Sexually Transmitted Diseases - I. I. Mavrov 2005

Sexual Dysfunction in Women

Genitalgia refers to painful and Paresthetic sensations in the genital area. Pain and fixed Paresthesias (such as discomfort, numbness, tingling, etc.) in the genitalia can be caused by inflammatory processes, genital trauma, psychogenic factors, sexual disharmony, menopause, vaginismus, erotophobia, and other conditions.

In inflammatory processes of chlamydial, mycoplasmal, or other etiologies, as well as genital trauma, pain may be deep, superficial, or burning. A burning sensation can be triggered by urine coming into contact with damaged epidermis. Sometimes genital pain is caused by interstitial cystitis, vaginitis, or tumor infiltrates. Deep pain may result from Endometriosis, making it essential to determine whether the onset of pain correlates with menstruation. Throbbing pain may indicate an abscess of the greater vestibular gland (Bartholin's gland). Pain is frequently accompanied by genital itching.

Unpleasant and painful sensations may intensify during sexual activity. In such cases, the pain sometimes takes on a psychosomatic character; any Touch in the genital area becomes unbearable, sexual intercourse becomes impossible, and sexual contact yields no pleasure.

Psychogenic genitalgia is often a consequence of hysterical neurosis and is frequently accompanied by anxiety and depression. It is typically characterized by aching, cutting, or shooting pain, along with Paresthesias such as formication (crawling sensations) and itching. The localization of pain is ill-defined, most commonly occurring in the vaginal area and lower abdomen, and less frequently in the external genitalia. These painful sensations emerge during specific psychotraumatic situations, when experiencing feelings of resentment or humiliation, or due to other tactless actions by the sexual partner. They are usually linked to sexual intercourse. Patients begin to avoid sexual contact by all means or even refuse it entirely. In some cases, itching and Paresthesias in the genitals may occur, with masturbation playing a leading role in their genesis. The urge to engage in masturbation is accompanied by mild Paresthetic sensations in the genitals. While this urge can be suppressed by an act of will, completely getting rid of these sensations is usually unsuccessful. Over time, Paresthesias begin to occur independently of sexual desire and gradually evolve into a sensation of itching. In such cases, the patient generally does not connect her Complaints with any difficulties in her sexual life, though such a possibility cannot be ruled out.

Fixed pain and various Paresthesias in the genital area can be a component of a more complex clinical picture involving coenestopathic-hypochondriacal syndrome or the neurosis-like form of Schizophrenia. The latter is characterized not only by pain and Paresthesias, but also by unusual sensations in the genital area (coenestopathies)—such as the sensation of "bubbles localized in the Vagina," "the walls of the vagina sticking together and peeling apart," or "bloating of the Uterus"—as well as dysmorphophobia, such as "the left labium majus has become thinner" or "a peculiar odor has appeared that others do not notice," among others.

Patients often interpret functional Paresthesias in the genital area as an excessive increase in sexual drive, blaming themselves for it while simultaneously trying to find an outlet through an intense sexual life. However, this brings no relief; instead, the Paresthesias may actually intensify.

Sexual disharmony as a cause of genitalgia is a fairly common phenomenon. Painful sensations in the vagina (sometimes radiating to the uterus or Ovaries) may occur during intercourse at the moment of orgasm, or less frequently, when the Penis enters the vagina or during pelvic thrusts. Genitalgia frequently arises after sexual intercourse as well. In some cases, such as during menopause, an enhanced sexual drive is observed, accompanied by periodic hot flushes to the genitals. This induces Paresthesias that often intensify—particularly when sexual drive finds no outlet in sexual activity or masturbation—or develop into itching in the genital region.

The primary method of therapy for genitalgia is hypnotherapy, inducing the patient into the deepest stage of hypnotic Sleep. In cases where genitalgia has a somatic origin (inflammatory processes, genital trauma, etc.), Treatment is reduced to their sanitization, while psychotherapy is aimed at helping the patient understand the genesis of the disorder and changing their attitude toward sexual life.

Vaginismus is a reflex spastic contraction of the Muscles of the vaginal introitus and pelvic floor that impedes sexual intercourse or gynecological examination. In some cases, convulsive contractions of the thigh and abdominal wall muscles are also observed.

