Sexual Dysfunction in Men E-Book

David L Rowland

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch

Seitenzahl: 241

Veröffentlichungsjahr: 2012

Beschreibung

"By far the best professional book ever published about understanding, assessing, and treating male sexual dysfunction." Sexual dysfunctions in men, such as erectile dysfunction, ejaculatory disorders, and low sexual desire, are typically sources of significant distress for men. This book, being published with the companion volume Sexual Dysfunction in Women, provides general therapists with practical, yet succinct evidence-based guidance on the diagnosis and treatment of the most common male sexual disorders encountered in clinical practice. It assumes that mental health professionals and other clinicians without expertise in the field of sex therapy have much to offer these men by combining a multidisciplinary understanding of issues surrounding sexual problems with their general clinical knowledge and expertise. With tables and marginal notes to assist orientation, the book is designed for quick and easy reference while at the same time providing more in-depth understanding for those desiring it. The book can serve as a go-to guide for professional clinicians in their daily work and is an ideal educational resource for students and for practiceoriented continuing education. Recent Praise: "Simply put, this is by far the best professional book ever published about understanding, assessing, and treating male sexual dysfunction. David Rowland examines the biopsychosocial model of sexual function and dysfunction and applies a multi-dimensional, complex approach to understanding and changing male sexual dysfunction. This book makes a major contribution to the field and should be on the bookshelf of every psychologist, physician, and couple therapist treating men individually or in couple therapy." Barry McCarthy, Professor of Psychology, American University, Washington DC; certified marriage and sex therapist; coauthor of Men's Sexual Health and Sexual Awareness (5th ed.) "David Rowland's text is an important addition to the literature and belongs in every therapist's library. It is especially valuable because it is designed to help the generalist deal with sexual problems and is written clearly with a practical emphasis." Robert Taylor Segraves, MD, PhD, Professor of Psychiatry emeritus, Case Western Reserve University, Cleveland, OH; Editor of Journal of Sex and Marital Therapy "Written for both professionals and the general population, David Rowland's work provides a comprehensive, scholarly review of men's sexual problems and up-to-date treatments. He concisely examines physiological and psychological causes and provides the theoretical underpinnings necessary for accurate diagnosis and treatment. This compact volume is a valuable source of useful information succinctly covering an all-too-often ignored area of human function and interaction." Diane Morrissette, PhD, Psychotherapist specializing in sex and relationship counseling, Palo Alto, CA "The interdisciplinary expertise of Dr. David Rowland makes this comprehensive book on sexual dysfunction in men an essential read for any professional. The excellent descriptions of assessment and treatment will prove enlightening to medical health providers as well as anyone in the mental health field. The inclusion of the empirical evidence of varying treatments will help clinicians focus on the most efficacious approach. Sex Dysfunction in Men is a welcomed addition to evidence-based practice." Lin Myers, Professor of Psychology, California State University, Stanislaus, researcher, educator, clinician in the field of sexology for over 25 years, full member of the International Academy of Sex Research, and a member of SSTAR, and ASSECT

Leseprobe

Sexual Dysfunction in Men

David L. Rowland

Department of Psychology, Valparaiso University, Valparaiso, IN

About the Author

David L. Rowland received his PhD from the University of Chicago in 1977, and since then has held numerous research fellowships in the US and abroad. His research focuses on understanding sexual response and disorders in men and women, particularly the interface between the physiological and psychological experience of sexual response. He has published over 130 articles, monographs, and chapters, including the 2008 Handbook of Sexual and Gender Identity Disorders. He served as editor of the Annual Review of Sex Research, 2005–2009, currently serves on the editorial boards of major journals in the field of sex research, and has provided expert consultation to pharmaceutical companies and professional societies, including service on the Standards Committee of the International Society of Sexual Medicine.

