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Male Sexual Dysfunction Disorders: an updated overview

Male Sexual Dysfunction Disorders: an updated overview

Lianet Pacheco
Florida National University

Abstract

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Male Sexual Dysfunction Disorders: an updated overview

Male sexual dysfunction disorder approach and perception has evolved in the last years. This
research will cover the main male sexual dysfunction disorders as stated by the DSM-5. The
purpose is to create an updated, organized, concise and complete guide for quick reference
regarding diagnosis and treatment of the main sexual disorders. What are the new guidelines in
the approach to male sexual disorders? How the approach has change in recent years? Many of
these questions answers will be found here.
Keywords: delayed ejaculation, erectile disorder, orgasmic disorder, arousal disorder, genitorpelvic pain, hypoactive sexual desire, premature ejaculation, medication-induced sexual
dysfunction

Introduction

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Male Sexual Dysfunction Disorders: an updated overview

The DSM has been and continue being the authority manual used by psychiatrist and
psychologist alike. Since its first edition in 1952 it has been the reflection of the contemporary
psychopsychiatric communitys investigations and thinking. As such, DSM and
psychopsychiatric literature in general has evolved significantly. Topics on male sexual
dysfunction have not been the exception. As an example, impotence was classified under
psychophysiological autonomic and visceral disorders on the 1952 DSM edition [1]. The
purpose of this paper is to provide an updated and concise reference for those looking for
guidance on male sexual dysfunction disorders approach including: criteria of diagnosis and
treatments options. When possible we will note recent changes on the DSM-5, including revise
classification, revise diagnostic criteria and revise on treatment approach.
Male sexual dysfunction disorders
In the DSM-5 the classification of sexual dysfunctions was simplified. There are now only four
male dysfunctions as opposed to six in the DSM-IV [2, 3]. Male sexual pain and male
dyspareunia entries were dropped from the sexual dysfunctions chapter of the DSM-5. Also, the
Not Otherwise Specified (NOS) category, sexual aversion disorder and sexual dysfunction due
to a general medical condition were not included at all in the newest edition. In addition, the
DSM-5 criteria now specifies that the condition has to last at least 6 months and have to cause
significant distress (the DSM-IV requirement of interpersonal difficulty was removed) to be
classified as a disorder [2]. These prerequisites will be assumed for all disorders explained in this
paper and will not be repeated. Other changes in the male disorders section of DSM-5 are minor
and will be covered when appropriate.
Delayed ejaculation

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Male Sexual Dysfunction Disorders: an updated overview

Delayed ejaculation (former male orgasmic disorder) is a mans inability for or persistent
difficulty (6 month or more) in achieving orgasm, despite normal arousal. In occasions,
ejaculation is only achieved after prolonged intercourse lasting for 3045 minutes or more [4].
Delayed ejaculation also includes those cases were man can only reach orgasm through
masturbation, but not sexual intercourse.
Causes include physiological, psychological and other like adaptation to masturbatory technique
[5].
Among the physiological causes, medical conditions or side effect to medication compromise the
main etiologies. Hypogonadism, thyroid disorders, pituitary disorders such as Cushings disease,
prostate surgery outcome, and drug and alcohol use are medical conditions that can lead to
delayed ejaculation [6]. Trauma o pelvic surgery affecting nerves responsible for orgasm have
been identified as a caused. Also, lack of sensation to the glands associated or not with
circumcision has been identified [7]. Delayed ejaculation as a possible side effect has been
described with the following medications: selective serotonin reuptake inhibitors (SSRIs),
opiates, benzodiazepines, antipsychotics, and antihypertensives [8].
Psychological causes include stress and anxiety in general, lack of sleep or quality of sleep,
anxiety about pleasuring the partner and anxiety resulting from relationship problems [9].
Traumatic masturbatory syndrome as a caused of delayed ejaculation has been proposed.
Proponents explain that sensations during masturbation greatly differ to sensations during
intercourse. Getting used to masturbation as the main sexual experience can make sexual
intercourse traumatically different impeding or delaying ejaculation. Also, the abrupt differences
in visual stimulation between masturbation and intercourse could play a role [10].

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Male Sexual Dysfunction Disorders: an updated overview

Treatment
The first step for a success treatment is to identify and remove the stressor when applicable and
possible. Assessing medication list and making changes when appropriate, rectifying endocrine
medical conditions.
A detail history can help in identifying psychological or behavioral causes. Nevertheless almost
all patients will benefit from sexual therapy. Through these sessions anxiety around sex and
relationship can be assessed and treated successful. In addition, through homework assignments,
exercises can be prescribed oriented toward adaptation to insertional intercourse were problems
exist. When appropriate, an increased of visualization during intercourse is advised [6].
Meditation has also yield positive results [11].
Unfortunately no medication has been proved to be effective. Most of the cases were delayed
ejaculation is secondary to trauma or damage to those nerve responsible of orgasm have very
poor prognosis [7].
Premature ejaculation
Premature ejaculation refers to that disorder where a male patient experiences orgasm and expels
semen within one minute of vaginal sexual intercourse. For premature ejaculation in the context
of non-vaginal penetration, DSM-5 does not provide a specific duration requirement [2].
Many causes have been theorized, however no clear etiology has been established [12].
Mechanism proposed include: elevated penile sensitivity, genetic predisposition, nerve
conduction atypicalities and irregularities in the serotonin receptors [13]. Premature ejaculation
and prostatitis have been linked [14].

