PART OF ANDROLOGY :

MALE SEXUAL DYSFUNCTION

Male Sexual Response Cycle
 Arousal
 Plateau Refractory Arousal

 Orgasm
 Resolution
 Refractory Period
Resolution Plateau

Orgasm
 Master & johnson  Others :
 Excitement  Desire

 Plateu  Arousal

 Orgasm  Orgasm

 resolution  resolution
Stage One – EXCITEMENT/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.
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.
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.
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.
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.
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.
Prevalence
 Extremely prevalent in the general population
 Simons & Carey (2001)
 3% orgasmic disorder
 5% erectile disorder
 3% hypoactive sexual desire disorder
 5% premature ejaculation
Diagnostic Questions
 Onset
 Primary
 Secondary
 Context
 Global
 Situational
 Contributing Factors
 Physiological
 Mechanical
 Psychological
The Big Three in MSD
 Erectile Dysfunction  Thepenis may be the
most honest parts of
 Premature Ejaculation
the male anatomy.
 Retarded Ejaculation
Phases in Disorder
 Desire
 Arousal
 Orgasm
 A BRIEF ANATOMY & PHYSIOLOGY

Male Sexual Stimuli Process

1. Erectogenic 2. Neural
stimulus initiation
Hypothalamus
4. Smooth Psychogenic sympathetic erection center
(Th11/12-L2/3)
muscle
relaxation Bulb of corpus spongiosum
Bulb of corpus
Reflexogenic
parasympathetic
erection center
(S2-S4)

3. Cellular
activation
Penis
Desire Disorders
 Hyperactive Sexual Desire
 Hypoactive Sexual Desire
 Sexual Aversion
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
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.
Hypoactive Sexual Desire Causes
 Stress, Anxiety
 Medications
 Drugs
 Alcohol
 Depression
 Hormonal Imbalances
 Relational Factors
 Sexual Arousal Disorder
 Endocrine Diseases
 Cushing’s
Syndrome
 Hypothyroidism
 Diabetes
 Systemic Diseases
 Chronic Renal Failure
 Testicular Atrophy
 Chronic Pain
 ADAM SCORE
 Lossof libido
 Decrease of erection

 Decrease of concentration

 Swinging mood

 Decrease of height

 Weakness

 Sleepy after meal

The Deadly Quartet (high risk ED)
Metabolic Syndrome

Diabetes Obesity Hypertension Dyslipidemia

Sydney Men’s Health
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.
 Hypoactive Sexual Desire Case
Formulation
Hormones:
Testosterone / Estrogen
History of
sexual activity

Hormone Supplements
Cognitive
Aschematic
Restructuring
Sexual Self View

Protective:
Partner
Factors Few positive romantic relationships /
sexual encounters

Low Desire
20 30 40 50 60
YO YO YO YO YO
Sexual Aversion Definition
 Aversion to and active avoidance of genital sexual
contact with a sex partner.
 Must cause marked distress or interpersonal
difficulty.
Sexual Aversion Causes
 Sexual trauma
 incest, sexual abuse, or rape
 Repressive family atmosphere
 Rigid religious training
 Pain during first attempts at intercourse
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.
 Sexual Aversion Disorder Case
Formulation
Negative Sexual Traumatic Event
Self-Schema (e.g. rape)

Cognitive Restructuring

Sexual Anxiety / Relaxation Training

Fear Response

Low arousal / Avoidance

sexual satisfaction

Exposure
Arousal Disorders
 Erectile Dysfunction
 Erectile Dyspareunia
 Fisiologi Ereksi
1. Fase O : fase flaccid
2. Fase 1 : fase pengisian
3. Fase 2 : fase tumensensi
4. Fase 3 : fase ereksi penuh
5. Fase 4 : fase ereksi rigid
6. Fase 5 : fase detumesen awal
7. Fase 6 : fase detumesen lambat
8. Fase 7 : fase detumesen cepat

Flaccid Erect
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.
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
 Male Erectile Disorder (ED)
35
Erectile Dysfunction Causes
 Depression  Fear
 Job loss  Rejection
 Diabetes or other disorders  Not able to satisfy wife
impacting circulation  Being compared to other men
 Losing erection
 Hypertension
 Inability to ejaculate
 Medications
 Ridicule
 Obesity
 Poor physical fitness
 Smoking and tobacco
products  Autosexuality
 Alcohol  Passive wife
 Age  Sagging vagina
 Rigid training  Nagging
 Guilt  Feminine dominance
 Unreasonable expectations  Unfavorable weather
 Burnt toast
 Drugs Associated with ED
37