Companion volume in this series:

Marta Meana (2012)

Sexual Dysfunction in Women

EPUB-ISBN 978-1-61334-400-2

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Professor of Psychology, California School of Professional Psychology / Alliant International University, San Francisco, CA

Associate Editors

Larry Beutler, PhD, Professor, Palo Alto University / Pacific Graduate School of Psychology, Palo Alto, CA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

David A. Wolfe, PhD, RBC Chair in Children’s Mental Health, Centre for Addiction and Mental Health, University of Toronto, ON

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a “reader-friendly” manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work, as well as an ideal educational resource for students and for practice-oriented continuing education.

The most important feature of the books is that they are practical and “reader-friendly:” All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Library of Congress Cataloging information for the print version of this book is available via the Library of Congress Marc Database

Cataloging data available from Library and Archives Canada

© 2012 by Hogrefe Publishinghttp://www.hogrefe.com

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Preface

The past decade has witnessed increased interest in and research on sexual problems in both men and women. At the same time, new pharmacological solutions to male sexual dysfunctions have become available, and a number of new agents are currently under investigation. These developments are, of course, not independent of one another, but in the course of these developments, two things have become apparent:

(1) We are still far from having a complete understanding of basic human sexual response, let alone sexual dysfunction. For example, we do not understand why some men seem unable to control or delay their ejaculation, or why other men are particularly vulnerable to developing “performance anxiety,” while others do not quickly lose their erections as a result of experiencing a sexual problem.

(2) Contrary to speculation that psychosexual counseling would become obsolete (given this pills-for-better-sex decade), its role has actually become better understood and defined. If nothing else, this decade has taught us that although pills can help fix the body and genitals, psychosexual counseling is needed to help heal both the person and the relationship.

This book is written for a broad audience that includes not only nonspecialist therapists, clinicians, and even physicians whose patients/clients raise concerns about their sexual well-being, but also for patients/clients themselves and their partners. Although some sexual problems invariably require the attention of a specialist, many others can be handled adequately by the nonspecialist assuming (1) he or she already has training as a therapist or clinician and (2) he or she has acquired a reasonably broad understanding of men’s sexual dysfunctions – their etiologies, diagnoses, and treatments. Meeting these assumptions ensures that the therapist’s general counseling skills are contextualized and tailored to meet the needs of clients who express a sexual concern or difficulty.

It is indeed the second assumption above that has provided the impetus for this book. Many therapists may not feel qualified or comfortable dealing with the sexual problems of clients. Together with its twin, Sexual Dysfunction in Women, authored by Marta Meana, these volumes not only give general frameworks for thinking about sexual response and sexual problems, but also set forth diagnostic and treatment strategies in a simplified and clear manner for the nonspecialist.

Acknowledgments

I am grateful to all who made this book possible: Marta who suggested the collaboration, Danny Wedding, the series editor, and Robert Dimbleby of Hogrefe Publishers.

Special thanks go to Beth Adamski, MA, editorial assistant for this project, who was instrumental in both task and stress management; to Paula Nieweem, MALS, who carried out research and investigation for the book; and to Kathleen Mullen, PhD, whose rhetorical eye and ear have helped ensure a smooth and easy read.

And finally, to those who continue to enrich my life: my daughter, parents, special friends left unnamed, and the staff of the Graduate School and Office of Continuing Education at Valparaiso University.

