What is anorgasmia and how is it treated?

Anorgasmia, the inability to achieve an orgasm, may be congenital or acquired. It is estimated that about 90% of anorgasmia problems are related to psychological issues. Surveys point to performance anxiety as a common psychological problem. There is a relationship between anorgasmia and childhood or adult sexual abuse or rape. Marital strife, boredom with a relationship, coupled with a monotonous sex life are other contributing factors. Some drugs, such as alcohol and the selective serotonin reuptake inhibitors may impair orgasmic response. Certain medical conditions such as spinal cord injury, multiple sclerosis, hormone conditions and diabetes have been implicated. Treatment of anorgasmia is often facilitated by a sex counselor or sex therapist with an emphasis on the couples developing playful and/or relaxed interactions. Success with therapy ranges from 65 to 85%.

What is Peyronie's disease and what causes it?

Peyronie's disease is a benign condition of the penis that tends to affect middle-aged males. The exact cause of Peyronie's disease is not known. The disease is characterized by the formation of plaques in the tunica albuginea of the penis. These plaques may be felt on penile examination and at times can feel as hard as bone. The plaques are like scar tissue and affect the function of the tunica in that area. Because the plaque is not elastic and stretchy like the rest of the tunica, it pulls the penis to the side of the plaque during an erection and may also cause wasting/narrowing^[1] at the site of the plaque. There may also be pain associated with an erection. Lastly, because the plaque does not behave like normal tunica, it may also cause erectile troubles. The plaque may occur anywhere along the penile shaft but is more commonly identified on the top (dorsal) surface of the penis. More than one plaque may be palpable. The hallmarks of Peyronie's disease are a palpable plaque (a hard spot along the shaft of the penis that one can feel when examining the penis), penile curvature, and a painful erection.

The disease typically has a slow onset, and most men cannot identify a precipitating factor. It is thought that minor trauma during intercourse leads to minor tears in the tunica or rupture of small blood vessels. Bleeding and abnormal healing occurs after this injury and produces the plaque. In some men, there is a family history of Peyronie's disease, and 16 to 20% of men with

Peyronie's have a disease called Dupuytren's contractures. An increased incidence of arterial disease (30%) and diabetes with its associated small arterial disease (2.7-12%) has also been noted in men with Peyronie's disease.

The natural history of Peyronie's disease is variable. The disease is thought to have two phases: the acute phase, which usually lasts up to 18 months and is associated with pain, penile curvature, and plaque formation, and a more chronic phase, in which there is minimal or no pain, a palpable plaque, and residual penile curvature. Over time, the disease may progress in about 42% of men, improve in 13%, and remain the same in about 45%. In many cases, the disease produces few symptoms, the curvature does not prevent sexual performance, and there is no pain or associated erectile dysfunction. In such cases, reassurance that there is nothing bad going on is often all that is necessary.

Peyronie's disease is evaluated by history and physical examination. It is important to know if there are any problems with achieving adequate erections, whether or not the curvature prevents penetration and the location of the curvature. Sometimes the physician will ask you to take a picture of your penis when it is erect to assess the location and degree of curvature. Another option is for the doctor to inject a medication, prostaglandin E1, into the penis, which causes you to have an erection and to examine you at that time.

• [1] An indentation in the penis.