Male Sexual Dysfunction

1. Male Sexual Dysfunction

2. Computer Sex

3. More Computer Sex

4. Male Sexual Response Cycle • Arousal • Plateau • Orgasm • Resolution • Refractory Period

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. Diagnostic Questions • Onset • Primary • Secondary • Context • Global • Situational • Contributing Factors • Physiological • Mechanical • Psychological

12. Erectile Dysfunction Premature Ejaculation Retarded Ejaculation The penis may be the most honest parts of the male anatomy. The Big Three in MSD

13. Phases in Disorder • Desire • Arousal • Orgasm

14. Desire Disorders • Hyperactive Sexual Desire • Hypoactive Sexual Desire • Sexual Aversion

15. 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

16. 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.

17. 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 Hypoactive Sexual Desire Causes

18. 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.

19. Hypoactive Sexual Desire Case Formulation Hormones: Testosterone / Estrogen History of sexual activity HormoneSupplements Aschematic Sexual Self View Cognitive Restructuring Protective: Partner Factors Few positive romantic relationships / sexual encounters Low Desire

20. 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.

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

22. 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.

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

24. Arousal Disorders • Erectile Dysfunction • Erectile Dyspareunia

25. 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.

26. 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

27. 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 Erectile Dysfunction Causes

28. Erectile DysfunctionMay Disguise • Paraphilic problem • Homosexual orientation • Gender identity disorder • Lack of desire towards partner • Immorality • Adultery • Pornography

29. 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

30. 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 Center for Marital and Sexual Health (CMASH)

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

32. Viagra (Sildenafil)

33. Viagra Side Effects • Headache • Flushing • Dyspepsia • Consult a doctor if on Nitroglycerine for possible cardiac effects

34. 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

35. 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

36. 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

37. Ejaculatory Disorders • Premature Ejaculation • Retarded Ejaculation • Ejaculatory Incompetence • Retrograde Ejaculation • Ejaculatory Dyspareunia

38. 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.

39. 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.

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

41. 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

42. 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

43. 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.

44. 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

45. 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

46. 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

47. 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

48. Ejaculatory Incompetence Definition • Consistent inability to reach orgasm no matter the duration or type of stimulation.

49. 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.

50. 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.