Christopher Yang1, Tariq S. Hakky2 and Rafael Carrion3
(1)
North Austin Urology, Austin, TX, USA
(2)
Advanced Urology, Snellville, GA, USA
(3)
Department of Urology, University of South Florida, 2 Tampa General Circle, STC6, Tampa, FL 33606, USA
Rafael Carrion
Email: rcarrion@health.usf.edu
Keywords
Orgasmic dysfunctionAnorgasmiaOrgasmic headacheSexual dysfunctionProlactinSerotoninCabergoline
15.1 Introduction
The sexual response cycle was first proposed in 1960 by Masters and Johnson [1] and revised multiple times to its current definition of four interactive phases: desire, excitation (or arousal), orgasm, and resolution [2]. The male orgasm phase of the sexual response cycle consists of the sensation of pleasure accompanied by ejaculation. The cognitive experience of pleasure during the orgasm phase is also called orgasm [3, 4]. Indeed, “orgasm” has at least 26 definitions with different meanings depending on whether it is defined by the basic scientist, the physiologist, the endocrinologist, the neuroradiologist, and the psychologist [5].
Because of the myriad definitions and usages of “orgasm,” a summary of orgasmic dysfunction (OD) can be challenging. As ejaculatory dysfunction is covered in a separate chapter, we will limit the scope of this discussion primarily to the organic aspects of non-ejaculatory dysfunction of the orgasmic phase of the male sexual response cycle.
15.2 Physiologic Control of Orgasm
While the neural, endocrine, vascular, muscular, and end-organ pathways for erection and ejaculation are well defined, the pathway that results in orgasm is poorly understood. Orgasm is a short-lived sensory manifestation that usually follows a series of physical events: contraction of accessory sexual organs and the urethral bulb and buildup and release of pressure in the distal urethra [3]. The pudendal nerve transmits the sensory stimuli resulting from the above physical events to the cerebrum, resulting in orgasm [6].
The distinction between ejaculation and orgasm is described by Newman and colleagues, who reported orgasmic sensations without input from the genitals or concomitant ejaculation [3]. Additionally, the sensation of orgasm after radical prostatectomy, which eliminates ejaculation, is well known. A similar phenomenon can be seen in patients taking alpha-blockers who experience orgasm with retrograde ejaculation.
15.2.1 Hormonal Control
The ejaculatory response is controlled by central neural pathways using serotonin and dopamine as primary neurotransmitters, with acetylcholine, nitric oxide, adrenaline, gamma-aminobutyric acid (GABA), and oxytocin playing secondary roles [6, 7]. As orgasm is normally intimately associated with ejaculation, these neurotransmitters also affect orgasm.
Oxytocin and vasopressin are also involved in sexual function. Murphy and colleagues measured oxytocin and vasopressin levels in 13 normal men during the sexual response cycle [8]. They found that vasopressin levels rise during arousal, returning to baseline levels by the time of ejaculation. Oxytocin is unchanged during arousal, rises at ejaculation, and returns to baseline levels 30 min after ejaculation. The authors do not distinguish between ejaculation and orgasm, and it can be inferred from their study design that all subjects achieved both ejaculation and orgasm at the time of increased serum oxytocin levels.
Prolactin levels rise following male orgasm, which is thought to cause the post-orgasmic refractory period [9]. Additionally, hyperprolactinemia can impair physiologic pulsatile LH release, reducing serum testosterone and leading to erectile dysfunction [10]. Despite this association with sexual function, conflicting reports exist about the association of prolactin with orgasmic dysfunction (OD). Buvat and colleagues reported 51 patients with anorgasmia, all with normal prolactin levels [11]. In contrast, Swartz and colleagues reported several men with hyperprolactinemia and isolated anorgasmia [12].
Low prolactin has also been associated with OD in middle-aged and elderly men in the European Male Aging Study, a population-based prospective study of aging in eight European centers [13]. In this study of nearly 3000 men, low prolactin levels had strong correlation with reduced enjoyment of orgasm, as measured by sexual function questionnaires.
15.3 Classification of Orgasmic Dysfunction
In 2013, the International Society for Sexual Medicine (ISSM) published its Standard Operating Procedures (SOPs) in the Disorders of Orgasm and Ejaculation [14], which provide recommendations and guidelines in the management of premature ejaculation, delayed ejaculation (DE), anejaculation, and anorgasmia. Unfortunately, the authors do not discuss anorgasmia separately from disorders of DE and anejaculation.
