Month: December 2020

Curve Penis

Peyronie
A disease produced by induration and fibrosis of the corpora cavernosa of the penis and evidenced as an upward bowing of the penis, plus a gradually increasing angulation to the right or left of the midline, makes coital connection somewhat difficult, and in advanced stages coition is virtually impossible.

There also may be pain attached to attempts at coital connection due to the unusual angulation of the penis creating resultant penile shaft strain, both with inserting and with thrusting experience.

Penile Chordee or Curved Penis

It is seen rarely in situations of penile trauma and only occasionally with neglected gonorrheal urethritis. Consultation has been requested by four men with severe penile chordee as a post traumatic residual.

In two instances the fully erect penis was struck sharply by an angry female partner. The remaining two men each described severe pain with a specific coital experience. During uninhibitedly responsive coital connection with the female partner in a superior position, the penis was lost to the vaginal barrel. In each case, the women tried to remount rapidly by sitting down firmly on the shaft of the penis.

The vaginal orifice was missed in the hurried insertive attempt and the full weight of the woman’s body sustained by the erect penis.

Each of the four men gave the remarkable verbal description that he felt or heard something snap. Shortly thereafter an obvious hematoma appeared on the anterior or posterior wall or lateral walls of the penile shaft.

Over a period of weeks, as the local hemorrhage was absorbed, fibrous adhesions developed and, with subsequent scar formation, there slowly developed a downward bowing and (in three cases) mild angulation of the penis.

Urologists state that due to the type of tissue involved in the penile trauma, there is little to offer in the way of clinical reprieve for men afflicted with these embarrassing erective angulations, Peyronie’s disease or chordee.

Attempts at surgical correction currently are of relatively little value and not infrequently make the situation worse. Any of these situations create responses of pain and tenderness during both masturbation and coital connection.

It always should be borne in mind that the erect penis can be traumatized by a sudden blow, by rapidly shifting coital position, by applying sudden angulation strain to the shaft, or from violent coital activity that places sudden weight or sudden pressure on the fully erect penis. The unfortunate residuals of such trauma have been described above.

Direct trauma of the penis occasioned by major accidents, war injuries, or direct physical attack sometimes requires that treatment for sexual dysfunction be patterned to include marked variation in the anatomical structuring of the penis. In anatomical deformity of the penis, the complaint of dyspareunia can be raised by either the male or female sexual partner.

Testicular Pain

Usually of the dull, aching variety, develops for some men who spend a significant amount of time in sexual play or in reading pornographic literature, concurrently maintaining erections for lengthy periods of time without ejaculating within the immediate present.

Frequent returns to excitement or even plateau-phase levels of sexual stimulation without ejaculatory relief of the accompanying testicular vasocongestion can cause an aching in either or both testes, particularly in younger men. Relief is immediate with ejaculation, which disperses the superficial and deep vasocongestion and returns the testicles to their normal size.

No permanent damage is occasioned by maintaining chronic testicular congestion for a period of days. Men with this syndrome of testicular pain occasioned by long-maintained sexual tension are in the minority.

Usually, the syndrome of involuntary testicular pain is relieved somewhat as the man ages.

There are painful reactions that develop during or shortly after coital connection that particularly reflect the influence of the vaginal environment. These situations are mentioned only in passing, but the therapist should keep in mind the fact that the basic pathology involved rests within the vaginal environment.

Condoms Allergies

Aside from direct infective agents, there are many other sources of burning, itching, or aching in the vaginal barrel that can produce chronic dyspareunia. Among those most frequently encountered are the sensitivity reactions associated with intravaginal chemical contraceptive materials.

Many women develop vaginal sensitivity to chemical factors included in contraceptive creams, jellies, suppositories, foams, or foam tablets. When persistent itching or burning is intense enough to engender the symptoms of dyspareunia during or shortly after intercourse, and when any of these above-mentioned intravaginal chemical contraceptive agents are employed routinely during coital connection, the possibility of sensitivity to the chemical agents should always be kept in mind.

