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Comprehensive Questionnaire for assessment of Dhat syndrome: development and use in patient population. J Sexual Medicine ; Comorbidity in patients with dhat syndrome: a nationwide multicentric study. Phenomenology and beliefs of patients with Dhat syndrome: A Nationwide multicentric study. Int J Soc Psychiatry ; Do female patients with nonpathological vaginal discharge need the same evaluation as for Dhat syndrome in males?.

Indian J Psychiatry ; Do females too suffer from Dhat syndrome: a case series and revisit of the concept? Indian J Psychiatry ; Clinical evaluation and management strategy for sexual dysfunction in men and women. Journal of Sexual Medicine, ; The diagnostic steps in the evaluation of patients with erectile dysfunction. J Urol,; Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation. European Association of Urology Web site. Updated Hawton K. Sex therapy: A Practical guide.

New York, Oxford University Press, Sexual dysfunctions. Oxford University Press, New York, Dapoxetine: in premature ejaculation. Drugs ; A benefit-risk assessment of dapoxetine in the treatment of premature ejaculation. Drug Saf. Vardenafil Levitra for erectile dysfunction: a systematic review and meta-analysis of clinical trial reports. Human Sexual Inadequecy. Churchill, London, Human Sexual Response. McMahon CG. Dapoxetine for premature ejaculation. Expert Opin Pharmacother. Efficacy and safety of phosphodiesterase type 5 inhibitors on primary premature ejaculation in men receiving selective serotonin reuptake inhibitors therapy: a systematic review and meta-analysis.

Rosen C. Prevalence and risk factors of sexual dysfunction in men and women. Curr Psychiatry Rep. The devil is in the details: An analysis of the subtleties between phosphodiesterase inhibitors for erectile dysfunction. Transl Androl Urol. World Health Organization. ICD classification of mental and behavioural disorders: Diagnostic criteria for Research. World health organization, Geneva, Ahead of Print.

Advanced search. Classification o Assessment of pa Management of se Erectile dysfunction. Article Figures. Article Tables. Indian J Psychiatry ;59, Suppl S Available evidence suggests that it is more efficacious than placebo. Recent studies show that sublingual apomorphine has a safe cardiovascular profile and thus making it a new treatment option for patients with concomitant disease including cardiovascular disease and diabetes mellitus.

It also has the advantage of lack of interaction with nitrates and hence has been suggested as an alternative to treatment of erectile dysfunction in patients with cardiac illness. Androgens are useful for erectile dysfunction in men with severe hypogonadism and may be useful as adjunctive therapy when other treatments are unsuccessful by themselves. Libido and an overall sense of well-being are likely to improve when serum testosterone levels are restored to the reference range.

Some evidence suggests that combination of testosterone and PDE-5 inhibitors yields better results. Usually testosterone is used parenterally, either once a week or once in 2 weeks. Other methods of administration like skin patches, testosterone gel is also available, but this is to be used daily and is costly. Testosterone implants are also available, which can last for months. However, it is to be remembered that use of exogenous androgens suppresses natural androgen production. Elevated serum androgen has the potential to stimulate growth of prostate gland and increase the risk of cancer.

Use of exogenous testosterone is also known to be associated with erythrocytosis, elevated serum transaminase levels, exacerbation of untreated sleep apnea, benign prostatic hyperplasia, and an increased risk of adenocarcinoma of the prostate. Accordingly, periodic examination of prostate, estimation of prostate-specific antigen PSA and heamogram are recommended in all patients receiving supplemental androgens.

Obtaining a testosterone level during therapy is necessary for optimizing the dosage. Since earlys, till advent of sildenafil, intracavernous injections were the mainstays of the treatment of erectile dysfunction. The agents which have been used for intracavernous injections include phentolamine mesylate, papavarine, vasoactive intestinal peptide VIP , forskolin and alprostadil. Clinical efficacy and safety of intracavernosal mesylate has been well documented.

Papavarine is a non-selective inhibitor of phosphodiesterase PDE and acts by increasing cAMP thus decreasing intracellular smooth muscle. It is used in papavarine mg induced penile erection PIPE test to distinguish between psychogenic and organic ED. However, it has limited efficacy so it is used with other agents such as phentolamine and with phentolamine and prostaglandin E1.