Indeed, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), published in 2013 no longer contains the diagnosis “male orgasmic disorder,” which is found in the fourth edition. This diagnosis was changed to “delayed ejaculation,” defined by the following criteria:
A.
B.
C.
D.
In defining DE, the DSM-V also contains the following discussion regarding OD:
It is important in the history to ascertain whether the complaint concerns delayed ejaculation or the sensation of orgasm, or both. Ejaculation occurs in the genitals, whereas the experience of orgasm is believed to be primarily subjective. Ejaculation and orgasm usually occur together but not always. For example, a man with a normal ejaculatory pattern may complain of decreased pleasure (i.e. anhedonic ejaculation). Such a complaint would not be coded as delayed ejaculation but could be coded as other specified sexual dysfunction or unspecified sexual dysfunction. [15]
Thus, DSM-V also attempts to separate the mainly organic etiologies of DE from the psychological etiologies of OD. In the interest of accuracy, any future classification systems should separate orgasmic and ejaculatory disorders as these are now recognized as separate entities.
15.4 Evaluation of Orgasmic Dysfunction
The ISSM gives an SOP for ) the diagnosis of DE, anejaculation, and anorgasmia:
Evaluation of men presenting with DE/anejaculation should include a full medical/sexual history, a focused physical examination, determination of serum testosterone levels, and any additional investigations suggested by these findings [14].
Evaluation should focus on differentiating whether the man has ejaculatory dysfunction or OD, as ejaculatory dysfunction may have congenital, endocrine, iatrogenic, infectious, neuropathic, or psychological factors as an underlying etiology.
Additional questions to be posed concern the chronicity and conditionality of the man’s OD. This determines if the OD is lifelong or acquired (occurring after a time of normal orgasmic function) and if it is generalized (occurring with every partner, stimulation, and situation) or conditional (occurring with certain partners, stimulations, and situations).
15.4.1 Pharmacologic Causes
The evaluation of the man with ) OD should focus on his medications, as these are the most common cause of OD. A Micromedex® search of package inserts shows 16 discrete medications that list OD (with terminology including “orgasm disorder” or “orgasm incapacity”) as an adverse ) reaction in men (Table 15.1) [16]. The reported risks of these adverse reactions are low, with the majority of drug inserts citing a <10 % incidence. All of the medications listed are psychoactive drugs, with effects on serotonin, norepinephrine, and dopamine neurotransmission.
Table 15.1
Medications with package inserts listing orgasmic dysfunction for men as a potential adverse reaction
|
Medication |
Class |
Risk of adverse event (%) |
|
Desvenlafaxine |
SNRI |
3 |
|
Venlafaxine |
SNRI |
2–5 |
|
Duloxetine |
SNRI |
3 |
|
Paroxetine |
SSRI |
3.7–10 |
|
Fluoxetine |
SSRI |
NA |
|
Sertraline |
SSRI |
NA |
|
Citalopram |
SSRI |
8 |
|
Escitalopram |
SSRI |
NA |
|
Clomipramine |
Tricyclic antidepressant |
NA |
|
Mirtazapine |
Tetracyclic antidepressant |
NA |
|
Vilazodone |
Miscellaneous antidepressant |
4 |
|
Bupropion |
Miscellaneous antidepressant |
NA |
|
Trazodone |
Phenylpiperazine antidepressant |
<1 |
|
Amisulpride |
Atypical antipsychotic |
NA |
|
Risperidone |
Atypical antipsychotic |
NA |
|
Ziprasidone |
Atypical antipsychotic |
NA |
SNRI serotonin-norepinephrine reuptake inhibitor, SSRI selective serotonin reuptake inhibitor
More unusual reports of medication-induced orgasmic augmentation exist. McLean and colleagues reported two patients (one male, one female) successfully treated for depression with clomipramine [17]. Both noted that after starting the medication, each time they yawned, they experienced orgasm. The male patient had an intense urge to yawn without feeling tired and did not experience an increase in libido. With every yawn causing orgasm, he also experienced ejaculation and overcame his awkwardness and embarrassment by continuously wearing a condom. Discontinuation of clomipramine led to a cessation of symptoms.