The Etiology of vaginismus varies. In the majority of women, its onset is triggered by an intense, overwhelming fear of the initiation of sexual life or resistance to forced initiation. Fear of sexual intercourse in patients may result from stories they have heard; sometimes it is a reaction to an excessively painful tearing of the hymen. It can develop due to rough behavior by the husband, or because of his impotence, which prevents the woman from achieving orgasm and leads to a negative attitude toward subsequent sexual relations. Psychoneurological predisposition plays an important role in The Development of vaginismus. Vaginismus is frequently observed in neurasthenia, obsessive-compulsive neurosis, and hysteria. Subsequently, the syndrome also manifests during attempts to perform a vaginal examination or insert any instrument into the vagina.

Clinical Features. The leading symptom is spasm of the vaginal and pelvic floor muscles. There are three degrees of severity of vaginismus. In the 1st degree, spasm occurs upon the insertion of a penis, instrument, or the physician's fingers during an examination; in the 2nd degree, a similar reaction occurs upon touch or when these approach the genitals; in the 3rd degree, the reaction occurs at the mere thought of sexual intercourse or a gynecological examination. The Diagnosis is established based on characteristic complaints and Objective Examination findings.

Vaginismus is generally experienced as highly distressing by the married couple and serves as the cause of dysfunctional relationship dynamics within the family. Women suffering from vaginismus get married, but refrain from initiating sexual life for a prolonged period. This, in turn, leads to a weakening of the husband's potency due to the development of expectancy anxiety, and in some cases, congestion in the Prostate Gland.

The main method of treating vaginismus is psychotherapy, aimed at explaining the causes of the disorder and properly guiding the patient regarding sexual life. In A number of cases, hypnotherapy with calming suggestions is useful to eliminate anxiety, anticipation, and fear, followed by motivational suggestions concerning the proper experience of intimacy. The participation of both the woman and the man is essential. Patients suffering from vaginismus require a benevolent, gentle approach. Instructions, reproaches, threats, and demands placed on the patients should be avoided, and recommending that the wives separate is unacceptable, as vaginismus is curable.

In treating vaginismus in an unspayed (virgin) woman, surgical defloration is indicated (performed by a gynecologist with the consent of the couple). It is best performed using a uterine cervix dilator, such as specially designed elastic dilators. The dilator is gradually inserted into the vagina, and once it reaches sufficient thickness, the patient is invited to see for herself that its insertion is painless. This acts as a form of persuasion and typically brings about a drastic change in her attitude toward her condition. During the treatment period, The Use of sedatives and the application of a 5% sovCAine ointment (to the mucous membrane of the vaginal entrance to reduce its sensitivity) are indicated.

Dyspareunia is a general term for sexual disorders in women; most commonly, this term denotes painful sexual intercourse.

A distinction is made between primary dyspareunia, which arises based on a specific experience of first sexual intercourse and is evidently psychogenic in character; secondary dyspareunia, which usually appears As a result of organic pathology; and functional dyspareunia, the genesis of which is rooted in functional deviations in the course of physiological reactions—specifically, parasympathetically induced increases in genital Blood engorgement during sexual arousal, smooth Muscle contractions, and vascular responses occurring during and after orgasm.

Most clinicians, wishing to emphasize the etiological factor in the onset of dyspareunia, divide it into introital and deep. In introital dyspareunia, the patient complains of pain at the beginning of penile insertion into the vagina, whereas in deep dyspareunia, pain occurs when the penis penetrates deeper into the vagina.

The causes of dyspareunia are varied. It may arise as a result of fibrosis of the hymenal ring or vaginal agenesis, cicatricial changes following obstetric complications and surgeries, pelvic Inflammatory Diseases, as well as situational refusal of sexual intercourse, lack of adequate sexual arousal and vaginal lubrication, and sometimes due to the fear of Pregnancy.

Causes of dyspareunia can also include fixed and rigid scars following tears of the cervix and vaginal fornices, endometriosis of the uterosacral ligaments, Peritoneum, or the pouch of Douglas. Patients who have undergone surgeries may have fixed adhesions originating from the pouch of Douglas, and a sleeve of Cytology/practical/45.html">Dense Connective Tissue may form around the vagina. Similar changes occur as a result of pelvic inflammatory diseases (more frequently of chlamydial or mycoplasmal etiology). In the absence of organic lesions, METABOLISM/18.html">The Influence of psychogenic factors can be assumed.