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Male Sexual Dysfunction Disorders: an updated overview

Premature ejaculation has been subclassified as lifelong premature ejaculation and acquired
premature ejaculation (classification terms are self-explanatory) [15].
Patients suffering the acquired type treatment options include psychoeducation and reassurance
[16]. More complicated cases should explore the benefits of behavioral treatment with selftreatment as option number one. Sexual practices that have been described as helpful among
premature ejaculation using self-treatment include: to focus their attention away from the sexual
stimulation, purposefully ejaculating before sexual intercourse, thrusting more slowly and using
two condoms (not recommended because of increase risk of breakage) [12]. Most severe cases
can benefit from sexual therapy with a reported success rate of 90 percent [17].
The first line of treatment for patient suffering lifelong premature ejaculation is medication along
the behavioral therapies covered above. Successful pharmacotherapies options include: selective
serotonin reuptake inhibitors [18], Tramadol [19] and desensitizing topical medications [20].
Male hypoactive sexual desire disorder
Male hypoactive sexual desire disorder found a separate entry on the DSM-5 for the first time. It
is characterized as persistent or recurrent lack or absence of sexual fantasies and desire for sexual
activity. Further subclassification includes: Lifelong/generalized, Acquired/situational and
Acquired/generalized [2].
Lifelong/generalized describes no sexual interest with partner or alone and never. The cause in
these cases is unknown [21]. There is no concrete treatment for this subtype, instead therapy is
oriented toward couple adaptation and coping [22].

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Male Sexual Dysfunction Disorders: an updated overview

Acquired/situational subtype compromises those patients that were previously sexually

interested in current partner but now they dont [2]. However they still show interests in sex
along or to someone else. For these patients psychotherapy may be used, either with the man
alone and also together with his partner [22].
In the Acquired/generalized subtype the patient previously sexually interested in current partner
develops general sexual apathy toward current partner, along or anybody else [2]. Possible
etiologies include: low testosterone levels, high level of prolactin or psychiatric problems. For
these reason hormonal levels should always be assessed and corrected as needed. Any psychiatric
pathology needs to be identified and treated accordingly [21]. After biological causes have been
rule out counseling therapy should be explore to identify psychological causes or relationship
stressors [23].
Erectile disorder
Erectile disorder is characterized by the inability to maintain or develop an erection of the penis
during sexual activity [2]. This pathology can be subclassified further into psychological or
physiological. A key element in determining what subtype the patient is suffering from is a detail
history presence of morning erections, medication list, past medical/surgery history, social
history, etc. Usually those patients capable of achieving nocturnal or morning erection dont
suffer from biological etiologies rather psychological causes; however this is not an absolute fact
and further investigation is warmed [24].
Most common physiological causes include: cardiovascular disease, diabetes mellitus, local
neurological problems, drug sides effects and hypogonadism [24]. Psychological causes include:
stress, performance anxiety and mental disorders [25].

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Male Sexual Dysfunction Disorders: an updated overview

Currently many tests have been developed to determine the exact erectile dysfunction etiology.
Treatment depends on the cause. The first step is to address behavioral issues. Smoke cessation
results in significant improvement [25]. Exercise and diet might have a role as well [26].
Treating any underlying condition should also be priority. Also addressing psychological causes
with therapy can potentially reverse the condition. For those irreversible etiologies
pharmacotherapy options include: Phosphodiesterase type 5 inhibitors, topical and injected
options, extracorporeal shockwave therapy, vacuum erection devices and erectile implants [25].

Conclusion
Out of the four pathologies about male sexual dysfunction disorders covered in this paper ( and
the DSM-5 for that matter), erectile disorder is the one with higher prevalence with 18.4 percent

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Male Sexual Dysfunction Disorders: an updated overview

of men age 20 and older suffering the disease in the United States on 2002 [27]. Consequently,
more studies, diagnostic test and treatment options are available for these patients. Vast
information and resources are available for both patients and providers regarding premature
ejaculation as well. This pathology also has found great cure rates and self-treatment option as
stated above. As a result, few men with premature ejaculation seek help; rather they cure
themselves, either on their own or with a partner, using self-help resources [28].
Further research needs to be undertaken on delayed ejaculation and arousal disorders. Perhaps,
now that the DSM-5 has dedicated an independent entry to male hypoactive sexual desire
disorder, more investigators pursuit the topic. It is unlikely that many studies will be dedicated in
delayed ejaculation disorders since this is the pathology with a much lower incidence in
comparison to the other three [6].
Overall male sexual dysfunction disorders are much better understood that in the first edition of
DSM in 1952. Although there is room for improvement, male sexual education, information and
treatment options have greatly improved the XXI century male sexual health.

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Male Sexual Dysfunction Disorders: an updated overview

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Male Sexual Dysfunction Disorders: an updated overview

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