Labbate reported a case of a 37-year-old patient with attention deficit disorder treated with bupropion SR [18]. He developed increased libido, increased feeling on orgasm, and rare spontaneous partial erections during the day. After 6 weeks taking the medication, he developed a surprise second orgasm during intercourse: he had normal initial ejaculation and orgasm, followed five seconds later by a spontaneous and pleasurable second ejaculation and orgasm. This phenomenon resolved after stopping bupropion SR, returned after restarting the medication several months later, and finally resolved after stopping once again.
15.5 Treatment of Orgasmic Dysfunction
The ISSM also provides a single SOP for the treatment of DE, anejaculation, and anorgasmia:
Treatment of DE/anejaculation should be etiology-specific and may include patient/couple psycho-education and/or psychosexual therapy, pharmacotherapy, or integrated treatment. Men/partners of reproductive age should be informed of the risk of infertility due to anejaculation following pelvic surgery and the need for sperm harvesting and assisted reproductive techniques [14].
Figure 15.1 shows a management algorithm for DE, anejaculation, and anorgasmia adapted from the ISSM SOPs that integrates diagnostic questions with the treatment of choice [6, 14]. Of note, the only recommended treatments for anorgasmia are disease-specific management for failure of emission and psychosexual therapy for inhibited male orgasm.
Fig. 15.1
Management algorithm for delayed ejaculation, anejaculation, and anorgasmia. With permission from the International Society for Sexual Medicine Standard Operating Procedures. © 2010 International Society for Sexual Medicine [6, 14]
Men with lifelong anorgasmia may also have sexual arousal disorder. Psychosexual therapy would include masturbation training starting with self-exploration to identify pleasurable sensations. This can lead to incremental increases in arousal that leads to orgasm; these techniques can then be communicated to the man’s partner.
15.5.1 Pharmacologic Treatment of Orgasmic Dysfunction
The treatment of OD with medications is limited (Tables 15.2 and 15.3). These therapies should be considered experimental, as they are not approved by regulatory agencies for the treatment of OD. Additionally, there are few large-population case series and no placebo-controlled trials showing efficacy.
Table 15.2
Drug therapy for anorgasmia unrelated to selective serotonin reuptake inhibitor usage
|
Dosage |
||
|
Drug |
As needed |
Daily |
|
Intranasal oxytocin |
20–24 IU just prior to or during intercourse [19, 20] |
20 IU twice daily [21] |
|
Cabergoline |
0.5 mg twice a week [22] |
|
With permission from McMahon CG, Abdo C, Incrocci L, Perelman M, Rowland D, Waldinger M, Xin ZC. Disorders of orgasm and ejaculation in men. J Sex Med. 2004 Jul;1(1):58–65. Copyright © 2004, John Wiley and Sons [23]
Table 15.3
Adjunctive drug therapy for selective serotonin reuptake inhibitor-induced sexual dysfunction
|
Dosage |
|||
|
Drug |
Symptom |
As needed |
Daily |
|
Amantadine |
Anorgasmia |
100–400 mg (for 2 days prior to coitus) |
75–100 mg twice or three times daily |
|
Decreased libido |
|||
|
Erectile dysfunction |
|||
|
Bupropion |
Anorgasmia |
75–150 mg |
75 mg twice or three times daily |
|
Buspirone |
Anorgasmia |
15–60 mg |
5–15 mg twice daily |
|
Decreased libido |
|||
|
Erectile dysfunction |
|||
|
Cyproheptadine |
Anorgasmia |
4–12 mg |
On demand |
|
Decreased libido |
|||
|
Erectile dysfunction |
|||
|
Yohimbine |
Anorgasmia |
5.4–10.8 mg |
5.4 mg three times daily |
|
Decreased libido |
|||
|
Erectile dysfunction |
|||
Used with permission from McMahon et al. [23]
15.5.1.1 Oxytocin
Ishak and colleagues reported the case of a patient with anorgasmia refractory to dopamine agonists, sex education, supportive measures, and growth hormone. The patient had resolution of OD while using 20–24 IU of intranasal oxytocin during intercourse at the point when ejaculation was desired [19]. Other studies have shown that intranasal oxytocin increases intensity of orgasm and contentment after orgasm as measured by the Arizona Sexual Experience Scale [20, 21]. However, additional research is necessary before the utility of oxytocin in the treatment of OD can be recommended.
