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 Table of Contents  
ALLIANCE GUIDELINE
Year : 2013  |  Volume : 2  |  Issue : 1  |  Page : 5-18

Consensus guidelines on male sexual dysfunction


1 Department of Endocrinology, Bharti Research Institute of Diabetes and Endocrinology (BRIDE), Bharti Hospital, Karnal, Haryana, India
2 Department of Psychiatry, National Drug Dependence Treatment Centre (NDDTC) WHO Collaborating Centre on Substance Abuse All India Institute of Medical Sciences (AIIMS), New Delhi, India
3 Department of Endocrinology, Excel Center, Ulubari, Guwahati, Assam, India
4 Department of Urology, Menz Health Clinic, Noida, Uttar Pradesh, India
5 Department of Surgery, Makker Medical Centre, Lucknow, Uttar Pradesh, India
6 Diplomate, American Board of Clinical Sexology and Fellow, American College of Sexologist, AASECT Certified Sex Therapist, Indore, Madhya Pradesh, India
7 Department of Urology, GadaLife ART Center, CHL Apollo Hospitals, Indore, Madhya Pradesh, India
8 Department of Urology, Asha Hospital and Tanvir Hospital, Hyderabad, India
9 Department of Medicine, Diabetes, Obesity and Thyroid Center, Gwalior, Madhya Pradesh, India
10 Department of Medical Affairs, Zydus Cadila, Ahmedabad, Gujarat, India

Date of Web Publication1-Jan-2013

Correspondence Address:
Yatan Pal Singh Balhara
Balhara Assistant Prof. Department of Psychiatry, Room No 4096, 4th Floor, Teaching Block, All India Institute of Medical Sciences (AIIMS) Ansari Nagar, New Delhi, 110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-019X.105288

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  Abstract 

Male sexual dysfunction (MSD) is a common and distressful condition which is often amenable to counseling and other non pharmacological therapy. These ALLIANCE guidelines are an exhaustive coverage of the counseling and related non-pharmacological methods used for management of MSD. The guidelines discuss various concepts of medical care, including the bio-psychosocial model, patient centered care, couple centered care, therapeutic patient education, shared decision making, minimizing the discomfort of change, and coping skills training, as related to MSD. They go on to describe the ideal environment and prerequisites in which a proper history should be elicited, and physical examination performed. Counseling related to investigations, physical activity and yoga is described. Specific examples of psychotherapy for various sexual disorders are presented to illustrate the usage of counseling. The guidelines discuss cognitive behavioral therapy, couple centered therapy, family therapy, and use of religion in detail. Counseling regarding pharmacological, device and invasive therapy is also covered. The guidelines conclude with a call to enhance community awareness of MSD

Keywords: Hypoactive sexual desire disorders, male sexual dysfunction, premature ejaculation, sex, erectile dysfunction


How to cite this article:
Kalra S, Balhara YS, Baruah M, Saxena A, Makker G, Jumani D, Kochhar K, Majumdar S, Agrawal N, Zaveri H. Consensus guidelines on male sexual dysfunction. J Med Nutr Nutraceut 2013;2:5-18

How to cite this URL:
Kalra S, Balhara YS, Baruah M, Saxena A, Makker G, Jumani D, Kochhar K, Majumdar S, Agrawal N, Zaveri H. Consensus guidelines on male sexual dysfunction. J Med Nutr Nutraceut [serial online] 2013 [cited 2019 Jan 24];2:5-18. Available from: http://www.jmnn.org/text.asp?2013/2/1/5/105288


  Introduction Top


Sexual dysfunction is common in men across the world,[1] and Indian men are no exception. Epidemiological data suggest that globally, a high prevalence of Male Sexual Dysfunction (MSD) is observed. Western studies have reported a wide variation in range of various MSDs. In the United States, an estimated 20% of persons have hypo-active sexual desire disorder. Acquired male erectile disorder has been reported in 10-20% of all men. A general prevalence of 5% of male orgasmic disorder has been reported. Premature ejaculation is the chief complaint in about 35-40% of men treated for sexual disorders in USA.

Earliest Indian medical literature on MSD in modern medicine dates back to 1950s.[2] Indian studies have reported findings primarily from hospital setting including general out-patients departments, skin and venereal disease out-patients departments, psychosexual clinics, psychiatry out-patients departments, addictive disorder clinics, and psychiatric in-patient settings. Based on the findings in these studies, commonly reported sexual dysfunctions by adult Indian males attending psychosexual clinics include premature ejaculation (77.6%), nocturnal emission (71.3%), and erectile dysfunction (23.6%).[3] Studies conducted in skin out-patient department have also found erectile dysfunction (34%), premature ejaculation (16.6%), and nocturnal emission (14%) to be some of the most common MSD.[4] Studies conducted in Marriage and Sex clinics have also found premature ejaculation and erectile dysfunction to be the most commonly diagnosed conditions in these clinics.[5]

It is important to mention here that a significant proportion of Indian males presenting to these treatment settings seek help for various other concerns related to sexual functioning. These include dhat syndrome, apprehension about potency, guilt associated with masturbation, concerns that loss of semen is harmful to health. Whereas many of these concerns do not fall under a diagnosable heading, they are an important source of distress and dysfunction in these individuals.

