Summary

Sexual problems have been and are still taboos in society, and many people with sexual dysfunctions have difficulties informing their doctors clearly. Doctors, on the other hand, are often not well trained to handle such dysfunctions even when informed. Broadly speaking, male and female sexual dysfunction are classified according to the stages of a sexual cycle, namely sexual desire, excitement, orgasm and resolution; but specific sexual problems of either gender do occur. Currently, there are quite a variety of treatment modules, and doctors in the primary care setting should be capable of using them, in combination with individual or couple therapy.

摘要

無論過去還是現在，性問題一直是社會禁忌。一方面，許多性功能障礙的病人不知如何清楚地將病情告訴醫生，另一方面，許多醫生也缺乏相關的訓練。一般來說，男、女性功能障礙是按照性週期的各個階段，即性慾望期、興奮期、高潮期和消退期，來分類的。此外還有一些特殊的性問題。目前有各種各樣的治療模式，基層醫生也應該能夠運用這些治療模式，以配合個人或配偶之輔導。

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Introduction

Up till 1970s, sexual problems were mainly psychoanalysed by psychiatrists. Since the publication of the book "Human Sexual Inadequacy",¹ there has been a radical change in the approach to sexual dysfunction to more behavioural type. In the beginning, emphasis was put on erectile, ejaculatory and orgasmic difficulties, but Kaplan² added difficulties in the area of desire in his book "The New Sex therapy".

Persons with sexual dysfunctions are often reluctant to seek help, though they often approach their family physicians for help in non-sexual complaints. Quite often the presenting symptoms are gynaecological for women or urological for men. Unfortunately, busy doctors often do not sense the underlying problem, and sometimes are not well trained to collect such information, thus missing the diagnosis altogether. Therefore, some basic understanding of the current issues of sexual dysfunction is important for primary care family physicians, especially if they are the sole family doctor.

Incidence

Sexual dysfunction is quite common, but not obvious. Up to 50% of married couples, even happily married ones, have some form of sexual dysfunction at one time or another, depending on the criteria.¹ Generally speaking, erectile impotence is most common among men, especially with increasing age (1.3% <35 years old; 6.7% <50; 18.4% <60). Among women seeking help, lack of sexual interest and enjoyment is the most common complaint. In about 30% of cases the sexual partner also suffers from one or more sexual dysfunctions.

Aetiology

Generally speaking, three types of problems are encountered in sexual therapy (Golden JS, 1982), each with its own aetiological issue.

1. Healthy, "normal" patients with unrealistic expectations, such as a demand for multiple orgasm. Usually, therapeutic success is achieved within a short period.
2. Physical illnesses/disabilities or treatments interfering directly with the nervous system or neuro- transmission that control sexual functions. Examples are the use of psychotropic drugs, diabetes mellitus, post-operative genital cancers, etc. (Table 1)
3. Patients with psychological concerns about physical illnesses, without directly interfering with sexual functioning. These persons have no real sexual dysfunctions, but are worried about their sexual abilities after a major disease such as myocardial infarction or post-mutilating surgery such as total mastectomy.

From the above description, it is obvious that the primary care doctor has to rule out organic causes of sexual dysfunction, especially treatable ones. There are fortunately some hints that help to differentiate organic cause from psychogenic cause. If the dysfunction is only occasional or fluctuating with time, is selective in time, place or person, is acutely linked to some clear cut psychological trauma, then it is more likely to be functional than organic. On the other hand, organic causes should be suspected if there is an obvious physical disease or drug usage. An alerting sign is a loss of male morning erection (or more specifically a loss of nocturnal penile tumescence during REM sleep). For women, there can be a similar loss of nocturnal vaginal lubrication.

Obviously, even with a primary organic causation of sexual dysfunction, this is often accompanied by some psychological reaction that can further aggravate the dysfunction. Last but not the least, when there is an interracial or intercultural couple coming for help, a wider scope of socio-cultural and religious perspective has to be applied.

