Broadly defined, sexual dysfunction is the general inability to enjoy sexual intercourse. Sexual disorders include sexual desire (libido) problems, disorders in the psychophysiologic processes of the sexual response cycle (desire, excitement, orgasm, resolution), and pain with sexual intercourse. Sexual dysfunctions are classified as primary (lifelong) or secondary (acquired after normal sexual functioning) and may be generalized (not limited to certain situations, partners, or stimulation) or situational.

This large group of vasocongestive and orgasmic disorders affects both males and females and may affect more than half of all couples at some time. The major subtypes are:

• Male erectile disorder (impotence)—the inability to attain or maintain an erection for sexual intercourse
• Ejaculation disturbances—primarily premature ejaculation in men
• Vaginismus—spasm of the vagina preventing penetration and sometimes causing pain during coitus
• Sexual aversion disorder—the inhibition of sexual arousal and excitement
• Orgasmic disorders—delayed or absent orgasm in either males or females who otherwise have normal sexual desires and arousal
• Dyspareunia—sexual pain disorders
• Sexual dysfunction due to general medical condition
• Substance-induced sexual dysfunction

Psychological influences (e.g., anger, fear, guilt, depression, and anxiety); interpersonal issues (e.g., marital discord and boredom); alcohol and drug use; certain medications; neurologic insult and/or biological causes can be factors in the etiology of sexual dysfunction.

• Medical comorbidity (e.g., diabetes, pelvic cancer, genitourinary disorders, urethral strictures, genital infections, endocrine and hormonal disorders)
• Pharmacological (e.g., antihypertensive, antipsychotic, and antidepressant medications)
• Alcohol or drug abuse
• Cigarette smoking (atherosclerosis of the penile artery may account for nearly 50% of impotence cases in men over 50)
• Depression, anxiety, or issues of self-esteem
• Age 65 and over in men
• Stressful life events
• Vascular surgery
• Previous sexual trauma
• Cultural pressures and expectations
• Fatigue

Dependent on the disorder:

• Premature or retarded ejaculation in men
• Inability to maintain an erection
• Pain during intercourse
• Lack or loss of sexual desire
• Difficulty achieving orgasm
• Anxiety and/or depression
• Inadequate vaginal lubrication in women

• Sexual dysfunction due to a general medical condition
• Substance-induced sexual dysfunction
• Sexual dysfunction due to combined factors (e.g., psychological and general medical condition)
• Sexual dysfunction not otherwise specified
• Personality disorder
• Relational problem
• Pseudodyspareunia

Varies depending on the type of sexual dysfunction. Examples of physical presentations include:

• Involuntary spasm in the perineal muscles surrounding the distal third of the vagina (vaginismus)
• Structural abnormalities of the penis, such as genital infections, Peyronie's disease, and lesions (dyspareunia and male erection disorder)
• Infectious vaginitis and atrophic vaginitis (female sexual arousal disorder)
• Scars, vulvar inflammation, clitoral inflammation or adhesions, and dermatitis (female dyspareunia)

Specific laboratory tests are available to aid diagnosis of sexual dysfunctions resulting from underlying medical conditions; these are usually not considered diagnostic alone. Blood tests, such as serum-free testosterone, luteinizing hormone (if low testosterone level), and serum prolactin tests can help detect hormonal problems and distinguish between psychological and organic causes for sexual dysfunctions like impotence and sexual aversion disorders.

CTs and MRIs are helpful for differential diagnosis (e.g., evaluating the sella turcica for pituitary tumors).

Duplex ultrasound can ascertain blood flow in cavernous arteries (erectile dysfunction).

• Clinician interview—assess symptoms and degree of severity; may include routine sexual history, modified sexological examination (e.g., sensitivity of vulva to touch); gather information on ethnic, cultural, religious, and social background, which may impact a patient's sexual desires, expectations, and attitudes
• Evaluate for concurrent substance abuse, medical conditions, psychiatric conditions
• Nocturnal penile tumescence measurements taken during REM sleep help to differentiate between psychological and organic causes.

Depending on the type, severity, and duration of the sexual dysfunction, one or more of the following are recommended.

