• Enhance communication
• Share warmth and tenderness
• Physical release
• ­ Self-esteem
• ­ Productivity
• ¯ Dependency + social WD
• Common cause of extramarital affairs

• Usually trivial problem goes through vicious cycle
• Problem exaggerated out of all proportions
• Early intervention: saves time, suffering + expenses

• Associate sex with shame and guilt
• Acknowledging self inadequacy
• Threatening to male ego and self-image
• Taken for being immoral
• Not realise doctor can help

• Complaints misleading
• Pressure of time
• Easier to give medication
• See more patients for more income
• Too demanding
• Difficulties with own sexuality
• Doctor incompetent
• Difficult to descend from pedestal

• Direct request for help
• Covert ® vaginal discharge, change of Pill, depression, martial disharmony, poor sleep

• Seeking information
• Adjustment problems
• Sexual dysfunctions
• Victims of sexual assault
• Physical problems
• Paraphilias

• Size, abnormality of organs
• Premarital check-up
• Sex during menstruation, pregnancy, after menopause, after illness/ surgery
• Oral/ anal sex
• Sexual inclination ® homosexuality

• Penis, testis, labia minora, vagina
• Normal variation
• Exclude organic causes - eg. Klinefelter (XXY): no libido, no nocturnal emissions, Tx: androgen injection every 3 weeks
• Orgasmic platform adapts to different sizes
• Problem with self-image, self-esteem
• There is more to the relationship between a couple
• May have other sexual problems

SESSION 1

• Hx: past + present health, hereditary diseases
• P/E: all systems including genital
• Ix: CBP, blood group, VDRL, HIV, HbsAg + Ab, rubella Ab, urinalysis
• Information + explanation

SESSION 2

• Results of Ix
• Process of sexual intercourse
• Environment: private, comfortable
• Attitude: respect, tender + loving, not to be spectator
• Communication
• Foreplay
• Responsibility to initiate and respond
• Understand prejudices
• Unrealistic expectations
• Fatigue
• Hymen

• No absolute contraindication
• ¯ libido, dysmenorrhoea
• ­ libido
• Messy
• Myth - bad luck

• Allowed until shortly before pregnancy
• Majority ¯ sexual activity, complete abstinence
• Uncomfortable, fear of abortion/ infection
• A common period for extramarital affairs
• Avoid orgasms if habitual abortion, premature labour
• Adjust positions, ¯ thrust
• Non-coital activities
• Communication, intimacy, affection
• Do not blow air into vagina ® air embolism

• Resume when comfortable
• Vaginal dryness due to ¯ oestrogens - use lubricant

Episiotomy wound - gradual return to non-coital activity [wait until stitches absorbed/ removed]

• Changes in marital relationship, stress in becoming new parents
• Husband - feels excluded, jealous
• Prolonged abstinence causes extramarital relationship (eg. No sex during pregnancy, then cannot wash hair/ see husband for 3m after birth - therefore 1 year at least with no sex)
• Communication, consideration for partner

• No need to stop
• Feels liberated
• ¯ Libido
• Problems at home - children leaving home, husband retired and ageing
• Feels old and unattractive
• ¯ Lubrication, senile vaginitis - KY jelly, oestrogens
• Uterine cramps during orgasm - oestrogens
• Hormonal replacement (<5y OK)

• Eg. MI, CVA, liver disease, renal disease, mastectomy, hysterectomy, colostomy, etc
• Offer information, help, rehabilitation
• Explore Pt's and partner's attitudes and fears
• Communication between couple very important
• Practical adjustments - eg. Adopt less tiring position
• Medications causing erection difficulties - ¯ dose, choose alternatives
• Encourage alternative forms of intimacy
• Personal hygiene
• Personal appearance
• Sex in HT ® no detrimental effect; chance of stroke appr defecation; drugs can decrease libido, cause erectile dysfunction (eg. Beta-blockers) [Note: ACE inhibitors and Ca+ channel blocker don't have any effect]; ¯ dosage/ change drug
• Sex after MI ® can resume if can walk up 2 flights of stairs; medication before sex can eliminate angina; posture adaptation: change from missionary position to woman on top, spoon position
• Sex in DM ® 27-55% Pt have erectile dysfunction (retrograde ejaculation and anorgasmia); satisfactory control of DM important; also: oral meds like Viagra, suction pump, penile injections - can ask "A lot of DM patients have ___ problem; do you have ___ problem?"
• Sex after mastectomy/ hysterectomy ® resume when comfortable; self-image @ incomplete woman; fear of injury and contagiousness; worry that husband won't be satisfied; spouse's reaction very important; discuss with doctor before and after operation [Eg. Pt who is a prostitute who refuses hysterectomy even though she has uterine bleeding; she worries that her clients will not consider her a real woman, and she will lose them]