There also are occasional irritations created by the rubber used in manufacturing both diaphragms and condoms. In a few women the response of the vaginal mucosa to latex products is quite irritative in character.

When these contraceptive techniques are employed with regularity and a chronic non infectious irritation in the vagina causes obviously increasing dyspareunia, sensitivity to rubber products should be suspected. The sensitivity to rubber is quite infrequent but must be kept in mind in the differential diagnosis of non infectious, irritative, vaginal dyspareunia.

Agents frequently most often responsible for making the vaginal mucosa sensitive to infective processes and emphasizing the potential irritation of maintained penile thrusting are the various douching preparations.

Many women feel they must douche after every coital exposure to maintain cleanliness. This is one of the most persistent and widespread misconceptions in the folklore of human sexual functioning. From a cleanliness point of view, there is not the slightest need for douching after intercourse.

The vagina returns to its natural protective pH value within 6 to 8 hours after seminal-fluid deposition. Repeated douching usually accomplishes only the untoward result of washing protective levels of residual acidity from the vagina.

Thereafter, secondary infection frequently develops from the elevated levels of pH usually found in the post-douching vaginal environment. Additionally, proprietary products used in douching can create a reactive, chemical-type vaginitis of the same pattern as that stimulated by intravaginal chemical contraceptives.

Esthetically concerned women should be reassured by authority that the simple expedient of external washing with soap and water is all that is necessary to maintain security from post ejaculatory drainage and to avoid any suggestion of post coital odor.

Forceful Penile Thrusting

There is another type of chronic vaginal irritation that should be highlighted. It frequently is seen associated with clinical complaints of dyspareunia and is described as senile vaginitis. Older women not supported by steroid protection techniques develop thin, atrophic mucosal surfaces in the vagina.

These tissue-paper-thin areas crack and bleed easily under duress of forceful or maintained penile thrusting. Many women in the 50 to 70 year age group complain of vaginal burning and irritation not only during but even for hours and occasionally days after coital exposure due to the atrophic condition of the mucosal lining of the vagina.

Sex Steroid

Aging women can be fully protected from these distressing symptoms by initiation of adequate sex steroid support. Although seen infrequently, yet in the same physiological category as senile vaginitis, is radiation reaction in the vagina. After local radiation for carcinoma, the vaginal barrel shrinks, the mucosa becomes atrophic, and dyspareunia usually develops not only from the atrophic mucosa but also on the basis of loss of vaginal wall elasticity and marked reduction of lubrication production.

Sexual Interest

Yet another advantage of the social-isolation factor is its effect upon the sexual interest of both marital partners. With the subject of sex exposed to daily consideration, sexual stimulation usually elevates rapidly and accrues to the total relationship. This specific psycho physiological support is indeed welcome to the cotherapists dealing with the blocking of sexual stimuli in individuals distressed by sexual inadequacy.

To help develop a level of sexual interest: 

For the couple which is realistic to their life style, vacations from any form of specific sexual activity are declared for at least two 24-hour periods during the two weeks, in a system of timely checks and balances. However, daily consideration of sexual matters and social isolation continue to give maximum return to this facet of the psychotherapy.

It might be held as part of this therapeutic concept that patients must have the opportunity to make those mistakes which reveal factors contributing to their particular distress. This means of learning is particularly important in reversing sexual dysfunction. In this interest, the patients are told that the cotherapists are not interested in a report of perfect achievement when they are following directions in the privacy of their own bedroom.

The cotherapists are interested in couple’s making their usual errors of reaction and interaction as they involve themselves in situations that provide opportunity for natural response to sexual stimuli. If the mistakes then are evaluated and explained in context, the educational process is infinitely less painful and more lasting. There are significant advantages in this technique.

When mistakes are made, they are examined impartially and explained objectively to the unit within 24 hours of their occurrence. Additionally, they are discussed within the context of the misunderstanding, misconceptions, or taboos that may have led to or influenced their occurrence initially.