Table of Contents

Preface

Acknowledgments

1        Description

1.1      Terminology

1.2      Definition

1.3      Epidemiology

1.3.1   Low Sexual Desire

1.3.2   Erectile Dysfunction

1.3.3   Premature Ejaculation

1.3.4   Delayed and Inhibited Ejaculation

1.3.5   Other Considerations

1.4      Course and Prognosis

1.4.1   Psychophysiology of Male Sexual Function: A Brief Overview

1.4.2   Etiology of Male Sexual Dysfunction

1.5      Differential Diagnosis

1.6      Comorbidities

1.7      Diagnostic Procedures and Documentation

1.7.1   International Index of Erectile Function (IIEF)

1.7.2   Sexual Health Inventory for Men (SHIM)

1.7.3   Self-Esteem and Relationship Questionnaire (SEAR)

1.7.4   Male Sexual Health Questionnaire (MSHQ)

1.7.5   Premature Ejaculation Prevalence and Attitudes (PEPA)

1.7.6   Index of Premature Ejaculation (IPE)

1.7.7   Premature Ejaculation Diagnostic Tool (PEDT)

1.7.8   Quality of Erection Questionnaire (QEQ)

1.7.9   Sexual Quality of Life Measure for Men (SQOL-M)

2        Theories and Models of Sexual Dysfunction

2.1      Introduction and Issues

2.2      Modified Biopsychosocial Model

2.2.1   Biological/Physiological Factors

2.2.2   Psychological Factors

2.2.3   Relationship Factors

2.2.4   Sociocultural Factors

2.2.5   Interaction of the Biopsychosocial Domains

3        Diagnosis and Treatment Indications

3.1      Establishing a General Framework for Evaluation

3.2      Organization of the Evaluation

3.3      Identifying the Problem and Quantifying Severity

3.4      Identifying Etiological Factors

3.4.1   Biomedical Assessment and Medical History

3.4.2   Psychosexual and Psychological Histories

3.4.3   Relationship Assessment

3.4.4   Probing Sociocultural Factors

3.5      Defining the Desired Outcome

3.6      Treatment of Male Sexual Dysfunction: Setting the Context

4        Treatment

4.1      Treatment of Low Sexual Desire

4.1.1   Nomenclature and Definition

4.1.2   Prevalence

4.1.3   Risk Factors, Comorbidities, and Other Red Flags

4.1.4   Methods of Treatment

4.2      Treatment of Erectile Dysfunction

4.2.1   Nomenclature and Definition

4.2.2   Prevalence

4.2.3   Understanding the Mechanisms of Erection

4.2.4   Risk Factors, Comorbidities, and Other Red Flags

4.2.5   Methods of Treatment

4.2.6   Combinations of Methods

4.3      Treatment of Premature Ejaculation

4.3.1   Nomenclature and Definition

4.3.2   Prevalence

4.3.3   Risk Factors, Comorbidities, and Other Red Flags

4.3.4   Methods of Treatment

4.3.5   Combinations of Methods

4.4      Treatment of Delayed and Inhibited Ejaculation

4.4.1   Nomenclature and Definition

4.4.2   Prevalence

4.4.3   Etiology, Risk Factors, and Comorbidities

4.4.4   Evaluation

4.4.5   Methods of Treatment

4.4.6   Treatment Efficacy

5        Final Thoughts and Notes

5.1      Overarching Strategies

5.2      Eleven Pointers From Clinical Notes

6        Case Vignette

7        Further Reading and Resources

8        References

9        Appendix: Tools and Resources

1

Description

The ability to have a fulfilling sexual relationship is important to almost all men’s mental health and psychological well-being. Not only is this a biologically and socially defining characteristic for men in our society, but studies suggest that men in such relationships tend to have greater longevity and to report a higher quality of life and overall satisfaction (McCabe, 1997; Palmore, 1985). Men whose sexual relationships are disrupted because of their inability to respond adequately, typically experience a number of psychological symptoms, including lack of confidence, anxiety, and distress.

Even the nonspecialized therapist can be helpful by understanding the etiology, diagnosis, and treatment practices for various dysfunctions

Although a select few therapists specialize in the treatment of sexual problems, most do not; therefore, the likelihood that a client or patient may approach a general therapist who counsels and treats patients with a variety of issues is quite high. Even the generalist can be helpful to men in need of sexual guidance and advice. Important to this process is an understanding of the components of sexual response, its etiology and diagnosis, and current treatment practices.