VIP and Forskolin which increase cAMP, have been found to be efficacious in moderate to severe erectile dysfunction resistant to monotherapy and polypharmacotherapy. No pain at site of injection has been reported with VIP, which is an advantage to patients. Alprostadil, a synthetic prostaglandin E1 is an adenylate cyclase activator and is now the drug of choice of intra-cavernosal pharmacotherapy.

It leads to erection in minutes and the duration of ejection depends on the dose of the medication used. Patient and partners also report high satisfaction rates. When used it is to be initially be given in the clinicians office at the lowest dose and gradually the dose need to be titrated to an adequate erectile response while monitoring for syncope.

Intracavernosal alprostadil is considered to be more effective and better tolerated over the intraurethral form. Due to this Intracavernosal alprostadil is preferred over intraurethral alprostadil. Common side effects of intra-cavernosal alprostadil are penile pain, edema and hematoma, palpable nodules or plaques, and priapism. Patients are to be clearly informed about the chances of occurrence of priapism and what do in such situation. The patient is to be counseled that if the erections persists for more than 4 hours, they need to seek emergency medical help.

Management of priapism in such situations involves aspiration of blood from corpus cavernosum under local anaesthesia. If this fails than intra-cavernosal phenylephrine injection is to be given with proper monitoring for severe hypertension, tachycardia and any arrhythmia. Due to its synergistic action, it is often used with phentolamine and papavarine. Some studies have demonstrated that patients of erectile dysfunction preferred combination [Phentolamine 0. A meta-analysis of 25, patients showed that the advantage of mixing above agents is that lower doses of drugs are required thus leading onto synergistic effects with lesser side effect.

Prominent side effects are pain, priapism, corporal fibrosis and scar tissue formation. Also, being an invasive procedure, many patients find it inconvenient to inject repeatedly. Procedural complicacy, bleeding and injury to urethra caused higher attrition rates at 1 year follow-up of patients being treated with intracavernous vasoactive drugs. It has advantages that it can be self-administered and has little systemic and local side effects. This option minimizes both systemic exposure and tissue traumatization and involves administration of vasoactive substances across skin of the penis.

This has added benefit from the patient's perspective in being a less invasive option.

Robert Taylor Segraves (Author of Clinical Manual of Sexual Disorders)

Nevertheless, this option requires more intensive research before approval by regulatory authorities. Testosterone therapy for ED is indicated only in confirmed cases of endocrinopathies and is to be reserved for patients with documented hypogonadism. Transdermal administration has been developed recently. Gel containing 2. Patients using testosterone skin patches have reported improvements in libido, sexual function, energy and mood. Serum prostate specific antigen PSA levels is to be measured before testosterone therapy is started. Nitroglycerine, a nitric oxide donor and minoxidil ointments have met with only minimal success.

Although still under investigation, but these agents could acts as another tool in the armamentarium for treating erectile dysfunction. Vacuum devices work by exerting a negative pressure on the penis, which results in an increase in corporeal blood flow and erection. A constriction ring placed around the base of the penis prolongs the erection by decreasing corporeal drainage. The erection obtained with a vacuum device is different from that obtained normally as there is no relaxation of the trabecular smooth muscle. Instead blood is trapped in the intra and extracorporeal regions of the penis.

The time taken to achieve an erection varies, but is generally around The band need not be left in the place for more than 20 mins. Majority of the vacuum devices currently marketed use either a battery or a hand pump to generate vacuum. Drawbacks of VCDs include pain, petechiae, obstruction of ejaculation, penile pivoting, numbness and slight bluish colouration due to cyanosis. The vacuum devices are contraindicated in patients with severe Peyronie's curvature, sickle cell anaemia or blood dyscrasias and those on anticoagulants.

Since their introduction about 3 decades ago, penile implants are still a widely chosen treatment option, mostly after failure of all forms of therapy for erectile dysfunction. There are various forms of penile prosthesis, i. Usually 3 piece inflatable penile prosthesis is preferred as it leads to more natural erections. Postoperative complications of penile implants include infection and mechanical malfunction.

