assessment and treatment of psychogenic impotence

1. PSYCHOGENIC IMPOTENCE
ASSESSMENT AND APPROCH
Presenter: Amitkumar chougule

2. Introduction
 Definition
 Psychogenic vs. organic
 Causes
 Assessment
 Approach
 Conclusion

3. DEFINITION
• Erectile dysfunction (ED)/ Impotence is
• “theconsistent or recurrent inability of a man to attain
and/or maintain a penile erection sufficient for sexual
performance,”
(First International Consultation on Erectile Dysfunction, convened by the
World Health Organization in 1999)
National Institutes of Health consensus development panel further specified
• “Recurrent inability” as being 3 months or greater in
duration

4. Epidemiology
• Incidence and prevalence is high worldwide
• Affects up to 52% of men (40-70yrs)
• Steep age-related increase
• Complete impotence:
1. 5% in 40yr olds
2. 15% in 70yr olds
• Only 10-20% solely psychogenic

5. • The multinational Men’s Attitudes to Life Events and Sexuality
(MALES) study
1. One of the largest prevalence studies to date
2. 16% overall prevalence of ED
3. 22% prevalence in the United States
4. 16% prevalence in Asia

6. INDIAN STUDIES
• Bagadia et.al 1972 , Nakara et.all 1977 , Gupta et.al 2004
found impotency to be commonest sexual disorder

7. A sentinel for cardiovascular disease
• Most significant social implication of ED is its increasingly
recognized status as an early marker of vascular disease

8. Risk factors
• Note shared risk factors with CVD:
1. Sedentary lifestyle
2. Obesity
3. Smoking
4. Hypercholesterolemia
5. Metabolic syndrome
6. Diabetes mellitus

9. Aetiology
• Organic
• Hormonal
• Anatomical
• Drugs
• Psychogenic

10. CAUSES
• Vascular Causes
1. CVD
2. Atherosclerosis
3. Hypertension
4. Diabetes
5. Hyperlipidemia
6. Smoking
7. trauma
• Central causes
1. Parkinson’s
2. Stroke
3. MS
4. Tumours spinal
disease/injury
Peripheral causes
1. poly-/peripheral
neuropathy
2. Diabetes
3. alcoholism
4. Uraemia
5. pelvic surgery

11. Hormonal causes
• Hypogonadism
• Hyperprolactinaemia
• Thyroid disease
• Cushing’s disease

12. Anatomical causes
• Peyronie’s disease
• Micropenis
• Penile anomalies (hypospadias )

13. Drugs
1. Antihypertensives (beta blockers, diuretics)
2. Antidepressants (tricyclic and SSRIs)
3. Antipsychotics (phenothiazines, risperidone)
4. Anticonvulsants (phenytoin, carbamazepine)
5. Antihistamines
6. H2 antagonists (cimetidine, ranitidine)
7. Recreational drugs (tobacco and alcohol)

14. Psychogenic impotence
• Psychogenic ED was defined by the International Society of
Sex and Impotence Research as
“the persistent inability to achieve or maintain an erection
satisfactory for sexual performance, owing predominantly or
exclusively to psychological or interpersonal factors”

15. ICD 10
• F52.2 Failure of genital response
• If erection occurs normally in certain situations, e.g. during
masturbation or sleep or with a different partner, the
causation is likely to be psychogenic
• Otherwise, the correct diagnosis of nonorganic erectile
dysfunction may depend on special investigations (e.g.
measurement of nocturnal penile tumescence) or the
response to psychological treatment

16. Psychogenic impotence
• Immediate causes :
1. Performance anxiety
2. Lack of adequate stimulation
3. Relationship conflicts
• Remote causes :
1. Childhood sexual trauma
2. Sexual identity issues
3. Unresolved partner or parental attachments
4. Religious or cultural taboos

17. Pathogenesis Model for Acquired Psychogenic
impotence/ ED
• Precipitating events
↓
• One episode of erectile failure
↓
• Performance anxiety
↓
• Another episode of erectile failure
↓
• More performance anxiety
↓
• Decreased frequency of sexual initiation
↓
• Changes in the sexual equilibrium
↓
• Established pattern of impotence with partner

18. Precipitants of Recently Acquired Psychogenic Erectile
Dysfunction
• Deterioration of marital relationship: anger, guilt,
disdain, sadness
• Divorce: abandonment, anger, guilt, sadness, shame
• Deterioration of personal or spousal health: sadness,
anxiety, anger, shame
• Death of spouse (“widower’s impotence”): sadness,
longing, guilt