1.1    Terminology

Sexual response is complex: It requires specific preconditions, involves multiple behavioral responses, and includes an array of psychosocial factors that have affective, cognitive, and relationship dimensions. Masters and Johnson (1966) succeeded in providing a rudimentary characterization of physiological sexual response, analyzing it into arousal, plateau, orgasmic, and resolution phases. Subsequent models introduced a role for sexual desire as a component of sexual response (Kaplan, 1979), with a more recent refinement that distinguishes between such constructs as spontaneous desire and arousability, the latter referring to sexual interest derived from a specific individual, object, or context as opposed to an “unprompted” desire. Further conceptualization has included separate pain-pleasure dimensions (Schover, Friedman, Weiler, Heiman, & LoPiccolo, 1982), as well as attention to other subjective factors such as the feelings, motivations, and attitudes that surround the sexual act (Byrne & Schulte, 1990). Recently, emphasis has also been given to the role of the dyadic relationship, an approach that seeks to understand and treat sexual dysfunction in its relational context (Schnarch, 1988, 1991).

Healthy sexual relationships, however, are not characterized merely by the absence of dysfunctional response. Key elements of healthy sexual relationships include passion, intimacy and caring, and commitment (Sternberg & Barnes, 1988).

Healthy sexual relationships involve more than just the absence of dysfunctional response; many problems include larger relationship factors beyond sexual response issues

Passion typically involves such characteristics as sexual feelings, physical attraction, and romantic love.

Intimacy and caring deal with dimensions of affection and expressiveness – the willingness to communicate and share beliefs, attitudes, and feelings.

Commitment refers to the decision to be with one partner and to work hard to maintain the relationship.

Because many sexual problems are rooted in a couple’s disparate expectations and emotional struggles, including the different ways in which these elements are often played out by each of the sexes, most sexual problems benefit not just from attention to specific sexual response issues but to larger relationship factors as well.

There are several different types of sexual disorders. In the field of sexology, distinctions are made among the sexual dysfunctions, the gender identity disorders, and atypical and paraphilic behaviors.

Sexual dysfunction

refers to disruption or inadequacy of normal sexual responding and is the topic of this book.

Gender identity disorders

refer to cross-gender identity or the lack of assimilation of, or satisfaction with, the gender identity consistent with one’s biological sex or assigned gender identity.

Paraphilias

refer to sexual arousal and behaviors that are directed toward inappropriate objects/partners or are carried out in inappropriate situations (e.g., fetishism, pedophilia, frotteurism, voyeurism, etc.).

1.2    Definition

The classification of sexual dysfunctions has evolved from the conceptual models discussed above and is related to the specific axes or dimensions important to functional sexual response (American Psychiatric Association, 2000). These include:

lack of desire, also known as hypoactive sexual desire disorder;

problems with either physiological sexual arousal (e.g., erection) or subjective sexual arousal (i.e., actually feeling aroused);

disorders of ejaculation/orgasm, most commonly premature ejaculation and inhibited ejaculation.

Although not part of this review, problems with painful intercourse and sexual aversion are also included in the diagnostic classification system.

Typically, the scope of the sexual problem is characterized as either situation- (including person) specific or generalized, and as either lifelong or acquired. An acquired sexual dysfunction may result from either pathophysiological developments or sexual experiences. Several classification systems are currently in use to define and characterize sexual dysfunctions: The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), the proposed 5th edition of the DSM (DSM-5), and the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) classifications are included in Table 1. Characteristics of each dysfunction, along with alternate terminology and prevalence estimates are provided in Table 2.

Although sexual dysfunctions in men and women generally parallel one another, the prevalence of the various dysfunctions differentiates the sexes; and, because of differences in physiology and evolution, they are often manifested in different ways (Lewis et al., 2004). For example, anorgasmia and lack of sexual desire are more common among women, whereas rapid ejaculation/ orgasm and physiological arousal problems (e.g., erection in men versus lubrication in women) are more common among men.

In broad terms, no matter what the problem, men’s sexual problems typically have three elements:

(1)  A functional impairment of some type is evident. For example, the man and his partner are unable to enjoy intercourse because he is unable to get or keep an erection, or because he ejaculates very quickly.

(2)  The man’s sense of self-efficacy is low, as he is typically unable to correct or control the problem through psychobehavioral changes. For example, the man just cannot seem to get interested in sex, or he is unable to delay his ejaculation.