15.5.1.2 Cabergoline
Cabergoline is a dopamine receptor antagonist that has an inhibitory effect on prolactin secretion by the anterior pituitary. Hsieh and associates showed that of 72 anorgasmic men treated with cabergoline 0.5 mg twice a week, 50 showed improvement in orgasm. Of these, 26 men had return of normal orgasm [22]. While this is a promising series, further studies are needed to confirm the efficacy of cabergoline in anorgasmic men.
15.5.1.3 Other Treatments
Other medications may be effective in treating OD, particularly in the treatment of selective serotonin reuptake inhibitor-induced sexual dysfunction. These include amantadine, bupropion, buspirone, cyproheptadine, and yohimbine. These improve OD via a dopaminergic or anti-serotonergic mechanism of action. Table 15.3 lists recommended dosages for these medications. Again, these drugs are used in an off-label fashion and may require an informed consent. Additional research is necessary using appropriate placebo controls to confirm efficacy.
15.5.1.4 Acupuncture
Acupuncture is part of the practice of traditional Chinese medicine (TCM) and is a pillar of modern healthcare in China. ) It continues to gain acceptance in Western medicine as an alternative therapy. TCM theory on acupuncture is based on the fact that there are approximately 2000 points on the human body connected with 12 channels or “Meridians.” Normal Qi (energy) needs to flow through these channels uninterrupted throughout the body to maintain one’s health. If one of these channels becomes blocked, disease or discomfort results. TCM focuses on attaining balance in the energy flow by placing needles into specific points on the Meridians. Western medicine touts acupuncture to release natural endorphins and opioids [24, 25].
TCM has been used to treat various sexual disorders; the central organ in male sexual dysfunction is the kidney. TCM holds that ejaculatory dysfunction is due to an imbalance between “yin” and “yang” along with deficiency of Qi. Today, TCM uses acupuncture alongside herbal therapy to treat male sexual dysfunction [26]. Khamba and colleagues reported subjective improvement in subjects with sexual dysfunction symptoms (including anorgasmia) due to antidepressant medication after a 12-week course of acupuncture [27]. However, controlled studies on the efficacy of acupuncture as a treatment for orgasmic dysfunction are still warranted.
15.6 Orgasmic Headache
The Headache Classification Subcommittee of the International Headache Society defines orgasmic headache as a sudden, severe (“explosive”) headache that occurs at orgasm and is not attributed to another disorder such as subarachnoid hemorrhage or arterial) dissection [28]. The pathophysiology is not well understood, but orgasmic headache may be caused by segmental arterial vasospasm due to an impaired myogenic mechanism of cerebral autoregulation [29]. Others postulate that orgasmic headache is related to thunderclap headache, migraine headache, or reversible cerebral vasoconstriction syndromes [30, 31].
As orgasmic headache is a diagnosis of exclusion, other possible causes of headache should be investigated. This type of headache typically responds poorly to analgesics. Lee and colleagues reported a case of a 34-year-old man with orgasmic headache and brain magnetic resonance angiography showing severe spasm of the bilateral middle cerebral arteries. The patient was successfully treated with a course of oral nimodipine, a calcium-channel blocker [30].
15.7 Summary
Orgasmic dysfunction is a spectrum of medical conditions that can cause significant distress to the affected man as well as his partner. OD can be a separate entity from ejaculatory dysfunction, though they are often described together. Hormones including serotonin, oxytocin, and prolactin are associated with normal orgasm, and medications altering these hormone levels are known to both cause and treat disorders of orgasm. All medications available to treat OD are currently used in an off-label fashion. Acupuncture is an alternative therapy for OD that has been described, although its efficacy remains to be rigorously determined. Further research into the hormonal pathways and effective treatments of orgasmic dysfunction are warranted.
Commentary: Evaluation and Treatment of Orgasmic Dysfunction
Daniel N. Watter4
(4)
The Society for Sex Therapy and Research (SSTAR), Morris Psychological Group, P.A., Parsippany, NJ, USA
Orgasmic and ejaculatory dysfunctions in men continue to be confused, often being used interchangeably. A clear distinction between orgasm and ejaculation exists, and it is clear that each process can occur independently of the other. However, orgasm and ejaculation are almost always linked in male sexual function, and therefore treatment of orgasmic and ejaculatory dysfunctions is often intertwined. Fortunately, the DSM-V now acknowledges ejaculatory disorders specifically, although male orgasmic disorders remain omitted. Furthermore, the combined, collaborative role of the physician and mental health specialist in approaching these dysfunctions is becoming clear.
