ?????
• ?????????????????
• ????? ???????

??? ?? ???? ??? ???? ???? ???? ED ????? ???? ??
????? ?????? ???? ?????? ? ?? ?????? ???? ??????
?????? ?? ?????? ?????? ? ????? ?? ?? ?? ????? ?
????? ??? ???? ???? ????.
29

• ????? ?? ??? ?? ?? ??????? ED ?? ????? ??? ??????
  (?????? ? ?? ???????)? ????? ?????? (????????
  ????? ?? ?????? ?? ???? ? ?? ?????) ? ???? ????
  ??????? ???? ???? ???? ????.
• ???? ???? ?? ?????? ?????? ? ?? ???? ????
  ??????????? ??????? ? ????? ????? ?? ???? ?? ???
  ?? ???? ?????? ????? ???? ?????? ????. ?? ?????
  ??? ???? ???? ???? ???
• ?????? ???????
• ?????? ???? ?? / ??????????/ ?????????/ ?? ???
  ??? ????? ??? ? ???
• ???????? ????? ??????/ ????????????????? ????
• ????? ???????? ???????? (?????? ???????? ????
  ????? ????? ? ...)
• ?????? ?????
• ??? ??? ???? ?? ????? ??/ ???? ????? ??/ ???? ??
  ?? ????? ??????
• ?????? ???? ?? ????????????
• ?????? ?????????
• ?????? ???? ??? ??????????? (????? S2 ?? S4 )/
  ???????? ??? ???????

30

• ??????? ?????? ???????? ?? ED ?? ??? ???? ??????
• ???? ??????? ???? ? ????? ???? ?? ? ???????? ??
  ???? ??????? ? ????? ???? ?? ???? ?? ??? ???? ??
• ??????? ? ????????? ????? ??? ???? ? ???? ????
  ????
• ????? ?????????
• ????? ?? ??? ?? ???? ??? ????
• ??????? ??? ?????? ?? ? ?????? ?? ????? ???? ????

31

• ????? ?? Performance anxiety ?? ??????? ?? ?????
  ???? ??? Sensate focus (????? ????? ?? ??? ?
  ?????? ???? ??? ????? ???? ??????? ?? ??????
  ????? ???? ????? ????? ?? ????? ??????). ?? ???
  ????? ???? ????? ??? ??? ? ?????? ?? ?? ????
  ??????? ????? ?????? ???? ?? ????. (????? ???????
  ??? ??? ?? ???? ?? ???? ?? ????? ???)
• Script modification (????? ???? ??? ????? ?????
  ?? ????)
• ??????? ?? ????? ? ?????? ??? ????? (???????
  ?????? ???? ?? ?????? ? ??????)

32

• ??????? ?????? ???????? ?? ED ?? ??? ????
• ????? ??????? ?????? ????? ??
• ????? ??????????? ? ?? ????????????????
• ????? ???? ????? ???? ? ?????? ???? ?? ?? ?????
  ?? ??????? ??? ?? ?? ???? ???? ????? ??? ?????
  ????.
• ??????? ??????
• Intracovernosal injections
• Urethral suppositories
• ????? ???? ???? ???? ?? ???? vacuum devices
• ???????
• ??????? ?????

33

• ??????? ??????
• Sildenafil 100mg (Viagra)
• ???? ????? ?? ?????? ???? 1 ????
• ???? ??? 4 ????
• ??? ???? ?????? ?? ?????? ??
• ?? ???? 50 ???? ?? ????? ?? ????? ????????????
  ??????? ? ???????? ?? ????? ?????? ?? ???????
  ??????? ?????? ?????? ?????.
• ????? ??????? ?????? flushing? ????????
  (???????? ?????? ?? ??? ???? ????? ??? ???.)
• Vardenafil 20mg (Levitra)
• ???? ????? ?? ?????? ???? 7/0 ????
• ???? ??? 4 ????
• Tadalafil 20mg (Cialis)
• ???? ????? ?? ?????? ???? 2/0 ????
• ???? ??? 5/17 ????