There is yet another specific advantage in daily conferences. If the distressed unit waits a matter of days after mistakes are made before consulting authority, the fears engendered by their specific episode of inadequacy or mistake in performance increase daily in almost geometric progression. In such a situation, alienation between partners is a common occurrence. By the time the next opportunity for consultation arises, a great deal of the effectiveness of prior therapy may have been destroyed by the takeover of the fears.

Fears of performance do not wait a few days or a week until the next appointment; in the meantime, the couple, separately or together, must use their own methods of coping. Most often this will be withdrawal of sexual or total communication, which places them further away from altering the sexual distress than before therapy was initiated.

When patients do not make mistakes during their acute phase of treatment, the cotherapists arrange for them to do so. It is inevitably true that individuals learn more from their errors than from their ability to follow directions effectively on the first attempt.

If marital partners reverse their sexual dysfunction and fully understand, through comparison with episodes of failure, why and what made it possible for them to function effectively, the probability of reduplicating the success in the home environment is increased immeasurably.

As evidence of the advantage to the therapeutic program of the unit’s social isolation, those couples referred from the St. Louis area require three weeks to accomplish symptom reversal rather than the standard two weeks for those living outside the local area. It is difficult to isolate oneself from family demands and business concerns if treatment is being ear tied out in the environment in which the couple lives.

For this reason it has been found more effective to see patients referred from the St. Louis area on a daily basis for the first week, there after five times a week, and to assign a total of three weeks to accomplish reversal of symptomatology. Partners in sexually distressed marriages who cannot or do not isolate themselves from the social or professional concerns of the moment react more slowly, absorb less, and communicate at a much lower degree of efficiency than those advantaged by social retreat.

The Foundation’s request for two weeks’ withdrawal from daily demands, at first rather an overwhelming suggestion to most patients, pales into insignificance when compared to the isolation demands engendered by necessary hospitalization for acute surgical or medical problems. When the couple’s presenting complaint is one of sexual inadequacy, it should constantly be borne in mind that there is not only the equivalent of two distressed people but also an impaired marital relationship to be treated.

Secondary Impotence

Definition of secondary impotence depends upon acceptance of the concept of primary impotence as expressed and discussed in primary impotence. Primary impotence arbitrarily has been defined as the inability to achieve and/or maintain an erection quality sufficient to accomplish coital connection.

If erection is established and then lost from real or imagined distractions related to the coital opportunity, the erection usually is dissipated without an accompanying ejaculatory response. If diagnosed as primarily impotent, a man not only evidences erective inadequacy during his initial coital encounter but the dysfunction also is present with every subsequent opportunity.

If a man is to be judged secondarily impotent, there must be the clinical landmark of at least one instance of successful intromission, either during the initial coital opportunity or in a later episode. The usual pattern of the secondarily impotent male is success with the initial coital opportunity and continued effective performance with the first fifty, hundred, or even thousand or more coital encounters.

Finally, an episode of failure at effective coital connection is recorded.

Secondary Impotence and Sex

The most distressing etiological influence upon any dysfunction in the cycle of male sexual inadequacy is a derogatory effect of consulted therapeutic opinion. Careless or incompetent professionals inadvertently may either initiate the symptoms of sexual dysfunction or, as is more frequently the case, amplify and perpetuate the clinical distress brought to professional attention.

There have been 27 cases in the total 213 units referred for treatment of secondary impotence that have been told at first consultation with selected authority for relief of symptoms that nothing could be done about their problem.

These cases are represented in all categories of etiological influence described previously in the chapter as prime initiators of the symptoms of secondary impotence. When the sexually incompetent male finally gathers his courage and reaches for the presumed security of authoritative consultation only to be told that nothing can be done about his problem, the psychogenic effect of this denial of salvation is devastating.

Of the 27 men denied hope of symptomatic relief by consultative authority, 21 individuals were so informed on their first and only visit to their local physician.