Need for guidelines

Though a number of guidelines are available for the management of MSD,[6],[7],[8],[9] these are limited in scope, as they focus predominantly on erectile dysfunction[10] and premature ejaculation, Though they cover investigations and pharmacological interventions in detail, they do not explain sexual counseling, and gloss over the soft skills required for sexual dysfunction management. In addition, being of western origin, they do not address some of the unique features and challenges of South and West Asian andrology, such as involvement of family members, or difficulty in practicing couple therapy. Recent authors have highlighted the differences between MSD in Asian and in North American populations 1.[11] Whether the lower reported rates of erectile dysfunction are due to a healthier habitus or due to lack of courage to report it needs to be studied. It is also possible that Asian patients rely upon complementary and alternative medicine to improve their sexuality, and hence do not report MSD. Another reason may be, in general, sub-optimal health care seeking behavior of Asian males.[12] Indian and other Asian patients who do seek medical care for MSD often have expectations from their healthcare professionals who are different from their western peers. They often expect a more powerful, more masculine personality who is able to maintain a close relationship through conversation, while ensuring competent therapeutic intervention. At the same time, accepted body language and physical contact varies from culture to culture. What may seem a threatening touch to an American patient might be perceived as a friendly, platonic gesture by an Indian with MSD.

The Diagnostic and Statistical Manual of Mental Disorders Fourth Revision (DSM-IV) clearly states that clinical judgments related to diagnosis of sexual dysfunction should consider ethnic, cultural, religious, and social backgrounds. It stands to reason, therefore, that clinical judgments related to therapy of MSD too, should be made after considering psycho-socio-cultural factors. These facts underscore the need for guidelines which address the specific needs of Indian patients, not focusing on pharmacotherapy alone, but rather on the soft and hard skills required for counseling patients. However, no comprehensive guidelines are available to address the issue of sexual counseling, either in India or abroad, whereas attempts have been made to standardize pharmacological practices in certain forms of MSD.

ALLIANCE, as a multidisciplinary team of experts, understands this lacuna, and feels it necessary to provide guidance to healthcare professionals regarding counseling in sexual dysfunction. This is, especially, necessary as counseling and communication skills are not a part of undergraduate, postgraduate, or fellowship curricula, and often do not keep pace with the "hard" skills or "pharmacology-related" skills of healthcare professionals. Sub-optimal counseling may also negatively impact the potential efficacy and efficiency of pharmacological or invasive therapy in men with sexual dysfunction.

The guidelines are planned as a comprehensive, updated synthesis of evidence and experience, meant for all healthcare professionals working with male patients with sexual dysfunction. They serve to provide a complete framework for practitioners to base the non-pharmacological therapy and enhance the efficacy of pharmacological interventions.


  Methodology Top


The need to have clinical guidelines on the subject of counseling in MSD was agreed upon at a multidisciplinary meeting of ALLIANCE held on 2 June 2012. The first draft of these guidelines was prepared by a core writing group of six authors, and then circulated among 25 members of ALLIANCE. These included specialists in endocrinology, psychiatry, urology, andrology, gynecology, infertility medicine, and internal medicine. Experts in psychiatry and public health were co-opted as authors to ensure a multi-specialty contribution to the guidelines.

Their suggestions and changes were incorporated, and a second draft was circulated for editing. After all relevant changes were made, a third draft was circulated among a group of 5 international reviewers, whose comments were utilized to create a fourth and final draft. These guidelines contain recommendations which were rated for level of evidence and strength of rating, using the methodology laid down by the American Association Of Clinical Endocrinology (AACE) protocol for production of clinical practice guidelines[13] [Table 1] and [Table 2].
Table 1: Evidence rating used in COGMED (as per American Association of Clinical Endocrinology protocol for production of clinical practice guidelines, 2010)

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Table 2: Grading of recommendation used in the COGMED (as per American Association of Clinical Endocrinology Protocol for production of clinical practice guideline)

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The ALLIANCE guidelines on counseling in MSD served as guide for all healthcare professionals, including physicians and non-physicians, involved in the management of MSD. It is hoped that this work will help improve the standard of care for patients with MSD, and contribute to improved therapeutic outcomes.

Planning the initial approach

Framework

Path-breaking work on counseling in sexual dysfunction was undertaken by Masters and Johnson in the 1960s, and published in 1970.[14] Since then, significant developments have taken place in our understanding of the pathophysiology of sexual function and dysfunction; the concepts of therapeutic patient education, counseling, motivational interviewing, shared decision making (SDM) and patient-centered therapy, and therapeutic modalities were available for management of sexual dysfunction.

