The limited consultation time available in the primary care setting makes it difficult to assess and advise on psychosexual problems, at least at the initial consultation. Psychosexual problems are common, may be transient, only arising within certain relationships or at certain times in life and may not be amenable to a "quick fix." Adequate time is needed to ascertain the exact problem, explore underlying tensions or issues, and develop a treatment strategy, which many primary care practitioners will consider beyond their area of expertise. Nevertheless, a great deal may be achieved during a slightly extended consultation repeated over a few sessions. Managing psychosexual problems provides the practitioner with confidence in taking a sexual history and dealing with other genital medical problems. As with other problems in primary care, specialist advice can be sought for difficult problems not responding to initial therapy.
Specialist texts are to be recommended for those dealing with psychosexual problems on a regular basis and training programs are available for those seeking more in-depth training. What follows is a very brief introduction to the kinds of approach that can be tried for the common psychosexual problems in the "time restricted" primary care consultation.
Spasm of the vaginal muscles on attempted penetration is not an uncommon problem. However, before diagnosing vaginismus as a cause of painful sexual intercourse ensure there is no vulval pathology. Probably the two most commonly missed diagnoses are vulvar vestibulitis (the areas of introital erythema and tenderness may be tiny and easily missed with naked eye examination) and posterior fourchette tears. With the latter condition, there is often acute pain during sex and pain with penetration on further
attempts at intercourse, until the tear heals (see Chapter 8, Figure 8.9). Vaginal muscle spasm may certainly arise secondary to these or other vulval conditions causing painful sex (e.g. vulval dermatoses, infections producing a vulvo-vaginitis) or, alternatively, may be present from the first time intercourse is attempted (primary vaginismus).
So check to see whether this is a primary problem or whether sex has previously been pain free. If the latter, ensure there is no vulval pathology.
Some women experience vaginismus as part of a more extensive sexual disorder associated with loss of sexual interest and sometimes aversion to sexual contact. This moves into the territory of requiring more intensive assessment and counseling.
Vaginismus may be encountered by the practitioner when performing a vaginal examination either by finger or speculum insertion. Inability to pass a speculum is much less common than a difficulty in opening the speculum to visualize the cervix. A question about past difficulties with sexual intercourse may unearth a long-standing problem and provide an opportunity to offer help.
Explain that vaginismus means tightening or spasm of the muscles at the opening to the vagina (pubococcygeus) and that the objective of treatment is to help relax these muscles. As the tightening is like a reflex muscle spasm, this retraining may take a while to achieve. The muscles involved are the ones used to stop urine flow suddenly and the patient should try tensing and relaxing these muscles for 30 seconds or more a few times a day, whenever there is a convenient moment. The next step is to tense and relax these muscles whilst placing a finger gently into the vagina. Vaginal "dilators" or "trainers" are available for women who prefer not to use a finger. Start with a small size and slowly work up. Once a finger can be accommodated she should try two fingers (or a larger trainer), again relaxing and tensing the muscles. Women with vaginismus secondary to vulvar vestibulitis may find the use of lignocaine gel helpful. This can be applied after a few minutes of non-anesthetized exercises and the program repeated after the gel has had time to take effect (20-30 minutes). There should now be less discomfort and provide some encouragement. The move from finger insertion to erect penis insertion is a major step and should not be rushed. Advise partner finger insertion before penis insertion and suggest vaginal containment with the female superior or lateral position (provides the woman with more control) before starting gentle pelvic movement. Good communication between partners is essential throughout and explain that it should be a "slowly-slowly" approach, gradually moving toward full penile penetration over a period of weeks with some setbacks to be expected.
22.1.2 Impaired Sexual Desire
Try to ascertain whether this is a new problem or an occasional or persistent feeling. Is the current relationship new or long-standing and is there any discord? Is there sexual interest toward other men and does the patient have sexual thoughts or fantasies? This gives some feel to whether the problem is partner related or a more complete lack of sexual desire.
Sexual desire may be impaired by a number of factors. These include unhappiness or discord in the relationship (a common precipitant and maintaining factor for many sexual problems), partner or self-infidelity, partner's sexual dysfunction (e.g. premature ejaculation), depression, post childbirth (may be multifactorial), ill health, and ageing. Unearthing and discussing these issue may have a good therapeutic effect and further counseling can be arranged as necessary.
