Male and female sexual dysfunction:Informative article

Impotence is a vague term applied for simple inability of man to penetrate the vagina.It is derived from a latin term impotentia coeundi.

We use the terms Sexual dysfunction. In male it can be erectile dysfunction, ejaculatory dysfunction (premature ejaculation or anejaculation-no ejaculation), and decreased libido (sexual desire). Erectile dysfunction (ED) is the commonest form and it is the inability to achieve and maintain an erection adequate for intercourse to the mutual satisfaction of the man and his partner. The premature ejaculation is ejaculation with minimal stimulation before, on or shortly after penetration and before the person wishes it, over which the sufferer has little or no voluntary control which causes the sufferer and / or his partner bother or distress

Female sexual dysfunction can be in the form of decreased desire (frigidity), difficult arousal or orgasm or painful intercourse.

So any sexual distress in male or female partner; there is a need to approach a sexologist/andrologist to improve sexual life.The erectile dysfunction can result in marital discord and dishormony and overall affect the quality of the life of the couple.

Erectile dysfunction is quite common in India.  It said to affect as much as 10 percent of the male population. Above the age of 40, nearly 52 % of men are affected with this sexual disorder.

In males as the age advances the erectile dysfunction becomes more and more. At age 40, approximately 40% of men are affected. The rate increases to nearly 70% in men aged 70 years. But with the advent of industrial/IT/BPO evolution the life style of the youth has changed drastically. Increased stress, smoking, drug abuse has started taking a toll of sexual life of the younger generation also. This is evident with the rise of unconsummated marriages .This is prevalent among 5 to 10 per cent of the marriage population in India.

In females, recently married woman present commonly with vaginismus.This is pain while insertion of the penis. The vaginal muscles contract because of anxiety /fear leading to severe pain.

While the perimenopausal/post menopausal women typically present with hypoactive sexual desire/difficulty in achieving orgasm because of hormonal changes. So there is a dichotomy in age groups of females presenting to sexology clinic.

Erectile dysfunction is a sensitive topic, and the clinician must be aware of the patient’s comfort level. Taking the history provides an opportunity for the physician to initiate patient and partner education about erectile dysfunction and its treatments and to facilitate communication. It also allows the physician to establish a rapport with the couple, which assists in treatment. A clear description of the problem entails determining if the patient has difficulty obtaining an erection, if the erection is suitable for penetration, if the erection can be maintained until the partner has achieved orgasm, if ejaculation occurs, and if both partners have sexual satisfaction. Taking the sexual history also allows the clinician to begin forming an objective opinion regarding the interpersonal relationship between the patient and his sexual partner. Many a times the patient and the partner feel shy to describe the problems so the onus is on the doctor to make them comfortable and extract the information regarding sexual dysfunction. We have seen mans ego coming in the way to admit the problem in depth as the matter is related to masculinity.

Misconception regarding masturbation is very high in Indian society. There is a feeling of guilt and people present with vague psychosomatic symptoms of fatigue, weakness, anxiety, loss of appetite, guilt and sexual dysfunction, attributed by the patient to loss of semen in nocturnal emission, through urine or masturbation. The doctor needs to ask leading questions regarding masturbation and try to dispel these myths. As the patient may not talk about it to the doctor because of shyness.

Previous sexual encounters, sexual abuse, guilt of previous exposure can lead to sexual dysfunction so these things should be asked taking the patient into confidence. The patient should be assured utmost confidentiality.

Erectile dysfunction in 85% of cases can be attributed to atherosclerotic vascular disease & diabetes.Erection is a basically blood flow phenomenon. The erectile problem is attributed to the decreased flow in penile arteries. There is a general observation that Indian men are at a higher risk of coronary heart disease and metabolic syndrome (occurrence of obesity, diabetes, high uric acid, heart disease together) than men in most other parts of the world. Erectile problem usually indicates the impending or existing problem of heart disease. So it is important to maintain the same lifestyle habits as those who face an increased risk for heart disease.

Health diet, good sleep, distressing (by exercise/yoga, pranayam), controlling comorbdid conditions (control of diabetes, bad cholesterol), reducing medciations, cessation of smoking and alcohol can go a long way in alleviating erectile dysfunction. It is necessary to seek attention of andrologist not only for improving the sexual life but also to get treated underlying serious condition which may be discovered during evaluation for erectile dysfunction. Life style modification plays a very important role in sexual dysfunction.