When elucidating the probable causes of dyspareunia, a thorough case history (Anamnesis) is of great importance. For instance, It is important to establish whether the patient has always experienced pain during sexual intercourse. If it is not constantly observed, it may be related solely to the sexual partner's behavior, thereby shifting the problem from a medical one to an issue of interpersonal relations.

The results of Objective Examination of patients should be evaluated carefully. Thus, a sharply pronounced spasm of the perineal muscles indicates vaginismus rather than dyspareunia; acute vulvovaginitis as a cause of dyspareunia is relatively rare compared to vaginal aplasia (Mayer-Rokitansky-Küster-Hauser syndrome) or a fibrosed, dense hymen. When delicate, poorly healing scars or coarse fibrosed scars resulting from obstetric complications and surgeries, as well as signs of acute vulvovaginitis, are detected, one should focus exclusively on organic disorders or purely psychological causes, since mixed etiologies of dyspareunia are frequently encountered. In some cases, the symptomatology persists even after the organic component has been resolved.

Treatment. If scars are present in the area of the vaginal entrance, its fornices, or on the cervix, digital stretching of the vaginal strictures is performed first. According to D. Fordney (1977), manual dilation can be entirely successful and sometimes even more effective than Surgical treatment, since the latter in some cases leads to similar or even more pronounced cicatricial changes. If manual dilation yields no positive results, a surgical (plastic) Procedure may be performed.

Even in the presence of organic lesions, it is necessary to investigate the psychophysiological factor. If the patient reports acute situational problems or neurological stress, the use of sedatives and psychotherapy are indicated. Since dyspareunia of mixed etiology is more common, combined, comprehensive therapy is typically administered, taking into account the underlying causes of the condition.

Virgogamy (unconsummated marriage) is a marriage in which the spouses are unable to initiate sexual life for a prolonged period (months or even years). Phobic, ignorant, and impotent forms of virgogamy are distinguished, with combinations of these also being recognized.

The phobic form is characterized by an obsessive fear of possible painful defloration or sexual intercourse, which is frequently accompanied by contractions of the muscles of the vaginal entrance and pelvic floor occurring upon attempts at sexual intimacy. In some cases, fear arises under the influence of stories about the wedding night; in others, after a painful attempt at defloration; and sometimes as a result of a negative attitude toward the husband.

Ignorant virgogamy is the result of the spouses' lack of preparation for sex and ignorance about the anatomy of reproductive Organs. Women with this form of virgogamy generally received inadequate sex education aimed at suppressing their sexuality, while their male partners lacked sufficient sexual experience.

Impotent virgogamy arises from sexual dysfunction in the man. These disorders are characterized by intense erections occurring in situations far removed from any prospect of intimacy, whereas actual physical closeness triggers the inhibition of erectile function (performance anxiety). Other potential causes include frequent, prolonged sexual arousal without ejaculation, suddenly postponed intimacy (for example, due to the onset of the wife's menstruation), or an exaggerated sense of responsibility in a specific intimate situation. As a rule, these disorders first manifest only during the attempt at the first sexual intercourse with the wife.

Virgogamy leads to a unique dynamic between spouses that paradoxically fosters the Stability of the marriage. Evidently, a shared sense of guilt, affection, and pity helps hold the family together. A husband's marital fidelity can be explained by the fear of failing in an attempt to have intercourse with another woman, while the wife's fidelity stems from the fear of being exposed as a virgin.

The principles of treating virgogamy are based on a combination of psychotherapy and the gentle dilation of the hymen using an elastic expander. Therapy is generally effective, and virgogamy is successfully resolved.

Sexual coldness (frigidity) refers to a weakness of sexual desire and sexual excitability in women. It may be accompanied by an absence of specific sexual sensations leading to orgasm, which can cause an aversion to sexual intercourse. Sexual coldness and female sexual dissatisfaction are the most frequent manifestations of marital disharmony. Unfortunately, this concept has acquired connotations that demean a woman's dignity (much like the term "impotence" regarding male sexuality), even though it masks a range of both clearly pathological and entirely normal variations of female sexuality.

There are numerous factors contributing to the onset of sexual coldness. First and foremost, one must consider a woman's susceptibility to various triggers that easily inhibit an adequate sexual response. For instance, if the partner fails to provide the necessary optimal conditions during the foreplay phase—conditions without which the mobilization of primary "trigger stimuli" is impossible—neither readiness for intercourse nor the engagement of the emotional component will occur. Frequently, the causes of frigidity include premature ejaculation in the man, a lack of harmony during intimacy, and other factors.