The preceding chapter focuses on orgasmic dysfunction from an organic perspective, highlighting the anatomy and physiology of orgasm as well as the contemporary classification of orgasmic disorders. Discussion of the evaluation and treatment of male orgasmic dysfunction shows that while medical therapies exist, their efficacy is either limited or unclear due to a paucity of studies, and all medications currently in use are used in an off-label fashion. In the following commentary, the focus is on orgasmic anhedonia, a poorly characterized disorder that can be successfully treated using a combination of medical and psychotherapies, individualized per patient, as becomes evident in the case examples presented. Together the chapter and commentary serve as a clarion call for an interdisciplinary approach to men with orgasmic disorders, which remain incompletely understood with few medical treatment options. Combination therapy is likely to improve outcomes in afflicted men and should be considered in a patient-specific manner in all men presenting with orgasmic disorders.
The Editors
Commentary
For the mental health clinician, the evaluation and treatment of orgasmic dysfunction poses several clinical challenges. From the outset, our imprecise terminology regarding sexual dysfunction may lead to some confusion regarding the disorders we are discussing. The frequent conflation of orgasm and ejaculation often leads clinicians down the wrong path regarding diagnosis and treatment. According to Waldinger [1] it is unfortunate that the DSM IV-TR [2] did not make a distinction between orgasm and ejaculation. This has been somewhat corrected in DSM-V [3] with the DSM-V substituting “delayed ejaculation” for the imprecise “male orgasmic disorder.” However, the DSM-V still does not address disorders of orgasm for the male, listing only those disorders of ejaculation. For the purposes of this commentary, orgasmic dysfunction in the male refers to those cases of diminished orgasmic sensation and those often referred to as “anesthetic ejaculation” or “orgasmic anhedonia.” For those looking for the mental health clinician’s perspective on rapid/premature ejaculation and/or delayed ejaculation, please refer to the commentary in Chap. 12.
Little is known or written about this disorder, so the clinician has little guidance in the evaluation and treatment of this dysfunction. Given the neurological implications of orgasmic sensation, initial assessment is best performed by a physician with expertise in sexual medicine. Oftentimes, the medical evaluation is unremarkable, and the patient will then be referred for mental health evaluation and/or treatment.
The diagnosis of orgasmic disorders is further complicated by the lack of specificity of our diagnostic markers and procedures. Evaluation is based primarily on patient self-report of the intensity, or change of intensity, of orgasmic sensation. This may be associated with a reduction in volume or force of the ejaculate itself, but while related to the ejaculation process, it is the subjective cognitive/emotional experience that is the focus [4]. Obviously, the subjective nature of such report requires an extensive clinical interview in order to assess mental health status and the potential implications of such findings on the orgasmic experience. According to Perelman [5], the mental health interview would explore psychological factors such as hypoactive sexual desire disorder, depression, difficulties with sexual arousal, anxiety, fatigue, past trauma/abuse, cultural/religious views on sex, partner’s sexual difficulties/concerns, and other emotionally based concerns. Sex therapy treatments may include teaching stimulation techniques to men and their partners, mindfulness techniques, yoga exercises, Kegel exercises, and challenging/realigning men’s expectations of the orgasmic experience. Treatment should also emphasize enhancing greater immersion in sexual ideation/fantasy (sexual cognitions) and minimizing self-monitoring, which inhibits awareness of both subjective pleasure and physical sensation [6]. It should be clear from the above that the evaluation and treatment of orgasmic disorders in men requires a thorough examination and evaluation of a multitude of potential variables, including the possible sexual side effects of many medications, most notably the SSRIs.
As was previously noted, there is little in the psychiatric literature regarding the phenomenon of orgasmic anhedonia. Most reports are anecdotal, and many suggest that the sexual dysfunction is a symptom of a more general psychiatric/psychological condition. For example, many men who present with the complaint of orgasmic anhedonia will describe a general feeling of anhedonia as well. Typically these men are clinically depressed, experiencing significant relationship distress or some other existential crisis. When any of these situations exist, treatment of the larger symptom picture will often result in improved sexual functioning. Yet, like many “chicken and egg phenomena,” it is critical to identify whether the depression is secondary to the orgasmic dysfunction or instead a precipitant to it.
In addition the mental health clinician must also be mindful of the effects this (as with any) sexual dysfunction may have on the couple’s relationship. Sexual dysfunction that presents in any coupled individual will likely have an impact on their partner and their relationship. Oftentimes, couple therapy, if not the primary modality, will need to be considered to repair any damage to the relationship the sexual difficulty may have created.
