The aim of this study is to evaluate the effectiveness of short-term sildenafil use in the management of unconsummated marriages diagnosed to be mainly psychogenic in origin. This retrospective study included 35 patients evaluated within an Andrology clinic. Patients underwent a complete medical and sexual history as well as a focused physical examination. Investigations were ordered as necessary following a goal-directed approach. Education about the male and female genital anatomy and the sexual response cycle was carried out, as well as a detailed explanation about the concepts of performance anxiety, vaginismus and the mode of action of sildenafil. Sildenafil on demand therapy was initiated for 1 month and the duration extended as needed. Of 35 patients included in our study, 32 (91%) were able to achieve vaginal intromission and perform sexually. In all, 23 patients needed the sildenafil (66%) for less than 1 month, five (14%) for up to 3 months and four (11%) for more than 3 months. Three patients (9%) were unsuccessful. Treatment failures were managed by intracavernous injection therapy, combined with psychosexual therapy, depending on the cause. We conclude sildenafil use is effective as a short-term treatment option in the management of unconsummated marriages.
Unconsummated marriages – frequently referred to as honeymoon impotence – appear to be a significant problem in conservative Middle-Eastern societies accounting for up to 17% of visits to sexual Health clinics.1 However, very little literature addresses this topic.2 Before the introduction of phosphodiesterase inhibitors, patients presenting with unconsummated marriages failing to respond to behavioral therapy (sex therapy) were offered intracavernous injections of vasoactive substances or surgery (penile implants) after the exclusion of female factors.3 The use of phosphodiesterase inhibitors helped resolve a great deal of frustration on the part of the patient as well as the physician treating patients with psychogenic Erectile Dysfunction (ED). Contemporary sex therapy currently includes the use of oral erectogenic medications in the treatment protocols for psychogenic ED.4, 5 It may be tempting to initiate a short course of oral sildenafil hoping to break the performance anxiety cycle and achieve a rapid resolution to the very distressing problem of an unconsummated marriage In this study, we present our experience with 35 patients presenting with an unconsummated marriage diagnosed to be mainly psychogenic in origin, treated with oral sildenafil.
Patients and methods
This is a retrospective study of 35 consecutive patients with no significant physical abnormality, presenting with failure to achieve vaginal intromission. A complete sexual and medical history was taken from each patient in addition to a general and local genital examination focused on examining the development of primary and secondary sex characters, pulses and excluding gynecomastia. All patients were also evaluated by a psychiatrist. Patients with psychotic disorders, depression and a history of substance abuse were not included in this study.
The standard questionnaire for assessing ED in our department is the validated Arabic version of the sexual health inventory for men.6 Since all patients were never able to achieve vaginal intromission, all scored as severe ED (never maintained an erection for intercourse, never confident, never satisfied). The diagnosis of a predominantly psychogenic etiology for ED was based on a clear history of full rigid morning or night erections, or rigidity of 70% or more recorded at the base and tip of the penis, and sustained for more than 5 min on at least one erectile episode during Rigiscan monitoring of nocturnal penile rigidity. The mean age was 29 years (range 22–46).
Serum testosterone and prolactin levels were evaluated in patients with suspected abnormalities based on the patient's age (above 40 years), complaints of decreased sexual desire, or an examination revealing gynecomastia or suspected hypogonadism. Penile biothesiometry was performed for all patients during their initial physical examination. Penile color flow duplex ultrasonography and dynamic infusion cavernosometry/cavernosography were not performed as part of the initial evaluation.
Sildenafil on demand therapy (50 mg) was initiated for one month and the duration extended as needed for sexual performance up to 3 months. The 50 mg dose was chosen as it is the only dose available in our country. Patients were allowed to double the dose to 100 mg (2 tablets) if unsuccessful with the 50 mg dose. Follow up visits were arranged at weekly intervals to assess the response to therapy and the continued need for therapy.
Female partner evaluation
The wives were evaluated by a gynecologist to examine the possibility of vaginismus. No attempt was made to point the blame on either the male or female partners. It was explained that some fear and resistance on part of the wife added to some anxiety on part of the husband would trigger the performance–anxiety cycle. The concept of performance anxiety was explained and illustrated by printed material. Couples with significant vaginismus were excluded from the study.
Patients with complicated psychiatric disorders, complicated endocrine disorders, patients with significant penile curvature (more that 30 degrees), and patients with multiple risk factors for ED (diabetes mellitus, hypertension and dyslipidemias) were not included in this study.