Sexual coldness is observed in hypogonadism, hypothyroidism, and other endocrine disorders; intoxications from drugs or sleeping pills; obesity; organic CNS diseases; mental disorders; and as a consequence of numerous abortions. Often, it may be a sign of Hermaphroditism, sexual infantilism, or the result of prolonged masturbation. Improper sex education plays a significant role in the development of female sexual coldness (instilling in a young woman a fear of being defiled), which inhibits all sexual activity.

With the development of a systemic approach to female sexual coldness, traditional views on The Nature and characteristics of female sexuality have largely changed, specifically regarding: its cyclical nature and focus on procreation; a higher degree of selectiveness compared to men alongside weaker internal mechanisms that depend heavily on the style of intimacy initiated by the partner; the retention of sexual desire at the platonic or erotic stage with a gradual stabilization of the orgasmic function; the predominance of the psychological aspect of pleasure over the physical; and a wide Variability in the degree and emotional tone of satisfaction derived from intimacy.

I. L. Bartnyova (1988) developed a scale for determining sexual constitution, which evaluates key sexological indicators: the stability of reproductive function, the degree and pattern of pubic and axillary Hair growth, the age of awakening of erotic libido (i.e., the desire for affection and tenderness), the age of the first orgasm, and the establishment of a "normal" level of orgastic capacity. Without determining a person's sexual constitution, it is difficult to judge whether we are dealing with a normal or pathological variant of female sexuality. Identical physical reactions may indicate diminished sexual function in individuals with a strong sexual constitution while simultaneously representing the absolute "ceiling" of psychophysiological capabilities for those with a weak one.

Anorgasmia. In some cases, There is a sharp reduction or complete omission of certain Stages of the sexual act. Most commonly, the orgasmic stage is impaired in women—it becomes achievable only under very high levels of arousal. The complete absence of orgasm is termed anorgasmia, while a significant decrease in its frequency or intensity is known as hypoorgasmia. Anorgasmia is frequently combined with lowered sexual desire or its complete absence (alibidinemia). Naturally, anorgasmias occur less frequently the stronger the libido is. However, for many women, sexual desire arises only after they begin experiencing orgasms.

Anorgasmia is distinguished into primary—occurring from the onset of sexual life—and secondary, which develops during sexual life in women who have previously experienced orgasm. Anorgasmia can be temporary or permanent. Depending on the causes, A. M. Svyadoshch (1988) identifies the following forms of anorgasmia: retardational, symptomatic, psychogenic, and constitutional.

Retardational anorgasmia is the result of a slight delay in the development of sexual feeling. It is temporary in nature and is always primary. This form of anorgasmia is observed not only in infantilized women but also in individuals with well-developed secondary sex characteristics. A significant role in its development is played by individual temperamental traits, shyness, and overly strict upbringing, which lead to a sharp suppression of sexuality and inhibit the maturation of sexual feeling, particularly at the beginning of marriage.

Women with retardational anorgasmia typically do not experience erotic dreams or orgasms outside of intercourse; their erogenous zones are unreactive or weakly reactive, and the sexual act is perceived as indifferent or mildly pleasant rather than frustrating.

Before marriage, they usually felt no sexual desire, nor did it appear During the first years of married life. However, upon unexpectedly experiencing an orgasm during intercourse, these women subsequently begin to experience it frequently. Over time, sexual desire awakens, sexual interests emerge, erotic dreams appear, and the reactivity of erogenous zones increases. Sometimes, the initial lack of orgasm in newly married women is simply due to a disharmony in sexual relations between the spouses.

Symptomatic anorgasmia can be primary or secondary. It is observed in individuals with organic Brain AND SPINAL cord lesions, chronic intoxications, endocrine disorders, post-infectious complications, painful intercourse (dyspareunia), overwork, sleep deprivation, etc.

In women with symptomatic anorgasmia caused by gynecological diseases, sexual desire, spontaneous erotic dreams, orgasm, and sensitivity of erogenous zones are preserved, whereas in cases driven by endocrine disorders or intoxication, they are usually absent.