Case Example
Samuel was a 39-year-old married male who was complaining of orgasmic anhedonia of 2 years of duration. Medical evaluation was unremarkable, and Samuel had no history of previous mental health treatment, psychiatric medications, or substance abuse. Samuel reported good erectile functioning, but a diminished interest in sexual activity, as well as the diminished sensation with orgasm. Samuel was highly distressed about these sexual changes, and only upon detailed questioning did it become apparent to Samuel that he had been feeling generally anhedonic and dysthymic. It was further discovered that at about the time Samuel’s sexual difficulties began, his best friend from childhood passed away from an undiagnosed cardiac condition. Since that time, Samuel had become preoccupied with thoughts of his own mortality, and he found himself often thinking his own death may be around the corner. Therapy focusing on Samuel’s apparent death anxiety led to substantial improvement in all symptoms, including his diminished orgasmic sensation. Couple sessions were also included toward the end of treatment in order to deal with the relationship stress that had resulted from Samuel’s sexual withdrawal.
Cases of orgasmic anhedonia need to be distinguished from those cases in which a man experiences diminished orgasmic sensation as a natural consequence of the aging process. Many men do not realize that sexual functioning may change with age, and while perhaps distressing, these changes do not result from a pathological condition. However, the promise of current medical technology and the advent of medications such as sildenafil citrate have given many the notion that the sexuality of youth need never be ceded. Perelman has noted that some men will confuse their pharmaceutically enhanced erection as evidence of a greater level of sexual arousal than is actually present and will subsequently have difficulty with either a delayed, diminished, or nonexistent ejaculation and/or orgasm. In fact, the prevalence of those conditions may be increasing along with our population’s age, and more and more men use medical procedures to enhance their erectile capacity and subsequently become vulnerable to diminished orgasmic disorders [7, 8].
While Kegel exercises may be somewhat helpful for many aging men, all must eventually face the reality of age-related changes in sexual function. This, in itself, may precipitate a mental health crisis for some men, and assisting them in dealing with the psychological distress some feel regarding the aging process may require therapeutic intervention, although sometimes patient education is sufficient to ameliorate the concern.
Case Example
Howard was a 57-year-old married male who complained of diminished orgasmic sensation. Medical evaluation was essentially unremarkable, but he did have a history of psychological treatment for anxiety approximately 10 years ago. Howard reported that his orgasmic changes appeared gradually, and while he still found orgasm pleasurable, it was significantly less intense than what was once the case. Howard’s primary fear was that his orgasmic changes signified a diminished love and attraction for his spouse of 31 years. He reported no obvious marital stressors but was unable to ascribe his “symptoms” to any other explanation. While Howard was aware that erectile functioning might change with age (he had begun taking sildenafil citrate approximately 2 years prior), he had never heard that orgasmic intensity could change as well. While Howard was relieved that this change did not necessarily suggest an unconscious marital dissatisfaction, he was troubled by the notion that orgasmic response may never be the same as in his youth. Kegel exercises were recommended and did produce some improvements, as Howard was a diligent and compliant patient. However, the bulk of therapy consisted of assisting Howard in coming to terms with the sexual changes of aging, his anger that medical science had to “antidote” for this situation, and his anxiety regarding his own mortality. Especially helpful for Howard was McCarthy and Metz’s [9] Good Enough Sex Model, in which the man and his partner are encouraged to become less rigid and performance-focused regarding sexual functioning and instead to develop a more flexible “sex for pleasure” orientation. Specifically, McCarthy and Metz suggest that intimacy and sex should be about acceptance, pleasure, and positive, realistic (including age-appropriate) sexual and relationship sexual expectations.
As can be seen from the above case examples, the mental health evaluation and treatment of male orgasmic disorders is varied and case-specific. For the mental health clinician, the treatment of these difficulties requires a careful assessment of underlying psychological disorders, most notably depression, anxiety, and relationship distress. As is true with all sexual dysfunctions, the mental health clinician must pay particular attention to the effect these disorders may have on the life of the couple. Rarely does the sexual dysfunction that manifests in one partner fail to have a significant effect on the patient’s partner and their relationship. Often following even a “successful” resolution of the sexual difficulty, the relationship will require therapeutic attention in order to repair the damage that may have been done as a result of the sexual breakdown of the couple.
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