Classification

There are different ways to classify sexual dysfunctions. The trend is to follow the DSM-IV-TR system⁵ that is related broadly to the sexual response cycle. Grossly speaking, the cycle comprises four phases: the desire (fantasies and desire about sex activity), arousal (pleasure and physiological response), orgasmic (release of sexual tension and rhythmic bodily response) and resolution (general relaxation and well-being). There are some specific disorders in the first three phases for the male and the female (Table 2).

It should be noted that sexual dysfunction can be "primary" (meaning lifelong or never "normal" before) or "secondary" (meaning "acquired" with experience of normal function before). Sometimes, the dysfunction is said to be "selective" if it occurs only under certain circumstances (such as at home, or with the wife only). In order to qualify for a disorder, the person concerned should suffer from marked distress or interpersonal difficulty, and that the dysfunction is not due exclusively to the direct effects of a substance or a general medical condition. According to the DSM-IV, the definitions for the various dysfunctions are now described below:

1. Hypoactive sexual desire disorder - persistently or recurrently deficient or absent in sexual fantasies or desire for sexual activity.
2. Sexual aversion disorder - persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner. This applies mostly to the female sex.
3. Male erectile disorder - persistent or recurrent inability to attain an adequate erection or to maintain until completion of the sexual activity.
4. Female sexual arousal disorder - persistent or recurrent inability to attain an adequate lubrication-swelling response of sexual excitement or to maintain until completion of the sexual activity.
5. Male or female orgasmic disorder (also called inhibited male/female orgasm or retarded ejaculation of the male) - persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity.
6. Premature ejaculation - persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.
7. Inhibited female orgasm - persistent inhibition of orgasm regardless of stimulation.
8. Dyspareunia - recurrent or persistent genital pain associated with sexual intercourse, in either a male or a female.
9. Vaginismus - recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse.

In theory, there is a possibility of a "hyperactive sexual desire disorder" when the patient has persistent or recurrent excessive sexual fantasies or desire for sexual activity. This is sometimes called promiscuity or sexual addiction or nymphomania, but is not included in the DSM-IV classification.

Management

The assessment of sexual dysfunction must include a detailed sexual history of both sexual partners. Frequently, the couple is shy about disclosing their sexual history, and at times can give misleading answers. On the other hand, some doctors are also anxious asking about intimate matters, and this can be anti-therapeutic. Not only should details of the sexual complaint be explored, but also the circumstances and the psychosocial consequences of the dysfunction. In particular, existing marital or interpersonal issues may have to be covered. Mental state examination is also important to exclude other psychiatric disorders, and to explore the guilt, shame, anger and other emotional elements associated with the sexual problem. Relevant physical examination and appropriate laboratory investigations are useful to rule out physical and genital diseases, besides observation of the primary and secondary sexual characteristics. A few perianal reflexes can be performed to check the lumbrosacral nervous system (Table 3). Last but not the least, appropriate additional laboratory tests such as urine analysis, hormonal assessment (especially prolactin, testosterone hormonal level) should be performed when indicated clinically. Though situational or selective dysfunctions often indicate a psychological cause, distinction between psychological and organic causes may not be easy despite physiological tests and investigations.

There are a number of tests to assess the physiology of sexual dysfunctions. The most common one is the use of nocturnal penile monitoring (penile tumescence studies, cavernosograms, penile-brachial blood pressure) with or without visual sexual stimulation. There is also one simple screening test for erectile dysfunction, the "stamp test", which uses a ring of postage stamps with perforations, placed around the base of flaccid penis before sleep. If the ring is not broken for 4-5 consecutive nights, organic cause of erectile dysfunction is suspected.

Finally, to help the doctor analyse the various aspects of sexual dysfunction, there are a number of psychometric measures that can be administered to the couple, including:

1. Derogatis Sexual Functioning Inventory⁶ - this measures ten areas of functioning from over 200 items questionnaire.
2. Maudsley Sexual Adjustment Questionnaire⁷ - this measures various sexual dysfunctions, in addition to communication and frequency of sex.
3. Prepare and Enrich⁸ - this measures various aspects of couple functioning from an over 100 items questionnaire.
4. Sexual Geneogram⁹ - this measures information on marriage, divorce, death and birth of the marital partners and family members, with special focus on sexuality and intimacy.
5. Sexual Interaction Inventory¹⁰ - this measures information on frequency, pleasure and perception of sex.