Peri-prosthetic infection requires immediate antibiotic therapy and removal of prosthesis. Surgery for venous leakage involves penile venous ligation or embolization. Arterial revascularization is an experimental procedure used for treatment of vasculogenic ED. Generally, good results are obtained only in young men with pure arteriogenic erectile dysfunction. A number of complications associated with arterial revascularization including arterial haemorrhage, glans-penis hyperemia, anastomotic occlusion, diminished penile sensation and fibrosis.

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First step is to confirm the diagnosis of erectile dysfunction as per the prevailing nosological system. The consensus is that inability to attain and maintain an erection sufficient to permit satisfactory sexual performance, lasting for more than 6 months, is considered to be an indicator of presence of erectile dysfunction. The general principles of evaluation of erectile dysfunction are shown in Table The most important issue in management is evaluation for the organic factors, look for comorbid psychiatric conditions, comorbid sexual dysfunction and marital disharmony.

However, it is to be remembered that although the cause may be organic, psychological causes can worsen the ED, so treating with behavioural measures in such cases is also an important step in the management. The selection of treatment strategy for erectile dysfunction is outlined in figure If patient has Dhat syndrome along with erectile dysfunction, it is to be addressed first. Psychiatric disorders and marital harmony is to be addressed prior to treatment of erectile dysfunction and a similar protocol need to be followed. Initial treatment involves providing sex education, clarifying the myths, teaching relaxation exercises, and sensate focus training.

After assessing coexistent problems, while providing formulation and sex education, education about factors that create a normal sexual response and erectile dysfunction can help patients and their partners cope with sexual difficulties. The success of psychosexual therapy is guided by the motivation of the patient, as this require him to work with the therapist to understand what prevents him from experiencing normal sexual arousal.

Follow-up plan is to be tailor made for the individual and there is no single follow-up regime. However, regular follow-up at 4 weeks for 6 months is usually recommended. In terms of pharmacological treatments see Table , PDE-5 inhibitors are considered to be the first line therapy in treatment of erectile dysfunction. The PDE-5 inhibitors available in India include sildenafil, vardenafil and tadalafil.

Apomorphine sublingual has the advantage of quick onset of action. It is well tolerated and there is no interactive action with other medications, food and alcohol. This can be prescribed by physicians to patients with psychogenic and a mild organic impotence. It is also used when PDE-5 inhibitors are contraindicated. VCDs are better accepted by older patients especially who have a stable partner. Penile pain, numbness and delayed ejaculation are some of the side effects that treating psychiatrist need to be aware of.

Psychosexual therapy is also the first line treatment and it is used in patients with significant psychological problems, though psychological component may be present in all cases of erectile dysfunction. It is used either alone or in combination with other first line therapies. The motivation of the patient is of utmost importance for any psychosexual therapy. The major advantages are that it is non-invasive, involves the partner, and leads to sustainable improvement in sexual function and satisfaction.

However, it takes time, is associated with high dropout rates and is associated with variable results. If the first line therapies fail or are contraindicated than the second line treatment includes use of intracavernosal and intraurethral injections. Patient's comfort and education is very important while using intracavernosal and intraurethral injections. Use of an automatic special pen that avoids the needle view can avoid fear of penile puncture. It is helpful in most cases of erectile dysfunction; however, it is contraindicated in patients with hypersensitivity to drug employed and priapism.

Erection appears within mins.

The psychiatrist is to be aware of the side effects like priapism, penile pain and fibrosis. In cases where the penile erection lasts more than 4 mins aspiration of blood by a 19 gauge needle has been suggested. If it still does not resolve then mg of Phenylepherine intracavernosal injections every 5 mins is recommended. Intraurethral PGE 1 as semisolid pellets is a less invasive procedure but success rates are lower. In case both first and second line therapies fail, use of inflatable penile prosthesis can be considered. It is considered that behavioural management is to be the first line of therapy where ever possible.

The specific behavioural techniques for PME involves stop- start or squeeze techniques, which are usually introduced during genital sensate focus.

