Sexual dysfunction

Definition

Sexual dysfunction is broadly defined as the inability to fully enjoy sexual intercourse. Specifically, sexual dysfunctions are disorders that interfere with a full sexual response cycle. These disorders make it difficult for a person to enjoy or to have sexual intercourse. While sexual dysfunction rarely threatens physical health, it can take a heavy psychological toll, bringing depression, anxiety , and debilitating feelings of inadequacy.

Description

Sexual dysfunction takes different forms in men and women. A dysfunction can be life-long and always present; acquired; situational; or generalized, occurring despite the situation. A man may have a sexual problem if he:

• Ejaculates before he or his partner desires.
• Does not ejaculate, or experiences delayed ejaculation.
• Is unable to have an erection sufficient for pleasurable intercourse.
• Feels pain during intercourse.
• Lacks or loses sexual desire.

A woman may have a sexual problem if she:

• Lacks or loses sexual desire.
• Has difficulty achieving orgasm.
• Feels anxiety during intercourse.
• Feels pain during intercourse.
• Feels vaginal or other muscles contract involuntarily before or during sex.
• Has inadequate lubrication.

The most common sexual dysfunctions in men include:

• Erectile dysfunction: an impairment of the erectile reflex. The man is unable to have or maintain an erection that is firm enough for coitus or intercourse.
• Premature ejaculation, or rapid ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.
• Ejaculatory incompetence: the inability to ejaculate within the vagina despite a firm erection and relatively high levels of sexual arousal.
• Retrograde ejaculation: a condition in which the bladder neck does not close off properly during orgasm so that the semen spurts backward into the bladder.

Until recently, it was presumed that women were less sexual than men. In the past two decades, traditional views of female sexuality were all but demolished, and women's sexual needs became accepted as legitimate in their own right.

Female sexual dysfunctions include:

• Sexual arousal disorder: the inhibition of the general arousal aspect of sexual response. A woman with this disorder does not lubricate, her vagina does not swell, and the muscle that surrounds the outer third of the vagina does not tighten—a series of changes that normally prepare the body for orgasm ("the orgasmic platform"). Also, in this disorder, the woman typically does not feel erotic sensations.
• Orgasmic disorder: the impairment of the orgasmic component of the female sexual response. The woman may be sexually aroused but never reach orgasm. Orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives.
• Vaginismus: a condition in which the muscles around the outer third of the vagina have involuntary spasms in response to attempts at vaginal penetration.
• Painful intercourse: a condition that can occur at any age. Pain can appear at the start of intercourse, midway through coital activities, at the time of orgasm, or after intercourse is completed. The pain can be felt as burning, sharp searing, or cramping; it can be external, within the vagina, or deep in the pelvic region or abdomen.

Causes and symptoms

Many factors, of both physical and psychological natures, can affect sexual response and performance. Injuries, ailments, and drugs are among the physical influences; in addition, there is increasing evidence that chemicals and other environmental pollutants depress sexual function. As for psychological factors, sexual dys-function may have roots in traumatic events such as rape or incest, feelings of guilt, a poor self-image, depression, chronic fatigue, certain religious beliefs, or marital problems. Dysfunction is often associated with anxiety. If a man operates under the misconception that all sexual activity must lead to intercourse and to orgasm by his partner, and if the expectation is not met, he may consider the act a failure.

Men

With premature ejaculation, physical causes are rare, although the problem is sometimes linked to a neurological disorder, prostate infection , or urethritis. Possible psychological causes include anxiety (mainly performance anxiety), guilty feelings about sex, and ambivalence toward women. However, research has failed to show a direct link between premature ejaculation and anxiety. Rather, premature ejaculation seems more related to sexual inexperience in learning to modulate arousal.

When men experience painful intercourse, the cause is usually physical; an infection of the prostate, urethra, or testes, or an allergic reaction to spermicide or condoms. Painful erections may be caused by Peyronie's disease, fibrous plaques on the upper side of the penis that often produce a bend during erection. Cancer of the penis or testis and arthritis of the lower back can also cause pain.