34

• Phentolamine ??????
• ???? ???? ??????? ? ?? ??? ????? ???
• ????? ????? ????? ???????????? ??????????
  Dizziness
• ???? FDA ?????.
• Sublingual Apomorphine
• ?????????????? ?? ????? ?? ????? ??????/ ??????
  ???? ? ????? ?? ?? ???? ????
• ????? ??? ?? ???? 20 ????? ?? ???? ????? ????
  ????
• ???? FDA ?????.

35

• Penile injection Urethral suppositories
• ???? ????? ? ??? ???? ????? ???? ??? ?? ????.
• Alprostadil ?? ???? ?????????????E ???? ????
  ?????????????? ?? ???.
• ??? ?? 2 ?? 3 ????? ? ??????? ??? ??? ?? ?? ????
• ????? ?????? ? ???? ??? ????? ?? ??? ? ????? ??
  ??? ??? ????
• ?????? ????? ???????? ? ?? ??????? ??????? ???
  ??? ???? ????.

36

• Topical cream
• ????? ????????? ?????? ???? ??? ????? ????? ????
  ????? ED ?? ??? ????? ???.
• ??? ???? ??????????? ??????????? ?? ?????? ?
  co-dergocrine mesylate (?????? ?? ????????????
  ????)
• ?? ???? Alprostadil ? ???????? ?? ??? ????? ??
  ???? ?? ???.
• ??? ???? Alprostadil ???? ???? ??????? ?? ????
  ???? ?????? arousal ?????? ??? ? ????? ???????
  ????? ???? ???.

37

• ?? ???? ???
• ?? ???? ?? ??? ???? ? ?? ??????? ??????? ????
  ????? ?????? ???? ?? ??? ???? ???? ?? ??? (??
  ???? ???? ???? ??????? ????????? ????????
  ???????? ??? ????? ???????? ????? ? ...) ??? ???
  ???? ?? ??? ????? ???? ????? ???? ? ???? ???? ??
  ???? ???? ??? ?? ?????? ?????? ???? ??? ?? ?? ???
  ???? ??????.

38

• External vacuum devices
• ?? ??????? ???? ???? ????? ???? ??????? ???. ????
  ????? ??? ??? ?? ?? ??? ?? ??? ? ???? ?? ?? ?????
  ??? ?? ???? ???? ?? ??????? ?? ???. ??? ?????? ?
  ????? ?? ???? ???? ?? ???? ????? ????? ??? ????.
• ????? ?????? ?? ??? EROS ???? ????? ???? ??
  ???????? ????? ??? ??? ?? ???? ??????? ??????? ??
  ?? ?? ????? ???? arousal ?? ???? ??????? ????
  ???.

39

• ?????? ?????
• ????? ????? ????? ????? ?? ????? ???? ?? ??????
• ????? ????? (Male prostheses) (???? ? ?? ????
  ?????)
• Penile injection
• ????? ???? ????? ????
• PGE-1
• Papaverine
• Phentolamine

40
???????? ?????? (Orgasmic Disorders )

• ?????? ?????? ?? ???? (Female Orgasmic Disorder)
• ????? ????? ?? ????? ?????? ?? ????? ?????? ?? ??
  ????? ?????? ???? ?????. ?? ?? ?? ??? ??? ?????
  ???? ???? ????? ?????? ?? ?????? ????? ??? ?????
  ?????. ????? ?????? ?? ?????? ?? ???? ???? ????
  ?? ????? ??????? ???? ?? ????? ?? ???? ?????
  ??????? ?? ???? ?? ???? ?? ?? ??? ????? ??? ?????
  ???? ? ???? ???? ????? ???? ??????? ?? ??????
  ????? ?? ??? ????.
• ?????? ???? ????? ??????? ? ?? ????? ?????? ????
  ?? ????? ??? ???? ?? ???.
• ?????? ?? ?????? ?? ?????? ????? ?? Axis I (???
  ?????? ???? ????) ???? ????? ????? ? ???? ??
  ????? ?????????? ?????? ???? ???? (?? ???? ????
  ???? ? ?? ??????? ?? ) ? ?? ?? ????? ????? ?????
  ??? ?????.