13.6 Somatoform, Factitious, and Sexual Disorders

The technique aims to increase the frequency of sexual contact and sensory threshold of the penis. It is best carried out in the context of sensate focus exercises because some males ejaculate so early that direct stimulation of the penis of any kind can trigger ejaculation straight away. Starting with non-genital caresses allows the male more time to identify the sensations that occur immediately prior to ejaculation.

The stop-start technique consists of the man lying on his back and focusing his attention fully on the sensation provided by the partner's stimulation of his penis. When he feels himself becoming highly aroused he is to indicate this to her in pre-arranged manner at which point she need to stop caressing and allow his arousal to subside. After a short delay this procedure is repeated twice more, following which the woman stimulates her partner to ejaculation. At first the man may find himself ejaculating too early, but usually gradually develops control. Later a lotion can be applied to the man's penis during this procedure, which will increase his arousal and make genital stimulation more like vaginal containment.

The squeeze technique is an elaboration of the stop-start technique, and probably only needs to be used if the latter proves ineffective. The couple proceeds as with the stop-start procedure.

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When the man indicates he is becoming highly aroused his partner should apply a firm squeeze to his penis for about seconds. During applying the pressure, the forefinger and middle finger are placed over the base of the glans and shaft of the penis, on the upper surface of the penis, with the thumb placed at the base of the undersurface of the glans. This inhibits the ejaculatory reflex. As with the stop-start technique this is repeated three times in a session and on the fourth occasion the man may ejaculate. Both procedures appear to help a man develop more control over ejaculation, perhaps because he gradually acquires the cognitive techniques associated with ejaculatory control, or perhaps because he gradually becomes accustomed to experiencing sexual arousal without getting anxious Hawton, Pharmacological treatment of premature ejaculation includes use of topical anesthetic agent, tricyclic antidepressants and selective serotonin reuptake inhibitors SSRIs Table There is preliminary data for use of sildenafil and some of the Chinese herbs.

However, it is important to note that none of these agents have been approved. Dapoxetine has been found to be efficacious in both lifelong and acquired PME. Dapoxetine is associated with side effects like nausea, diarrhoea, headache and dizziness. Combining dapoxetine with PDE-5 inhibitors is associated with increased risk of syncope. It is generally recommended that patient's blood pressure is to be evaluated prior to starting of dapoxetine.

Among the SSRIs, paroxetine has been found to be useful. However, data also exist for the beneficial effect of sertraline. Studies which have compared various SSRIs suggest that paroxetine is superior to fluoxetine, clomipramine and sertraline. Data also suggest that sertraline is better than fluoxetine; however, the efficacy of clomipramine is not significantly different from fluoxetine and sertraline. Chinese herbs like S-S cream, which are used as topical agents, have claimed good efficacy and favorable side effect profile.

SSRIs can be used on continuous basis or on situation basis, i. It is unclear as which of the two is more effective. The general consensus is that PME usually returns upon discontinuation of therapy. Firstly, the diagnosis of premature ejaculation be made as per the prevalent nosological system. The working diagnosis of PME is made if ejaculation occurs sooner than desired either before or soon after penetration causing distress to either or both partner for more than 3 months. The general principles of management are shown in Table The general guideline for selection of mode of treatment is given in figure The first step for treatment involves evaluation for presence of comorbid sexual dysfunctions, comorbid psychiatric disorders and marital discord.

If patient has erectile dysfunction or Dhat syndrome along with PME, these is to be addressed first. If patient has a psychiatric disorder it needs to be carefully evaluated — is it primary or secondary to sexual dysfunction, and how severe it is. Sometimes the PME is secondary to the poor interpersonal relationship between the couple, so it needs to be addressed prior to treatment of PME. It is considered that behavioural management is the first line of therapy wherever possible.

If either of the therapeutic measure fails then a combination of both may be tried. Selection of specific treatment modality is to be made based on physician judgment and patient's informed choice. The primary outcome measure is to be the patient's and partner satisfaction. Risk and benefits of all treatment options are to be discussed with patient prior to any intervention. The first step in the management of Dhat syndrome involves evaluation for comorbid sexual dysfunctions, psychiatric disorders and presence of possible urinary tract infection UTI and sexually transmitted diseases STD.