Retrograde ejaculation occurs in men who have had prostate or urethral surgery, take medication that keeps the bladder open, or suffer from diabetes, a disease that can injure the nerves that normally close the bladder during ejaculation.

Erectile dysfunction is more likely than other dysfunctions to have a physical cause. Drugs, diabetes (the most common physical cause), Parkinson's disease , multiple sclerosis , and spinal cord lesions can all be causes of erectile dysfunction. When physical causes are ruled out, anxiety is the most likely psychological cause of erectile dysfunction.

Female

Dysfunctions of arousal and orgasm in women also may be physical or psychological in origin. Among the most common causes are day-to-day discord with one's partner and inadequate stimulation by the partner. Finally, sexual desire can wane as one ages, although this varies greatly from person to person.

Pain during intercourse can occur for any number of reasons, and location is sometimes a clue to the cause. Pain in the vaginal area may be due to infection, such as urethritis; also, vaginal tissues may become thinner and more sensitive during breastfeeding and after menopause . Deeper pain may have a pelvic source, such as endometriosis, pelvic adhesions, or uterine abnormalities. Pain can also have a psychological cause, such as fear of injury, guilt feelings about sex, fear of pregnancy or injury to the fetus during pregnancy, or recollection of a previous painful experience.

Vaginismus may be provoked by these psychological causes as well, or it may begin as a response to pain, and continue after the pain is gone. Both partners should understand that the vaginal contraction is an involuntary response, outside the woman's control.

Similarly, insufficient lubrication is involuntary, and may be part of a complex cycle. Low sexual response may lead to inadequate lubrication, which may lead to discomfort, and so on.

Diagnosis

In deciding when a sexual dysfunction is present, it is necessary to remember that while some people may be interested in sex at almost any time, others have low or seemingly nonexistent levels of sexual interest. Only when it is a source of personal or relationship distress, instead of voluntary choice, is it classified as a sexual dysfunction.

The first step in diagnosing a sexual dysfunction is usually discussing the problem with a health care professional, who will need to ask further questions in an attempt to differentiate among the types of sexual dysfunction. A physical exam of the genitals may be performed, and further medical tests may be ordered, including measurement of hormone levels in the blood . Men may be referred to a specialist in diseases of the urinary and genital organs (urologist), and primary care physicians may refer women to a gynecologist.

In general, causes of sexual dysfunction are either physical or psychological. Physical causes often have an underlying condition that effect sexual function including:

• diabetes
• heart disease
• neurological disorders
• pelvic surgery or trauma
• alcoholism and drug abuse
• chronic disease such as kidney or liver failure
• side effects of medicines
• hormone imbalance
• heavy smoking

Psychological factors including the following:

• stress or anxiety
• insecurity about sexual performance
• relationship discord
• confusion regarding sexual orientation
• depression
• trauma in previous sexual experiences

The following agents have been associated with sexual dysfunction, so patients should speak to their doctors if they have concerns regarding: Tamoxifen, Luminal, Dilantin, Mysloine, Tegretol, Tricyclic, Anafranil, Prozac, Paxil, Inderal, Lopressor, Corgard, Blocadren, Tenormin, Cimetidine, Tagament, Thorazine, Haldol, Zyprexa, Xanax, Valium, and some progestin-dominant birth control pills. It is important to note that there may be alternate medications available that do not affect sexual function. Other agents may also be available to counteract any sexual dysfunctions experienced with these medications. Prescribed medication should not be discontinued without first speaking with a physician.

Treatment

Treatments break down into two main kinds, physical and behavioral psychotherapy .

In many cases, doctors or advance practice nurses may prescribe medications to treat an underlying physical cause or sexual dysfunction. Possible medical treatments include:

• Viagra (Sildenafil) is a treatment for erectile dysfunction in men.
• Papaverine and prostaglandin are used for erectile difficulties.
• MUSE (Medical Urethral System for Erection), a prostaglandin E-1 pellet which can be inserted into the urethra. In addition, Caverject and Edex are prostaglandin E-1 injection medications for erectile dysfunction.
• Surgically implanted inflatable penile prosthesis for erectile dysfunction.
• Androgel, a topical gel for testosterone/androgen replacement in men. Testosterone injections and patches may also be used in men and women to stimulate sexual desire.
• Clomipramine, fluoxetine, as well as serotonin reuptake inhibitors such as Prozac, Zoloft, and Anafranil for premature ejaculation.
• Hormone replacement therapy for female dysfunctions.
• EROS-CTD, a clitoral therapy device approved by the FDA in May 2000 is designed to enhance lubrication and sensation in women who have arousal disorders. With a gentle suction, it increases blood flow to the clitoris and surrounding area.