41

• ????
• ?? ???? ??????????? ?????? ???? ?? ????? ????????
  ? ?? ??????? ?????? ?? ?????? ?????? (??????
  ?????? ?????)? ????? ???? ?? ???? ?????? ??????
  ?????? ????? ??? ?? ???? ?? ???.
• ????? ???? ??? ?? ???? 5 ???? ?? ???? ????? ?????
  35 ??? ???? ?????? ?? ?? ??? ????? ????? ?????
  ???.
• ???? ??? 30 ????? ??? ?? ???. (?? ???? ??? 35
  ???)
• ??? ????? ?? (lifelong generalized) ???? ?? 5
  ?? 10 ???? ?? ???? ???? ?? ???. (???? ?? ???
  ????? ?????)
• ??? lifelong situational (?? ???? ????? ??????
  ???? ?? ????? ??????) ???????? ??? ?? ???.
• ??? acquired generalized ?? ????? ????? ????
  ???? ? ???? ?? ?????? ?? ? ???? ???? ? ???? ????
  ????? ???? ???? ???.

42

• ???????? ??? ???????
• ?????? ????? ? ??????? ????
• ???? ?????? ?? ? ???? ???? ?????? ???? ??? ????
  ??? ??????? ?? ????.(????? ????? ?? ????? ? ??
  ??????? ????????? ? ?? ???? ????????? ??? ????
  ????????? ?? ? ??????????? ??) (??? ???? ??
  ?????? ??? ???? ???? ??? ???.)
• ??? ????? ?? ????
• ??? ?? ??????
• ??? ??? ?? ??? ???? ????
• ??? ?? ???? ?? ????
• ????? ???? ?? ????? ?? ???? ????
• ????? ???? ?????? ????? ??? ????
• ??? ?? ??? ???? ????? ?? ?????? ??? ?? ?????
  ?????? ? ?? ????? ?????? ?? ?? ????? ??? ????????
  ? ?? ?????
• ??????? ??? ?????? ? ??????? (????? ???? ??????
  ?? ???? ?? ??? ???? ?? ???? ?? ?? ??????? ??????
  ???? ?? ???.)

43

• ??????? ?????? ????
• ????? ??????? ????? ? ????
• ????? ????? ?? ????? exploration ?? ???? ?? ?????
  ???? ?? ??? ? ???? ???? ?? ???. (???? sex aids,
  fantasies, Kegels exercises)
• ????? ?? ???? ??? ?? ????? ?? ?????? ??? ??????
  ??????? ???? ????? ?????? ???????? ?? ??? ?? ????
  ?? ???? ????? ???? ????. (normalizing
  reassurance) (????? ??????? ???? ?? ??? ?? ?????
  ???.)
• The bridge maneuver ????? ?????? ???????? ??
  ??? ????? ?? ?????? (? ?? ??? ????? ??) ???? ???
  ?? ?????? ??????? (?? ??? ????? ??? ???? ???????
  ?? ?????? ???? ????? ?? ?????? ? ?? ????? ??????
  ????? ?? ???.)