Where ever there is a suspicion, local examination, appropriate investigations for infective pathology and phosphaturia need to be done and adequate treatment is to be provided.

Even after appropriate treatment, if the symptoms persist then the subject is to be provided adequate sexual knowledge. The most important aspect of treatment of Dhat syndrome is providing adequate sex knowledge and clarifying sexual myths. Sex education mainly focuses on anatomy and physiology of sexual organs and their functioning with reference to masturbation, semen formation, nocturnal emissions and their functioning with genitourinary system independent of gastro-intestinal tract etc.

Besides the general measures, no particular procedures are used in the treatment of this problem. The main emphasis is on setting the right circumstances for sexual activity, reducing anxiety, establishing satisfactory fore play, focusing attention on erotic stimuli and cognitions and resolving the general issues of relationship between the couple. In addition, therapy tends to be more difficult and the conventional sex therapy techniques e.

Hence, a more flexible and person centric approach to treatment is required. Many authors have tried approaches like cognitive-behavioral therapy, systems approach, script modification, clinical hypnosis, guided fantasy exercises, and sexual assertiveness training. Cognitive-behavioral therapy emphasizes the role of thoughts and beliefs in perpetuating the maladaptive behavior and is useful when beliefs held by the patient or couple about norms or responses is contributing to the sexual problem. The most important issue in management is evaluation for the organic factors, evaluation for presence of comorbid psychiatric conditions, comorbid sexual dysfunction and marital disharmony.

But it is to be remembered that although the cause may be organic, psychological causes can decrease the sexual interest, these also need to be focused adequately. Many couples have marital disharmony associated with decrease sexual interest and treating the same would be the only thing which is required. More flexible and individualistic approach to treatment is required. The general outline of management is shown in figure Firstly female sexual disorders need to be diagnosed as per the current definitions.

The thorough assessment includes a comprehensive medical and psychological history of the patient and her partner. Like in male sexual dysfunction, psychiatrist treating female sexual dysfunction is to be aware of the etiology including genitourinary, endocrinological, vascular and neurological systems.

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The general principles of assessment of female patients with sexual dysfunction are given in Table A multidisciplinary approach is of paramount importance in female sexual dysfunction. It is important to remember that many women who present with vaginismus have negative attitude towards sex and quite a few are victim of sexual assault. Some may also have the belief that premarital sex is wrong or sinful. This belief may be so ingrained that, even when intercourse is sanctioned by marriage, it may be difficult to relax physically or mentally during sexual intercourse.

Some times the cause of vaginismus may be a fear that is instilled by friends or family by suggesting that the first experience of intercourse is likely to be painful or bloody. Another important cause of vaginismus is fear of pregnancy. The sex education needs to focus on clarifying normal sexuality and reducing negative attitude for sex. Besides the use of general relaxation exercises, the relaxation procedure also needs to focus on teaching the women to relax muscles around the inner thigh and pelvic area. Helping the woman develop more positive attitudes towards her genitals.

After fully describing the female sexual anatomy, the therapist need to encourage the woman to examine herself with a hand mirror on several occasions. Extremely negative attitudes especially concerning the appearance of the genitals, or the desirability of examining them may become apparent during this stage, possibly leading to failure to carry out the homework.

Some women find it easier to examine themselves in the presence of the partners; others may only get started if the therapist helps them do this first in the clinic. If this is necessary a medically qualified female therapist is to be involved. Pelvic muscle exercises. These are intended to help the woman gain some control over the muscles surrounding the entrance to the vagina. If she is unsure whether or not she can contract her vaginal muscles she may be asked to try to stop the flow of urine when she next goes to the toilet. The woman can later check that she is using the correct muscles by placing her finger at the entrance to her vagina where she need to be able to feel the muscle contractions.

Subsequently she is advised to practice firmly contracting these muscles for an agreed number of times e. Vaginal penetration. Once the woman has become comfortable with her external genital anatomy she is advised to explore the inside of her vagina with her fingers. This is partly to encourage familiarity and partly to initiate vaginal penetration. Negative attitudes may also become apparent at this stage e. The rationale for any of these objections is to be explored. At a later stage the woman might try using two fingers and moving them around. Once she is comfortable inserting a finger herself, her partner need to begin to do this under her guidance during their homework sessions.