22.1.3 Problems with Orgasm
This may be a total inability to achieve orgasm or a situational problem with orgasm occurring under certain circumstances, such as masturbation. Sometimes expectations are high; an inability to achieve multiple orgasms should not be considered abnormal. You may have to describe an orgasm as occasionally there can be uncertainty on the patient's part as to whether orgasm has ever been reached. A reasonable clinical description would be increasing arousal, a feeling of tension reaching a climax and then being released, accompanied by a feeling of relaxation. This may or may not be accompanied by a feeling of muscle contraction.
Check through the list of possible precipitating factors mentioned in the section "Impaired sexual desire" and address these as necessary. Make sure that foreplay is appropriate in nature and duration; this may require an overview on anatomy with reference to the position of the clitoris.
A "masturbation training programme" can achieve good results. Advise genital self-examination with reassurance that it is perfectly acceptable to touch the genitals. Some women are
hesitant to do this and may consider their genitals unattractive. Reassurance and encouragement may be required. Once she is comfortable with touching the labia and the opening to the vagina she should proceed to gently touch the clitoris and the vaginal opening, perhaps contracting the vaginal muscles as she does this. The next step is to advise gentle clitoral stimulation with a finger whilst at the same time imaging a sexual fantasy. A vibrator may be used if an orgasm is not achieved after a few weeks of finger stimulation. This should be considered a temporary aid which will be required less and less as progress is made. Once self-masturbation induced orgasm has been achieved, suggest that the partner, or herself, performs clitoral stimulation during vaginal containment and then with pelvic thrusting.
22.2.1 Erectile Dysfunction
This is a common problem that may range from total erectile failure to situational or intermittent failure. The latter is unlikely to be due to a physical disorder and possible precipitating factors such as stress, depression, "performance anxiety," alcohol excess and medication side effect should be addressed. Oral medications taken before anticipated intercourse are highly effective at producing an erection and, as a consequence of this, improving confidence. Patients with total erectile failure or a history of only partial erections should be investigated for physical causes.
22.2.2 Premature Ejaculation
Rapid ejaculation is common in young men particularly when entering new sexual relationships. Ejaculation prior to or on vaginal insertion is obviously premature; however, whether the timing of ejaculation is too rapid once thrusting has begun really depends upon whether intercourse is satisfactory to both partners. Premature ejaculation can occur at times of stress and when the frequency of intercourse has been reduced, such as when a partner has been absent for some while. Detecting frustration in the partner can lead to loss of confidence and may produce even more rapid ejaculation or erectile dysfunction. In turn the partner may develop organic dysfunction and loss of sexual desire.
The "stop-start" technique involves the partner stroking the penis to the level of arousal and then stopping before the stage of inevitable ejaculation. This should be repeated a few times before allowing the stroking to achieve ejaculation.
The "squeeze technique" involves the partner squeezing just below the glans penis at the man's indication that he has reached a level of high arousal (as with the "stop-start" technique). This is repeated a few times before allowing ejaculation.
Once the man has achieved a degree of control, the couple should move onto vaginal containment, with the partner lifting herself off at the stage of high arousal. Movement is introduced gradually once some control has been achieved.
Failures from time to time are to be expected and success may require some weeks or months of practice. It is important that the man continues to stimulate his partner sufficiently during or after these exercises.
Selective serotonin reuptake inhibitors (e.g. paroxetine, sertraline) have proved successful in treating some cases of premature ejaculation, although this is currently an unlicensed use of these medications in the UK.
22.2.3 Retarded Ejaculation
Ascertain whether this is partial failure with ejaculation occurring during masturbation or sleep or total failure. Men with retrograde ejaculation reach orgasm but fail to produce an ejaculate.
The use of a lotion as the partner stimulates the penis may enhance sensation and increase arousal. If this fails to achieve ejaculation, in future sessions the man should masturbate with the partner stroking the penis progressively earlier during the session until she can bring him to ejaculation. When ejaculation has been achieved, further sessions should focus on masturbation close to the vaginal entrance with penile insertion at the point of high arousal in conjunction with vigorous thrusting.
Just a final note on "sensate focus" treatment. This is considered an important and useful part of the management of psychosexual problems by many practitioners and is probably best left to those with expertise in this area. However, success may certainly be achieved without this approach.