Sexual difficulty that prevents the individual or couple from enjoying sexual activity may be physical, psychological, or both (which includes desire, arousal, orgasm, and resolution).

Emotional factors may include both interpersonal problems (such as relationship problems, or trust and communication problems as well as work problems) and psychological problems within the individual (sexual fears or guilt, past sexual trauma, anxiety or depression ).

Physical factors contributing to sexual problems include:

• Drugs (alcohol, antihypertensives, narcotics, antihistamines, stimulants, nicotine)
• Injuries to the back
• Prostate gland disease
• Cardiovascular disease
• Nerve damage (spinal cord injuries)
• Disease (diabetic neuropathy, multiple sclerosis)
• Breathing difficulties
• Endocrine disorders (thyroid, pituitary, or adrenal gland problems)
• Hormonal deficiencies (low testosterone, oestrogen)

Sexual dysfunction disorders are generally classified into 4 categories:

• desire disorders
• arousal disorders,
• orgasm disorders
• dyspareunia.

Desire disorders (decreased libido) may be caused by a decrease in normal oestrogen (in women) or testosterone (in both men and women) production. Other causes may be aging, fatigue, pregnancy, medications (some anti-depressants are well known for reducing desire in both men and women). Depression and anxiety have a negative affect on libido.

Sexual arousal disorders were previously known as frigidity in women and impotence in men, though these terms are now obsolete, the latter being referred to as erectile dysfunction now.

Medical causes include chronic disease. Many erectile disorders in men are primarily physical, not psychological conditions; hence the success of Viagra.

Persistent delay or absence of orgasm following a normal sexual excitement phase occurs in both women and men. SSRI antidepressants are frequent culprits.

Dyspareunia may be Superficial or Deep. Superficial may be caused by insufficient lubrication in women. However there may be painful local lesions on the vulva, such as Herpes simplex. Vaginismus is an involuntary spasm of the muscles of the pelvic floor that interferes with intercourse. It is an involuntary physical reaction to a psychological anxiety. There may have been a past traumatic history or it may be that there is deep dyspareunia that is anticipated resulting in the muscle spasm.  Deep dyspareunia (painful intercourse) may be due to some gynaecological condition. If it is of recent onset there may be a sexually transmitted infection such as chlamydia. A longer history might suggest endometriosis or pelvic adhesions.

Another condition that affects the vulva is vulvodynia. In this condition, women experience burning pain related to problems with the skin in the vulval area. The cause is unknown.

Desire disorders may respond to hormone therapies. Men may benefit from investigation and treatment by a urologist. For women a sympathetic discussion about HRT or other supplements may be obtained from a gynaecologist. In some cases, women with androgen deficiency can be helped by taking testosterone

Arousal disorders in women may benefit from psychosexual counselling. Men may also benefit but the ease of use of sildenefil has revealed that many of the male problems are physical rather than psychological.

Orgasm disorders, if not drug induced are difficult to treat and psychosexual counselling is advised.

Dyspareunia due to vaginal dryness may benefit from simple lubrication. H however in the postmenopausal woman a sympathetic discussion about Hormone Replacement may be helpful.

Deep dyspareunia needs a diagnosis. A gynaecological Endoscopic Surgeon with an interest in pelvic pain will want to map the pain on examination and relate the site of pain to laparoscopic findings. It may be possible to offer laser surgery to endometriosis and adhesions.

Vulvodynia  requires diagnosis by vulvoscopy and biopsy to establish a diagnosis. Creams appropriate to the result may then be prescribed. Low doses of some antidepressants may also help nerve pain.

Behavioral treatments involve many different techniques Masters and Johnson treatment strategies are among the many behavioral therapies used that have been described.

COMPLICATIONS

Some forms of sexual dysfunction may cause infertility. If the sexual problem is persistent it may cause depression and may lead to conflicts or potential breakups.

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