• Nothing wrong if enjoyable to both partners
• Should be no coercion
• Should not cause pain/ injury
• Be open-minded
• Variation
• Hygiene

• Usually acknowledged
• May underlie sexual problem
• Psychological complaints - eg. Break-up of relationship

• Pt's may dare not ask
• Fear of sexual difficulties may cause Pt to refuse medications or operation
• Offer information when the opportunity arises, before the operation and early in management
• Speak to Pt and partner, enhance communication

• Not dysfunctions/ deviations
• Couple's adjustment to each other
• Can cause a great deal of unhappiness and marital discord
• Illogical and immature when dealing with sex

• "She's never interested"
• "He enters me before I'm even warmed up"
• "Why can't she initiate sometimes"
• "He is finished and rolls over and falls asleep when I'm just starting to warm up"
• "He wants sex in the morning when I'm still very sleepy"

• Clarify the precise issue
• Effective communication
• Flexible solutions

• Respect each other, be considerate
• Male sexual arousal is more quicker, more genital oriented
• Female requires more time and intimacy
• Foreplay, communication
• Female orgasm requires sufficient clitoral stimulation
• Compromise, variety, planning
• Do not use sex as reward/ punishment for power struggle

• Newborn ® normality of genitalia; penile erection; vaginal lubrication
• 1-4 yo ® genitalia fondling; part of self-discovery; curiosity about other people's bodies
• Masturbation ® normal, no ill-effects (eg. Infertility); do not induce guilt feelings, can start as early as 2-3 yo
• Sexual play ® common in 6-9 yo; normal process of growing up; no pain; no coercion
• Puberty ® early or late menarche; thelarche (6-8 yo) [thelarche: beginning of the development of breasts at puberty]

• Strike a rapport
• Be considerate, non-judgemental, do not over-react
• Genital examination: female - gentle; male - may feel intimidated
• Do not force Pt's to discuss sexual problems - LEAVE DOORS OPEN

• 2 mo baby w/ URTI, mother 30 yo
• Dr asked mother about her sex life, mother started crying
• "I don't know what sex is, my husband has never entered me" (husband with premature ejaculation)

• 50/M, MTR accountant, HT poorly controlled 1 yr, wife requested consult from other Dr
• Dr asked if he takes meds regularly
• He takes meds erratically because he has heard HT meds can cause impotence
• Dr: explain importance of taking med to control HT, explain meds that he has been taking does not affect erectile function (Dr has to know details of meds)
• Need rapport (good DPR) for Pt to trust (knowledge, sincerity)

• 36/M, Bank Executive, IDDM for 6 yr, went to Dr for f'up (blood chem, eye)
• Dr asked any S/E from insulin?
• Dr asked about sexual function (50% male DM have erectile dysfunction - therefore, must ask about it)
• Note: use 'erectile dysfunction' rather than 'impotence'
• Pt: no problems
• Several mth later: wife saw Dr crying
• Wife requested IVF b/c husband hasn't had erection in years, always tired after work, bad-tempered
• Husband's family thinks that wife is at fault because she works (is modern) and doesn't want to have another baby
• Problems: (1) Secondary infertility due to sexual dysfunction (2) Problem with the couple's relationship
• If couple have a bad relationship, shouldn't complicate with a second child
• Try: counsel wife and husband
• But: husband refused to see Dr
• Therefore, just leave doors open ("you can talk to me anytime")

• F/32, Software engineer, married 8m, requested gynae check-up
• Dr tried to perform gynae exam but woman is extremely frightened
• Dr tell Pt 'calm down, we won't do anything yet'
• But Pt didn't calm down
• Does Pt perform this way with husband?
• Reasons: painful during intercourse? Uncooperative?
• Dr found out: non-consummation of marriage
• Commonly seen in GP: usually in young couples, open-minded, willing to see Dr, pressure from in-laws
• Note: Pt didn't tell Dr any problems, just asked for a gynae check-up
• Pt has vaginismus (involuntary contraction of vaginal and thigh muscles; due to fear of intercourse - pain; maybe in people who have been previously abused; fear of loss of control because someone else puts something inside their body; sex therapy successful in 80-90% of Pt's, esp. if couples having loving relationship)