Good counseling with both the partners is very essential. Still a lot of newly married couples are not well versed with each other’s anatomy and need to be educated about sexuality. We have seen many women having painful vaginal contractions (vaginismus) leading to unconsummated marriages. Fear /anxiety of pain can lead to vaginal spasm and the woman can altogether develop phobia for sex.Proper counseling and vaginal dilatation can help the couple leading a normal sexual life.

Life style modification- regular exercise,distressing,quitting of smoking can lead to increased level of testosterone(male sexual hormone) and increased blood circulation leading to better erections.

Treating comorbid conditions like diabetes, Decreased testosterone hormone (age related-So called Andropause a term synonymous to menopause), anxiety and depression, deranged cholesterol levels also can treat the underlying etiology behind erectile dysfunction.

Any drug that improves the blood circulation to the male organ (sildenafil- Viagra,tadalafil) can be started. It can be taken either regularly to improve overall blood circulation or as and when   needed before the sexual activity. There are creams which when applied externally can improve penile blood flow can also be used. There is general misconception that the Viagra like medications can lead to heart attacks. Most of the patients – even those with heart disease qualify for taking Viagra like drugs but it is essential that a proper andrologist/qualified doctor assesses the patient before.

Those who cannot take Viagra (because of heart conditions) need not get disappointed. There are other methods of inducing erection.

Vacuum erection device- Specially designed vacuum devices to produce erections have been used successfully for many years. They are safe and relatively inexpensive. They work by using a manually generated vacuum to draw blood into the penis to create the erection.It can be used before every sexual activity. The erection stays for half an hour or so. It is a bulky instrument and needs to be used before very copulatory act so not preferred by young individuals. It suitable for elderly couples who perform the sexual activity infrequently.

Penile Injections: The patient can be taught to take injection of vasodilator drugs (drugs improving blood circulation).It is simple and effective. But many people disapprove self injection. The pain is also a factor for high drop out from this therapy (around 30-70% people discontinue it on continuous usage).

Penile implant: In the past, the placement of prosthetic devices within the penis was the only effective therapy for men with impotence. Now, with the advent of good medications this is considered as the last resort. Nevertheless, this remains a reliable form of therapy in cases where all other options are exhausted. Nearly 100% of the men with implants express satisfaction. There is no need to take Viagra or use pump or self injection. It is suitable for young people who are motivated and want to lead a very sexually active life. There are grossly two types of implants- malleable: this is simple surgery where two rods are implanted in penis.This is a cost effective option but the penis always remains in erected position. So there is difficulty in concealing erection especially in loose clothes.

The other type of implant is inflatable prosthesis. This is a costly implant but gives almost natural erection and flaccidity (unlike the malleable one).

Female sexual dysfunction:

Female sexual dysfunction (FSD) can be in the form of decreased desire (frigidity), difficult arousal or orgasm or painful intercourse. In India there are very few systematic sex surveys on female sexual dysfunction (FSD) so proper information about FSD is not available. FSD is highly prevalent to the extent of around 2/3 rd of married woman suffering from it.

Average Indian woman has a tendency to neglect the body predisposition after marriage. Multiple child births most often by Dayas (synonym: midwifery in rural Indian set up) in a rural set up, sedentary life style, lack of  exercise leads to problems like putting on weight and loose vagina.The lack of self esteem and culture of silence further aggravates the sexual dysfunction in them. Frigidity is common and many a times they just indulge in coital act for fear of verbal/physical abuse upon refusing it. There is cultural inhibition to approach the doctor and also there is definitely a scarcity of female sexologists in India.

We treat the FSD patients with a dedicated female sexologist (In India the socio-cultural circumstances make it necessary for woman to do the job of female sexology) to boost the confidence of the female patient:

1) Educating the woman about her anatomy

2) Enhancing the stimulation (either with erotic materials or masturbation)

3) Distraction technique-with fantasies, Kegels exercise during coitus (for those who face problem with arousal)

4) Encouraging non coital behavior- stimulation of sensate focus

5) Treatment of vaginismus (painful intercourse) and pain-dilatation therapy/lots of lubricants

6) Treating underlying anxiety/depression

7) Life style modifications –exercise, aerobic activities for improvement of body image

8) Estrogen creams/HRT to improve local vascularity (to dispel off the pain due to dryness of vaginal mucosa)

It has been observed that female sexual response is akin to males in a way there is increased blood flow by dorsal clitoral and cavernosal clitoral arteries. It leads to tumescence of clitoris triggering the female orgasm. As physical stimulation of tumescent clitoris leads to pelvic floor muscle contraction. So there is renewed interest in use of Viagra in low doses to improve vaginal blood flow and local vasodilator creams like L-arginine creams in females with sexual dysfunction.