A lotion e. K-Y or baby lotion can make this easier. Graded vaginal dilators can be used. However, clinical experience has shown that the use of fingers is just as effective. Vaginal containment. When vaginal containment is attempted the pelvic muscle exercises and the lotion are used to assist in relaxing the vaginal muscles and making penetration easier. This is often a difficult stage and the therapist therefore needs to encourage the woman to gain confidence from all the progress made so far. Persisting concerns about possible pain may need to be explored, including how the woman might ensure that she retains control during this stage.

Movements during containment: Once containment is well established the couple is asked to introduce movement during containment, with preferably women starting the movements first. With this the general programme of sex therapy is completed and now the treatment needs to include superimposition of treatment for specific sexual dysfunctions.

Psychological issues as well as interpersonal issues need to be addressed first. Besides the use of general relaxation exercises, the relaxation procedure needs to focus on teaching the women to relax muscles around the inner thigh and pelvic area. The specific behavioural management is to be followed. Besides the general measures and sensate focus, treatment of dyspareunia involves sex education.

The sex education need to focus on the importance of adequate arousal and the couple may also be helped by specific suggestions for modifying their usual intercourse positions. Another important aspect of treatment of dyspareunia due to psychological causes is helping the woman become aroused by teaching the sensate focus programme. In woman with repeated pain experience on intercourse, it is likely that they will tense up on future occasions in anticipation of further pain. Such tension may actually increase pain as the muscles may be more resistant to penetration.

Due to this, relaxation exercises prior to or during intercourse may be helpful. Progressive muscle relaxation prior to sexual activity may allow the women to reduce the body tension, while more specific relaxation exercises just prior to intercourse may help to relax the muscles around the pelvic region and may enhance arousal. As a woman acquires a number of coping techniques for minimising the likelihood of pain, positive self-talk may be helpful. Such self-talk can involve the woman reminding herself that she is in control of the situation and she will be the one to determine when penetration is to occur and how deep penetration will be.

Also the assessment needs to rule out vaginismus and dryness of vagina. Treatment of dyspareunia includes sex education and teaching sensate focus Figure It is very important to rule out comorbid desire disorders before treating arousal disorders. If there is comorbid desire disorder then it needs to be treated first before arousal disorders are treated. There is no empirically validated treatment available for arousal disorders due to the fact that this is a less researched area. Approach usually depends on the etiology of the arousal disorders.

Sensate focusing, CBT, systematic desensitization, individual and couples therapy, directed masturbation and communication skills have been tried in arousal disorders with moderate results. Assessment regarding whether primary or secondary needs to be settled. Also, whether the desire disorder is generalized or partner specific needs to be explored. In recent times, a pharmacological agent, flibanserin has been approved for the management of hypoactive sexual desire disorder in premenopausal women. The recommended dose0 is mg per day at bed time. Data from metanalysis shows that compared to placebo, flibanserin is associated with higher satisfying sexual events per month.

Its use is associated with side effects like dizziness, somnolence, nausea, and fatigue. If a patient does not show improvement, the drug needs to be discontinued after 8 weeks. Sexual abuse or rape, trauma, relationship problem, marital problem can lead to sexual aversion disorder. Therefore, all clinicians treating sexual aversion disorders need to be aware of these causes.

The termination of the treatment must be planned carefully. The various strategies and component of termination are:. Towards the end of treatment extend the intervals between sessions: The intervals between the last two to three sessions need to be extended to two to three weeks. Prepare for relapse: The therapist need to prepare the couple for relapse. About three-fourth of men will experience recurrence of their problem following treatment. Hence, treatment also needs to assist men to cope well with relapse.

Most recurrences occur in a temporal pattern i. The understanding that relapses are normal expected helps to reduce the anxiety and sense of failure that may otherwise prolong erectile difficulties. Follow-up assessments: Follow-up assignments help the therapist to evaluate the short-term effectiveness of treatment. National Center for Biotechnology Information , U. Journal List Indian J Psychiatry v. Indian J Psychiatry. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: ni. This article has been cited by other articles in PMC.