44

• ?????? ?????? ?? ????? (Male Orgasmic Disorder)
• ????? ?? ????? ???? ?? ???? ???? ??? ?? ???.
• ?????? ??????
• Inhibited orgasm
• Retarded ejaculation
• ?? ????? ???? ?? ????? ????? ???.
• ???? ?????? ????? ????? ??? ????? ? ?????? ????
  ????? ???? ??. ?????? ???? ?????? ??? ????? ? ??
  ????? ????? ??? ???? ?????? ????? ?? ???.
  (Orgasmic anhedonia)

45

• ??? ????? ?? (Lifelong) ???? ?? ?? ?????????????
  ??? ????? ???. ?????
• ???? ? ?????? ??????? ?????? ????? ?? ??? (?????
  ???? ? ?????? ????? ???? ?? ????? ?? ?????.)
• ????? ???? ??????? ? ?? ????????? ??????? ???? ??
  ????? (Incest) ? ?????? ?? ????? ???? ?????.
• ????? ?????? ?? ??????? ??? ???? ?? ?????? ?????
  ????? (Attention deficit disorder) ????? ??? ???.
• ??? ??????? ?? ???? ????? ?? ?? ?????? ??? ????
  ???. ?????
• ???? ??????? (coping)?? ?????? ????? ? ?? ?????
  ?? ?? ????? (????? ?????? ???? ???? ????? ?????
  ?? ???? ?? ??? ???? ???? ???? ?? ??? ???? ?????
  ???? ???? ?? ???? ????)
• ???? ?????? ????? ???? ?? ?? ???? ????
• ??? ?????? ?? ????? ????? ?? Obsessive-compulsive
  disorder ?? ???? ?????? ???? ?? ???.

46

• ????? ??? ?? ???? (Premature Ejaculation)
• ????? ?? ????? ???? ?? ???? ???? ? ?? ?????
  ?????? ???? ?? ??? ? ?? ???????? ??? ?? ???? ?
  ??? ?? ????? ???. ??????? ???? ????? ????????? ??
  ??? ???? ????? ???? ????? ??? ???? ???? ?????? ?
  ?? ???? ???? ? ??????? ?????? ???? ???? ?? ?? ???
  ???? ???.
• ?????? ???? ????? ??????? ? ?? ????? ?????? ????
  ?? ????? ??? ???? ?? ???.
• ????? ????? ??????? ????? ?? ????? ?????? ????
  (????? ??? ??????????) ?????.
• ?????? ??????
• Early ejaculation / Rapid ejaculation

47

• ???? ??? ???? ?? ????? ??????? ????? ???? ??????
  ????. (???? ?? ??? ???? ????? ?? ????? ???? ????)
• PE ????? 35 ?? 40 ???? ?? ?????? ??? ?? ????
  ????? ???????? ???? ??? ????? ???? ?? ?????.
• ???? ???????
• ?????!
• ????? ???? ?? ?????? ?? ??? ?? 50 ?????? (??????
  ?? MJ ???? ?? ??????)
• ????? ??????
• ?? ???? ??? ?? ????? DSM IV ???? ?? ?? ???? ????
  ????
• ??? ?? ????? ???
• ????? ?????? ???????

48

• ???????? ??? ???????
• ????? ??? ???????????? (?????????? ????? ???? ??
  ???? ?? ??? ?? ????)
• ????? ????? (?? ???? ?????? ?? ???? ? ???? ????)
• ?????? (?? ??????? ??? ????? ?? ???? ?????
  ???????? ??? ????? ?? ????? ????? ??? ???? ??
  ????? ?...)
• ?????? ???? ?? ????? ????
• ?????? ? ????? ??????? ???? ?? ?????
• ????? ???? ??????
• ????? ?? ????? ????? ????? (shorter nerve latency
  time)

49

• ??????? ?????? ????
• ????? ?????? (????? ?? 4 ????)
• ???? ??????? ? ????? ?? ???? ???????????????? ?
  ???? ??? ??? ?? ????? ????
• ????? ??? ???????
• ??????? (Adaptation) (Ladies first !)
• ???? ?? ???? ??? ???? ?????? ????? ? ????? ?????
• (??????? ?? ???? ????? ??? ?? ??? ???? ??? ??????
  ?? ?????? ???? ???? ???.)