19. • Threat of or actual unemployment: anxiety, worthlessness,
guilt, anger, shame
• Financial reversal: shame, guilt, anxiety
• Extramarital affair: guilt
• Reunited marriage after extramarital affair: shame, anxiety

20. Psychogenic factors
• In 1910 Freud referred sexual dysfunction in men as
"the most prevalent failure of human life“
• The pejorative implications of the term impotence often
forms the main reason for men not seeking help

21. • Patients have varied psychological reactions to the
realization that he is impotent like:
 Loss of self-esteem
 Depression
 Fear of failure ("performance anxiety")
 Concern about his partner's feelings
 Fear about the possibility of the partner "acting out"
with potent men

22. • He may resort to certain tests to determine if he is indeed
impotent under all circumstances - for example,
 Masturbating
 Reading and viewing erotic material
 Attempting relationships with other women
• This may endanger his present relationship and he may lose
his only social support

23.  Men may be afraid that if intercourse is attempted and is less
than satisfactory then:
1. Their partner will be critical
2. Will withdraw love
3. Look elsewhere or tell others

24.  Delusions or paranoid feelings towards their partner :
1. They may fear the vagina (vagina dentata)
2. May fear that the partner is "diseased" as the result of an
affair
3. May fear that they have contracted a disease during an affair
and could then infect their original partner

25. • The fear or experience of sexual inadequacy results in the use
of tranquillizers or alcohol
• This act can worsens the problem
• Intervention is crucial to prevent further psychological and
physical decompensation

26. Changes in brain in psychogenic impotence
• Recent research shows macro structural changes in gray
matter of two subcortical regions
• These regions play an important role in the motivational
aspects of male sexual behavior:
1. Nucleus accumbens
2. Hypothalamus
• These findings highlight the importance of the
motivational component of sexual behavior to permit
satisfactory sexual performance in healthy men

27. EVALUATION

28. Sexual history taking
 Are you having sexual relations currently?
 If so, with men or women or both?
 If not, when did you last have sexual intercourse?
 Are you satisfied with the frequency and quality of your
sexual experience?
 Do you have more than one sexual partner?

29. Sexual history taking
• Assess libido/arousal
Do you have sexual thoughts?
How often do you want to have sex with your partner
• Assess erectile function
How often do you get an erection when you want to have
sex with your partner?
Do you get nighttime erections?
• Assess ejaculatory function:
Do you ejaculate too early, or is it difficult to ejaculate?

30. History for psychogenic component
• Was onset of ED instantaneous (one time, and then ever
since)?
• (except for post surgical nerve damage, this is always
psychogenic)
• common in;
1. first-time encounters
2. conflicted relationships
3. when patient feels obligated to have intercourse but does
not want to

31. • Rapidity of onset
• Sexually competent men who had no sexual problems
until "one night when they could not perform" and
thereafter become impotent invariably have psychogenic
impotence
• This problem may be caused by performance anxiety or
emotional problems

32. • Men suffering from impotence of any organic cause complain
that
“sexual function failed sporadically at first and then more
consistently”

33. Erectile reserve
• In men with ED presence or absence of spontaneous erections
is an important clue to diagnosis
• Most men experience spontaneous erections during REM
sleep and often wake up with an erection
• This indicates the integrity of neurogenic reflexes and corpora
cavernosa blood flow

34. • Information regarding nocturnal or early morning erections
can be elicited by history from patient and/or partner
• Nocturnal penile tumescence testing may be required for
proof
• Complete loss of nocturnal erections is present in men with
neurologic or vascular disease

35. Physical examination
A careful assessment of femoral and peripheral pulses as a clue
to the presence of vasculogenic impotence
A search for visual field defects present in hypogonadal men
with pituitary tumors
A breast examination to detect gynecomastia, often present in
Klinefelter's syndrome

36. Physical examination
oA search for penile strictures indicative of
Peyronie's disease
oExamination of the testicles looking for atrophy,
asymmetry or masses
oEvaluation of the cremasteric reflex, an index of
the integrity of the thoracolumbar erection
center

37. Lab evaluation
1. Testosterone level (consider peak 8 am and trough 8 pm
when evaluating result, can be 30% difference)
2. Prolactin level
3. TSH
4. Hematology
5. Hepatic and kidney function
6. Hemodynamic evaluation
7. Nerve conduction studies

38. Psychiatric Assessment
• Full psychiatric history from the patient and mental status
examination
• Interview patient's sexual partner separately as she can
provide information and details from her point of view