Sexual dysfunction is described in the DSM-IV-TR fourth edition, Text Revision[15] as follows: A sexual dysfunction is characterized by a disturbance in the processes that characterize the sexual response cycle or by pain associated with sexual intercourse. The term MSD includes a wide variety of disorders which can be classified according to the etiology (due to psychological or combined factors), phase of sexuality that is involved, duration of illness (lifelong or acquired), and the context in which the dysfunction occurs (generalized or situational) 2. The various male sexual disorders that affect these phases and their DSM-IV codes are listed in [Table 2] and [Table 3]. These lists form the basis of the diagnostic and therapeutic interventions that are necessary to improve MSD.
Table 3: Sexual disorders (as mentioned in Diagnostic and Statistical Manual of Mental Disorders fourth revision, with codes)

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ALLIANCE recommendations

  • MSD HCPs should be aware of psychological aspects of MSD management. Grade A, EL4.
  • Healthcare professionals involved in counseling of patients with male sexual dysfunction (MSD) health care professionals (HCPs) should be aware of the DSM-IV and International Classification of Disease (ICD) classification of sexual disorders: Grade A, EL1.
  • Healthcare professionals involved in counseling of patients with male sexual dysfunction (MSD HCPs) should be aware of the Masters and Johnson technique: Grade B, EL1.


Philosophy

It is important to understand the underlying bio-psychosocial underpinnings of various MSDs. MSDs can be manifestations of biological (biogenic) problems or intra-psychic or inter-personal (psychogenic) conflicts or even a combination of these factors. Stress plays an important role in pathogenesis of MSDs. Stress associated with emotional disorders or by ignorance of sexual function and physiology can impact sexual functioning. Hence management of MSDs calls for a multi-pronged approach. The management plan should focus on the biological, psychological, and the environmental factors relevant to a particular individual seeking help for MSD.

Though a patient-centered approach should be followed in every sphere of medicine, nowhere is this more true than in sexual dysfunction. When many factors are shared by individuals suffering from MSDs, some factors such as psychological and environmental could be unique to an individual patient. Hence, the management plan needs to be individualized. Not only will such approach help improve effectiveness of the intervention, but it will also improve its acceptability and ensure active patient participation.

Patient-centered approach has been defined as "care that is respectful of and responsive to individual patient preferences, needs, and values" and that ensures "that patient's values guide all clinical decisions."[16] This approach has been accepted not only in family medicine, but also in management of chronic endocrine disorders such as diabetes mellitus and hypothyroidism.[17],[18] In MSD as well, patient centered care (PCC) is necessary if one is to achieve expected therapeutic outcomes.

PCC, in the context of MSD, implies understanding the patient's background, his attitudes, beliefs, knowledge, and misconceptions about sexuality, fertility, and related issues. It also includes understanding the social environment that he lives in and his attitudes and behavior towards members of the other gender (and his own). Not only that, PCC mandates an appreciation of the physical environment of the patient, such as privacy and comfort available to him and his partner. PCC, without saying, also requires an in-depth analysis of the biological status of the patient with MSD, viz, his medical, endocrine, and urological health.

The concept of PCC in MSD, however, goes beyond the individual. Sexual function is not possible without a partner. Therefore, MSD counseling and management require the use of a couple-centered approach, also termed by use as couple-centered care (CCC). In the CCC model proposed by ALLIANCE, the couple may be taken as the basic unit for intervention.

At times, the issue of sexual dysfunction takes on such importance in a young couple's life, that the entire family gets involved in the couple's personal life. This is especially true in traditional joint families, where the young couple has to face pressure from older family members to prove their fertility and fecundity immediately after marriage. In some selective cases, it is possible that counseling is broadened to include important family members. Another clinical scenario where family counseling may be required is when an elder brother or brother-in-law accompanies a patient with MSD to the clinic, and agrees to take partial responsibility for therapeutic education (TPE).

TPE is a concept originally used in chronic disease such as diabetes and asthma. [19] The concept of TPE states that educating and empowering patients about their diabetes leads to therapeutic benefits per se, and improves the benefit noted with other therapeutic modalities such as diet, physical activity, and drugs. TPE is a patient-centered approach.

TPE is an integral part of sexual counseling, even though the term has not been used so far in this context. Educating the patient with MSD about the anatomy, physiology, and psychology of sexuality, the possible pathophysiological mechanisms of sexual dysfunction, and available treatment modalities is in itself an important therapy. Understanding these aspects of health and illness forms the basis of any successful management strategy in MSD. Treating MSD, without adequate patient education, whether by drugs or non-pharmacological means, runs the risk of relapse. Patient education is therapeutic not only in the sense that it helps the patient understand what he is going through, but also provides a feeling of empowerment, and helps the patient take appropriate decisions. For example, an informed patient may choose a method of androgen replacement therapy which is most suitable for his needs. One individual may prefer monthly testosterone ester injections, if he visits his spouse every month, whereas another may wish to take long-acting depot preparations if he dislikes visiting the healthcare facility, or does not have time for the same.

This concept of MSD management is known as SDM. Shared medical decision making is a process by which patients and providers consider outcome probabilities and patient preferences and reach a healthcare decision based on mutual agreement.[20] For MSD management to be successful, SDM is essential. SDM is possible only if the patient is empowered,[21] by means of TPE, to understand his condition. Hence, TPE becomes an indispensable part of counseling in MSD.

Most patients of MSD, during the course of treatment, will undergo a change in their thoughts, attitudes, behavior, and practice. These changes may be linked directly to sexuality, e.g., appreciating pornography, accepting the use of stimulatory toys, or practicing self-stimulation. At the same time, some changes might be non-sexual in nature, e.g., maintaining personal hygiene, improving physical fitness, practicing yoga, or joining confidence-building classes. Any such changes will certainly be linked with some degree of discomfort. Any counseling strategy for MSD should contain in-built measures to help patient minimize the discomfort of change. MSD is associated with significant stress.

