Problem 4
Part 1a Learning Goals
- What are sexual dysfunctions in men?
o prevalence, risk factors, treatments, effects etc. (DSM 5)
DSM - 5
Sexual dysfunctions overall:
- characterized by a clinically significant disturbance in a person’s ability to respond
sexually or to experience sexual pleasure
- a person may have several dysfunctions at the same time
- it should be determined whether the difficulties are a result of inadequate sexual
stimulation in that case a diagnosis would not be make
- subtypes:
o lifelong: has been present from first sexual experiences
o acquires: develops after a period of relatively normal sexual function
o generalized: not limited to certain types of stimulation, situations or partners
o situational: only occur in certain types of stimulation, situations or partners
- factors that should be considered for all disorders:
o partner factors (partner’s sexual problems, partner’s health)
o relationships factors (poor communication, discrepancies in desire)
o individual variability factors (poor body image, history of sexual or emotional
abuse), psychiatric comorbidity (depression, anxiety) or stressors (job loss,
death)
o cultural or religious factors (attitudes or prohibitions towards sexuality)
o medical factors relevant to prognosis, course or treatment
- sexual function involves a complex interaction among biological, sociocultural and
psychological factors
- diagnosis requires ruling out problems that are better explained by a nonsexual
mental disorder, by the effects of substance, by a medical condition or by severe
relationship distress, partner violence or other stressors
DELAYED EJACULATION
Criteria:
- one of these 2 symptoms must be experienced 75-100% of the occasions of
partnered sexual activity
o 1. marked delay in ejaculation
o 2. marked infrequency or absence of ejaculation
- must be persistent for minimum 6 months
- clinically significant distress in individual
- specify whether lifelong or acquired, and whether generalized or situational
- specify mild distress, moderate distress or severe distress
Diagnostic features/supporting:
- definition of delay doesn’t have precise boundaries bc there’s no consensus on
what’s a reasonable time
, - prolonged thrusting to achieve orgasm to the point of exhaustion or genital
discomfort
- some men report avoiding sexual activity
- some partners may report feeing less sexually attractive bc their partner can’t
ejaculate easily
Prevalence:
- unclear bc of lack of precise definition
- least common male sexual complaint
- less than 1% complain about this
Development and course:
- lifelong delayed ejaculation begins early in life
- there’s minimal evidence of acquired delayed ejaculation
- prevalence is constant until age 50, then the incident begins to increase significantly
- men in their 80s report it twice as much
Risk and prognostic factors:
- age related loss of fast-conducting peripheral sensory nerves and age-related
decreased sex steroid secretion may be associated in men older than 50 years
Culture related:
- more common among men in Asian populations than in men living in Europe,
Australia and the U.S
Differential diagnosis:
- another medical condition (interruption of the nerve supply to genitals from
traumatic surgery etc.)
- substance/medication use (antidepressants, antipsychotics)
- dysfunctional with orgasm (ejaculation is in the genitals but orgasm is psychological,
important to distinguish the two)
Comorbidity
- may be more common in severe forms of MDD
ERECTILE DISORDER
Criteria:
- at least one of these 3 symptoms must be experienced 75-100% of occasions
o 1. marked difficulty in obtaining an erection during sexual activity
o 2. marked difficulty in maintaining an erection until the completion of sexual
activity
o 3. marked decrease in erectile rigidity
- symptoms must be present for a minimum of 6 months
- significant distress to the individual
- specify whether lifelong or acquired, and whether generalized or situational
- specify mild distress, moderate distress or severe distress
- coded as Failure of Genital Response in the ICD-10
, Diagnostic features/supporting
- repeated failure to obtain or maintain erection
- may have low self-esteem, self-confidence, a decreased sense of masculinity, and
depressed affect
Prevalence:
- unknown
- age-related increase in prevalence and incidence of problems with erection
- 13-21% of men between 40-80 complain of occasional problems
- 2% of men younger than 40 complain of occasional problems
- 40-50% of men older than 60-70 have significant problems with erections
- 20% of men fear erectile problem on their first sexual experience
- 8% experience erectile problems during their first sexual experience
Development and course:
- erectile failure on first sexual attempt is related to: sex with unknown partner, use of
drugs or alcohol, not wanting to have sex, peer pressure
o some men continue have episodic problems after
- acquired erectile disorder is associated with biological factors like diabetes and
cardiovascular disease
- lifelong erectile disorder is associated with psychological factors but natural history is
unknown
- some men with moderate failure may experience spontaneous remission without
medical intervention
- distress associated erectile disorder is lower in older men compared to younger men
Risk and prognostic factors:
- neurotic personality traits may be associated in college students
- submissive personality traits may be associated in men older than 40
- Alexithymia (deficits in cognitive processing of emotions) is common in psychogenic
erectile disorder
- common in men with depression and PTSD
- risk factors for acquired: age, smoking tobacco, lack of psychical exercise, diabetes,
decreased desire
Diagnostic markers:
- checking penile tumescence in sleep to determine whether the problem is
psychological
- to assess vascular integrity: ultrasonography, intravascular injection of vasoactive
drugs, dynamic infusion cavernosography
- pudendal nerve conduction
- serum bioavailable or free testosterone levels
- thyroid function
Functional consequences:
- may interfere with fertility and developing intimate relationships
Part 1a Learning Goals
- What are sexual dysfunctions in men?