50
(No Transcript)
51
Premature Ejaculation

• The Start-Stop Technique
• Step 1 Learn your Point of Ejaculatory
  Inevitability
• The first step towards lasting longer is learning
  your point of ejaculatory inevitability. Once
  youve reached this point, you are going to
  ejaculate within 1-3 seconds no matter what (even
  if you suddenly realize some big men are
  repossessing your car outside your window). Your
  task is to learn what your body (especially your
  penis) feels like when you reach this point. You
  can do this by masturbating or by having your
  partner stimulate you to orgasm.

52
Premature Ejaculation

• Step 2 Stimulate your penis until you are very
  aroused
• The next step is to hold onto the sensations of
  high arousal without moving to the point of
  inevitability. By learning to become comfortable
  with these sensations, you can last longer. One
  way to help you learn this is to pause
  stimulation of your penis when you become very
  aroused and resume stimulating when you are no
  longer aroused. Continue doing this for ten
  minutes (even if you have to stop often). At the
  end of ten minutes stimulate your penis until you
  ejaculate and enjoy the sensations. You can do
  this on your own or with your partner but it is
  best with your partner because this is a team
  effort. If your partner is stimulating you,
  signal your partner to stop by saying stop or
  holding up your hand.

53
Premature Ejaculation

• Step 3 Stimulate your penis using a lubricant
• Once you have become comfortable with the
  previous step, spend the next session stimulating
  your penis (or have your partner stimulate you)
  using a lubricant . This will simulate the
  feeling of being in a vagina. This will usually
  feel more arousing and will be more difficult to
  control. Again, stimulate until you feel very
  aroused but before you reach the point of
  inevitability and then stop. After 10 minutes of
  practicing this step, stimulate your penis until
  you reach orgasm. Again, pay attention to the
  sensations and enjoy them. Spend a few sessions
  practicing this exercise until you feel
  comfortable to move to the next step.

54
Premature Ejaculation

• Step 4 Your partner stimulates you with her body
• During the next step, ask your partner to
  stimulate you by rubbing your penis on various
  parts of her body like her vagina (without
  inserting your penis) and breasts. This may be
  even more stimulating than the previous steps.
  Continue pausing stimulation when you become
  aroused. After 10 minutes of starting and
  stopping, stimulate the penis until ejaculation.

55
Premature Ejaculation

• Step 5 Female-on-top position
• The next step involves intercourse. The
  female-on-top position is ideal for this next
  step because men usually feel less sexual
  intensity in this position. So, with the
  woman-on-top, insert the penis in the vagina.
  Again it is your task to signal her to stop when
  you feel very aroused (before the point of
  inevitability). As you continue to practice, you
  will be able to resume regular intercourse again,
  with fewer and fewer pauses.

56

• ??????? ?????? ????
• ????? ??????
• Paroxetine (Paxil)
• Serteraline (Zoloft)
• Clomipramine (Anafranil)
• ?? ???? ??????? ?? ??? ???? ???? ?????? ???? ???
  ???.
• ??????? ?? ???? ?? ????? ????? ???? ????? ?? ???.
  ?? ????? ??????? (situational) ??? ???? ?? ????
  ???? ??????? ??? ? ???? ?? ????? ???? ??????.
• ?? ????? ???? ???? ???? ???????? ??????? ???.
• ?? ???? ?? ????? ???? ???? ?? ???????? ?? ???
  ????? ????? ?????? ?? ?????? ? ???? ???????
  ????????? ???? ????? ?????? ???.

57
???????? ??? ???? (Sexual Pain Disorders)

• ?????? ?????? (Dyspareunia)
• ??? ?????? ???? ???? ? ?? ??? ????? ????? ??
  ?????? ???? ?? ?? ??? ? ?? ??
• ?????? ???? ????? ??????? ? ?? ????? ?????? ????
  ?? ????? ??? ???? ?? ???.
• ???? ??????? ?? ??? ???????? ? ?? ?????
  ??????????? ????? ???? ???? ? ?? ?????? ????? ??
  Axis I (??? ?????? ???? ????) ???? ????? ????? ?
  ???? ?? ????? ?????????? ?????? ???? ???? (??
  ???? ???? ???? ? ?? ??????? ?? ) ? ?? ?? ?????
  ????? ????? ??? ?????.