Patients with MSD must be viewed as human beings, in a holistic manner. Therefore, stress management, or specifically, coping skills training (CSI) becomes an important part of counseling for MSD. In a nutshell, to be successful, counseling for MSD should include a part from sexual counseling, elements contained in [Table 4].
Table 4: Elements in the philosophy of ALLIANCE guidelines

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Thus, ALLIANCE guidelines are complementary to and concordant with bio-psychosocial model of disease.

ALLIANCE recommendations

  • MSD counseling must follow a patient-centered approach. Grade A, EL4.
  • MSD counseling must be accompanied by Therapeutic patient education Grade A, EL4.
  • MSD counseling must be based on SDM Grade B EL4.
  • MSD counseling must involve some element of CST Grade B EL 4.


Pre-requisites

External environment

A patient friendly external environment is mandatory if counseling is to be successful.[22] The external environment need not be luxurious or lavishly furnished or decorated. However, it must fulfill a few basic needs of the patient [Table 5].
Table 5: Attributes of external environment

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ALLIANCE recommendations

  • MSD HCPs must ensure a patient-friendly external environment conducive to counseling Grade A, EL4.


Pre-requisites

The counselor

The counselor plays a pivotal role in management of MDSs. Counseling for MSD can be done by a single counselor of either gender or by a couple. They may choose to interact with the male counselor (s) as patient alone, or with the couple (patient and partner) as a unit.

The decision to interact with the individual patient or with the couple will depend upon the comfort level of the patient, the expertise of the treating physician, the socio-cultural environment, and the physical ambience of the clinical setup. Irrespective of the external factors, the counselor must possess certain basic qualities to successfully manage MSD. When there are hundreds of adjectives to describe "humane" and "interactive" properties expected of any healthcare professional, the CARES mnemonic seems to encapsulate all of them. Counseling in MSD should be performed by a person who exhibits the attributes and possesses the skill set listed in [Table 6].[23]
Table 6: Attributes of a counselor

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Learning, internalizing, and utilizing these skills is an ongoing process in every healthcare provider's professional life. Fine tuning of these habits creates a launching pad for successful counseling.

The MSD counselor should carry an air of confidence, buttressed by competence, while conveying that he is accessible to the patient. The relationship between the patient and provider dyad must be based on respect for each other's beliefs and attitudes. The counselor should be able to express his empathy (as opposed to sympathy) and understanding for the patient's condition, and should behave in a simple honest manner. The counselor should offer an accepting atmosphere and a non-judgmental attitude.

The counselor should be trained in the science of motivational interviewing, as he may have to help motivate the patient to bring about change in his lifestyle.

The WATER approach represents a simple step-wise method of motivational interviewing, which can be adapted for use in MSD counseling[24] [Table 7]. This mnemonic, originally used in diabetes care, reminds the counselor to welcome the patient, make him feel at ease, take a relevant history, address his queries and doubts, suggest therapeutic measures, and build his confidence.
Table 7: WATER approach

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Verbal language

Counseling must be carried out in the language that the patient is most comfortable with. Using the specific dialect or speaking in an accent understood by the patient.

The choice of euphemisms suggestive words and phrases to describe sexual issues will depend upon the socio-cultural background and the educational level of the patient. An educated person may prefer using English terminology, whereas a relatively less literate patient will be comfortable with street slang. Patients may use euphemisms based upon their occupation and lifestyle, and counselors should be alert to the subtle suggestions contained in words. Confident patients will approach the issue directly, whereas shy men may use an indirect method of asking for help. Some of the symptoms which may be reported by patient as a surrogate for sexual inadequacy are listed in [Table 8].
Table 8: Surrogate symptoms of sexual inadequacy

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Non-verbal language

Counselors should be trained to pick up non-verbal cues of discomfort. Presence of these cues implies that discomfort – allaying or confidence building measures are necessary before counseling can proceed. It also indicates that the counselor has stRayed into "threatening territory" while eliciting a history or discussing sexuality, and should return to safer, less threatening ground. Some non-verbal language cues, gleaned from the patient's body language which suggest discomfort, are mentioned in [Table 9].
Table 9: Non-verbal cues of discomfort

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ALLIANCE recommendations

  • MSD HCPs must develop the skillset enumerated in the CARES mnemonic [confident competence, authentic accessibility, reciprocal respect, expressive empathy, and straightforward simplicity] Grade A, EL4.
  • MSD HCPs must develop proficiency in motivational interviewing Grade B, EL4.
  • MSD HCPs should develop an understanding of verbal and non-verbal body language Grade C, EL4.


History taking

A complete history taking should precede counseling and therapy for MSD. History taking serves multiple purposes [Table 10]. It not only provides an opportunity to gather information, but also helps in building the therapeutic ALLIANCE.
Table 10: Benefits of history taking

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History taking in MSD follows the same pattern as a general medical history. However, certain points merits mention [Table 11].
Table 11: History taking in MSD

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Each relevant aspect of history should be explored in detail. A few words from a poem in, The Elephant child, by India born Novel Prize laureate Rudyard Kipling, help one understand how much detail to go in while taking a sexual history [Box 1].[19] The five Es of sexual history taking must be followed [Table 12] at all times.
Table 12: The five E's of sexual counseling

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A simple hierarchy of questioning, moving from non-threatening to threatening, must be followed while eliciting a sexual history. This hierarchy of questioning helps both patients and clinical to be at ease, minimized discomfort and shyness, helps avoiding wrong or vague answer, and ensures both correctness and completeness of history. This in turn facilitates a correct diagnosis and creates optimal therapeutic outcomes.

