Mr. N,36 years male studied till 10th class, a farmer by occupation from a rural background, married 5 months ago, presented to the Psychiatry outpatient department with a complaint of difficulty during sexual intercourse. From the time of marriage, the patient reported that they had difficulty to consummate the marriage. The patient was worried about the sexual acts and he would ejaculate before initiating penetrative sex.
These thoughts made him anxious while carrying out sexual activity. The couple had a cordial relationship between them. The patient had the normal desire and arousal was not a problem but had difficulty initiating penetrative sex. The patient was preoccupied with thoughts of failed penetrative sex and concerns about the possibility of not having children.
The patient’s wife, aged 18years, corroborated the given history. The patient had no history of substance abuse, persistent sadness, hypertension, diabetes mellitus, thyroid problem.
The patient had a past history of episodes of anxiety with autonomic symptoms and had taken treatment 3 years ago for a period of 3 months. Details were not available. No family history of psychiatric illness.
General physical examination:
Moderately built and nourished.
The patient is conscious, coherent, cooperative.
General physical and systemic examination was within normal limits.
Genital examination: no abnormality observed.
Mental Status Examination: The patient was well-groomed, cooperative, and oriented to time, place, and person.
Thoughts: preoccupied with thoughts regarding his sexual dysfunction.
The mood was Anxious, with insight 3/6.
ASEX (Arizona Sexual Experiences Scale score):16
Possible total scores range between 5 and 30, higher scores indicating greater sexual dysfunction.
ICD-10 diagnostic guidelines: The inability to control ejaculation sufficiently for both partners to enjoy sexual interaction. In severe cases, ejaculation can occur before vaginal entry or in the absence of an erection.
Sex education and intervention model: PLISSIT model of sex therapy was initiated that includes permission (P), limited information (LI), specific suggestions (SS), and intensive therapy (IT).
Therapy was provided to the couple in their own language (Kannada).
Progressive Muscular Relaxation Therapy was initiated.
Education about Start and stop technique was initiated: In this, during sexual intercourse when the male partner gets the sensation of ejaculation, penile stimulation is stopped and when the sensation of ejaculation reduces, sexual activity is restarted. This can be repeated four times before ejaculation.
Pharmacological Therapy: selective serotonin reuptake inhibitors (SSRI).
TAB.SERTRALINE 25mg OD was advised.
People in India, more from rural backgrounds have many myths and misconceptions about sexual intercourse, and sex education is considered a topic of taboo that leads to a lack of sexual knowledge. However, there is assumed sociocultural pressure over conceiving immediately after a marriage that adds up to anxiety. This case highlights the need for sex education in schools and communities .
Also, premarital counseling would help in these scenarios. Premature ejaculation is one of the most common sexual dysfunctions reported which is wrongly assumed as erectile dysfunction. A detailed history helps in clarification.
Nonpharmacological methods such as the “Start and stop” technique and the Penile “Squeeze” technique are known to beneficial and delayed ejaculation, which is a known adverse effect of SSRI medications is utilized in the treatment of premature ejaculation in many patients with satisfactory outcomes .
Premature ejaculation is one of the most common male sexual disorders and has been estimated to occur in 4-39% of men in the general community .
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