• Underlying causes, such as psychiatric or medical illness, should be managed appropriately.

• Psychological approaches: simple explanation and counselling may be all that is required, and sometimes can be best provided from the many useful books and videos available to the public. More complex cases may need formal psychotherapy, individually or as a couple.

• Sex therapy: this derives from the methods of Masters and Johnson. The couple are usually treated together. Treatment begins with a 'sensate focus' phase during which intercourse is not attempted, so that the couple stop repeating an experience of failure, but spend a set time alone together each day to concentrate on talking about relationship issues and exchanging non-genital physical affection. In stages, the couple then work toward genital stimulation, followed by intercourse. They may be taught specific techniques according to the type of dysfunction present; for example, the 'squeeze technique' for premature ejaculation, or extended foreplay in orgasmic delay.

Case example

A man aged 52, happily married for 23 years, was referred to psychiatric outpatients by his GP, who said his patient was distressed by 'progressive impotence', and had recently watched a television programme about Viagra, which he was keen to try. The man himself seemed rather embarrassed by the referral. He attended without his wife, and had not told her about it; she had 'not seemed especially keen on sex' after the menopause, and they had been having intercourse about every 2 weeks in recent years, largely at his request. He had recently taken an antihypertensive drug, and had been finding it more difficult to sustain an erection; although his blood pressure had since settled and he was able to stop this medication, his erectile difficulty had not entirely resolved. Direct enquiry established that there was less of a problem during masturbation.

The psychiatrist could detect no physical or mental disorder, and blood tests including prolactin were normal. He advised that the problem would probably continue to resolve, and that specific treatment was not required at present, although sildenafil (Viagra) would be effective, if it was necessary to use it in the future.

At follow-up, the patient was invited to ask his wife to attend. There had been some further improvement in his erections, but it emerged that his underlying fear was that he was 'failing in his marital duties'. The psychiatrist advised that their sexual relationship, in particular their frequency of intercourse, was not abnormal for their age. Although it was possible that the wife was suffering from some oestrogen deficiency symptoms, including vaginal dryness, that might well have responded to hormone replacement therapy, the couple declined further appointments, saying they were 'reasonably happy with things as they are'.

• Systemic drugs: these are appropriate when a specific medical indication is present. Examples include:

- oestrogen/progesterone hormone replacement therapy in postmenopausal women

- the phosphodiesterase type-5 inhibitors sildenafil (Viagra), tadalafil, and vardenafil increase cyclic guanosine monophosphate (cGMP), leading to penile smooth muscle relaxation. Taken 1 hour before sexual activity, they have revolutionized the treatment of erectile dysfunction. Although generally well tolerated, they occasionally cause priapism, however, which is a medical emergency for which the patient must be advised to go immediately to hospital. For erectile dysfunction, these drugs have largely replaced agents such as yohimbine tablets and penile injection treatments (although these treatments were never widely used). They are being tried for premature ejaculation and also for female sexual dysfunction, although there is as yet no clear evidence of effectiveness.

- androgen treatment for reduced sexual drive in men who have low testosterone levels

- bromocriptine for male sexual dysfunction secondary to hyperprolactinaemia.

• Local treatments for female partner.

- topical lubricants/oestrogens for vaginal dryness

- vaginal dilators, of progressively larger size, for vaginismus.

• Local treatments for males with erectile failure.

- intracavernosal injection of vasoactive drugs such as papaverine and prostaglandin Ej (aprostadil)

- vacuum devices using suction to establish erection, which is then maintained by a ring

- surgical implants.

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