New agents not yet FDA approved as of March 2001, but are expected to gain approval are:

• ICOS is an agent for treatment of erectile dysfunction that will likely receive FDA approval in 2001 or 2002.
• Uprima (apomorphine) claims to induce erection in men and arousal in women.
• Vasomax, an oral tablet, is said to facilitate an erection within 10–15 minutes. It is anticipated that Vasomax may aid women as well as men.
• Trials using Viagra in women are ongoing as of 2001.
• SS Cream is a topical agent with natural plant extracts which appears to desensitize the penis and is used to treat premature ejaculation.

In some cases, a specific technique may be used during intercourse to correct a dysfunction. One of the most common is the "squeeze technique" to prevent premature ejaculation. When a man feels that an orgasm is imminent, he withdraws from his partner. Then, the man or his partner gently squeezes the head of the penis to halt the orgasm. After 20–30 seconds, the couple may resume intercourse. The couple may do this several times before the man proceeds to ejaculation.

In cases where significant sexual dysfunction is linked to a broader emotional problem, such as depression or substance abuse, intensive psychotherapy and/or pharmaceutical intervention may be appropriate.

KEY TERMS

Ejaculatory incompetence —The inability to ejaculate within the vagina.

Erectile dysfunction —Difficulty achieving or maintaining an erect penis.

Impotence —The inability to achieve and sustain an erection suitable for intercourse.

Orgasmic disorder —The impairment of the ability to reach sexual climax.

Painful intercourse (dyspareunia) —Generally thought of as a female dysfunction but it also affects males. Pain can occur anywhere.

Premature ejaculation —Rapid ejaculation before the person wishes it, usually in less than one to two minutes after beginning intercourse.

Retrograde ejaculation —A condition in which the semen spurts backward into the bladder.

Sexual arousal disorder —The inhibition of the general arousal aspect of sexual response.

Vaginismus —Muscles around the outer third of the vagina have involuntary spasms in response to attempts at vaginal penetration, not allowing for penetration.

A variety of alternative therapies can be useful in the treatment of sexual dysfunction. Counseling or psy chotherapy is highly recommended to address any emotional or mental components of the disorder. Botanical medicine, either western, Chinese, or ayurvedic, as well as nutritional supplementation, can help resolve biochemical causes of sexual dysfunction. Acupuncture and homeopathic treatment can be helpful by focusing on the energetic aspects of the disorder.

Some problems with sexual function are normal. For example, women starting a new or first relationship may feel sore or bruised after intercourse and find that an over-the-counter lubricant makes sex more pleasurable. Simple techniques, such as soaking in a warm bath, may relax a person before intercourse and improve the experience. Yoga and meditation provide needed mental and physical relaxation for several conditions, such as vaginismus. Relaxation therapy eases and relieves anxiety about dysfunction. Massage is extremely effective at reducing stress, especially if performed by the partner.

Prognosis

There is no single cure for sexual dysfunction, but almost all can be controlled. Most people who have a level of sexual dysfunction fare well once they get into a treatment program. For example, a high percentage of men with premature ejaculation can be successfully treated in two to three months. Furthermore, the gains made in sex therapy tend to be long-lasting rather than short-lived. Viagra produces an erection in 75% of men with erectile dysfunction. For men who are not responsive to drug treatment, studies with surgically implanted inflatable penile prosthesis claim a success rate at approximately 98%.