Out of 511 files reviewed within a sexual dysfunction clinic 42 (8%) were found to present with a complaint of an unconsummated marriage, that was diagnosed to be of predominantly psychogenic etiology. Seven patients were excluded from the study due to significant vaginismus. Patients were seen over a 1 year period. Of the 35 patients included in our study 32 (91%) were able to achieve vaginal intromission and perform sexually. A total of 23 patients needed sildenafil (66%) for less than 1 month, five (14%) for up to 3 months and four (11%) for more than 3 months. Three patients (9%) were unsuccessful due to an inadequate response to sildenafil (Table 1) Treatment failures were reevaluated and managed by intracavernous injection therapy, combined with psychosexual therapy.
El-Meliegy1 reported an alarming (17%), presentation of Honeymoon impotence among 2375 ED patients seen within a sexual dysfunction clinic in Saudi Arabia. Although we report a lower prevalence of unconsummated marriages (8%) within our study population (attendants of a sexual dysfunction clinic), yet we find these rates remain alarmingly high and warrant serious public awareness and sex education programs. Other forms of ED also appear to be prevalent among young men in the Middle East. Heruti et al.,7 conducted a large-scale study that included 5836 young men and reported a 22.1% prevalence of ED in men under the age of 40 years based on low SHIM scores (<21). Clearly Public awareness and sex education programs are needed to help young men and women understand and cope with this disorder. This may be achieved through patient help lines, media recruitment and the involvement of professional societies in educating the public.8
A significant limitation with this work is that it is an unblinded and uncontrolled study. The authors decided that withholding effective medical therapy in such a distressing social crisis would be against the patient's best interests. Physicians attending patients with ED in certain conservative societies frequently face unique situations related to the culture and family attitudes.1, 2 Newly wed couples in conservative societies probably have limited premarital sexual experiences. Although this makes the wedding night a very special event, yet men failing to consummate their marriages are subjected to a significant amount of stress. Not only do they suffer embarrassment with their wives but also possible humiliation with the bride's family.
Sex therapy requires a level of understanding, cognitive ability to conceptualize the problem and challenge its basis. The cultural acceptance of joint couple therapy, which is the mainstay of sex therapy, is greatly compromised in our population and probably for many in the developing world. These factors seem to have encouraged noncompliance with sex therapy in the majority of the sample studied.
We declined from performing penile color flow duplex ultrasonography and dynamic infusion cavernosometry/cavernosography as part of the initial evaluation – as described in other studies1 – since these investigations are not gold standards and false-positive results do occur.9, 10, 11, 12 We judged that false-positive results would add to the patient's anxiety and could thus be counterproductive to the outcome of therapy. One must weigh the benefit of performing these tests for a patient with clear history of full rigid morning or night erections, or rigidity of 70% or more recorded at the base and tip of the penis, and sustained for more than 5 min on at least one erectile episode during Rigiscan monitoring of nocturnal penile rigidity, versus the risk of adding to the patient's anxiety with a false-positive result on penile vascular studies. On the other hand, using pharmaco-arteriography would be excessively invasive and would not be in line with a goal-directed approach to treatment.13
We evaluated serum testosterone and prolactin levels only when we suspected them to be abnormal on basis of the patient's age, medical history and physical examination. Our goal was to be cost effective. Buvat and Lemaire14 screened 1022 men with ED and concluded that low prevalence and effects of low testosterone and high prolactin levels in ED cannot justify their routine determination.
Our results are comparable to previously reported results with intracavernous injection therapy for the treatment of honeymoon impotence in the prephosphodiesterase era.2 Of 72 patients presenting with honeymoon impotence 67 (93%) reported successful intromission and subsequent intercourse, while five (7%) were still unable to perform due to severe vaginismus. In all, 46 (64%) patients were able to discontinue the treatment in less than 3 months of self-injections while 15 (21%) were able to discontinue the medication from 3 months to less than 1 year. Six (8%) patients still needed long-term self-injection for more than 1 year.
‘Unconsumated marriages’ appear to be frequent complaints within our patient population. Sildenafil therapy was safe and effective in the short-term management of this disorder. Evaluation of the female partner is important as vaginismus accounted for the exclusion of 17% from our cases.
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Ghanem, H., Zaazaa, A., Kamel, I. et al. Short-term use of sildenafil in the treatment of unconsumated marriages. Int J Impot Res 18, 52–54 (2006). https://doi.org/10.1038/sj.ijir.3901370
- erectile dysfunction
- honeymoon impotence
International Journal of Impotence Research (2008)