This hierarchy of questioning is mentioned with examples in [Table 13]. Another order of questioning is based on the phase of sexual response [Table 14]. With practice, both hierarchies can be followed concurrently during a sexual history taking. It is the responsibility of the healthcare provider to make the patient at ease, so that the history can be elicited with minimal discomfort.
Table 13: Hierarchy of questioning

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Table 14: Hierarchy of questioning: Phase based

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ALLIANCE recommendations

  • MSD HCPs should follow a non-threatening to threatening, or non-intimate to intimate hierarchy of questioning while eliciting a sexual history Grade A, EL4.
  • MSD HCPs should use appropriate language, dialect, slang, and euphemisms, while eliciting a sexual history. Grade C, EL4.


General physical examination

Counseling in MSD must be preceded by a complete general and gonadal physical examination. All reversible (and irreversible) physical causes of MSD should be ruled out before counseling. Whereas the details of examination are beyond the preview of this guideline, the counselor must be alert to the physical signs of hypo-androgenic states in his patients. Some of these signs which can be inspected are listed in [Table 15].
Table 15: Signs of hypoandrogenism

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ALLIANCE recommendations

  • MSD HCPs should be aware of the phenotypic abnormalities which need to be assessed in patients with MSD Grade C, EL4.


Investigations

Necessary and appropriate investigations should be ordered for all patients with MSD, to identify and/or exclude organic causes, and to ensure correct choice of therapy. The details of investigations are beyond the scope of these guidelines. However, these can be classified as in [Table 16], and to arrive at a correct diagnosis patient must be counseled about the need for investigations.
Table 16: Investigations in male sexual dysfunction

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ALLIANCE recommendations

  • MSD HCPs should be aware of the phenotypic abnormalities that need to be assessed in patients with MSD Grade C, EL4.


Non-pharmacological therapy

A healthy diet forms part of counseling for MSD. Counselors must encourage patient with MSD to take a balanced diet, rich in vitamins and minerals, supplemented by nutraceuticals if necessary. Avoidance of smoking and moderation of alcohol intake are essential points for discussion.

Physical activity

Sexual fitness will be achieved only if one is physically fit, attention should be paid to aspects of physical health which may impair sexual function, such as obesity, musculoskeletal weakness, lack of flexibility and other medical conditions. Patients should be encouraged to indulge in moderate physical activity at least thrice a week.

Yoga

Yoga is an ancient Indian regime which keeps the body both fit health and flexible. Yoga helps ensure in general, there are specific exercises or "asanas" which may improve sexual function by improving pelvic blood flow. Some of these "asanas" are listed in [Table 17].
Table 17: Yoga asanas useful in male sexual dysfunction

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ALLIANCE recommendations

  • MSD HCPs must be aware of the role of nutraceuticals in MSD management, Grade A, EL2.
  • MSD HCPs must be aware of the role of diet, physical fitness, and yoga in MSD management Grade B, EL4.


Psychological therapy

Various methods of psychological therapy have been described for the management of MSD. Some of these are listed in [Table 18]. Most experts use an eclectic combination of these therapies, and adjust the weightage of each psychological intervention according to the individual of each psychological intervention according to the individual patient's psyche and needs. This section provides brief overview of CBT. It describes simple methods of counseling which can be used in patient with desire disorder, erectile dysfunction, and premature ejaculation, which are the commonest MSD encountered in clinical practice. It also discusses relevant aspects of couple therapy, which are important in the Indian context.
Table 18: Types of psychological therapy

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Cognitive behavioral therapy (CBT)

The ALLIANCE guidelines recommend CBT which follows the ABC (antecedents, behavior, consequences) approach. After identifying the C (Consequences), i.e., the specific type of dysfunction, one should focus the B (Behavior) which preceded it, and then try to analyze the A (Antecedents) which led to the behavior. The consequence (sexual dysfunction) cannot be corrected until the dysfunctional antecedents and behavior that have led to it are identified and resolved. Certain issues which are commonly cited by patients as leading to dysfunction are listed in [Table 19].
Table 19: Common antecedents of male sexual dysfunction

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Example of psychotherapy: Erectile dysfunction

After taking an informed consent, the patient is given a sublingual tablet of sildenafil 50 mg or apomorphine 2 mg [this step is optional] and made to relax in supine position, in a dimly lit, in a quiet and isolated room with comfortable ambience, alone, for 15-30 min.[21]

The counselor then begins general non-threatening conversation to make the patient feel relaxed. He instructs the patient to imagine a pleasant fantasy, e.g. being alone at the beach or on a hilltop. Vivid imagery and use of visual stimuli is encouraged.

Once the patient has imagined this, he is taught a series of progressive muscle contraction and relaxation exercises, beginning from distal to proximal. He first contracts and then relaxes various muscle groups of lower limbs, followed by upper limbs, and then by the head, neck, chest, and abdomen. After each relaxation, the patient is encouraged to relax and feel comfortable, while imagining him to be alone with the same fantasy.

