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Male Sexual Dysfunction


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Title: Male Sexual Dysfunction

Male Sexual Dysfunction
Computer Sex
  • More Computer Sex

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

Stage One - Arousal
  • Vasocongestion contributes to erection of the
  • 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
  • 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

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
  • 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.

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

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

Phases in Disorder
  • Desire
  • Arousal
  • Orgasm

Desire Disorders
  • Hyperactive Sexual Desire
  • Hypoactive Sexual Desire
  • Sexual Aversion

Hyperactive Sexual Desire
  • Deregulation or lack of control over sexual
  • 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
  • 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
  • Cushings Syndrome
  • Hypothyroidism
  • Diabetes
  • Systemic Diseases
  • Chronic Renal Failure
  • Testicular Atrophy
  • Chronic Pain

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
Aschematic Sexual Self View
Cognitive Restructuring
Protective Partner Factors
Few positive romantic relationships / sexual
Low Desire
Sexual Aversion Definition
  • Aversion to and active avoidance of genital
    sexual contact with a sex partner.
  • Must cause marked distress or interpersonal
  • Not better accounted for by an Axis I disorder,
    substances, or a general medical condition.

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
  • 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 Self-Schema
Traumatic Event (e.g. rape)
Cognitive Restructuring
Relaxation Training
Sexual Anxiety / Fear Response
Low arousal / sexual satisfaction
Arousal Disorders
  • Erectile Dysfunction
  • Erectile Dyspareunia

Erectile Dysfunction Definition
  • Inability to attain or to maintain an adequate
    erection until the completion of sexual activity
  • Must cause marked distress or interpersonal
  • Not better accounted for by an Axis I disorder,
    substances, or a general medical condition.

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

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

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
  • Second Line
  • Intraurethral Suppositories
  • Injection Therapy
  • Third Line
  • Penile prosthesis
  • Semi-rigid
  • Inflatable

Center for Marital and Sexual Health (CMASH)
  • 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

Erectile Dysfunction Case Formulation
Organic Factors / Medication Side Effects
Low Sexual Experience
Protective Factors Positive emotions, love
Medical Treatments
Non-demand Pleasuring
Dysfunctional Attentional Processes
Inhibited Parasympathetic Activity
Sensate Focus
Low Arousal
Negative Expectations
Viagra (Sildenafil)
Viagra Side Effects
  • Headache
  • Flushing
  • Dyspepsia
  • Consult a doctor if on Nitroglycerine for
    possible cardiac effects

Viagra Contraindicators
  • A clear reason for recent onset of erectile
  • Severe marital discord
  • Performance anxiety is the cause
  • The client does not like to use medications
  • Althof

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

Erectile Dyspareunia
  • Peyronies 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
  • 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
  • In a study by Kinsey in 1948, 75 of men were
    found to ejaculate within 2 minutes.
  • We have no empirical way to diagnose thisit 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
  • 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 Sexual Experiences
High Arousal Sensitivity
History Rewarding Speedy Circumstances
learned response
Premature Ejaculation
Pause squeeze Technique
Often disappears with age / experience
Retarded Ejaculation Definition
  • Delay in or absence of orgasm following a normal
    sexual excitement phase.
  • Must cause marked distress or interpersonal
  • 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
  • Often the erection is maintained even when not

Retarded Ejaculation Causes
  • Damage to nerves in penis or nerves transmitting
    signals to the brain lessening sensation in the
  • 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
  • Coutnerbypassing
  • Control sexual content
  • Woman verbalizes her worries about her partners
    impatience, which are validated
  • Focus attention on self

Retarded Ejaculation Case Formulation
Negative Affect / Self-schema
Medical Condition
Desire / Arousal Deficits
Low relationship satisfaction
Cognitive Restructuring
No Orgasm
Sensate Focus
Negative Expectations
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

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
  • 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
  • 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

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

  • 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