Although approaches to treatment of sexual dysfunction vary, some general principles are applicable. The careful taking of a history, an appropriate clinical examination and investigations should help distinguish between organic and psychogenic causes. Although there are no controlled research studies of most sexual dysfunctions, it is estimated that 60-80% are of psychogenic origin, marital disharmony and depression being the commonest. Once such a differentiation is made, appropriate treatment can be instituted. We see the role of the non-specialist as three-fold. First, ruling out organic disease and assessing a contributing physical illness (arthritis, radical mastectomy, stroke, heart attack, etc). Second, identifying psychologic factors, either as a primary cause for dysfunction or contributing to an organic cause. Third, eliciting discussion and educating the patient. The clinician should assist the patient in understanding the basis of the human sexual response and the intricate interplay between the physiologic and psychologic components. Open discussion about sexual matters can dispel many fears, anxieties or misinformation. Many patients have never had an opportunity to discuss their sexual experiences with a health professional. Breaking the barrier of silence, reducing anger and improving communication between partners may be sufficient for some patients. The doctor needs to assess the motivation of the patient/couple because treatment often requires considerable investment of time and effort.
A detailed description of the treatments is beyond the scope of this book and only selected treatments are going to be discussed. We believe that the patient should be given practical advice and treatment where possible but if (1) the diagnosis is in doubt; (2) the problem is too difficult; (3) there is poor rapport; or (4) there is no response, prompt referral to a psychosexual clinic should be made. Organic causes for sexual response disorders, painful penetration and painful sex should be treated accordingly. Depression needs to be excluded. If the problem persists in spite of accurate diagnosis and adequate treatment, it may be that the pathology cannot be fully resolved or there are coexisting psychologic factors. Strategies to cope with the problem, rather than a complete cure, may be more realistic.
Disorders of desire are the most difficult to treat. As mentioned above, educating the patient about a decline in desire with age, habituation, stress and relationship difficulties is important. A common sense suggestion, also applicable for arousal disorders, is setting time aside for relaxation; the need for warmth and perhaps flowers, scents, music, lubricants and in some cases sex aides.
Possible therapeutic avenues are pharmacologic doses of testosterone, hormone replacement therapy in postmenopausal women, apomorphine, buproprion, yohimbine. Of those only the first two have been shown to be effective.
Because a sexual arousal disorder almost invariably leads to an orgasmic disorder, the treatment of both disorders is similar. Counseling is very important. It should explore the relationship and its strengths, the domestic situation, occupation (e.g., shift work) and stressful life situations, etc..
Possible pharmacologic treatments are sildenafil, apomorphine, topical prostaglandins, testosterone and hormone replacement therapy in postmenopausal women. The first three are promising, but unproven; the latter two are the effective ones.
The Masters and Johnson sensate focus exercises, in which the couple moves stepwise from non-genital pleasuring to genital pleasuring to non-demanding coitus, generally benefit women regardless of the level of sexual inhibition. Education should be provided regarding the function of the genital organs, sexual responses and the best methods of stimulating the clitoris and the vagina. Kegel’s exercises strengthen voluntary control of the pelvic floor muscle. The muscles are contracted 10-15 times three times a day. Alternatively women are advised to do their pelvic floor exercises each time they pass urine — so it becomes simple routine. In two to three months, perivaginal muscle tone improves, as do the woman’s sense of control and the quality of the orgasm.
The standard treatment of vaginismus consists of self-exploration by looking at and feeling the genitals, information about genital anatomy and the physiology of arousal, learning relaxation techniques, pelvic floor exercises, discussing the problem with the partner, stopping attempts at penetrative sex, and gradual vaginal dilation until confidence is rebuilt. Dyspareunia may also be relieved by the use of artificial lubricants, or by the changing of sexual position to one where penetration is limited (side by side) or controlled (the woman on top).