After completing alternate muscle contraction and relaxation, the patient is encouraged to repeat the exercise with vivid imagery, imaging that a preferred sexual partner is facilitating the muscle relaxation. The first session may conclude here, with a plan to have repeat session later, if the therapist feels that the patient has not relaxed fully.

If, however, the patient is comfortable, the counselor moves on. He asks the patient to imagine that all the energy, released by the progressive muscle exercise, is transferred to the genital area. Once the patient begins to feel "heat" in the genital area, he is encouraged to self-stimulate, supported by vivid imagery of the preferred partner or by visual stimuli.

Usually, this procedure leads to a successful erection either at the first or subsequent visits. Once the patient achieves this erection, he is asked to reach an orgasm on his own. Encouragement and motivation makes him try out these exercises at home, in a suitable environment, alone.

After he is able to experience adequate erection, ejaculation, and orgasm alone, with vivid imagery or stimuli, the patient tries the same exercise with a partner without trying to achieve penetrative intercourse.

Success in these exercise leads to enhanced confidence in the patient, who by this time is usually able to achieve good erectile function in the bedroom.[21]

Example of psychotherapy: Premature ejaculation

The same framework is followed as mentioned above. When the progressive muscle relaxation and contraction is over, the patient is taught pelvic floor exercises.[21]

A sample talk instruction is as follows: "Imagine that you suddenly feel the urge to pass urine. Contract your muscles so that you stop the flow of urine. Feel your penis moving and contracting. Maintain this state of tension for 30 s.

Now release this tension and for 30 s pretend that you are passing urine. Feel the penis relaxing and softening. Contract the muscles again after 30 s and maintain this alternate contraction and relaxation for 10-15 min.

Once this is done, perform the same exercise with anal muscles, contracting and relaxing the anal sphincter, while pretending that you are interrupting or are passing stool.

Regular repetition of these exercises improves pelvic muscle tone and helps improve duration of erection. During therapy, the patient is taught to utilize the exercises the moments he feels the urge for ejaculation during sex. The key is to transfer thoughts of ejaculation to micturition or defecation, for a few minutes, prevent premature ejaculation, and then restart the act.[21]

Another technique commonly used for management of PME is an exercise known as the squeeze technique. It is aimed at raising the threshold of penile excitability. In this exercise, the man or the woman stimulates the erect penis until the earliest sensations of impending ejaculation are felt. At this point, the woman forcefully squeezes the coronal ridge of the glans, the erection is diminished, and ejaculation is inhibited. The exercise program eventually raises the threshold of the sensation of ejaculatory inevitability and allows the man to focus on sensations of arousal without anxiety and develop confidence in his sexual performance. A variant of the exercise is the stop-start technique, in which the woman stops all stimulation of the penis when the man first senses an impending ejaculation. No squeeze is used.

Example of psychotherapy: Desire disorder

The same frame work is followed as mentioned above. While performing the muscle relaxation exercise, various examples of vivid imagery or visual, auditory, tactile or olfactory stimulation are used, and the patient asked to comment on their effectiveness.[21]

The patient is encouraged to touch himself on every part of the body, in every way possible, varying the force, direction, pressure, and method of his stroke, using different parts of his fingers, palms, and hands. This exercise help him create a sexual identity for himself, identity various sensate focus spots and erogenous zones in his body, assess his sexual preferences, and communicate these to his partner.

The next step is to receive touch from the partner in a passive manner. The partner is asked to touch from the partner in a passive manner. The partner is asked to touch the patient again on every part of the body in every way possible.

Passive touch then gets converted to active touch, with the patient keeping his hand on the partner's hand and guiding her to his preferred zones, in a mutually acceptable manner. The patient is instructed to begin with non-sensual or non-genital areas of the body, then to move to the breast area, and to fondle the genitals last.

Verbal communication between both partners is encouraged, and they are asked to find positive non-sexual attributes in each other as well.[21]

ALLIANCE recommendations

MSD HCPs should use appropriate psychotherapeutic interventions for patients with MSD. Grade A, EL 3.

Coupled centered care

Male patient with sexual dysfunction is part of a unit, i.e., the couple, Often, counseling of the both partners is required to achieve desired outcomes depending upon the case, this counseling may include education about anatomy and physiology, explanation about menstruation and contraception, encouragement to become friends, and resolution of others, and domestic discard.

Each couple will have their unique challenges. The female partner's physical, mental, emotional, and social health need must be addressed to manage her partner's sexual dysfunction. Special attention must be given to women in phases of pregnancy.

Dual sex therapy, pioneered by Masters and Johnson, is an example of couple-centered approach to the management of MSDs. The theoretical basis of the dual-sex therapy approach is the concept of the marital unit as the object of therapy. Both individuals are involved in a relationship in which there is sexual distress. Hence, participation of both is needed in the therapy program. The marital relationship as a whole is treated, with emphasis on sexual functioning as a part of that relationship. Improved communication in sexual and non-sexual areas is a specific goal of treatment. Psychological and physiological aspects of sexual functioning are discussed with an educational attitude. Suggestions are followed in the privacy of the couple's home. The squeeze technique described above is an example of dual sex therapy for premature ejaculation.