Health care team roles

Nursing and allied health professionals play a critical part in the diagnosis and treatment of sexual dysfunction. Sex therapy, which is ideally provided by a member of the American Association of Sexual Educators, Counselors, and Therapists (AASECT), universally emphasizes correcting sexual misinformation, the importance of improved partner communication and honesty, anxiety reduction, sensual experience and pleasure, and interpersonal tolerance and acceptance. Sex therapists believe that many sexual disorders are rooted in learned patterns and values. These are termed psychogenic. An underlying assumption of sex therapy is that relatively short-term outpatient therapy can alleviate learned patterns, restrict symptoms, and allow a greater satisfaction with sexual experiences.

Registered dietitians and nutritionists can be instrumental in giving dietary guidance and nutrition supple-mentation that may improve overall health and energy levels. Health improvements may impact general wellbeing and sexual function.

Resources

BOOKS

Berman, Jennifer, M.D., Laura Berman, PH.D., and Elisabeth Bumiller. For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life. New York: Henry Holt, 2001.

Masters, William H., Virginia E. Johnson, and Robert C. Kolodny. Human Sexuality. New York: HarperCollins Publishers, 1992.

Weiner, D. N., and R. C. Rosen. "Medications and Their Impact." In Sexual Function in People with Disability and Chronic Illness: A Health Professionals Guide. Gaithersburg: Aspen Publications, 1997, pp.437

PERIODICALS

Laumann, E., A. Paik, and R. Rosen. "Sexual dysfunction in the United States prevalance and predictors." Journal of the American Medical Association 281 (1999): 537-544.

Phanjoo, A.L. "Sexual dysfunction in old age." Advances in Psychiatric Treatment 6 (2000): 270-277.

Phillips, N., M.D. "Female sexual dysfunction: evaluation and treatment." American Family Physician 62 (2000): 127-36. <http://www.aafp.org/afp/20000701/127.html>.

ORGANIZATIONS

American Academy of Clinical Sexologists. 1929 18th Street NW, Suite 1166, Washington, DC 20009. (202) 462-2122.

American Association for Marriage and Family Therapy. 1100 17th Street NW, 10th Floor, Washington, DC 20036-4601. (202) 452-0109.

American Association of Sex Educators, Counselors & Therapists. P.O. Box 238, Mt. Vernon, IA 52314.

American Foundation for Urologic Disease, Sexual Function Health Council. 1126 N. Charles Street, Baltimore, MD21201. (410) 468-1800. <http://www.impotence.org>.

National Kidney and Urologic Diseases, Information Clearinghouse. 3 Information Way, Bethesda, MD 20892-3580. <http://www.niddk.nih.gov>.

Network for Excellence in Women's Sexual Health (NEWSHE). Female Sexual Medicine Center, UCLA Medical Center. 924 Westwood Blvd., Suite 520, Los Angeles, California 90095. (310) 825-0025, Fax (310) 794-0211. <http://www.newshe.com>.

OTHER

Berman, Jennifer, M.D., Laura Berman, PH.D., Elisabeth Bumiller. Non-pharmacological possibilities for treating female sexual dysfunction now on the horizon. 2001. <http://www.hisandherhealth.com/articles/Non-Pharmacological_Possibilities_for_Treating_Female_Sexual_Dysfunction.shtml>.

Hwang, Mi Young, and Richard Glass, M.D., ed. "Silence about sexual problems can hurt relationships." The Journal of the American Medical Association 281, no. 6(1999). <http://jama.ama-assn.org/issues/v281n6/fpdf/jpg0210.pdf>.

Mulcahy, John, M.D. "What's new: drug therapies for treatment of erectile dysfunction." His and Her Health.com (1999), <http://www.hisandherhealth.com/articles/Drug_Therapies_for_Treatment_of_Erectile_Dysfunction.shtml>.

Murdock, Myron, M.D. "Be the first: learn about new treatments on the horizon for treating sexual function." His and Her Health.com 1999. <http://www.hisandherhealth.com/articles/New_Treatments_on_the_Horizon_for_Treating_Sexual_Function.shtml>.

Murdock, Myron, M.D. "Medical aspects of male/female sexual dysfunction in the next millennium." His and Her Health.com On-line videotape. (1999), <http://www.hisandherhealth.com/articles/Sexuality_and_the_Millennium.shtml>.

Crystal Heather Kaczkowski, MSc.