Among these 21 men, 11were told that the onset of symptoms of secondary impotence was concrete evidence of clinical progression of the aging process and that they and their wives would have to learn to adjust to the natural distress occasioned by the sexual dysfunction.

Among these 11 men the eldest was 68, the youngest 42, and the average age was 53 years. These men and their wives experienced an average of 28 months of sexual inadequacy before seeking further consultation.

In the 10 remaining instances of authoritative denial of hope of reprieve from symptoms of impotence, there were 4 instances of negation of clinical support by the consulted theologian; in 2 of these instances the men were informed that symptoms of impotence were in retribution for admitted adulterous behavior.

One of the husband and wife was informed by a clergyman that the symptoms of secondary impotence developed as a form of penance because this particular unit had mutually agreed that a pregnancy conceived prior to marriage should be terminated by an abortion.

Finally
One unit was assured that the symptoms of impotence would disappear if there were regularity in church attendance for at least one year. Two years later, despite fanatical attendance at all church functions, the symptoms of impotence continued unabated.

In each of the 6 remaining couples there were individual patterns of authoritative denial of hope of symptomatic relief. They ranged from the statement that “once a grown man has a homosexual experience, he always ends up impotent,” to the authoritative comment that “any man masturbating after he reaches the age of thirty can expect to become impotent.” The authorities consulted were psychologists, marriage counselor, and lay analyst.

The incidence of erective failure progressed rapidly after authoritative denial of support.

Sexual Disability

Male fears of performance were magnified and marriages were shaken and even disrupted by projection by the professional sources of a black future with full sexual disability.

This mutually traumatic experience for husband and wife could easily have been avoided had the consulted authority figure accepted the fundamental responsibility either by admitting lack of specific knowledge in this area or by acquiring some basic understanding of human sexual response, or at least by not confusing personal prejudice with professional medical or behavioral opinion.

In addition to the 27 cases in which the presenting symptoms of sexual dysfunction were amplified or perpetuated by consultative authority, there were 6 instances in which consultative authority was directly responsible for the onset of symptoms of secondary impotence.

The susceptibility of the human male to the power of suggestion with reference to his sexual prowess is almost unbelievable. Two classic histories defining iatrogenic influence as an etiological agent in onset of symptoms of secondary impotence provide adequate illustration of the concept.

Vaginal Penetration

A man in his early thirties married a girl in her mid twenties. Both had rather extensive premarital sexual experience. His was intercourse with multiple partners, hers was mutual manipulation to orgasm with multiple partners, but never vaginal penetration. She had retained her hymen for wedding night sacrifice.

However, the honeymoon was spent in repetitively unsuccessful attempts to consummate the marriage. The husband and wife felt that the difficulty was the intact hymen, so she consulted her physician for direction. She was told that it was simply a matter of relaxation, to take a drink or two before bedroom encounters.

By relieving her tensions with alcohol she should be able to respond effectively. The drinks were taken as ordered, but the result was not as anticipated.

The marriage continued in an unconsummated state for three years, with the wife’s basic distress (in retrospect) a well established state of vaginismus. Throughout the three-year period, the husband continued penetration attempts with effective erections at a frequency of at least two to three times a week.

There usually was mutual manipulation to orgasm, when coitus could not be accomplished.

As a second consultant, her religious adviser assured the couple that consummation would occur if the husband could accept the wife’s (and the adviser’s) religious commitment. The husband balked at this form of pressure.

Hymen

Finally, a gynecologist, third in the line of consultants, suggested that the difficulty was an impervious hymen. The wife immediately agreed to undergo minor surgery for removal of the hymen. It is not only the human male that is “delighted to find some concept of physical explanation for sexual dysfunction.

When the physician spoke with the husband after surgery, the husband was assured that all went well with the simple surgical procedure and that his wife was fine. The physician terminated his remarks to the husband with the statement, “Well, if you can’t have intercourse now, the fault is certainly yours.”