Family Therapy

At times, family influence in personal affairs of couples may cause or rather perpetuate MSD. This genuine concern may have a negative effect on a young couple, as it does not give them the privacy and personal space required a close relationship. Such instances are not uncommon in the Indian context.

Family members therefore may as well need a counseling. They should be requested to provide both physical and emotional space to the patient with MSD and his spouse, and ensure that privacy is maintained. At the same time, family members must provide support and confidence to the MSD patient, albeit in a non-overbearing manner.

ALLIANCE recommendations

  • MSD HCPs should treat the couple as a unit, rather than focusing on the male patient alone Grade A, EL3.
  • MSD HCPs may treat the male patient alone, if socio-cultural environment dictates so. Grade B, EL3.
  • MSD HCPs should be sensitive to the impact of the family on their patients, and attempt to optimize it Grade A, EL4.


Coping Skills Training

MSD is associated with significant stress both in the patient and his partner. One of the aims of counseling is to provide the patient with the skills required to cope with stress. This aspect of counseling is known as CST. CST can be easily explained by the mnemonic AEIOU[25] [Table 20].
Table 20: Coping skills training AEIOU model

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All coping mechanisms can be classified into nine types.[26] These can further be studied as positive mechanism and negative mechanism of coping. AEIOU approaches aims to ask (and identify all coping mechanism (A), eliminate all negative mechanism (E), internalize positive coping styles (I), observe the patient on an ongoing basis (O), and continually try to upgrade oneself while learning communication (U).

The negative mechanisms which should be eliminated are listed in [Table 21], whereas those which should be encouraged can be found in [Table 22]. CST should form a part and parcel of every counseling season on MSD.
Table 21: Negative coping mechanisms

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Table 22: Positive coping mechanisms

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ALLIANCE recommendations

  • CSI should be an integral part of MSD counseling Grade B, EL4.


Religion and counseling

Religion is an important aspect of life, especially in South Asia. Religion impacts MSD in multiple manners. Some patients grow up in a puritan atmosphere, believing that sex is sin, and find it difficult to differentiate between the religious strictures against premarital sex and sanction for marital co-habiting. Others feel upset because of MSD, and may rationalize their condition by saying that they have to suffer in silence because of past mistakes. Yet others may approach religious leaders for treatment of MSD, instead of consulting modern medical practitioners.

In all such cases, religion can be used as a means of motivation, rather than demotivation. The counselor should be able to quote examples from relevant religious texts which encourage a pro-active approach in dealing with health problems, including sexuality. Some examples of useful quotations from holy books are given in Boxes 2-4.







ALLIANCE recommendation

  • MSD HCPs should be aware of the effect of religion on sexuality, and attempt to optimize it. Grade A EL 4.


Pharmacological therapy

Nutraceuticals

The patient should be counseled regarding the availability, safety, and utility of nutraceuticals, prepared to improve libido and sexual function. The need for proper investigations, medical supervision, and follow-up during use of nutraceuticals must be stressed. Fenugreek is a well-known nutraceutical substance, it displaces bound testosterone from SHBG, causing an increase in the free/bound ratio and therefore making the testosterone more active.

Hormone therapy

Patient should be counseled about the potential use and abuse of androgens in clinical practice. Androgen supplementation will help only those patients with MSD who have androgen deficit. Androgen therapy should not be self-prescribed, and should be taken on the advice of a qualified specialist. Patients should be made aware of various oral, transdermal and injectable preparation of testosterone, as well as other androgens such as dehydroepiandrosterone sulfate (DHEA-S). Counseling should include advance information regarding necessary investigations to be carried out as part of screening and follow up.

Phosphodiesterase inhibitors

Patient should be made aware of the utility, correct usage, limitations, side effects, and potential risk of using phosphodiesterase inhibitors such as sildenafil and tadalafil. Correct timing and methods of use should be explained to patients on these drugs. They should also be counseled about the different routes of administration of various preparations.

Apomorphine

During counseling, patients who are prescribed apomorphine should be informed about the correct method of usage, its efficacy, and its limitations.

Concomitant drug therapy

Counseling for MSD must include detailed history taking related to concomitant medication. There is a long list of drugs which are associated with sexual dysfunction in men [Table 23]. Patients should discuss with their medical care providers about the possibility of changing to safer alternatives.
Table 23: Drugs associated with sexual dysfunction in men

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Substance abuse

Certain substances of abuse may lead to MSD [Table 24]. These include alcohol, tobacco, opioids, and amphetamine.[27],[28] Their use must be discouraged and abuse must be managed by appropriate measures.
Table 24: Drugs causing male sexual dysfunction

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ALLIANCE recommendations

  • MSD HCPs should try to replace dysfunction-causing concomitant drug therapy where possible Grade A, EL2.
  • MSD HCPs should discourage substance abuse in patients with MSD. Grade A, EL2.
  • Grade A, EL4.


Device and invasive procedure-related counseling

Patients who do not respond to non-pharmacological and conventional pharmacological therapy may need to be treated with various devices, invasive procedures, or surgery.