Psychogenic anorgasmia occurs when sexual Functions are inhibited by psychological factors. This is observed in patterns of sexual desire where the personal component dominates the sensual one, accompanied by a significant lag in the awakening of sensuality during The formation of sexual drive. Hence, the intensity of desire becomes exceptionally dependent on the woman's attitude toward her partner—how he expresses his feelings, whether his actions elevate or degrade her dignity, and whether he lives up to the pedestal her affection places him on. Anything that tarnishes this emotional aspect can exert a pronounced inhibitory effect on a woman's sexual desire (e.g., the partner falling short of her ideal, feelings of resentment, a disregard for her modesty, or a lack of emotional security). Most frequently, this leads to a temporary suppression of sexual feeling, though later on, given good male potency, sexual attachment may develop.

The adequate realization of sexual drive can easily be inhibited by traumatizing psychological experiences, particularly those concerning the sexual side of life. The suppression of sexual desire in such cases can be selective—directed toward a specific person while not extending to others; this is known as selective anorgasmia.

The causes of persistent anorgasmia may include psychogenic factors that provoke external inhibition, notably fear, aversion, stressful situations, or instances where a woman consciously suppresses the onset of orgasm through willpower. Anorgasmia can also stem from a fear of pregnancy, Sexually Transmitted Infections, or the fear of being overheard during intercourse. Distrust of the partner and behavior that falls short of expectations play a crucial role, especially when an orgasm is accompanied by audible groans, convulsive body movements, etc. For some women, the approach of an orgasm—particularly the first one—is accompanied by a fear bordering on terror, which forces them to interrupt intercourse.

A. M. Svyadoshch (1988) identifies a specific form of psychogenic anorgasmia known as protective frigidity. It shields a woman from sexual arousal that fails to culminate in satisfaction. For example, premature ejaculation in a partner can induce depression and dissatisfaction in the wife; she fails to achieve orgasm, and her sexual drive drops sharply. The entire context of such intimate encounters can become an inhibitory stimulus for her sexual function, eventually leading to various neurotic states.

Performance anxiety (neurosis of anticipation) is one of the most common forms of psychogenic anorgasmia. It typically occurs in anxious, self-doubting women, as well as those who, even before marriage, expected something extraordinary from sexual intimacy. During intercourse, they remain tense, vigilantly monitor what is happening, and are unable to relax and let go.

Constitutional anorgasmia is exclusively primary and is characterized by a total absence of sexual desire and orgasm. The genesis of this form is presumably rooted in an innate deficiency of psychosexual functions. Anatomically and physiologically, these women are generally healthy, possess well-developed secondary sex characteristics, and are capable of motherhood. However, their sexual desire is absent or extremely weak, they experience no erotic dreams or extragenital orgasms, their genital erogenous zones are insensitive, their anorgasmia is generalized, and intercourse feels indifferent, mildly pleasant, or occasionally burdensome. Notably, they do not suffer distress from their frigidity.

Such women can be devoted wives and mothers, are capable of creating family happiness, enjoy affection and tenderness, and feel love for their husbands, even though the intimate side of life leaves them indifferent.

Unfortunately, under the influence of inadequate sex education in recent years, the fetishization of orgasm has emerged, destabilizing marriages based on the erroneous notion that if a wife does not experience orgasm, the couple is fundamentally incompatible. Therefore, great caution is required when diagnosing anorgasmia.

Sexual coldness—primarily the absence of orgasm—often impacts a woman's health, while male partners frequently react negatively to the lack of sexual response from their wives, leading to feelings of dissatisfaction that undermine marital stability.

Women who do not experience orgasm often complain of nervous tension, general depression, malaise, and a downcast state. The lack of orgasm causes congestion and hyperemia of the genital organs, which in turn leads to dysmenorrhea, menorrhagia, and other disorders.

Treatment must be strictly individualized, aimed at creating optimal conditions for the expression of female sexuality and eliminating existing sexual dysfunctions. A leading role belongs to active corrective psychotherapy, based on a thorough investigation of the causes underlying the sexual disorder. The success of therapy depends on how skillfully the physician guides the patient toward optimal conditions of sexual life that can alleviate inhibition. At the same time, it is essential to understand not only the psychological aspect of the marital relationship but also the intimate details of sexual life that may cause disharmony (the type of female sexual excitability, the range of acceptable sexual intercourse forms for each partner, the choice of the optimal coital position, etc.). Individual characteristics of male partners are also taken into account. The specifics of psychotherapeutic work also lie in ensuring that the proposed conditions are accepted by the patient, which requires a very skillful, subtle, and delicate approach.