39. • Systematic psychiatric assessments have shown that factors
contributing to psychogenic impotence are:
1. Heterosexual maladjustment
2. Lack of support from the partner
3. Anxiety and/or depression
4. Occupational stress
5. Economic and domestic stress
6. Use or abuse of some drugs

40. Nocturnal penile tumescence recording
 (NPT) occurs in all normal males from early infancy to old
age
 NPT is closely linked to rapid eye movement (REM) sleep
 Its measurement is widely accepted in the differential
diagnosis of impotence

41. The rationale for its use is :
 In cases of organic impotence NPT is absent or diminished
 In psychogenic impotence sleep erections occur with normal
frequency and magnitude

42. • Ideally done in a sleep laboratory with simultaneous standard
polygraphic sleep recording:
1. Electroencephalogram
2. electro-oculogram
3. Electromyogram
• Diagnostic accuracy depends more on the expertise of the
individual interpreting the recording
• It is commonly assumed that penile expansion of more than
15 mm indicates psychogenic impotence, while lesser
expansion indicates organicity

43. INTERNATIONAL INDEX OF ERECTILE
FUNCTION(IIEF)
 Superficial assessment of psychosexual background
 Very limited assessment of partner relationship
 An adjunct to rather than a substitute for a detailed sexual
history and examination
• (Rosen R, Riley A, Wagner G, et al. Urology, 1997, 49: 822-830)

44. International Index of Erectile Dysfunction
IIEF
• The following guide-lines may be applied:
 Patients with low IEEF scores (<14 out of 30) in Domain A
(Erectile Function) may be considered for a trial course of
therapy with Sildenafil unless contraindicated. Specialist
referral is indicated if this is unsuccessful

45.  Patients demonstrating primary orgasmic or ejaculatory
dysfunction (Domain B) should be referred for specialist
investigation
 Patients with reduced sexual desire (Domain C) require testing
of blood levels of androgen and prolactin
 Psychosexual counselling should be considered if low scores
are recorded in Domains D and E

46. 1. SEXUAL HEALTH INVENTORY FOR MEN (SHIM)
2. ERECTILE DYSFUNCTION QUESTIONNAIRE

47. Management
• Main goal: diagnose and treat underlying cause
• Modify reversible causes (lifestyle, drugs)
• Physical exercise and weight loss leads to 70% improvement

48. PSYCHOTHERAPY FOR ED
• Rosen divided treatment for psychogenic ED into four
types:
1. Anxiety reduction and desensitization
2. cognitive-behavioral interventions
3. Increased sexual stimulation
4. Interpersonal assertiveness and couples’
communication training

49. Anxiety reduction and desensitization
• Designed to reduce performance anxiety by avoiding
intercourse in early treatment and using relaxation techniques
• Instead of having coitus, the couple follows a series of
nongenital, non demand, sensate focus exercises popularized
by Masters and Johnson

50. Cognitive behavioural interventions
• In attempts are made to overcome unrealistic sexual
expectations
• Psychoeducation of the couple

51. Interpersonal and systemic interventions
• Issues concerning status and dominance, intimacy and trust,
and loss of sexual attraction may be addressed

52. • Psychological factors are often significant contributors to all
types of organic ED
• Some form of sex therapy or counseling as an adjunct is
crucial for organic ED

53. Dual-Sex Therapy
• Originated and developed by Masters and Johnson
• Both individuals are involved in a relationship in which there
is sexual distress
• Both must participate in the therapy program

54. Continued…
• The marital relationship as a whole is treated
• Improved communication in sexual and nonsexual areas is a
specific goal of treatment
• Psychological and physiological aspects of sexual functioning
are discussed with an educational attitude

55. Behavioral Exercises
• Sexual dysfunction often involves a fear of inadequate
performance
• Initially, intercourse is avoided and couples learn to give and
receive bodily pleasure without the pressure of performance
• Sensate focus exercises are used to lessen anxiety
• They are urged to use fantasies to distract them from
obsessive concerns about performance, which is termed
spectatoring

56. Hypnotherapy
• Hypnotherapists focus specifically on the anxiety-producing
symptoms
• Helps the patient gain control over the symptom that has
been ;
1. lowering self-esteem and
2. disrupting psychological homeostasis

57. Behaviour Therapy
• Behavior therapists assume that sexual dysfunction is learned,
maladaptive behavior
• Therapist sees the patient as phobic of sexual interaction
• Therapist sets up a hierarchy of anxiety-provoking situations
for the patient
• Patient masters the anxiety through systematic
desensitization
• Assertiveness training is used to teach patients to express
their sexual needs openly and without fear

