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STACY ELLIOTT
Diminishing Orgasmic Sensation
4 July 2009: 18 Messages
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I have a very fit, 29 year old lifeguard patient who is in a steady relationship with his fiancée for over 5 years. He initially came to see me with complaints of diminishing libido and orgasmic sensations but an
extensive endocrine workup was normal, with am testosterone levels of 18 nmol/L (normal range 10 - 30), normal gonadotropins, prolactin and fasting glucose. He pushes himself to work out daily. He has normal sexual erections (but has lost his REM
sleep erections) and ejaculation (not delayed), but the orgasmic component has gone to zero over the last year. He still has antegrade ejaculation but the projectile strength has diminished. He has seen urology who found nothing wrong on
examination, and neurology: the latter ruled out MS after doing a MRI of the brain and spine. He has also been seen with his fiancée for 5 visits by a superb PhD therapist who directed them in sex therapy and mindfulness. They continue it on their
own and find it rewarding but it does not change the anhedonic orgasms. He is doing approximately 100 Kegels per day and is booked to see a pelvic floor therapist. He isn't overly anxious or histrionic: just disappointed and confused by this lack
of sexual payoff and convinced there must be something organic going on. He is an intelligent man and says he can live with it but feels pretty ‘ripped off’. Any further suggestions?
Stacy Elliott (Stacy.Elliott@VCH.CA)
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The unconscious emotional and relational aspects of this couple ought to be considered, particularly as no organic cause of the problem has yet been uncovered. A psychosexual/couples therapist who works with
unconscious defenses needs to be consulted.
There are 3 potential clues to problematic relational dynamics. First, the couple stopped therapy after only 5 sessions. This suggests that Sensate Focus (SF), if used, MAY have provoked powerful feelings that were
uncomfortable, including boredom or anxiety, and which were left unexplored. I doubt very much that this couple can maintain the SF program on their own. Moreover, the man's or the couple's relational anxieties would not necessarily be evident in
a medical consultation.
The second clue is the man's particular focus on his body (e.g. ‘lifeguard’ and ‘daily workout’). This may 'conceal' attachment insecurity, perhaps also indicated by the third clue, which is the length of the
engagement - 5 years. Does ‘steady’ indicate lack of passion and repressed emotions?
Susan Pacey (susanpacey@YAHOO.COM)
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What are the SHBG and calculated free testosterone levels? I have had some young and fit patients with symptoms of lowered libido and diminished orgasmic sensations and their total testosterone levels have between 15
and 20 nmol/l and calculated free testosterone levels in the low normal range (225-250 pmol/l). Forceful testosterone therapy has been successful in most cases.
Juhana Piha (juhana.piha@FIMNET.FI)
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Your patient has a number of symptoms of hypogonadism. He has decreased libido and decreased energy and motivation possibly (he has to push himself to exercise). These, however, are non-specific. We have found that
decreased orgasmic power and perhaps decreased seminal volume are fairly specific for androgen deficiency, and neurological conditions have been ruled out in an excellent workup.
An a.m. testosterone of 18 nmol/L or 510 ng/dL would seem to be fine, even for men in their 20s. I wonder if it might have been a lab error and should be repeated. I would also recommend a free testosterone, by either
the equilibrium dialysis method....and throw in a bioavailable testosterone for good measure. Quest and other commercial laboratories, like Lab Corp, can do these and they even offer the total T by LCMS, which would be the best.
We have seen hints in the literature about genetically modified SHBG levels, and one good recent article seemed to show that some men have elevated or low SHBG levels that are genetically controlled. SO, your patient
could have an elevated SHBG, which would give him a normal total T, but have a low free or bioavailable T.