Patient who may need these treatments should be explained about the need for such therapy well in advance. This allows a danger period of contemplation, which encourages stronger maintenance of decision regarding choice of treatment, and proven post-device or post-surgery regret.

The advantage and disadvantage, efficacy, limitation and possible risk, and discomforts must be explained to the patient in simple, easy-to-understand language. Potential alternatives should also be explained to the patient, and SDM followed in letter and spirit.

At times, patients may request information about the effects of circumcision on sexuality. Counseling should be done in sensitive terms without involving religious issues. Circumcision is not proven to have any beneficial effect on sexuality.

ALLIANCE recommendation

  • MSD HCPs should be aware of the details of devices and invasive procedures used to manage MSD. Grade A, EL2.


Counseling related to medical and psychiatric co-morbidity

Patients with MSD may suffer from medical comorbidity, such as cardiovascular disease and diabetes mellitus. MSD may be the only, or the initial, presenting symptom of these diseases. These illnesses impact the choice, efficacy, and tolerability of treatment of MSD. Adequate counseling regarding the need for appropriate investigations and treatment must be done. If required, the patient with MSD must be referred to the appropriate health care provider for evaluation and management.

MSDs are frequently associated with other mental disorders such as depressive disorders, anxiety disorders, personality disorders, and schizophrenia. In many instances, a sexual dysfunction may be diagnosed in conjunction with another psychiatric disorder. In some cases, it is only one of many signs or symptoms of the psychiatric disorder. Interestingly, with the possible exception of premature ejaculation and anorgasmia, sexual dysfunctions are rarely found separate from other psychiatric syndromes.

Mental illness has a significant effect on sexual function. Sexual dysfunction is associated with depression[29] and anxiety,[30],[31] These associations have been observed for decreased desire, erectile dysfunction, anorgasmia, and delayed ejaculation. In fact, sexual dysfunction has been considered a physical (or somatic) symptom of major depression.

Psychiatric disorders and sexual dysfunctions share a bi-directional relation with both impacting each other. Course of a primary sexual dysfunction is likely to be complicated by emergence of psychiatric conditions such as depression and anxiety disorders. Hence, it is important to address the associated psychiatric disorder with appropriate pharmacological or non-pharmacological intervention.

Many individuals diagnosed with MSDs do not have psychiatric co-morbidity syndrome. However, they are still significantly distressed, manifesting in form of symptoms of depression and anxiety. These individuals may develop feelings of guilt due to beliefs based on inadequate and wrong knowledge. The counseling should address these issues among these individuals.

ALLIANCE recommendations

  • Patients with MSD and associated medical or psychiatric illness must be referred to the appropriate health care provider for evaluation and management. Grade A, EL 1.
  • Physicians should be trained to evaluate sexual problems in both genders to facilitate recognition and possible treatment. 22,40 (Grade A; EL 3).
  • Diabetic hypertensive/neuropathic patients should be evaluated for sexual dysfunction and appropriate therapy should be considered. 41 (Grade A; EL 3).
  • Therapeutic interventions should include basic psychological counseling, biomedical treatment, as well as treatment of comorbidities and/or sex therapy. 42 (Grade A; EL 3).


Community awareness

MSD may seem, superficially, to be an individual's problem, or at the most, a couple's concern. In reality, the impact of MSD goes for beyond this. Sexual dysfunction affects a person's functioning and health in multiple ways, leading to sub-optimal personal, professional, and social performance. If not managed, this may lead to significant psychological and psychiatric morbidity.

Such patients are often subjected to ridicule by spouse, family members, or friends, and this only serves to aggravate the illness.

The community must be sensitized to treat men with sexual dysfunction in a human and supportive manner, and not to act as barriers or hurdles in their sexual rehabilitation process. The onus of spear-heading this public health campaign lies with healthcare professionals, who should actively involve themselves in MSD patient advocacy.

Public awareness must also be raised about the lack of evidence and potential risk and discomfort and harm of untested treatments offered by unqualified practitioners of complementary and alternative therapy. Every window of opportunity should be utilized to spread awareness about the utility and benefits of modern non-pharmacological, medical, and surgical strategies for MSD.

ALLIANCE recommendation

  • MSD HCPs must actively practice patient advocacy and improve community awareness related to MSD. Grade A, EL 4.



  Conclusion Top


Counseling is an integral and essential part of management of MSD. No medical or surgical therapy is complete without counseling. However, sexual counseling is a challenging task which requires in-depth expertise in soft skills as well as through knowledge of hard skills.

The ALLIANCE guidelines provide guidance reporting various aspects of MSD counseling in a patient and physician manner. While maintaining a patient-centered approach, the guidelines draw upon experience and evidence, to ensure scientific integrity for the recommendations contained here in. ALLIANCE hopes that diligent practice of these guidelines will ensure a healthier future for our patients with MSD.


  Acknowledgment Top


The authors acknowledge the contribution of all ALLIANCEers in formulating these guidelines.The authors acknowledge the contribution of the South Asian panel of reviewers: Dr. Syed Abbas Raza, Dr. Osama Ishtiaq, Dr. Noel Somasundaram, and Dr. Prasad Katulanda, in reviewing the manuscript.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19], [Table 20], [Table 21], [Table 22], [Table 23], [Table 24]


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[Pubmed] | [DOI]



 

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