Sexual dysfunction is a signiﬁcant disturbance in the sexual response cycle, which is not due to an underlying organic cause.
To understand sexual dysfunction, a brief outline of normal human sexual response cycle,a normal human sexual response cycle can be divided into 5 phases
The phase before the actual sexual response cycle. This consists of sexual fantasies and a desire to have sexual activity
The ﬁrst true phase of the cycle, which starts with physical stimulation and/or by appetitive phase.
Males: Penile erection,elevation of testes with scrotal sac.
Females: Lubrication of vagina by a transudate; erection of nipples (in most women); erection of clitoris; thickening of labia minora.
Males: Sexual ﬂush (inconsistent); autonomic hyperactivity; erection and engorgement of penis to full size; elevation and enlargement of testes; dew drops on glans penis (2-3 drops of mucoid ﬂuid with spermatozoa).
Females: Sexual ﬂush (inconsistent); Autonomic hyperactivity; retraction of clitoris behind the prepuce; development of orgasmic platform in the lower 1/3rd of vagina, with lengthening and ballooning of vagina; enlargement of breasts and labia minora; increased vaginal transudate.
Males: 4-10 contractions of penile urethra, prostate, vas, and seminal vesicles; at about 0.8 sec intervals; Doubling of pulse rate and respiratory rate, and 10-40 mm increase in systolic and diastolic BP occur; ejaculatory inevitability precedes orgasm; Ejaculatory spurt (30-60 cm; decreases with age); contractions of external and internal sphincters.
Females: 3-15 contractions of lower 1/3rd of vagina, cervix and uterus; at about 0.8 sec intervals. No contractions occur in clitoris; autonomic excitement becomes marked in this phase. Doubling of pulse rate and respiratory rate, and 10-40 mm increase in systolic and diastolic BP occur; contractions of external and internal sphincters.
This phase is characterised by the following common features in both sexes: A general sense of relaxation and well-being, after the slight clouding of consciousness during the orgasmic phase; disappearance of sexual ﬂush.
Duration- refractory period for further orgasm in males varies from few minutes to many hours; there is usually no refractory period in females.
A.Disorders of Excitement and Plateau Phase
Male erectile disorder ( Impotence; Erectile dysfunction)
This disorder is characterised by an inability to have or sustain penile erection till the completion of satisfactory sexual activity.
- Ignorance regarding the sexual act.
- Fear of failure and performance anxiety (e.g. during ‘honeymoon’).
- Interpersonal difﬁculties between the sexual partners (e.g. marital conﬂict).
- Anxiety disorder.
- Mood disorder.
- Masturbatory anxiety (and ‘dhat syndrome’ in India).
- Fatigue (e.g. after the day’s hard work).
- Fear of pregnancy, or sexually transmitted disease.
- Fear of ‘damaging’ the sexual partner or one-self.
- Certain environmental factors (e.g. lack of privacy).
- Lack of a consistent sexual partner.
- Fear of commitment (in premarital and extramarital sexual relationships).
- Poor self-image or inferiority complex .
- Sexual abuse in childhood.
- Congenital malformations .
- Surgical procedures on pelvic region, e.g. perineal prostatectomy.
- Hydrocele or varicocele.
- Diabetes mellitus.
- Thyroid dysfunction.
- Alcohol and Drugs
B.Disorders of Orgasmic Phase
Male orgasmic disorder
Failure or marked difﬁculty to have orgasm, despite normal sexual excitement, during coitus.
3.Psychological (e.g. Marital conﬂicts).
Female orgasmic disorder (Female anorgasmia)
Failure or marked difﬁculty to have orgasm, despite normal sexual excitement, during coitus. This is a very common disorder.
3.Psychological (e.g. Marital conﬂicts).
This disorder is deﬁned as ejaculation before the completion of satisfactory sexual activity for both partners. In severe cases, it is characterised by ejaculation either before penile entry into vagina or soon after penetration. It is a very common disorder in the clinical setting.
Treatment for Sexual Disorders
Patients of same sex with different sexual problems or of both sexes with similar sexual problems can be treated in group therapy sessions. The focus is usually on providing education regarding normal sexuality and to remove anxiety or guilt by sharing viewpoints in a group setting.
Masters’ and Johnson’s technique: This is one of the most popular and successful methods of treatment for psychosexual dysfunctions. The patient is not treated alone, but both the partners are treated together. This is called as dual-sex therapy, where both the sexual partners are treated by a team of therapists (one male and one female) .Some common steps before starting therapy include:
a.Detailed history taking (sexual history) from each partner separately
b.Understanding of the couple’s current sexual problem(s).
c.Enhancing communication between the partners regarding sexual matters.
d.Education about normal sexuality.
e.Sensate focus technique:
This is used particularly for treatment of impotence, although it is also useful in management of other dysfunctions as well. The aim is to ‘discover’ on body (excluding genital area) ‘sensate focuses’ (body areas where manipulation leads to sexual arousal). This is usually a general exercise before any sex therapy.
f.Squeeze technique ( Seman’s technique):
This has been used in treatment of premature ejaculation. The female partner is asked to manually stimulate the penis causing erection. When the male partner experiences ‘ ejaculatory inevitability’, the female partner ‘squeezes’ the penis on the coronal ridge thus delaying ejaculation.