Andre Guay (Andre.T.Guay@LAHEY.ORG)
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I agree with everything that has been suggested so far, and strongly suspect that this man's problem is a manifestation neither of hypogonadism nor of organic dysfunction. Nevertheless he needs help. Pursing another
member's comments from a recent article, this man's masturbation habits should be explored to rule out excessive masturbation or specific orgasmic trigger points which are not met by his partner. If a new girlfriend or a surrogate is not what the
patient feels comfortable doing, then adding private fantasy material may be helpful (although I would imagine that there is plenty of that in his work as a lifeguard). Are we certain that he is in love with this woman? Is he completely
heterosexual? Is he monogamous? As a urologist, I like Dr. Montorsi's idea of daily Cialis. PDE-5 inhibitors have been shown to improve the orgasmic experience, probably through an indirect (? psychological) mechanism. In the United States, the
manufacturer has coupons good for a free 30-day trial of Cialis once daily. He may even want to split the 5 mg. tablet in two and thus get a ‘free’ 60 days' worth. As we all know, there is also a significant placebo effect with any sexual
enhancing drug from which this patient may benefit. In the meantime, I would complete the androgen deficiency work-up and continue couples therapy.
Stephen.Smith
(stephen.smith19@COMCAST.NET)
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How about looking at this man from a somewhat other, more developmental, perspective?
I have met athletic men who experience a certain change in their sexual expression around their thirties. From having experienced an intense sex-drive and great sexual enjoyment, it diminishes, and enjoyment of the
partner becomes of greater value to them. It might be one of the maturing aspects of becoming a grown up, more caretaking male. Becoming a responsible grown-up, a man of greater social value, includes more qualifications than being young, good
looking, strong and sexy. This man has so far been successful in creating ‘masculinity’, a fit body and a tough occupation, which probably have been rewarding to him.
We do not know ‘what has happened’ to him in other parts of his life outside his sex life. Is there a history of any drug-use? Disappointment at work? Is his work satisfying to him? Disappointment in relation to his
fiancée? Are they planning for a family with kids or not? What are his feelings towards that? What about his relationship with his own mother, father and siblings? The experience of death and loss of an important person can contribute with deep
sorrow that affects sexual enjoyment, as does anger and lost self-esteem after offenses. Important personal events might lead him to questioning the meaning of his own life. (depression ?) His choices and decisions up to this point might have to
be reconsidered. Forcing himself to `work-out’ daily’, he might need resting ! This way of not listening to his body might tell that he does not listen to other signals, feelings and thoughts he might have. Signals of weakness and vulnerability
can be scary to the man, threatening the ‘idea of immortality’ that a young, strong man can experience. It should be okay for the grown up man to relax also... What about his masturbation experiences lately? Does he satisfy his partner sexually?
By intercourse with his penis or by other means? In what aspects has she changed?
The suggestion to change partner might be effective on his sexual enjoyment, but for his maturation as a human being he has to go through the separating process with his present girlfriend first... Guilt feelings?
This might be culture dependent...
Human sexual expression fascinates me: it is not like any other bodily function, so many aspects influence aside hormones, as does the advanced cooperation in the couple.
I’d appreciate comments.
Birgitta Hulter (birgitta.hulter@karolinska.se)
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Yes, I certainly agree with Birgitta. When simple medical causes are ruled out, there are always good reasons to look for ‘energy leakage’ somewhere. Many men (sometimes
supported by their doctors) do not see or understand that their sexuality, and their sexual experiences can be influenced by factors not directly linked to sexual matters.
Esben Esther Pirelli Benestad (esben.esther@SEXOLOGI.COM)
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We all see cases like this from time to time and it is interesting to see the differences between the approach of a therapist like Susan and physicians like Francesco and Andre. I think that we can read too much into
the history of being a ‘very fit lifeguard’ and Stacy has, I am sure, evaluated this and her conclusion is that he isn't anxious or histrionic. The loss of REM sleep erections would seem highly significant and I assume that he must get the same
lack of satisfaction with masturbation (if he does so). I would also assume that ‘extensive endocrine workout’ rules out abnormal SHBG. I would therefore favour the line Francesco suggests of tadalafil 5 mg nightly with a 3 month combination with
testosterone gel, and re-evaluate. This would be cost-effective as most other suggested interventions will be time-consuming and relatively expensive. He probably feels that he and his
fiancée have tried the therapy approach for several months with little result and will be quite positive to a trial of medication, especially if we explain the significance of lost REM erections.