(3)  The man and/or his partner suffer negative consequences from the condition. For example, the man is bothered or even obsessed by the problem, perhaps to the point of avoiding intimacy; or the partner is distressed by the situation, not knowing what to do, perhaps feeling frustrated and unattractive, and so on. The challenge in the field of sexology, however, is that although there is only “one” unified sexual response in the patient’s view – the man typically does not distinguish among the desire, erection, and ejaculation phases of the response – the physiology underlying the functional impairment associated with each of these phases is quite distinct. Thus, dysfunction within each phase has its own prevalence, etiology, diagnosis, and treatment. To provide greater depth and understanding, this book takes a dual approach, dealing with common and comprehensive issues underlying all dysfunctions in Chapters 1–3, and then devoting individual sections to each phase/dysfunction in Chapter 4.

The functional impairment associated with each phase of the sexual response cycle has a distinct underlying physiology

1.3    Epidemiology

For obvious reasons, determining the prevalence of any sexual dysfunction in men is complicated and challenging. To illustrate the point, defining a problem as a sexual dysfunction requires that the functional impairment meet specific criteria. In many instances, a man may view his response as problematic, but it may not meet the criteria necessary for a clinical diagnosis. For example, a man has occasional erectile failure, or ejaculates before he wants to even when ejaculation occurs 3 or 4 minutes after vaginal insertion. Furthermore, for a man to be classified as dysfunctional also requires that he recognize the symptoms and potentially defines himself in this category. Yet, issues of privacy, discretion, and sometimes stigmatization may inhibit men from disclosing what might be viewed as a “weakness” (what man wants to admit to being classified as dysfunctional?). Finally, prevalence is a moving target. For example, for some men, the problem may be transient, as when life stressors or particular sensitivity or vulnerability to specific relationship interactions contribute to or intensify a problem that is initially “subclinical.” Cultural attitudes, expectations, and acceptance regarding men’s sexual problems may influence the willingness to acknowledge and report such problems. And for those sexual dysfunctions that are partly age-related (e.g., problems with erection and/or sometimes sexual interest), as the age demographic of a population changes, so also does the prevalence (see Table 2 for prevalence estimates).

Many factors contribute to the difficulty of determining the prevalence of sexual dysfunctions in men

Men may be hesitant to identify themselves as dysfunctional, since classification as “dysfunctional” is stigmatizing and requires their recognition of the symptoms

1.3.1   Low Sexual Desire

Data from the National Health and Social Life Survey (Laumann, Paik, & Rosen, 1999) suggest the prevalence of low sexual desire is around 5%. This particular survey had several limitations, and the more recent Global Study of Sexual Attitudes and Behaviors (Laumann, Nicolosi, Glasser, Paik, & Gingell, 2005) suggests a higher prevalence, somewhere between 13% and 28%. Given the general superiority of this latter survey, these rates are probably more reflective of the true prevalence. Several other studies report rates ranging from 0 to about 25%, depending on the nature of the question, the population sampled, and whether the individuals were clinically- or self-diagnosed. Taken together, these and other studies (Lewis et al., 2010) suggest prevalence somewhere between 15% and 25% of men, with the potential of higher rates in men over 60. However, most such studies have not distinguished between sexual “desire” and “interest.” Whereas desire is presumed to be internally driven and physiologically based (at least for men), interest is a more inclusive term that may be affected by such factors as partner attraction, relationship issues, environmental stressors, and so on. The extent to which this more inclusive condition (low sexual “interest”) prevails in the population is not known despite the fact that low sexual interest undoubtedly affects the sexual relationship.

