Case Studies
NON CONSUMMATION OF MARRIAGE PRESENTING AS ANEJACULATION
Mr. Arvind (name changed), 40 yrs old came with H/O inability to ejaculate for last 3 years. He got married 8 years back with a teacher. The girl was not interested to have sex because as she said “I am not mentally prepared as yet” the boy took it as a sign of tiredness due to marital chores so didn’t object but it continued as such. The girl kept on postponing sex (there was no extra marital involvement as revealed by the boy himself) on one pretext or the other. The boy tried to force himself 2-3 times, there was appropriate erection but no significant penetration could take place and boy ejaculated on the outside of vulva. The girl got herself transferred to other city and ultimately they took divorce by mutual consent. The occasional sexual activity of the boy was limited to masturbation with reasonable enjoyment.
After divorce, the boy was convinced that he was impotent and developed moderate depression. He still masturbated occasionally but his libido decreased. Since 2 years – he couldn’t ejaculate as well while masturbating.
He approached me when his family members were forcing him for remarriage.
He was non alcoholic, non smoker, normotensive,nondiabetic. His srum testosterone level was at lower side of normal range, penile perfusion index was normal, NPT showed 2 episodes of erection for 15 minutes in total and rigidity was normal.
We started him on psychotherapy, antidepressants, testosterone supplementation, penile rehabilitation programme and PDE-5 inhibitors. It had less than expected response so intrapenile inj and vibrator therapy with 5 mm lateral displacement was added. He started ejaculating after 2 sessions.
Discussion – In this case, the girl was having severe vaginismus so she was extremely scared to have penetrative sex. The worst part was that she was not aware of her problem or she didn’t want to accept that she had a problem. Such cases need desensitization, dilation, psychotherapy, sex education and medicines. If such cases come to us, we take about 3-4 weeks to treat such a problem and results are extremely good.
NON CONSUMMATION PRESENTING AS ED
Mr. A, 38 year old engineer came from Ahmedabad with complain of ED for last 3 years.
He was married 12 years back with a CA girl. Their first night sex consisted of some foreplay, good erection, slight entry (10% according to the boy) and ejaculation outside. The boy never retracted the skin behind the glans. The boy realized that THERE WAS INCOMPLETE PENETRATION, but never communicated this to his wife for fear of being labeled impotent. Even they had a SON, probably because the sperms could get inside the uterus from vulva. Mr. A was hypertensive, had very high work pressure, non smoker and non diabetic, BMI 24. His investigations were normal.
Discussion – ED in this case could be due to hypertension, high stress or the antihypertensive he was taking but he had never penetrated as is evident from h/o never retracting skin behind glans during sex. I suggested him to talk to his wife to initiate couple therapy but she may or may not agree because there was not much distress in their married life. But striking feature in this case was the lack of awareness about steps to have penetrative sex, absence of pleasure in female partner because she can never have orgasm in this way and developing ED because he felt incomplete and incompetent. This feeling is likely to keep on increasing until his wife takes part in sex therapy and agrees for full penetrative sex.
RESISTENT VAGINAL DISCHARGE ( LEUCORRHOEA)
A 38 years lady, post graduate , average built , married for 10 years came for treatment of vaginal discharge and reduced sex desire for the last 8 year. She had consulted many gynecologists and taken all possible antifungals and antibiotics , She had developed reduced desire for sex as well and tried to avoid sex on one pretext or the other. ( average frequency of sex was less than once a month) . The husband was quite angry and threatened for divorce . On careful history taking, it emerged that all was well for two yeaars after marriage. They had very good sex life and had a son 9 months after marriage. The itching would start after bleeding stopped , there was white discharge which was not foul smelling. She used to wash her vagina many times during the day to make sure there was no discharge left ,some times apply antiseptic lotion and scratch vigrously if there was very mild itching. Theis would be followed by more itching and infection, she would consult a doctor , take treatment so infection would be cured but recurred in next cycle. this usually was an excuse to avoid sex. even during sex, she would wash the vagina vigrously till she was sure that all semen was washed. Actually she was suffering from OCD and felt disgusted with body fluids like vaginal or seminal fluid. She would avoid sex to avoid this feeling ,though was upset not to make her husband happy. We treated her for OCD, gave counselling and sex therapy to the couple . Actually cases of chronic vaginal infection are very common and large number are associaated with a psychiatric problem They need to be assessed by a psychiatrist.
REDUCED DESIRE IN A WOMAN
Mr and Mrs X came to me with C/O reduced sex desire in woman. She was 36 years old, married for 12 years , Post graduate and was running her own business at home. The husband was 38 years, professional, working in a company requiring frequent travel , occasional alcohol abuser & a smoker. Morning erections were occasional. Initial time , for around 3 years were good , had sex every night. They had a 9 years old son . The husband could recollect that it all began after the birth of son. But since then, Mrs. X would avoid intimacy, would sleep early or would tell that she had headache. Post delivery, there was no sex for 1 year . when they attempted sex, there was poor erection so it was not satisfactory. He tried to have sex with another woman where it was good. Next time, Mrs X felt a lot of pain , vagina was dry and she presumed that it was due to operation ( baby was born after LSCS) The man would request for sex, but she would repeatedly take one plea or the other to avoid it. Physical examination was normal, lab investigations were normal as well. The woman was found to be having moderate depression with sadness ,disturbed sleep, reduced energy , headache and getting no pleasure from any source. We put the woman on antidepressants, gave them sex counseling with emphasis on spending quality time together, start touching, fondling and going for outing once a week. The man was suggested life style changes, quit smoking . It had magical effect in 6 weeks time. Now they are having sex 3-4 times a week and happy
MARITAL DISCORD DUE TO FEAR OF INADEQUATE SIZE OF PENIS
A 38 yr man, artist by profession and married to a 36 yr lady for 10 years. They dated for 1 year before marriage without having sex . Frequency of sex was 2-3 times a month for initial 3 years, reduced gradually to no sex for last 3 years . Wife had filed for divorce . History revealed he always had a doubt of small penis size . He was never confident while having sex so generally avoided intimacy . They had a 8 year old son . History also revealed he was bisexual with attraction to men if female was not available He denied to have intercourse with men . He was perfectionist by nature
Here the man had misconception about size, producing anxiety and poor self esteem . He avoided wife and tried to boost himself by getting close to males. All this could have been avoided if he had consulted a sexologist. Though size doesnot matter medically, it matters a lot for a few.