Geoff Hackett (geoff.hackett@VIRGIN.NET)
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I would make one comment on Geoff's second sentence. I distinguish between generalised ‘anxiety’ or ‘histrionic’ disorders, which are fixed personality features, and anxiety (often unconscious) as a temporary response
to emotional or sexual intimacy with a partner. The latter type of anxiety is associated with insecure patterns of attachment.
Susan Pacey (susanpacey@YAHOO.COM)
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I would like to share my experience to the ISSM group of helping men achieve a stronger forceful expulsion by the combined use of a dose of an SSRI which delays but does not inhibit
ejaculation; with carefully taught pelvic floor exercises and greater cognitive awareness of his pelvic sensations. This allows much greater control for the experience of forcing out of the ejaculate from the point of experiencing the
‘inevitability of ejaculation’ and the surge of the expulsion has been described by several patients as much more enjoyable and successful. This can be practiced by techniques of masturbation in the first instance but this is not essential. Of
course, it will not work for everyone but offers another clinical option.
Kevan Wylie (k.r.wylie@SHEFFIELD.AC.UK)
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Dear All: Are we sure that we are not making a `medicalization’ of a boy who is no longer in love with his
fiancée and doesn’t accept that ? I don’t know the level of free testosterone or SHBG in a man in love....In conclusion I agree on the one hand with Chico Montorsi and on the other with Birgitta
Hulter. Certainly, this man is not satisfied with his life and this is the result !
Ida Bianchessi (idabianchessi@LIBERO.IT)
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Thanks for the clarification but I was only repeating Stacy's history and used her terms.
Geoff Hackett (geoff.hackett@VIRGIN.NET)
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Stacy: I wonder if this man has ever had a course or courses of anabolic steroids. It has been my experience that this sort of problem can crop up many years down the track.
Richard Clarke (Contact@MENSCLINIC.NET)
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I have used pramipexole (a dopamine agonist with good affinity for the D3 receptor) in some of these guys. It's worth a try. Start with 0.125 mg daily.
Michael P. O'Leary (MOLEARY1@PARTNERS.ORG)
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Thank you for that very intriguing suggestion, Dr. O'Leary. In which specific patient type would you consider prescribing pramipexole? Any worrisome side effects that you have noted? Thanks.
Stephen J. Smith
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I have asked the psychologist if she found any personality disorders and/or other traits that may explain things but she felt, besides being a high achiever and disciplined, that he is not overly anxious or OCD. I
hope this helps. It is interesting that his relationship has improved, become more intimate and relaxed with the sex therapy work, but the sensation has further diminished.
Stacy Elliott (Stacy.Elliott@VCH.CA)
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Have used in different age men, all who claim difficulty ejaculating. No real side effects that I've seen
Michael O'Leary (MOLEARY1@PARTNERS.ORG)
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Hello Stacy: I have been observing this discussion of this ‘interesting’ patient. One question that comes to my mind is whether your local psychologist/sex therapist feels
there is any connection to
performance anxiety, visa vis his ‘high achiever...almost observer’ style that could be inhibiting his ability to ‘truly’ relax and allow the neurological and vascular
systems to work the way they were intended to work. In other words, I have many patients who ‘report being relaxed’ and yet have serious sexual dysfunction. So, while they are ‘relaxed and aroused’ with
their intimate partner there is really another part of their brain that is not fully relaxed. Once we are able to get some funding for more FMRI research, we should be able to show this in real time.
Linda Banner (llbanner@EARTHLINK.NET)
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