58

• ??? ?????? ?? ???? ?? ????? ???? ?? ?? ????? ???
  ? ?? ????? ?? ???????? ?????? ????? ???? (?????
  ???? ?????). ??? ?? ????? ????? ??????? ???? ??
  ????.
• ?????? ?????????? ????? ?? ?????? ?? ??? ???
  ??????? ???? ? ?? ??????? ?? ??? ???????? ?????
  ?? ??? ????? ???.
• ??? ???????
• ??? ???? ??? ?? ???? ?? ????? ?????????? ????
  ???? ???.
• ?????? ? ??? ?? ????? ????? ???? ?? ????? ????
  ?????? ??? ????? ????? ???? ???.
• ???? ??? ????? ??? ? ???? ??? ???? ??????? ?? ??
  ?????? ??? ???? ??? ? ?? ???? ????? ???? ?? ???
  ???? ????? ???? ??? ????? ??.

59

• ??? ?????? ????? ?? ????? ???? ???? ??? ??? ??
  ????? ?? ????? ??? ?????? ???
• ?????????
• ???? ??????
• Peyronies disease ?????? ???? ??? ????????? ??
  ?? ?????? ???? ?????? ??? ????.

60

• ???????? (Vaginismus)
• ?????? ???????? ????? ?? ??? ????? ???? ???? ????
  ? ?? ??? ????? ?? ???? ?????? ???? ?? ???.
• ?????? ???? ????? ??????? ? ?? ????? ?????? ????
  ?? ????? ??? ???? ?? ???.
• ???? ????? ?? ?????? ????? ?? Axis I (?? ????
  Somatization disorder) ???? ????? ???? ? ???? ??
  ????? ?????????? ?????? ?? ????? ????? ????? ???
  ?????.

61

• ??? ?????? ?? ???? ????????? ? ????? ???????
  ??????? ?????? ????? ???? ?? ???. ()
• ??? ???? ??? ????? ?? ??????? ????? ???? ?????
  ??? ???? ????????? ????? ????? ?? ???? ??? ??? ??
  ???? (? ??? ?? ?????? ????????) ?? ??????.
• ???????? ??? ???????
• ????? ?????? ???? (?? ???? ????? ????)
• ???? ???? ????? ?????? ??????????? ???? ??? ???
  ???? ???? ?? ?? ????? ???? ????.
• ??? ? ?? ?????? ?? ????? ?????? ?? ?????? ?????
  ??????()
• ????? ???????? ????? ?? ?????? ????? ???? ?? ????
  ???? ?? ????.
• ??? ????? ?? ????? ??? ????? ???. ??? ?? ????? ??
  ??? ?? ??? ???? ???? ?? ???? ????? ? ??? ???
  ??????? ???? ????? ??? ???? ??? ????????? ?? ???
  ??? (????????) ????? ???? ???.

62

• ??????? ?????? ????
• ???? ???????? ????? ? ????? ????
• ?? ???? ??? ??????? ???? ??? ?? ????? ????
• ????? ??? ?? ????? ????? ???? ???? ??? ??????
  (???? ??? ??? ???? ? ?? ?????? ?? ??? ???? ??????
  ???? ????? ???? ???? ???.)
• ??????? ???? ?????? ? ????? ???? ???? ??? ???????
• ??????? ?? ????????? ? ????? ??? ?????? (???
  dilator ????? ?? ????? ???? ????? ??? ?? ????
  ???????? ???? ????? ? ????? ?? ?????? ?? function
  ???.)
• ??? ????? ?????? ???? ???? ?????? ??? ????? ???.
• ????? Relaxation ? ??????? ????? ??

