Approach to low sex drive and orgasmic dysfunction:
Low sex drive may be caused by low testosterone but commonly it is caused by repetitive failure in sexual activities. Men do not like doing things at which they fail. Hence restoring good erections and confidence in sexual performance is a critical first step in helping men with low sex drive. Detailed history of recent marital problems, job-loss, depression etc may lead to temporary situational loss of interest in sexual activity, as such helping with depression and reassuring patients is all that is needed. In younger men, fact checking and education about “average” frequency of sexual activities: 2-4 a week is an important aspect of treatment.
Older men may have low sex drive because of subtle degeneration in the dopamine controlled reward system in the brain. In such cases we use off label medications like Mirapex (dopamine agonist), buspar, and low dose of trazodone. Improving penile sensitivity, use of lubrication during sex, change of positions which may be more comfortable for older men and women with limited hip mobility are important aspects of holistic approach to sexual health and medicine.
“Orgasm is what we feel, ejaculation is what we see ” (DAP) it is known from Dr. Paduch’s work that younger men perceive their quality of orgasm lower than experienced men. It is believed that sexual inexperience is a key factor in younger men with low orgasmic sensitivity. However there are medications like 5-alpha reductase (finasteride and dutasteride), narcotics, beta-blockers, SSRIs which can directly impair sensation of orgasm by either direct suppressive effect on brain or decreased sensitivity in the peripheral nerves (Cymbalta). Excellent knowledge of psychopharmacology is critical to help patients, we often work with psychiatrists and perform pharmacogenetic response studies to help with changing medications to groups with less orgasmic dysfunction.
Here again using sex toys and focusing on identifying what makes men excited is important part of therapy.