• Psychotherapy and sex therapy, especially interpersonal therapy
• Behavioral therapy (e.g., dysfunctions like premature ejaculation and vaginismus may stem from conditioned responses)
• Pharmacotherapy, and adjusting/alleviating existing medications
• Surgery of penile venous system for severe cases in which venous leakage occurs; NIH recommends procedure be performed in investigational setting at medical centers
• Penile prostheses
• Vacuum/constrictive devices for erectile dysfunction

• Sildenafil citrate (Viagra)—enhances natural response to sexual stimulation in men by blocking effect of enzyme that breaks down cyclic guanosine monophosphate (cGMP); complications include serious cardiovascular event (e.g., myocardial infarction and sudden cardiac death), primarily in patients with preexisting risk factors; other side effects include anxiety, priapism, and temporary vision loss or decreased vision; contraindicated for patients taking nitrates
• Tricyclics or MAOIs—for treating panic states leading to sexual aversion disorder
• Testosterone—for treating low androgen levels in erectile dysfunction and impotence (200 mg IM every two weeks for three to four months)
• Vasodilators—such as papaverine, phentolamine, or prostaglandin E₁ used alone or in combination and administered via penile injections for erectile dysfunction; may cause priapism and transient hypertension
• Nefazodone (Serzone) and other antidepressants—may help decrease psychological side effects of sexual dysfunction; contraindicated for use with MAOIs or in pregnant women
• Dibucaine (1%) or lidocaine (1%)—ointment applied externally for vulval distress

Sexual dysfunction that is secondary to decreased peripheral circulation, hormonal imbalance, or depression and/or anxiety may be reduced with the use of alternative therapies. Mind-body techniques such as meditation, progressive muscle relaxation, yoga, tai chi, and stress management may be helpful in relieving anxiety around sexual performance.

• Vitamin C (1,000 mg tid) to support vascular integrity.
• Vitamin E (400 IU/day), B6 (50 to 100 mg/day), and zinc (30 mg/day) to support hormone production.
• Magnesium (200 mg bid) supports hormone production and is a vasodilator.
• B-complex (50 to 100 mg/day) helps to reduce the effects of stress and may improve symptoms of depression and/or anxiety.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Consider the following herbs for sexual dysfunction related to vascular insufficiency.

• Ginkgo (Ginkgo biloba, 50 to 100 mg/day) increases peripheral circulation and may improve sexual function related to arterial insufficiency. Long-term treatment (six months or more) may be required for best results. Ginkgo should be used cautiously with other blood-thinning agents (e.g., coumadin).
• Hawthorn (Crataegus monogyna), rosemary (Rosmarinus officinalis), ginger root (Zingiber officinale), and prickly ash bark (Xanthoxylum clava-herculis) are circulatory stimulants. Use singly or in combination, 3 cups of tea/day or 20 to 30 drops tincture tid.
• Yohimbe bark (Pausinystalia yohimbe) is used for sexual dysfunction; however, because of its side effects it should not be used without physician supervision.

Consider these herbs for sexual dysfunction secondary to hormonal imbalance.

• Chaste tree (Vitex agnus cactus) helps to normalize pituitary function but must be taken long term (12 to 18 months) for maximum effectiveness. Use only under physician supervision with hormone therapy.
• Saw palmetto (Serenoa repens) may reduce excessive androgen production.
• Damiana (Turnera diffusa) may support testosterone levels. It is also tonifying to the central nervous system and may help alleviate anxiety and depression in conjunction with sexual dysfunction.
• Milk thistle (Silybum marianum), dandelion root (Taraxacum officinale), and vervain (Verbena officinale) support the liver and may help restore hormone ratios. Use equal parts in a tea (1 cup before meals), or tincture (15 to 20 drops before meals).

For sexual dysfunction associated with depression or anxiety, consider the following.

• St. John's wort (Hypericum perforatum)
• Kava kava (Piper methysticum)
• Skullcap (Scutellaria lateriflora) 
• Lemon balm (Melissa officinalis)
• Passionflower (Passiflora incarnata) 
• Gotu kola (Centella asiatica) 

Combine equal parts in a tea (one cup bid) or tincture (20 to 30 drops bid). It may take up to six weeks to see best results.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.

Contrast sitz baths may relieve symptoms and promote circulation, relieving pelvic vascular congestion. You will need two basins that can be comfortably sat in. Fill one basin with hot water, one with cold water. Sit in hot water for three minutes, then in cold water for one minute. Repeat this three times to complete one set. Do one to two sets per day three to four days per week.

Therapeutic massage may be beneficial in reducing the effects of stress and increasing overall sense of well-being.

Sexual dysfunctions tend to be chronic and episodic and require long-term monitoring.

In cases that are primarily psychological in nature, continued psychological, behavioral, and interpersonal therapy decreases chances of a relapse. Men should avoid smoking to help prevent vascular problems associated with erectile dysfunction.

Drug side effects (e.g., androgen replacement therapy may have significant health risks for men with normal testosterone levels, especially in cases of unrecognized prostate cancer)

Sexual dysfunctions can adversely affect other areas of social functioning.

Sexual disorders are usually recurrent and chronic; a spontaneous remission occurs in 15% to 30% of patients with acquired erectile dysfunction; increased sexual experience often leads to control of premature ejaculation in males.

Fluctuations in libido may be normal during and after pregnancy and should not be treated.

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