63

• Step 1 Relax
• Begin by relaxing. Remember your deep breathing
  exercises. Tensing and releasing different muscle
  groups can help too. Use relaxing music. Take a
  warm bath.

64

• Step 2 Gradually insert fingers of different
  sizes
• When you feel completely relaxed, insert your
  smallest finger. Use lots of lubrication. You may
  be hesitant to do this, especially at first.
  Notice that youre feeling tense and take a deep
  breath to release that tension. While inserting
  your finger, pay attention to how it feels. Try
  and keep your finger in for a few minutes. Once
  you can comfortable insert your finger for five
  minutes or more, move to the next size finger and
  do the same. Once youve successfully inserted a
  larger finger for five minutes or more, insert
  two fingers and do the same. Continue with this
  until you can insert 2-3 fingers at once. This
  may take a few weeks. Go at your own pace.

65

• Step 3 Gradually insert his penis
• Once youve successfully inserted 3 fingers at
  once for over five minutes, insert his penis.
  Begin by inserting it one inch at a time.
  Remember to relax first. You control the amount
  of time and depth of penetration. With each
  insertion, pay attention to how it feels.
  Continue your deep breathing exercises. With each
  session, youre getting your body used to having
  something inside your vagina. Youre in control.
  This step will also take a few weeks. Go at your
  own pace. Soon you will be able to resume
  intercourse. Take it slow.

66
???????? ???? ????? ?? ????? ??? ????? (Sexual
Dysfunction Due to General Medical Condition)

• ?? ?????? ????? ?? ???? ?? ?????? ???? ????? ??
  ?? ?? ??? ??????? ?? ?????? ??? ???? ???? ????
  ??? ??? ???? ?? ??????? ?????? ????? ?????? ?
  ?????????? ?????? ???? ?? ??? ?????????? ?????? ?
  ?? ????? ????? ????? ???? ????? ????. ??????
  ?????? ???? ???? ?????? (????? ??????? ?????) ??
  ?? ????? ????.
• ?? ????
• ??? ???? ???? ED ?? ??? ??. (???? ????? ???????
  ?? ????? ??? ??????? ????? ??? ??? ????? ? ??
  ????? ?????? ????? ? ?? ?????? ???? ???? ????? ?
  ????? ??? ?????????? ? ??????? ????? ??????? ??
  ???.) (20 ?? 50 ???? ???????? ?????)

67

• ??? ???? ?????????? ???
• ?????? ????? ??? ???? ? ??????
• ????? ????? ??? ?????? (???????? ???????? ?????
  ??? ???????? ?????????? ??????)
• ??????????
• ?????? ??????? ???? ?? ??????
• ??? ?????????? ?????? ?????? ?? ????? ?? ????
• ??? ?? ????? ??? ?????? ?????? (?? ????
  ????????????)
• ?????? ?????????
• ?????? ????????? ????? ???????????
• ???? ??????? ?? ???????/ ????????? ?? ? ?????????
  ??
• Retrograde ejaculation ????? ??? ???????? ????
  (?????? ????? ?????? ?????? ? ?? ???? ???????
  ????? ??? ???? ????????)

68

• ????? ????? ???? ?? ????? ?????? ?????? ?? ????
  ?? ????
• ?????? ??? ???????? (????????????? ??????
  ???????????????? ?????)
• ??????? ?????????/ ????????? ??

69
???????? ???? ????? ?? ???? ????(Substance
Induced Sexual Dysfunction)

• ???? ?? ????? ?? ??? ???? ?? ??? ???? ?????? ?
  ????? ?????????? ???? ?? ?????? ?????? ??????
  ???? ?? ???? ? ?? ??? ???? ???? ???. (?? ??????
  ????? ?? ??? ?? ???? ? ?? ??? ??)
• ????
• ???????? ?? ? ???? ?????
• ???????
• ??????????
• ????????? ???? ????? ? ???????? ??