It is important to distinguish between sexual desire and sexual interest

1.3.2   Erectile Dysfunction

Prevalence of erectile dysfunction (ED) among men varies significantly according to the way in which the dysfunction is defined, the population sampled, and information collected (Lewis et al., 2010). Overall, an estimated 18% of males 20 years and older, or about 18 million men in the United States, have erectile dysfunction (Selvin, Burnett, & Platz, 2007). However, the most important source of variation in ED prevalence is the age of the respondents. Among men below the age of 40, ED ranges from 1% to 10%; for those between 40 and 49, ED is higher, perhaps closer to 8–12%; for those 50 or older, the prevalence approaches 25% and can reach as high as 50%+ for men in their 70s and 80s. Clearly, the age-related increase in prevalence strongly suggests an ED of somatic/biogenic origin; reliable estimates regarding the prevalence of psychogenic ED are not available.

Undoubtedly, the link between biogenic and psychogenic ED is important – as men experience increased difficulty getting and maintaining an erection due to biogenic factors, they are more likely to experience anxiety and performance demand, two psychological factors that interfere with erectile response. Nevertheless, such links between biogenic and psychogenic factors may not necessarily presume higher levels of psychogenic ED in older men. Just as readily, younger men having limited experience with sexual intimacy, entering new relationships, or having to deal with strongly defined social roles are also vulnerable to the antierectile effects of anxiety and performance demand within a sexual relationship.

The prevalence of biogenic ED is easier to estimate than psychogenic ED, as the age-related increase offers evidence of a biogenic origin

1.3.3   Premature Ejaculation

Premature ejaculation (PE) appears to be fairly common; in fact, it is probably the most common sexual dysfunction in the general population, including primary care patients, with studies reporting ranges from 11% to 66% (Ahn et al., 2007; Aschka, Himmel, Ittner, & Kochen, 2001). Most studies estimate 20–30% of men, regardless of nationality, will experience PE at some point in their lives (see Rowland, 2011). Variability in estimates likely arises from:

PE is probably the most common sexual dysfunction in men

(1)  the use of different definitions of premature ejaculation, particularly definitions for the latency to ejaculation, which has ranged anywhere from one to several minutes after partner penetration;

(2)  whether the estimate is based on a clinical diagnosis versus self-report by the responder;

(3)  the extent to which the man is actually bothered by the condition. Several studies, for example, report rates as high as 30%, but only half those men indicate the problem is sufficiently serious to seek treatment.

As expected, prevalence estimates from clinical samples of men attending sex clinics or seeing primary care physicians suggest somewhat higher rates than in the general population (Aschka et al., 2001), with 34.8% of men in one sample reporting having experienced PE at some time during their lifetime (Riley & Riley, 2005). Overall, such data suggest that the rates of PE or PE-like complaints are quite high – probably around 15-25% within the general population. Some research indicates that age is not a factor with respect to the prevalence of PE; other research, however, suggests that PE may either increase or decrease with increasing age (e.g., Ahn et al., 2007). Given the inconsistent results, the most parsimonious position is to assume that there is no large change in PE prevalence related to age.

1.3.4   Delayed and Inhibited Ejaculation

The prevalence of delayed or inhibited ejaculation (IE; the latter being the complete inability to reach ejaculation) is unclear – normative data for defining the duration of “normal” ejaculatory latency, particularly regarding the right tail of the distribution (i.e., beyond the mean latency to ejaculation), is essentially nonexistent. Furthermore, larger epidemiological studies have not subdivided men into various types of diminished ejaculatory function. For example, the continuum (and/or overlap) from delayed to inhibited ejaculation has not been adequately explored.

In general, IE has been reported at fairly low rates in the literature, typically around 3% (Rowland et al., 2010), and thus it has been seen as a clinical rarity. Masters and Johnson (1966) initially reported only 17 cases; Apfelbaum (2000) reported 34 cases and Kaplan fewer than 50 cases in their respective practices (see Perelman & Rowland, 2008). However, based on clinical experiences, some urologists and sex therapists are reporting an increasing incidence of IE (Rowland et al., 2010) leading to newer estimates of anywhere between 3% and 10% (see Lewis et al., 2010). The prevalence of IE appears to be moderately and positively related to age – not surprising in view of the fact that ejaculatory function as a whole tends to diminish with age. However, no large-scale studies have systematically investigated the strength or reliability of this putative relationship.

