An advocate walked into our clinic with his only college-going son in 1969 and asked for our help. The son was observed to masturbate frequently and was showing some behavioural changes. Our lack of understanding of the subject was so evident that the lawyer hesitantly wanted to know whether he came to the correct place or not. We felt we were totally exposed to our inadequacies about human sexual aberrations. However, it was a challenge and we accepted it.

Family planners while advising contraceptions deal with the most intimate sex life of the couple. Satisfactory sexual functioning may not be the only requirement of healthy family life but is undeniably the most important thing. If sexual dysfunction is considered like any other disease by our learned physicians, then it is the most prevalent disease in our society. Masters and Johnson state that almost fifty percent of the couple need some kind of help for their sexual abnormalities.

Since 1969 twelve years have passed and we are convinced about the high incidence claimed. Cases having all types of sexual dysfunctions coming to family welfare centre from 1969 to September 1980 were included in the study. These long years of experience also convinced us that sympathetic understanding of the problem, prompt evaluation and accurate management were the prime factors for success. Outstanding research and therapy work of Masters and Johnson also stressed on the quick management programme.

Couples or individuals coming for the first time were interviewed about the socio-economic background and about their problem. They were told about our approach and the co-operation needed between the couple and with us. In unmarried cases, stress was laid on the patient’s own attitude to get cured.

Detailed history right through family background, childhood and adulthood, followed by marriage was taken from both the partners. Full medical history was essential. In our situation, assessment of poor nutrition, incidence of tuberculosis, viral and other infections, hypertension, diabetes, thyroid disorders, addiction to drugs or any other physical condition were of immense help. Enquiries were made in detail about any old investigations and treatment. Thorough physical examination and laboratory investigations as indicated were carried out. These helped not only to create confidence in the couples or individuals seeking help but also enabled assessment of the progress made in the cases. Poor health, chronic diseases and particularly gastrointestinal disturbances played a major enough role to be the cause of sexual dysfunction. However, we entirely agree with Masters and Johnson that it is the ignorance more than anything else that causes sexual dysfunction.

Usually two or more interview sessions were required for proper assessment of cases. During this period, necessary laboratory investigations were also made available.

Evaluation of the improvement was made on the subjective feelings, performance, behaviour, general appearance and attitude. Husband and wife both participated in the evaluation and were confirmatory to each other.

Altogether 945 cases were treated during the twelve-year period under review, 195 cases could not be included in the study as we probably failed to convince them or they found it difficult to attend the clinic and follow the therapy. The remaining 750 cases presented in order of prevalence were as follows:

There was overlapping of symptoms in almost 30% of cases.

Night Emission

From Table I it is obvious that this was a problem of the young and unmarried.

Night emission is a normal phenomenon in the male on reaching adulthood. So long as it did not affect the man or the couple psychologically, healthwise or ethically, no treatment was required except probably reassurance. Where the man was affected, bothered or felt that it was the cause of his ill-health, unsatisfactory sexual function or change in social behaviour, we put him on therapy.

The causes we found are shown in Table II.

It is known that night emission does not occur in deep sleep. Reasons that cause disturbed sleep like indigestion, flatulence, distended urinary bladder, itching, scratching, etc. were found to be the cause of frequent night emissions. Idiopathic cases were those where we could find no definite cause.

Out of 247 cases 74 (30%) cases of poor health improved with general management, better food, general and perineal exercises and encouragement. Treatment of chronic diarrhoea, dysentery, helminthiasis, tuberculosis, liver dysfunction, scabatic, fungal or bacterial skin lesions etc. all formed a part of general management. Physical exercise was recommended preferably during the evening so that the patient slept better in the night. Better planned food within the budget helped in fast recovery of the conditions. Patients were taught to exercise pubococcygeal muscles by withholding urine in between. Once the patient knew how to do that he was asked to practice it any time, and to take a deep breath while keeping the pubococcygeal muscle contracted. Dissociation of muscular contraction and other functional activities was found essential for better results.

Where a full bladder was the cause the patient was advised to regulate his fluid intake. Last fluid was to be taken at least one hour before retiring to bed and the patient should also urinate immediately before going to sleep. Improvement of health, evening exercise and perineal exercise were also found beneficial. Management of the remaining cases with the results are shown in Table III.