58. Group Therapy
• For patients who feel ashamed, anxious, or guilty about a
particular sexual problem
• It is a useful forum to :
1. Counteract sexual myths
2. Correct misconceptions
3. Provide accurate information regarding sexual anatomy,
physiology

59. Integrated Sex Therapy
• Sex therapy integrated with supportive, psychodynamic,
or insight-orientated psychotherapy is very effective
• Insight-oriented therapy helps to deal with problems in
interpersonal relationships or intrapsychic conflicts that
frequently are at the root of the sexual problem
• Sex therapy integrated with pharmacotherapy is very
effective

60. Biological Treatment Methods
• Pharmacotherapy useful in treatment of erectile dysfunction
of various causes
• Drugs explored in the treatment of ED are:
1. Nitric oxide enhancers/ PDE 5 Inhibitors
2. Oral prostaglandin (Vasomax)
3. Alprostadil (Caverject)
4. Injectable phentolamine
5. Transurethral alprostadil (MUSE)

61. Nitric oxide enhancers/ PDE 5 INHIBITORS
• Sildenafil augments the natural process involved in gaining
and maintaining an erection during sexual stimulation
• Sildenafil has no effect in the absence of sexual stimulation
• Two other nitric oxide enhancers are:
• Vardenafil
• Tadalafil

63. How to use sildenafil (Viagra)??
• Prescribe 25, 50, or 100 mg tab to be taken 30 min to 4 hrs.
before intercourse
• Contraindicated if patient taking nitrates
• Reduce dose if >65 or impaired liver or kidney function

64. INTERACTION WITH FOOD
• Presence of fatty foods can double the absorption time of
Sildenafil and Vardenafil from 1 hour to 2 hours
• Absorption is reduced by 20-50%
• If taken after meals then people should wait at least 2 hours
prior to activity

65. • Tadalfil onset of action is after 2-4 hours
• Should be taken at least 4 hours prior to activity
• Side effects seen within 30-60 minutes of taking the pill and lasts
30-60 minutes
• These are usually mild and disappear after a while
• Visual disturbances
sildenafil/vardenafil cross react with an enzyme in the retina known as
PDE6, thus causes blurred vision, double vision or loss of colour vision

66. Oral phentolamine (Vasomax)
1. Has proved effective as a potency enhancer in men with minimal
erectile dysfunction
2. Useful for men with cardiac problems as sildenafil is
contraindicated for men using organic nitrates
3. Not currently approved by the FDA
Apomorphine
• being tested as an oral remedy for erectile dysfunction
Alprostadil
• Injectable and transurethral alprostadil act locally on the penis
• can produce erections in the absence of sexual stimulation

67. Self-injection of papaverine and phentolamine in the
treatment of psychogenic impotence
• Self-injections four times monthly has a 94% success rate
• Increase in frequency of intercourse and sexual satisfaction
• Decreased anxiety is seen

68. YOHIMBINE IN TREATMENT OF PSYCHOGENIC
IMPOTENCE
• Yohimbine is a safe treatment for psychogenic impotence
• As effective as sex and marital therapy for restoring
satisfactory sexual functioning
• Response to yohimbine is unrelated to the cause of
impotence

69. Testosterone Replacement Therapy: Should It Be
Performed in Erectile Dysfunction?
• The first choice of therapy in ED is PDE-5 inhibitors
• No response in 30-50% of the patients
• When TRT is added to the therapy of non responders, the
outcome is positive
•
(Orcun Celik 1, *, Selcuk Yücel, July 2013)

70. Bibliotherapy
• Books for patients
• The new male sexuality, by Bernie Zilbergeld, Ph.D
• Practical book debunking sex myths
• has exercises for ED, losing erections, premature ejaculation.
• Humorous and useful,
• Good anatomy descriptions

71. • The passionate marriage: love, sex, and intimacy in
emotionally committed relationships by David Schnarch,
Ph.D.
• A little higher reading level
• Better for couples looking to understand sexual policies in
their marriage

72. Conclusion
• ED is the one of the most common and most distressing sexual
dysfunction in men
• Psychiatrist has a crucial role to play in the evaluation and
management of ED as he the only specialist who has a adequate
knowledge of both organic and psychogenic causes of ED
• Even after recent advances in pharmacotherapy sex therapy
remains gold standard for psychogenic impotence
• Sex therapy has a vital role as an adjunct in treatment of organic
causes

73. ……with our knowledge and
support lets bring back the light
lost in the dark bedroom of couples
with sexual dysfunction….

74. ……….Thank you………