 Alcohol  ß-blockers
 Estrogens  Psychotropics
 Antiandrogens  Cigarettes
 H2 receptor blockers  Cocaine
 Anticholinergics  Spironolactone
 Ketoconazole  Lipid-lowering agents
 Antidepressants  NSAIDs
 Marijuana  Cytotoxic drugs
 Antihypertensives  Diuretics
 Narcotics
Erectile Dysfunction
May Disguise

 Paraphilic problem
 Homosexual orientation
 Gender identity disorder
 Lack of desire towards partner
 Immorality
 Adultery

 Pornography
Prevalence of medical diseases in men
with a diagnosis of ED
 Hypertension 41.6%
 Hyperlipidaemia 42.4%
 Diabetes mellitus 20.2%
 Depression 11.1%
 Hypertension & lipids 29.3%
 Hypertension & diabetes 12.8%
 Hperlipidaemia & depession 11.5%

Seftel, Sun, Swindle. J Urol 2003;171:2341-5

Sydney Men’s Health

Arterial blockage compromises penis first

 Penile artery 1-2mm

 Coronary artery 3-4mm

 Internal carotid artery 5-7mm

 Femoral artery 6-8mm

Sydney Men’s Health

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
 Male Erectile Disorder (ED)
43

 Sildenafil: Mechanism of Action

 Nitric oxide acts through a second messenger, cGMP, in the normal
development of erections
 cGMP relaxes corpus cavernosal smooth muscle cells, promoting blood
flow into cavernosal spaces
 cGMP broken down by PDE - the predominant enzyme of this type in the
corpus cavemosum is PDE type V
 Sildenafil is a selective and potent inhibitor of PDE type V
 Vacuum Pumps and
44
Constrictive Devices
 Male Erectile Disorder (ED)
45

 Penile Implants
 Two types: semirigid and multicomponent inflatable
 Patient satisfaction: 81% to 97%
 Average functional life: 7 to 10 years
 Inflatable Penile Implant
46
 Malleable Penile Implant
47
 Erectile Dysfunction Case Formulation
Organic Factors /
Medication Side Effects Protective Factors: Low
Positive emotions, Sexual
Medical love Experience
Treatments
Non-demand
Pleasuring
Anxiety
Dysfunctional
Attentional
Processes
Inhibited Parasympathetic Activity
Sensate
Focus Psychoeducation

Low Arousal Negative Expectations

Viagra (Sildenafil)
Viagra Side Effects
 Headache
 Flushing
 Dyspepsia
 Consult a doctor if on Nitroglycerine for possible
cardiac effects
Erectile Dyspareunia
 Peyronie’s 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
Ejaculatory Disorders
 Premature Ejaculation
 Retarded Ejaculation
 Ejaculatory Incompetence
 Retrograde Ejaculation
 Ejaculatory Dyspareunia
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 this…it 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.
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.
Premature Ejaculation Causes
 Anxiety
 Performance pressure
 Novelty of experience or partner
 Interpersonal difficulties
 Conditioned to be quick
 Possible biological differences in men
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
Premature Ejaculation Case Formulation
Low History: Rewarding Speedy
Sexual High Arousal
Circumstances
Experiences Sensitivity

learned response

Premature Ejaculation
Pause – squeeze
Technique

Often Anxiety
disappears
with age /
experience
Avoidance
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.
 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
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
Retarded Ejaculation Treatments

 Increase pressure to perform (could be too relaxed)

 Coutnerbypassing
 Control sexual content
 Woman verbalizes her worries about her partner’s
impatience, which are validated
 Focus attention on self
Retarded Ejaculation Case Formulation
Desire / Arousal Negative Affect / Low relationship
Medical Condition
Deficits Self-schema satisfaction

Cognitive
Restructuring

Sensate No Orgasm
Focus

Negative Expectations

Relaxation
Anxiety
Ejaculatory Incompetence Definition

 Consistent inability to reach orgasm no matter the

duration or type of stimulation.
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.
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.
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).
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)
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.
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
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.