Though modern medicines showed fairly good results, the indigenous drug Confido (Speman forte) showed better results with recovery in 65% and another 25% cases improved. There were cases having urinary tract infection who needed appropriate course of chemotherapy or antibiotics. They received other drugs only when required. There was no case of urinary calculus in our series.

Premature Ejaculation

Premature ejaculation is the inability of the man to delay ejaculation long enough for the woman to have orgasm or to the full satisfaction of both the partners. The primary criterion remains the satisfaction of both partners as defined by Masters and Johnson. This probably is the commonest sexual dysfunction in married men. Many other dysfunctions were found to have their origin in early ejaculation and unsatisfactory sex life. Many cases of premature ejaculation recover from unsatisfactory sexual experiences on their nuptial night or in early marriage, after they become accustomed to married life but probably an equal number suffer in silence.

We had 185 cases of premature ejaculation out of 750 cases (24.6%) in this series. We found 50 cases (27%) to be in poor health. In these cases initial management was the same as already described. With improvement in health, we introduced general and perineal exercises along with gradual introduction of sensuate sessions and squeeze technique. Different coital positions were explained in detail.

Most of the patients were married and came during the early years of marriage.

Here the success rate in all the categories was remarkable and it was felt that if there was full co-operation between the couples and therapist, hundred per cent success could have been achieved. Failures were mostly in cases where there was no co-operation between the couple and it was mostly the men who did not co-operate. There were altogether five women who proved to be unco-operative. Additional drugs were required and these helped in many cases. Confido (Speman forte) given 2 tablets three times a day till improvement and then 2 tablets 2 times a day for another 6 to 8 weeks made the recovery much quicker and long lasting. It had no side-effect except occasional feeling of giddiness, drowsiness and allergic rhinitis (cough and cold).

Discharge per Urethra

Cases having frank pus discharge or discharge per urethra with a history of contact were not included in the study.

Fifty-six patients (45%) out of 125 cases were found to be having poor health either due to nutritional deficiency or due to some chronic diseases or helminthiasis. They were given specific treatment for the disease and supportive iron, vitamins and nutritional therapy within his means. General and perineal exercises were given in all cases. Cases having oxaluria were advised to avoid items of diet known to be the probable cause, over and above the other therapy. Some cases having urinary tract infection needed repeated prostatic massage along with other therapy.

Different causes of discharge per urethra are shown in the following Table.

A period of three weeks to nine months was required to achieve recovery with chemotherapy or antibiotics etc. In cases where Cystone 2 tablets 3 times daily were added from the beginning, the percentage of recovery was not only better but also had quicker response. Maintenance dose of Cystone 2 tablets 2 times a day for 3 to 6 weeks was given thereafter. In some cases, the course of treatment had to be repeated. Counselling was necessary in these cases to counter the psychological bias on general health and behaviour.

Impotence

Inability to perform sexual intercourse by man due to lack of erection or improper erection or problem in sustaining the erection of the penis for penetration is known as impotence. Cases of primary impotence had been unable to have any intercourse whereas cases of secondary impotence had a history of having had successful intercourse earlier. Apprehensive and depressed, we found these patients the most difficult to cure. Cases suffering from diabetes, hypertension, endocrinological or developmental anomaly or mental illness were referred to the respective physicians for management. We had 132 cases out of 750 cases constituting 17.4% of the total cases.

It will probably be incorrect to assign any single cause for impotence. Many social and familial factors hostile to the normal development of personality during childhood or adolescence were found to be responsible.

Majority of the patients were young and in early years of their marriage, but some couples came to us at middle age and after many years of suffering in silence.

For clinical assessment and management we combined primary and secondary impotence together because of common causative factors.

Under social and family factors we included cases affected by religion, ageing, addiction to drugs, domineering parent, psychologic susceptibility and improper counselling from other sources.

Traumatic sexual experiences visual or actual, homosexuality and excessive masturbation were grouped under adolescent sexual experiences. Eight cases (6%) who were found to be in poor health, were treated on the same line as already described along with sensuate sessions and squeeze technique. Seven of them showed complete recovery while one did not respond.

General exercise, perineal exercise, better nutrition were advised to each patient. Wives were interviewed individually and in presence of the husbands and together. Co-operation was sought and confidence was gained, so that sensuate sessions and squeeze techniques were understood and followed properly. Drugs along with technique sessions described gave reasonably high percentage of success to rehabilitate the couple to their normal sexual activities. Indigenous drugs alone or in combination, where given, definitely proved better. Confido (Speman forte) 2 tablets were given three times a day where premature ejaculation was the cause till regular erection was established and then gradually withdrawn. Tentex forte alone or in combination with Speman tablet were given three times a day of each once the man could accept the woman in superior position. Couples were regularly called for assessment and if necessary, dosage of drugs or frequency of therapy sessions were adjusted. It was heartening to learn the happy response from the couple who had been on the verge of complete breakdown.