o prevalence, risk factors, treatments, effects etc. (DSM 5)
DSM - 5
Sexual dysfunctions overall:
- characterized by a clinically significant disturbance in a person’s ability to respond
sexually or to experience sexual pleasure
- a person may have several dysfunctions at the same time
- it should be determined whether the difficulties are a result of inadequate sexual
stimulation in that case a diagnosis would not be make
- subtypes:
o lifelong: has been present from first sexual experiences
o acquires: develops after a period of relatively normal sexual function
o generalized: not limited to certain types of stimulation, situations or partners
o situational: only occur in certain types of stimulation, situations or partners
- factors that should be considered for all disorders:
o partner factors (partner’s sexual problems, partner’s health)
o relationships factors (poor communication, discrepancies in desire)
o individual variability factors (poor body image, history of sexual or emotional
abuse), psychiatric comorbidity (depression, anxiety) or stressors (job loss,
death)
o cultural or religious factors (attitudes or prohibitions towards sexuality)
o medical factors relevant to prognosis, course or treatment
- sexual function involves a complex interaction among biological, sociocultural and
psychological factors
- diagnosis requires ruling out problems that are better explained by a nonsexual
mental disorder, by the effects of substance, by a medical condition or by severe
relationship distress, partner violence or other stressors
DELAYED EJACULATION
Criteria:
- one of these 2 symptoms must be experienced 75-100% of the occasions of
partnered sexual activity
o 1. marked delay in ejaculation
o 2. marked infrequency or absence of ejaculation
- must be persistent for minimum 6 months
- clinically significant distress in individual
- specify whether lifelong or acquired, and whether generalized or situational
- specify mild distress, moderate distress or severe distress
Diagnostic features/supporting:
- definition of delay doesn’t have precise boundaries bc there’s no consensus on
what’s a reasonable time
, - prolonged thrusting to achieve orgasm to the point of exhaustion or genital
discomfort
- some men report avoiding sexual activity
- some partners may report feeing less sexually attractive bc their partner can’t
ejaculate easily
Prevalence:
- unclear bc of lack of precise definition
- least common male sexual complaint
- less than 1% complain about this
Development and course:
- lifelong delayed ejaculation begins early in life
- there’s minimal evidence of acquired delayed ejaculation
- prevalence is constant until age 50, then the incident begins to increase significantly
- men in their 80s report it twice as much
Risk and prognostic factors:
- age related loss of fast-conducting peripheral sensory nerves and age-related
decreased sex steroid secretion may be associated in men older than 50 years
Culture related:
- more common among men in Asian populations than in men living in Europe,
Australia and the U.S
Differential diagnosis:
- another medical condition (interruption of the nerve supply to genitals from
traumatic surgery etc.)
- substance/medication use (antidepressants, antipsychotics)
- dysfunctional with orgasm (ejaculation is in the genitals but orgasm is psychological,
important to distinguish the two)
Comorbidity
- may be more common in severe forms of MDD
ERECTILE DISORDER
Criteria:
- at least one of these 3 symptoms must be experienced 75-100% of occasions
o 1. marked difficulty in obtaining an erection during sexual activity
o 2. marked difficulty in maintaining an erection until the completion of sexual
activity
o 3. marked decrease in erectile rigidity
- symptoms must be present for a minimum of 6 months
- significant distress to the individual
- specify whether lifelong or acquired, and whether generalized or situational
- specify mild distress, moderate distress or severe distress
- coded as Failure of Genital Response in the ICD-10
, Diagnostic features/supporting
- repeated failure to obtain or maintain erection
- may have low self-esteem, self-confidence, a decreased sense of masculinity, and
depressed affect
Prevalence:
- unknown
- age-related increase in prevalence and incidence of problems with erection
- 13-21% of men between 40-80 complain of occasional problems
- 2% of men younger than 40 complain of occasional problems
- 40-50% of men older than 60-70 have significant problems with erections
- 20% of men fear erectile problem on their first sexual experience
- 8% experience erectile problems during their first sexual experience
Development and course:
- erectile failure on first sexual attempt is related to: sex with unknown partner, use of
drugs or alcohol, not wanting to have sex, peer pressure
o some men continue have episodic problems after
- acquired erectile disorder is associated with biological factors like diabetes and
cardiovascular disease
- lifelong erectile disorder is associated with psychological factors but natural history is
unknown
- some men with moderate failure may experience spontaneous remission without
medical intervention
- distress associated erectile disorder is lower in older men compared to younger men
Risk and prognostic factors:
- neurotic personality traits may be associated in college students
- submissive personality traits may be associated in men older than 40
- Alexithymia (deficits in cognitive processing of emotions) is common in psychogenic
erectile disorder
- common in men with depression and PTSD
- risk factors for acquired: age, smoking tobacco, lack of psychical exercise, diabetes,
decreased desire
Diagnostic markers:
- checking penile tumescence in sleep to determine whether the problem is
psychological
- to assess vascular integrity: ultrasonography, intravascular injection of vasoactive
drugs, dynamic infusion cavernosography
- pudendal nerve conduction
- serum bioavailable or free testosterone levels
- thyroid function
Functional consequences:
- may interfere with fertility and developing intimate relationships