Obviously, surgical removal of the hymen will provide no relief from a state of vaginismus, so three weeks after surgery, when coital connection was initiated, penetration was still impossible.

For two weeks thereafter, attempts were made to consummate the marriage almost on a daily basis, but still without success. By the end of the second week both husband and wife noted that the penile erections were no longer full or well sustained.

The symptoms of impotence increased rapidly over the next few weeks. Three months after the hymenectomy, the husband was completely impotent. Both partners were now fully aware that the inability to consummate the marriage was certainly the husband’s fault alone, for so he had been told by authority.

The problem presented in therapy two-and-a-half years later by this husband and wife was not only the concern for the wife’s clinically established vaginismus but additionally the symptoms of secondary impotence that were totally consuming for the husband.

In another instance:
The husband and wife in a three-year marriage had been having intercourse approximately once a day. They were somewhat concerned about the frequency of coital exposure, since they had been assured by friends that this was a higher frequency than usual.

Personally delighted with the pleasures involved in this frequency of exposure, yet faced with the theoretical concerns raised by their friends, they did consult a professional. They were told that an ejaculatory frequency at the rate described would certainly wear out the male in very short order.

The professional further stated that he was quite surprised that the husband hadn’t already experienced difficulty with maintaining an erection. He suggested that they had better reduce their coital exposures to, at the most, twice a week in order to protect the husband against developing such a distress.

Finally, the psychologist expressed the hope that the husband and wife had sought consultation while there still was time for his suggested protective measures to work.

Sexual Response

The husband worried for 48 hours about this authoritative disclosure. When intercourse was attempted two nights after consultation, he did accomplish an erection, but erective attainment was quite slowed as compared to any previous sexual response pattern.

One night later there was even further difficulty in achieving an erection, and three days later the man was totally impotent to his wife’s sexual demands with the exception of six to eight times a year when coitus was accomplished with a partial erection. He continued impotent for seven years before seeking further consultation.

When duly constituted authority is consulted in any matter of sexual dysfunction, be the patient man or woman, the supplicant is hanging on his every word.

Extreme care must be taken to avoid untoward suggestion, chance remark, or direct misstatement. If the chosen consultant feels inadequate or too uninformed to respond objectively, there should be no hesitancy in denying the role of authority. There is no excuse for allowing personal prejudice, inadequate biophysical orientation, or psychosocial discomfort with sexual material to color therapeutic direction from duly constituted authority.

There are innumerable combinations of etiological influences that can and do initiate male sexual dysfunction, particularly that of secondary impotence. It is hoped that the survey of these agents in this chapter will serve not only as a categorical statement but also render information of value to duly constituted authority.

Secondary impotence is inevitably a debilitating syndrome. No man, or, for that matter, no husband and wife emerges unscathed after battle with the ego-destructive mechanisms so intimately associated with this basic form of sexual dysfunction.

There must be support, there must be relief, and there must be release for those embattled husband and wifes condemned by varieties of circumstance to contend with male sexual dysfunction. As emphasized earlier in this chapter, most men are influenced toward secondary impotence by manifold etiological factors.

Although case histories have been held didactically open and brief for teaching purposes, it must be understood that frequently there was a multiple choice of determining agents. Other professionals well might make a different assignment if given an opportunity to review the material.

For example
there remain 12 cases referred for treatment that could not be categorized from an etiological point of view. No dominant factor could be established among a multiplicity of influences despite in-depth questioning by Foundation personnel.

It must be emphasized that, regardless of the multiplicity of etiological influences which can contribute to incidence of secondary impotence, it is the untoward susceptibility of a specific man to these influences that ultimately leads to sexual inadequacy. It is this clinical state of susceptibility to etiologic influence about which so little is known.

A statistical evaluation of the returns from therapy of secondary impotence will be considered as an integral part of the chapter on treatment of impotence. Present concepts of treatment for secondary impotence have been joined with those of the current clinical approaches to primary impotence in a separate discussion devoted to these therapeutic considerations.