Treatment

For the primary care doctor, there is a responsibility of ruling out common organic causes, especially if there is any suspicious finding as mentioned above. Any correctable primary cause, be it physical disease or psychiatric disorder (including drug-induced sexual dysfunction), should be treated. General measures such as sexual education and re-education, alteration of attitudes (myths, taboos, etc.) are often necessary. Some conscious or subconscious behaviour of sabotage should be explored, including repelling smell of alcohol, garlic, nicotine or even perfumes, the resentment in wearing certain costumes or to make love in the nude, etc. The importance of romantic foreplay (including sex talks) must not be forgotten, and role-playing can help desensitize any embarrassment.¹¹ Relaxation techniques are useful to relieve any obvious anxiety and to encourage a feeling of control. Co-morbid psychiatric disorders have to be treated at the same time. As sexual intercourse always includes two persons, communication improvement and relational enrichment, including perhaps interpersonal psychotherapy and social skill training, are often valuable adjunctive therapies. Finally, there are some specific therapies for the various dysfunctions, including the following:

A.		Psychotherapy
1.		Behavioural therapy: Masters & Johnson1 requested the couple to stay in a hotel for two weeks, and to attend to the therapist daily with discussion about their "homework exercises". Such approach is not practical because of its costs, but the approach of graded tasks with homework assignments, recording and discussion is still maintained by many sex therapists. The homework exercises consist mainly of "sensate focus" which is a concentration on foreplay and body touch, with an initial ban on touching erogenous zones or actual intercourse. Afterwards, the couple then advances (graded) into gradual genital contact and final penetration. Sexual positions are also advised, and the female superior position appears better for the dysfunctional male, allowing him to relax and penetrate smoothly without undue manoeuvres of the body while the female partner has more room or freedom for movement. In addition, the Kegel exercise, in which the patient contract and relax the pelvic muscles, is often taught, and is found particularly useful for those erectile disorder due to venous leakage.
2.		Psychodynamic and sometimes psychoanalytic psychotherapy are useful when there is resistance, usually due to unconscious conflicts, even on an individual basis. This individual psychotherapy is particularly useful if one party has features of a sexual post-traumatic stress disorder.13
3.		Specific treatment
		i.		Low sex drive - the sexual brain is the most important organ and sexual fantasy is often the fuel for sex drive. Guided imagery, with or without the help of erotic audio-visual material, is sometimes used to increase sex drive, and foreplay is encouraged, with discouragement of any unreasonable sexual inhibitions or taboos. Sometimes the low sex drive is relative only to the other sex partner, and the readjustment or "balance" of the "dominant/demanding versus submission/reluctant" interactions can improve the situation.
		ii.		Anorgasmia - Hite14 pointed out that only 30% achieved "no hands orgasm" during sexual intercourse. Thus, manual stimulation of the penis or the clitoris (by self or by partner) and aided by sexual fantasy, can be taught to enhance sexual pleasure, with or without the help of a vibrator. Gillan11 advocated the method of "exaggerated fear" for female orgasmic problems, so that they become desensitized to such fears in front of the partner.
		iii.		Premature ejaculation - e.g. the "squeeze technique"1 and the "stop-start" technique.15 When approaching the point of "no-return" in ejaculation, by squeezing the penis painfully (but not causing injury) or by stopping all stimulation altogether, and resuming the stimulation when sexual urge wears off. By repeating the same process, a delay in orgasm (of up to 15 minutes) may be achieved.
		iv.		Delayed ejaculation - Masters & Johnson1 prescribed the technique of "superstimulation" in which the penis is being rubbed very vigorously with a lubricated hand. Initially, extravaginal ejaculation is allowed, but gradually vaginal entry is encouraged after stimulation to the point of near ejaculation.
		v.		Erectile dysfunction - the "rubber band technique" is placed over the base of the penis16 but is not always satisfactory. The constriction ring should not be worn for more than 30 minutes because of the danger of ischaemia, and is contraindicated in patients with clotting disorders.
		vi.		Vaginismus - the use of size-graded dilators and lubricated fingers (of herself or that of the male partner) intravaginally is often successful with practice in a relaxing environment.
B.		Drug treatment
		i.		Low sex drives - androgens can induce sex drives, and are indicated in those males with low free androgen index (total testosterone / sex hormone binding protein), after excluding the presence of prostate carcinoma. This androgenic effect can help explain why menopausal women on the hormone Tibolone (Livial) sometimes have increased libido.
		ii.		Premature ejaculation - antidepressants including the tricyclics, but particularly the SSRI are quite successful. The local application of some local anaesthetic to dampen the penile stimulation is still being used by some.
		iii.		High sex drives - phenothiazine has been used to17 decrease sex drive but without significant success, and SSRIs have been tried with success. The anti-androgen drugs (cyproterone acetate and medroxyprogesterone) may be useful, especially for those with sexual crimes, but they pose ethical problems in application.
		iv.		Erectile dysfunctions - currently, the most popular drug therapy is the nitric oxide related phosphodiesterase 5 inhibitor medications such as Sidenafil, Tadalafil or Vardenafil that can induce smooth muscle relaxation and penile erection. Before such medications were available, intracavernosal injection of vasoactive agents was the choice, even for psychological impotence. Self-injection of Alprostadil, (a prostaglandin E1) or Papaverine (an a1 blocker) helps, though this also carries risk of priapism (prolonged painful erection).18 Local application of a cream (containing aminophyline, etc.) or the transdermal nitrate patches to the shaft of the penis may result in local vasodilation of the penile arteries, but the success rate is uncertain. The antidepressant, trazodone, which may also produce priapism in high dosage, has been used before. Oral yomhibine hydrochloride was viewed as an aphrodisiac, but actually an alpha-adrenoreceptor blocker, has been found better than placebo,19 but works only in about 50% of the patients.
C.		Mechanical devices
1.		Sex aids - the high-speed vibrator on the undersurface of the penis may induce superstimulation, and can be useful for low sex drive as well as retarded ejaculation or anorgasmia. Use of lubrications to facilitate entry is of importance for dyspareunia, and the jelly can be applied by the sexual partner.
2.		Vacuum devices by suction through a hand-held or electrical pump - a penile ring is placed over the base of the penis and a cylindrical tube over the shaft. The negative pressure around the penis is able to draw blood into the erectile tissues thereby causing the erection.20 Sex aids (including vibrators) for low sex drive and for delayed orgasm or ejaculation.
3.		For erectile disease of organic cause, penile implants or splints (semi-rigid device and the inflatable prostheses) are used when other methods are not successful. Arterial surgery to improve penile circulation has controversial results, unless there is clear evidence of single blockage of the blood vessel.21
4.		In the past, the use of a surrogate therapist has been tried in the U.S. and the U.K., employing sex workers to engage in genuine sexual activity with the patient. However, the legal, contractual and ethical problems (especially the possibility of contracting HIV) incurred have made this approach obsolete.