For psychogenic, retardative, and even constitutional anorgasmia, hypnotic suggestion, autogenic training, and autosuggestion can be recommended. Psychotherapy for retardative psychogenic anorgasmia aims to clarify the genesis, eliminate frustration and feelings of inferiority, and orient the patient toward deriving pleasure from the joy brought to her partner. In The process of psychotherapy for constitutional anorgasmia, it is desirable to reduce The Significance of orgasm, convincing the woman that love and family happiness are possible even if she does not experience orgasm, provided that sexual satisfaction is present and intercourse is pleasant for both partners, even without an orgasm occurring.

Such psychotherapeutic Methods usually remove psychological inhibitions that prevent orgasm, enhance the psycho-erotic mood preceding intercourse, influence neuro-endogenous processes and the functional state of the cortical and sexual centers, and affect the peripheral PARTS OF THE Reproductive System and the vascular Innervation of the genital organs.

Psycho-erotic exercises practiced by couples are successfully used to treat anorgasmia. First, during a gynecological examination, the woman's erogenous zones are identified, and then, during a consultation, the physician delicately recommends that the partner stimulate the wife's corresponding erogenous zones prior to intercourse in such a way that her sexual arousal gradually builds up and an orgasm occurs. In addition, hot sitz baths, gynecological massage, vibratory massage of the vaginal introitus, and the like can be recommended to the woman.

Medical treatment for sexual coldness is carried out in combination with other methods. Hormonal medications (taking into account endocrine pathology), biostimulants and Vitamins (for asthenization), and tranquilizers and antidepressants (for depressive states) are prescribed.

Physiotherapy plays only a secondary role and is prescribed in combination with other measures. It mainly consists of Procedures that cause hyperemia of the genital organs, thereby promoting erotization.

Nymphomania (hypersexuality) is a pathologically increased sexual drive in women, manifested by an irresistible urge for sexual intercourse with various partners. The woman is constantly tormented by sexual arousal that is difficult to relieve through orgasmic discharge. Therefore, she remains aroused even after intercourse that ends in orgasm. In some cases, a woman painfully experiences intense sexual desires triggered by her partner's constant premature ejaculation. In her desire to find relief from tension, she strives for multiple acts of sexual intercourse, but this only intensifies her sexual arousal and leads to renewed frustration.

Nymphomania generally arises as a result of vascular neuroinfections or TRAUMATIC BRAIN INJURIES (specifically in the hypothalamic region or the limbic system). Sometimes it is observed in the development of a brain tumor in the pituitary-diencephalic region, adrenal cortex hyperfunction, or ovarian hyperandrogenemia. Nymphomania can also be the initial symptom of manic states of various origins (psychopathy, oligophrenia, Epilepsy, circular schizophrenia).

As a result of demographic shifts, changes in human psychology and behavior, family dysfunction, and other factors, the individual characteristics of psychosexual experiences in certain individuals, particularly hypersexuality, acquire socio-epidemiological significance. According to our observations, women with increased sexual drive play a certain role in the spread of Sexually Transmitted Diseases, including AIDS. This is explained by the relatively early awakening of their sexual drive, early onset of sexual life, promiscuous sexual relations, frequent changes of sexual partners, and extramarital sexual contacts.

It is well known that psychosexual characteristics vary not only among different individuals but also at different stages of The life cycle. Adolescence and early youth are times when an individual has the most acute need for strong emotional attachments, yet is also most susceptible to environmental influences. In recent years, many teenagers consume alcohol and drugs and lead promiscuous sexual lives; negative Examples and the desire for self-affirmation drive teenage girls with an increased sexual drive toward multiple sexual contacts. For this reason, teenage girls with increased sexual drive constitute a particular risk group for sexually transmitted infections.

Nymphomania is generally a syndrome associated with various medical conditions. Therefore, therapy for increased sexual drive must be aimed primarily at treating the underlying disease. To reduce the intensity of sexual drive, chlorpromazine, thioridazine (Mellaril, Sonapax) are recommended. For hypersexuality accompanied by feelings of anxiety and tension, amitriptyline is prescribed.