Open in a separate window. Table 2 Subtypes of sexual dysfunctions according to DSM Important aspects of evaluation of patients with sexual dysfunctions Discussing sex-related issues can be embarrassing both for the clinician and the patient. Table 3 Important aspects in evaluation of sexual dysfunctions. Table 4 History taking for sexual disorders. Table 5 Differentiating features between psychogenic and organic sexual dysfunction. Table 6 Psychological factors associated with sexual dysfunctions. Table 7 Psychosocial assessment of sexual dysfunctions.

Physical Examination Every effort be made to ensure the privacy, confidentiality and personal comfort of the patient while conducting the physical examination. Recommended Laboratory Testing Recommended laboratory tests for men and women with sexual problems typically include blood glucose levels, cholesterol, lipids, hormonal profile and X-ray spine for spina bifida.

Assessment of Knowledge and Attitude towards sex Few patients may not actually have sexual dysfunction, but may perceive the same, because of poor knowledge and negativistic attitude towards sex. Specialist Consultation and Referral Patients with history of medical problems be referred to appropriate specialty to evaluate the severity and state of disease control See table Table 8 Medical history, physical examination and investigations for sexual dysfunctions. Table 9 Principles of treatment.

Figure 1. Figure 2. Table 10 Aims and Components of education about sexuality. Table 11 Common Myths about Sex. Specific Non-pharmacological management of Sexual Dysfunction The specific non-pharmacological measures will vary according to the type of sexual dysfunction. Table 12 Principles of giving and carrying out the homework assignments. Table 13 Non-Genital Sensate Focus.

Table 14 Genital Sensate Focus. Home work assignments for single male Management of sexual dysfunctions in single males also involves same principles. Table 17 Differentiating features between psychogenic and organic erectile dysfunction. Specific Non Pharmacological treatment for erectile dysfunction Men with psychogenic erectile dysfunction will usually start experiencing erections during either non-genital or genital sensate focus. Pharmacological treatment for erectile dysfunction Besides the psychological measures, other therapeutic options for erectile dysfunction includes medications, constriction ring, vacuum constriction devices, intra-cavernosal injections, intra-uretheral medication devices, penile prosthesis and reconstructive surgery Table Table 18 Treatment options for erectile dysfunction.

Oral erectogenic agents Oral therapy with vasoactive agents has emerged as the first line treatment and has transformed the management of erectile dysfunction. Table 19 Comparison of various PDE-5 inhibitors. Other oral erectogenic agents Trazodone: One of the earliest drugs used in erectile dysfunction was trazodone. Androgens Androgens are useful for erectile dysfunction in men with severe hypogonadism and may be useful as adjunctive therapy when other treatments are unsuccessful by themselves.

Vasoactive Intracavernosal Injections ICI Since earlys, till advent of sildenafil, intracavernous injections were the mainstays of the treatment of erectile dysfunction. Topical therapy Transdermal delivery This option minimizes both systemic exposure and tissue traumatization and involves administration of vasoactive substances across skin of the penis. Vacuum constriction devices VCD Vacuum devices work by exerting a negative pressure on the penis, which results in an increase in corporeal blood flow and erection.

Penile Prosthesis Since their introduction about 3 decades ago, penile implants are still a widely chosen treatment option, mostly after failure of all forms of therapy for erectile dysfunction. Reconstructive surgery Surgery for venous leakage involves penile venous ligation or embolization. Steps in the Management of Erectile Dysfunction First step is to confirm the diagnosis of erectile dysfunction as per the prevailing nosological system. Table 20 General principles of evaluation of erectile dysfunction.

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Figure 3. Table 21 Management of Erectile dysfunction. Premature Ejaculation PME Specific Non Pharmacological for specific sexual dysfunctions It is considered that behavioural management is to be the first line of therapy where ever possible. Pharmacological management of Premature Ejaculation PME Pharmacological treatment of premature ejaculation includes use of topical anesthetic agent, tricyclic antidepressants and selective serotonin reuptake inhibitors SSRIs Table