Diminished Libido

There were 26 cases who sought help for diminished libido.

Management of poor health was on the same lines. Counselling, teaching various sensuate sessions and encouragement played the key role to success.

We experienced difficulty in persuading couples to co-operate with each other in implementing our therapy programme. Female partners who were inhibited about showing any interest in sexual activities, due to social and family factors or due to a feeling of being let down by the husband, needed the utmost care, encouragement and co-operation. A warm, relaxed and sensuous atmosphere in which the man could devote his loving and undivided attention to the needs of the beloved was absolutely essential.

Addition of drugs fulfilled the psychological need and also helped in quick recovery. Indigenous drugs showed better results in this category also.

Masturbation

2.4% numbering 18 cases out of 750 came with the problem of excessive masturbation. they felt for themselves or were observed to suffer from ill health, loss of memory and behavioural changes.

It will be observed from the Table that this was a problem mainly to the male unmarried youths. We had no woman patient coming to us with this problem.

Restoration of confidence, encouragement, participation in games and sports, participation in family and social activities, weaning from parental domination and treatment of any cause for poor health, skin or urinary infection were the essential requirement for success. Discussion on political, literary or socio-economic problems depending on the literary and social background of the patient were found to be extremely helpful to restore confidence. Drugs like hypnotics, sedatives and tranquillisers as also Confido (Speman forte) all helped to cut down the frequency of masturbation. General and perineal exercise and advice to parents to be more affectionate but less dominating or demanding were needed for improvement. Here again indigenous drug Speman forte showed better result and had very little side-effect or chance of addiction.

Painful Coitus

Fifteen couples came to us complaining of discomfort or pain during intercourse. The problems along with treatment in Table XVII.

Correct diagnosis, lots of reassurance and gradual approach proved to be most valuable, not only to win over the confidence of the patient but also for the patient to undergo treatment. Improvements obtained were very rewarding.

Ejaculatory Incompetence

There were two cases who found it impossible to ejaculate semen after inter course or masturbation. Sensuate sessions followed by quick manual stimulation helped the patient to ejaculate. In both the cases, Tentex forte 2 tablets three times a day were given. Our experience in these cases was very limited to merit further discussion.

Composition of Indigenous Drugs with Ayurvedic References

All these drugs are manufactured by The Himalaya Drug Company, Bombay.

1.  Speman tablets: Composition: Orchis mascula, Lactuca scariola, Hygrophila spinosa, Mucuna pruriens, Exts. Parmelia perlata, Argyreia speciosa, Tribulus terrestris, Leptadenia reticulata, and Suvarnavang (Mosaic Gold).

These tablets are claimed and have been found efficacious to promote spermatogenesis and to relieve prostatic congestion.

2.   Confido (Speman forte) tablets: Composition: Orchis mascula, Lactuca scariola, Hygophila spinosa, Mucuna pruriens, Exts. Parmelia perlata, Argyreia speciosa, Tribulus terrestris and Leptadenia reticulata, Suvarnavang (Mosaic Gold) and Rauwolfia serpentina standardised to contain 1.5mg of the total alkaloids.

Addition of Rauwolfia serpentina acts as a sedative to the higher and spinal sex centres. Proved clinically to act better in controlling excessive night emissions, masturbation and to increase the threshold of tolerance to sex stimuli.

3.   Tentex forte tablets: Composition: Saffron, Amber, Ext. Muskdana, Nux vomica (detoxified), Makardhwaj, Shilajeet (purified), Orchis mascula, Anacyclus pyrethrum, Withania somnifera, Sida cordifolia, Bombax malabaricum, Argyreia speciosa, Mucuna pruriens, Trivang. Processed in Sida cordifolia, Asparagus racemosus, Ipomoea digitata, Piper betle, Withania somnifera, Tribulus terrestris, Tinospora cordifolia, Argyreia speciosa, Acacia arabica fruit and Dashamoola.

Some of the ingredients are used since ages as general tonic in Ayurvedic medicines. Some act probably as aphrodisiac also and are androgenic in their action.