1.3.5   Other Considerations

The various dysfunctions themselves do not represent mutually exclusive categories. In fact, the interrelatedness of the components of the sexual response cycle increases the likelihood that men with a problem related to one phase of the sexual response cycle may exhibit a problem in another phase. Important to any evaluation and treatment process is determining which problem is primary and which is secondary. Thus, a man who has significant problems with erection may eventually “lose” or suppress interest in sex altogether. Similarly, nearly one third of men reporting problems with premature ejaculation also experience difficulties with erection.

Due to the interrelatedness of the phases of the sexual response cycle, men with one sexual problem will often manifest other sexual problems

When multiple problems are encountered, it is important to distinguish between which problem is primary and which is secondary

Generally, a common underlying theme for all sexual dysfunctions is that they are bothersome and cause significant worry or distress to the individual. In some instances, the distress may not just be caused by inadequate sexual performance, but may stem from the impact the dysfunction has on the couple (e.g., disruption of intimacy, lack of partner satisfaction, etc.). In contrast, some men may experience minimal distress due to their condition. For example, a man who ejaculates very rapidly may employ strategies other than coitus to ensure his partner’s sexual enjoyment and therefore may have little distress and consequently little motivation to seek treatment. The question – one that has been debated vigorously in sexological circles – is whether such men, that is, those showing the symptoms but without stress or bother, manifest a true sexual dysfunction.

1.4    Course and Prognosis

1.4.1   Psychophysiology of Male Sexual Function: A Brief Overview

To understand risk factors and treatment options, a basic familiarity with the psychophysiological processes of sexual desire, sexual arousal, and orgasm is helpful. Libido or sexual desire is a psychological construct intended to explain the likelihood or strength of a sexual response. Constructs do not have the same observable qualities as, say, erection or ejaculation, but they are nevertheless presumed to exist and are invoked to explain variations in response frequency and intensity. In men, libido or desire is usually assessed through self-reports of interest in sexual activity and a sexual partner, the presence of self-generated fantasies, and the frequency of sexual activity (coitus, masturbation). At the neural level, libido represents a state of “arousability” that most likely involves “motivation” centers in the diencephalon (e.g., medial preoptic area; paraventricular nucleus of the hypothalamus), operating in conjunction with cortical level sensory and cognitive centers responsible for processing sexually relevant information about the environment (e.g., appropriate partner, appropriate time, etc.) (Pfaus, Kippin, & Coria-Avila, 2003). The presence of androgen, particularly testosterone, appears to be an important modulator of sexual desire in men, “priming” (i.e., lowering the threshold for) neural responsivity under specific contexts/conditions and to sexually relevant stimuli.

Libido or sexual desire is a psychological construct

Given the appropriate stimulus conditions, the man will respond with sexual arousal, a process that involves both central (brain) and genital activation. The precise brain mechanisms for arousal appear to be centered in the hypothalamic and limbic areas, but whole brain processing of contextual stimuli (sensory input), emotional state (positive or negative), and past experience/future consequences (probable frontal lobe contribution) is important to the process. Arousal most probably involves autonomic (sympathetic?) activation (giving rise to “erotic feelings”) integrated with the aforementioned “motivation” and cognitive processing centers that then regulate the descending neural impulses responsible for penile response.

Sexual arousal involves both brain and genital activation

Penile erection is a vascular process involving increased arterial inflow to the penis, penile engorgement with blood, and decreased venous outflow from the organ, processes that result in sufficient rigidity for sexual intercourse (Lue, 1992). Whether the penis is erect or flaccid depends upon the physiology of corporal cavernosal smooth muscle tone, that is, the equilibrium between proerectile and antierectile mechanisms controlling, respectively, relaxant and contractile responses of the smooth muscle cells comprising the penile blood vessels and cavernous tissue. Specifically, the erect penis results from relaxation of smooth muscle cells – the vasculature (arteries, arterioles, and capillaries) in the penis opens to allow the increased flow necessary for engorgement. The flaccid penis is characterized by contraction