Prognosis

It is difficult to expect a complete cure in the treatment of sexual dysfunctions, as relapses are common, especially if there were an in-between period of child-bearing. Watson & Brockman²² found that only 55% of the 29 couples who showed initial improvement maintained their success at follow-up, and outcome of psychotherapies for inhibited sexual desire is also very poor.²³ Premature ejaculation for the man and vaginismus for the woman often carry a much better success rate, but motivation and regular practice remains the most crucial factors.

Conclusion

Sexual dysfunction is often the result of a complicated interaction of biological, psychological and interpersonal difficulties between sexual partners. It can adversely affect marital relationships, and may result in avoidable infertility and extramarital affairs. Though sex therapy can be viewed as a special medical discipline by itself, the primary care doctor is still in a good position to help the couple in the first place. Fortunately, there is now a better understanding of the sexual physiology, and the availability of a wide range of practical and simple-to-apply treatment options.

Key messages

1. Sexual dysfunctions are often complained of by patients, but can present in various ways, many indirect or covert.
2. Doctors are often not well trained to detect, or even ask, about sexual problems.
3. Currently, male and female disorders are mostly treatable by various biological and psychological means.
4. There is often some underlying individual psychopathology and/or interpersonal problems associated with sexual dysfunction, and these should be appropriately tackled.

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References