NO SEX AFTER MARRIAGE DUE TO PENIS PHOBIA
A couple of ages Male-35/Female 33 came to me for inability to have penetrative sex despite best efforts during 2 years of marriage. Both wereIT professionals , settled in Europe. They had arranged marriage . . They had tried treatment in Europe from a reputed institute but was not successful . Both had medium severity depression. The girl had talked to her married friend about sex life. She wastold that initial sex was extremely painful for her. Close questioning revealed that the boy felt a resistance when he tried to enter and the girl expressed significant pain . He became nervous so lost the hardnesss. The same pattern was repeated again and again . Despaired, they stopped to try but when family members started to enquire about pregnancy, the fact was revealed . We treated the couple by sex education, importance of foreplay and progressive desensitization. The girl started to accept full size dilator and slowly had penetrative sex, It was a case of Vaginismus due to penis phobia because the vagina got closed on attempt of penetration
REDUCED DESIRE IN A WOMAN
A 29 year old pretty looking working woman came with reduced desire for sex. She was married to a 32 years old handsome professional lawyer for 3 years. They had affair for 6 months before marriage but had sex only after marriage . She was a teacher so stayed with parents even after marriage . They would meet every weekend or in 10 days for 2-3 days till 6months after marriage. This period was “ok” but initiation was always done by husband . She had never masturbated and she did’t know what climax is all about. They had no sex during pregnancy time but continued her teaching duties as before. Stayed together for 6 months after delivery but had occasional sex (once every 7-10 days) . She observed that the vagina was getting drier and she had no excitement . Her husband would label her as cold , some times putting her down and got irritable when he lost erection a few times. She was always focussing on child lest she would get up . She started avoiding sex and occasionally allowed just as marital duty. once husband also requested her to take a bath before sex but she ignored.
The case here is typical of a woman having lots of inhibitions with poor understading of orgasmic pleasure. She never enjoyed the sex fully so started avoiding it. . Their staying apart perfectly suited her but since the time they started living full time together, the problem increased . They would need sex education, sex therapy sessions and strategies to face the inhibitions . Such cases have good prognosis provided they both are committed to work as a team to have the pleasure of satisfaying sex life
EXPERIENCE WITH SEX WORKER LEADING TO EARLY EJACULATION
A 26 years boy , graduate and working in a hotel came with Pre Mature Ejaculation for 2 years and ED for 6 months. He was originally from a village but had a job in big city 9 years back. He was a floor manager in night club where young boys and girls would come for fun, have drinks and involved in activities which resulted him feeling wet in underwear. He had no knowledge of sex so thought it was semen discharge. One day friends called a sex worker . He was prompted to have a go . he tried but got ejaculation within seconds. This happened 3 more times when the girl reacted negatively saying” you are not good so consult a doctor”. This sentence kept on hitting his mind again and again. He developed fear of sex so desire dipped drastically and erection was not to be seen.
In this case, the boy was already charged due to erotic environment and anxiety of job, had poor sex education and the remark by girl was the final nail in the coffin . This is very dangerous path and a certain invitation to sex problems later. Going for sex to a worker where you have to perform adequately for paisa vasool will put enormous burden . You will face similar situation, until you are a super human
A CASE OF NOT REACHING CLIMAX IN A FEMALE
A 38 years,graduate ,housewife, married for 12 years and mother of 2 kids came with history of poor satisfaction with sex life. It was arranged marriage and the husband agreed that they loved each other very much. Husband had occasional early discharge but overall he was happy. He was a 40 years old good looking businessman . They had sex every other day and there was no pstchiatric or physical illness in either of them
A detailed questioning revealed that she could reach climax if it was in female superior position. Husband also agreed that it was more enjoyable for him as well. But in missionary position, she had never reached climax . The reason came out was that while in missionary position, she was a passive participant so her mind wandered to non sexual and some times anxious thoughts. Distraction could cause ED is a known fact but it can cause anorgasmia is interesting They were suggested non demand pleasurin exercises . Slowly she could focus on sexual cues and enjoy in missionary position as well
PRE MARITAL SEX CAUSING ED AND REDUCED DESIRE
A 32 year handsome professional man came with complains of reduced desire for sex and ED for 1 year. His was an arranged marriage with a good looking educated girl. He had a premarital affair with a girl for 3 years. They had sex 3 times a week . He was very happy with the sex life before marriage as the girl was ” fully cooperative, experimental , had sex in different ways but his wife was very shy. She insisted to switch off lights before sex which made him very uncomfortable. Last i year , was a low sex marriage with no enjoyment and frustration. Sex was once in 15-20 days . Now they wanted to plan a baby so he came to me .
The problem was that he had poor communication with wife and was comparing his girl friend with her. He was feeling quite resentful . I suggested him to come with his wife. I suggested non demand pleasuring with psychotherapy . Shy ness was reduced with encouragement and he started to have good erections with satisfactory sex life . They had sex once in full light and next in dim light