4.   Cystone tablets: Composition: Exts. Didymocarpus pedicellata, Saxifraga ligulata, Rubia cordifolia, Cyperus scariosus, Achyranthes aspera, Onosma bracteatum and Vernonia cinerea, Shilajeet (purified) and hajrul yahood bhasma. Hajrul yahood bhasma is prepared with Ocimum basilicum, Tribulus terrestris, Mimosa pudica, Dolichos biflorus, Pavonia odorata, Equisetum arvense and Tectona grandis seed.

Ingredients of Cystone are used in Ayurveda as urinary antiseptics and to correct crystalluria. Some of them also act as a diuretic.

Drugs were needed and were found useful. Many working in the field have commented that the use of male hormone inhibits endogenous production. High levels of circulating exogenous testosterone were able to help in some cases and these cases were probably low androgenic at the beginning. Once the exogenous hormone was stopped, patients did not show uniform rebound phenomenon and the response was unpredictable. Poor general health was found to be responsible for sex deficiencies in a large percentage of cases. Improvement of sexual performance in these cases was remarkable with the improvement of general health.

Co-operation between the spouses and determination to get cured was absolutely essential to follow sensuate sessions and squeeze technique. These procedures proved their worth. We strongly felt that the cause of failures was the lack of desire and determination which inhibited one of the partners to observe these techniques.

Indigenous drugs like Confido (Speman forte), Tentex forte or Speman manufactured by The Himalaya Drug Company, Bombay were found to be more efficacious. They did not have any side-effects also.

Nine hundred forty-five came to us seeking help for their sexual dysfunction during the last twelve years. Out of these 750 cases were managed and 195 cases dropped out.

There were 247 cases (33%) of night emissions, and 215 (87%) showed improvement with our management. One hundred and eighty-five cases (24.66%) of premature ejaculation reported to us. One hundred and sixty-seven cases (90%) improved. Sensuate sessions, squeeze techniques along with drugs were thought to be the reason for the high percentage of success.

17.4% numbering 132 cases complained of impotence. 82%, 108 cases could rehabilitate themselves with our therapy programme.

Cases with discharge per urethra showed improvement in 117 cases (94%) out of 125.

Twenty four cases (92%) out of 26 cases of diminished libido started enjoying sexual activities normally after our counselling and therapy. 18 cases (2.4%) of masturbation, 15 cases (2%) of painful coitus and 2 cases (0.2%) of ejaculatory incompetence were treated. And 16, 12 and 2 cases respectively benefited from our management.

Credit of this compilation goes to my junior colleague and staff members for their active help. My wife Smt. Pratima Banerjee and Dr. B.G. Kotwani, Head of the Department of Obstetrics and Gynaecology and Family Welfare deserve special mention for constant help and encouragement.

I am thankful to the Medical Superintendent, Dr. S.D. Vohra for allowing me to publish the paper. I must also mention the names of Shri S.K. Ghai, Bhanwar Lal and Raman Kumar and Shri Shi Kumar for their secretarial help.

1. William Masters and Virginia Johnson, "Human Sexual Response" (Little Brown & Co., 1966) and "Human Sexual Inadequacy" (Little Brown & Co., 1970).
   
   
2. Kumar -"Tentex forte - A controlled cross over study in Psychiatric Patients with Male Libidinal Hypoactivity", Probe (1975): 3, 208-214.
   
   
3. Paul Brown & Carolyn Faulder "Treat Yourself to Sex" (1979), Penguin Books, J.M. Dent and Sons Ltd.
   
   
4. Montesano, P. and Evangelista, I., "Methyl Testosterone for Treatment of Sexual Impotence", J. Clin. Med. (1966): 4, 69.
   
   
5. Rajasekharappa, M., "The Approach to and Management of Male Sexual Complaints", Probe (1970): 4, 164.
   
   
6. Varandani, B.P., "Impotency and Its Treatment with Indigenous Drugs". Probe (1970): 4, 164.
   
   
7. Chatterjee, B.N., "Tentex forte and Himcolin in Sex Disorders", Probe (1978): 4, 309-312.
   
   
8. Sarkar, M.K., "Tentex forte and Himcolin in Sex Disorders". Probe (178): 4, 309-312.
   
   
9. Banerjee, N., "Management of Sex Disorders through Family Welfare Planning Centre", Probe (1973): 4, 177-182.