Case Studies

                                                                           Case Studies

NON CONSUMMATION OF MARRIAGE PRESENTING AS ANEJACULATION
Mr. Arvind (name changed), 40 yrs old came with H/O inability to ejaculate for last 3 years. He got married 8 years back with a teacher. The girl was not interested to have sex because as she said “I am not mentally prepared as yet” the boy took it as a sign of tiredness due to marital chores so didn’t object but it continued as such. The girl kept on postponing sex (there was no extra marital involvement as revealed by the boy himself) on one pretext or the other. The boy tried to force himself 2-3 times, there was appropriate erection but no significant penetration could take place and boy ejaculated on the outside of vulva. The girl got herself transferred to other city and ultimately they took divorce by mutual consent. The occasional sexual activity of the boy was limited to masturbation with reasonable enjoyment.
After divorce, the boy was convinced that he was impotent and developed moderate depression. He still masturbated occasionally but his libido decreased. Since 2 years – he couldn’t ejaculate as well while masturbating.
He approached me when his family members were forcing him for remarriage.
He was non alcoholic, non smoker, normotensive,nondiabetic. His srum testosterone level was at lower side of normal range, penile perfusion index was normal, NPT showed 2 episodes of erection for 15 minutes in total and rigidity was normal.
We started him on psychotherapy, antidepressants, testosterone supplementation, penile rehabilitation programme and PDE-5 inhibitors. It had less than expected response so intrapenile inj and vibrator therapy with 5 mm lateral displacement was added. He started ejaculating after 2 sessions.
Discussion – In this case, the girl was having severe vaginismus so she was extremely scared to have penetrative sex. The worst part was that she was not aware of her problem or she didn’t want to accept that she had a problem. Such cases need desensitization, dilation, psychotherapy, sex education and medicines. If such cases come to us, we take about 3-4 weeks to treat such a problem and results are extremely good.
NON CONSUMMATION PRESENTING AS ED
Mr. A, 38 year old engineer came from Ahmedabad with complain of ED for last 3 years.
He was married 12 years back with a CA girl. Their first night sex consisted of some foreplay, good erection, slight entry (10% according to the boy) and ejaculation outside. The boy never retracted the skin behind the glans. The boy realized that THERE WAS INCOMPLETE PENETRATION, but never communicated this to his wife for fear of being labeled impotent. Even they had a SON, probably because the sperms could get inside the uterus from vulva. Mr. A was hypertensive, had very high work pressure, non smoker and non diabetic, BMI 24. His investigations were normal.
Discussion – ED in this case could be due to hypertension, high stress or the antihypertensive he was taking but he had never penetrated as is evident from h/o never retracting skin behind glans during sex. I suggested him to talk to his wife to initiate couple therapy but she may or may not agree because there was not much distress in their married life. But striking feature in this case was the lack of awareness about steps to have penetrative sex, absence of pleasure in female partner because she can never have orgasm in this way and developing ED because he felt incomplete and incompetent. This feeling is likely to keep on increasing until his wife takes part in sex therapy and agrees for full penetrative sex.
RESISTENT VAGINAL DISCHARGE ( LEUCORRHOEA)
A 38 years lady, post graduate , average built , married for 10 years  came for treatment of vaginal discharge and reduced sex desire for the last 8 year. She had consulted many gynecologists and taken all possible antifungals and antibiotics , She  had developed reduced desire for sex as well and tried to avoid sex on one pretext or the other. ( average frequency of sex was less than once a month) . The husband was quite angry and threatened for divorce . On careful history taking, it emerged that all was well for two yeaars after marriage. They had very good sex life and had a son 9 months after marriage. The itching would start  after bleeding stopped , there was white discharge which was not foul smelling. She used to wash her vagina many times during the day to make sure there was no discharge left ,some times apply antiseptic lotion and scratch vigrously if there was very mild itching. Theis would be followed by more itching and infection, she would consult a doctor , take treatment so infection would be cured but recurred in next cycle. this usually was an excuse to avoid sex. even during sex, she would wash the vagina vigrously till she was sure that all semen was washed. Actually she was suffering from OCD and felt disgusted with body fluids like vaginal or seminal fluid. She would avoid sex to avoid this feeling ,though was upset not to make her husband happy. We treated her for OCD, gave counselling and sex therapy to the couple . Actually cases of chronic vaginal infection are very common and large number are associaated with a psychiatric problem They need to be assessed by a psychiatrist.

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