• Neighbour of 8 yo brings in the little girl to see doctor (mother works full-time)
• Child has itchy, painful vaginal discharge for 3-4d. Foul odour, pants stained
• Must rule out sexual abuse
• Any female < 16 yo cannot legally have sex with anyone in HK, even if they give consent (statutory rape)
• O/E: vaginal swab for microscopy and culture
• Asked girl: why do you have such an infection?
• Girl: don't know how to clean myself after voiding and defecating
• Examine: vagina and hymen -> swollen (but child objected)
• Dr: did anyone touch you?
• Girl: no
• Reports showed gonorrhoea (STD, very common in HK)
• Becomes medico-legal case: social worker, police
• Girl developed (fever) pelvic infection - admitted to QEH
• Father admitted to incest

• Young man c/o haemorrhoids
• O/E: genital warts
• Homosexual?

Aus 0.2-5%

USA 10-15%

50% of married couples sometime in their married life (Masters & Johnson)

EXCITEMENT

• Increased blood into genital organs
• Testes elevate
• Scrotal skin and tunica thicken
• Arterial engorgement of penis
• Urethral meatus dilates

PLATEAU

• Colour of glans deepens
• Cowper's gland secretion (neutralise female genital tract)
• Testes elevate, rotate, enlarge
• Seminal fluid collects

EJACULATION

• Internal sphincter of UB closes
• Contractions of seminal vesicle
• Internal rectal sphincter closes
• High spike and wave form on EEG
• Muscles in genitalia contract
• Each contraction 0.8 sec apart (5-13 contractions)

RESOLUTION

• Blood drains from genital organs

EXCITEMENT

• Vagina beginning dilatation
• Vaginal sweating (transudate from blood)
• Uterus elevates pulling cervix away from vagina

PLATEAU

• Further elevation of uterus
• Orgasmic platform
• labia minora enlarged, colour deepens

ORGASM

• Uterus contracts
• Orgasmic platform contracts
• Rectal and urethral sphincters close

RESOLUTION

• Uterus returns to unstimulated position
• Cervix dips into seminal pool

• Gasping
• Flexion of fingers
• Arching of feet
• Nipple erection
• Flushing of skin of upper body
• Sweating

[Signals from brain to lumbosacral region]

• Vaginal discharge
• Persistent lower ab pain
• Vaginal bleeding
• Chronic discomfort during intercourse
• Vague urinary symptoms
• Anxiety during vaginal examination

• Anxiety symptoms assoc. with genital organs; size, shape, pain, penile discharge, urinary difficulties, chronic prostatitis
• Low self-esteem

• Chronic LBP
• Chronic headache
• Chronic fatigue
• Chronic depression

• Routine questioning
• Blend in with related areas
• Atmosphere of comfort
• Reassure Pt
• ".. That is very common"
• "... That is normal..."
• Non-judgemental caring attitude
• Open the door for later discussion

• Semi-sitting position, mirror, warmth
• Observer Pt's demeanour
• Inspect vulva
• Speculum
• Bimanual exam

• Observe pt's demeanour
• Inspection penis and prepuce, etc
• Palpation: penis, testes, etc
• Rectum: warts, muscle tone, etc

• Result of significant early experiences (eg. Child sexual abuse, incest)
• Profound psychological problems
• Brief counselling ineffective
• Doctor incompetent or not suited

FEMIDOM: female condom

• 2 rings (inner is narrower)
• Insert into vagina until inner ring touches pubic bone
• After intercourse, rotate femidom so semen is trapped inside
• $69 / 3 femidoms

PAIN during intercourse

• Pelvic infection: from vagina -> uterus -> tubes -> ovaries (more likely with increased STD)
• Psychological: hates husband and sex with him
• Endometriosis: uterine lining has exited into pelvis (ovaries, nr cervix, vaginal wall, back of uterus) undergoes menstruation but blood cannot exit (no opening); ask about painful menstruation

• 34/F with vaginal discharge, ulcers
• She has sex without foreplay
• Cramped living environment
• No privacy, no foreplay
• Dyspareunia: painful intercourse
• Male arousal quicker, more genital oriented

• 3 yo hymen
• Child: push vulva apart with thumb and index finger
• Normal: crescentic, notch at 12 o'clock, 9 o'clock, redundant cuff-like hymen
• 13 yo: cotton swab under hymen
• Septic vagina: if thin can cut, can have 2 vaginas
• CAH: clitoral hypertrophy, can mistaken baby to be male
• Imperforate hymen: menstruation clogged inside, need to cut hymen