Related Terms

• Adrenal gland, angina, anorgasmia, arousal, candidiasis, cardiovascular disease, chlamydia, desire, diabetic neuropathy, dyspareunia, ED, ejaculation, endometriosis, erectile dysfunction, estrogen, female arousal disorder, frigidity, glans, gonorrheal infection, heart attack, hormonal replacement therapy, HRT, hysterectomy, impotence, inhibited sexual desire, ISD, libido, libido disorders, lichen sclerosus et atrophicus, LSEA, melanocortin, menopause, multiple sclerosis, orgasm disorder, orgasmic, pelvic trauma, Peyronie's disease, pituitary, prostatitis, renal failure, selective-serotonin reuptake inhibitors, sexual arousal disorder, sexual desire disorder, sexual malfunction, sexual pain disorders, SSRIs, testicular, testosterone, thyroid, trichomoniasis, tumors, urethritis, urinary tract infections, vaginal lubrication, vaginal, vaginismus, xerosis.

Background

• Sexual dysfunction or sexual malfunction is defined as difficulty during any stage of the sexual act (which includes desire, arousal, orgasm, and resolution) that prevents the individual or couple from enjoying sexual activity.

• Sexual dysfunction includes desire, arousal, orgasmic, and sexual pain disorders, including dyspareunia (painful intercourse) and vaginismus (involuntary spasm of the muscles of the vaginal wall that interferes with intercourse). Estimates of the number of women who have sexual dysfunctions range from 19-50% of the normal population, and increase to 68-75% when sexual dissatisfaction or problems (not dysfunctional in nature) are included. One in 10 men in the world has erectile dysfunction, and approximately 30 million men in the United States have erectile dysfunction.

• Sexual difficulties can begin early in an individual's sex life or they may develop after an individual has previously experienced enjoyable and satisfying sex. Sexual dysfunctions are more common in the early adult years, with the majority of people seeking care for such conditions during their late 20s through their 30s. A problem may develop gradually over time, or may occur suddenly as a total or partial inability to participate in one or more stages of the sexual act.

• The causes of sexual difficulties can be physical, psychological, or both.

• Sexual dysfunction is more common in people who abuse alcohol and drugs. It is also more likely to occur in people suffering from health conditions such as circulatory disorders and lack of vaginal lubrication (common in women with hormonal changes such as pre-menstrual syndrome or menopause), diabetes, and degenerative neurological disorders. Sexual dysfunctions are also common among patients with chronic renal (kidney) failure. Ongoing psychological problems, difficulty maintaining relationships, or ongoing stress with the current sexual partner can also interfere with sexual function. The incidence increases again in the geriatric population, typically with gradual onset of symptoms that are associated most commonly with medical causes, such as circulatory disorders, of sexual dysfunction.

• For both men and women, conditions of sexual dysfunction may appear as an aversion to, and avoidance of, sexual contact with a partner. In men, there may be partial or complete failure to attain or maintain an erection, or a lack of sexual excitement and pleasure in sexual activity.

Types and Causes

• Sexual desire disorders: Sexual desire disorders (decreased libido) may be caused by a decrease in the normal production of estrogen (in women) or testosterone (in both men and women) and the balance between progesterone and these hormones. Other causes may be aging, fatigue, pregnancy, and medications, such as the selective-serotonin reuptake inhibitors (SSRIs), anti-depressants that include fluoxetine (Prozac®), sertraline (Zoloft®), and paroxetine (Paxil®), which are all well known for reducing desire in both men and women. Psychiatric conditions, such as depression and anxiety, can also cause decreased libido.

• Emotional factors affecting sex include both interpersonal problems, such as marital/relationship problems or lack of trust and open communication between partners, and psychological problems within the individual, including depression, sexual fears or guilt, past sexual trauma, and sexual disorders.

• Physical factors include drugs, such as alcohol, nicotine, narcotics, stimulants, antihypertensives, antihistamines, and some antidepressant drugs; injuries to the back: problems with an enlarged prostate gland: problems with blood supply; nerve damage (as in spinal cord injuries); diseases affecting the nerves (diabetic neuropathy, multiple slcerosis, tumors, and, rarely, tertiary syphilis); failure of various organ systems (such as the heart and lungs); endocrine disorders (thyroid, pituitary, or adrenal gland problems); hormonal deficiencies (low testosterone, estrogen, progesterone, or androgens such as testosterone); and some birth defects. Androgens, including testosterone, are thought to be the hormones that increase sexual desire in men and women.

• Inhibited sexual desire (ISD) is a very common sexual desire disorder. The most common cause of ISD seems to be relationship problems wherein one partner does not feel emotionally intimate or close to their mate. Communication problems, lack of affection that is not associated with continuing into sexual intercourse, power struggles and conflicts, and a lack of time alone together are common factors. ISD may also be associated with a very restrictive upbringing concerning sex, negative attitudes toward sex, or negative or traumatic sexual experiences (such as incest or sexual abuse).

• Physical illnesses and some medications may also contribute to ISD, particularly when they produce fatigue, pain, or general feelings of malaise. Hormone deficiencies may often be implicated. Psychological conditions such as depression and excessive stress may inhibit sexual interest. Insufficient dietary mineral intakes, such as vitamins A, C, and E, may also lead to inhibited sexual desire.

• Commonly overlooked factors include insomnia or inadequate amounts of sleep, resulting in fatigue. ISD may also be associated with other sexual dysfunctions and sometimes may be caused by them. For example, the woman who is unable to have orgasm or has pain with intercourse, or the man who has erection problems (impotence) or slow ejaculation, may lose interest in sex because it is commonly associated with failure or is not very pleasurable. As women age beyond their child-bearing years, their interest in sex may begin to decline. This may lead to sexual dysfunction. The dysfunction may cause problems in a relationship where, typically, the male partner continues to seek an active sexual experience with his partner.

• Individuals who were victims of childhood sexual abuse or rape, and persons whose marriages are lacking in emotional intimacy, are particularly at risk of ISD.

• Sexual arousal disorders: Sexual arousal disorders were previously known as frigidity in women and impotence in men. These have now been replaced with less judgmental terms. Impotence is now known as erectile dysfunction, and frigidity is now described as any of several specific problems with desire, arousal, or anxiety. For both men and women, these conditions can manifest as an aversion to, and avoidance of, sexual contact with a partner. In men, there may be partial or complete failure to attain or maintain an erection, or a lack of sexual excitement and pleasure in sexual activity. There may be medical causes to these disorders, such as decreased blood flow or lack of vaginal lubrication. Estimates of the percentage of female sexual dysfunction attributable to physical factors, such as vaginal dryness, have ranged from 30-80%. Chronic disease can also contribute, as well as the nature of the relationship between the partners. Most erectile disorders in men are also primarily physical, not psychological conditions. Estimates suggests that from 15-30 million (20-40%) American men suffer from ED.

• Orgasm disorders: Orgasm disorders are a persistent delay or absence of orgasm following a normal sexual excitement phase. The disorder can occur in both women and men. The SSRI antidepressants are frequent causes of orgasm disorders. These drugs can delay the achievement of orgasm or eliminate it entirely.

• Anorgasmia, often related to delayed ejaculation in males, is a form of sexual dysfunction sometimes classified as a psychiatric disorder in which the patient cannot achieve orgasm, even with "adequate" stimulation. However, it can also be caused by medical problems such as diabetic neuropathy, multiple sclerosis, pelvic trauma, hormonal imbalances, total hysterectomy, spinal cord injury, and cardiovascular disease. Anorgasmia is far more common in females than in males and is especially rare in younger men.

• A common cause of anorgasmia, in both men and women, is the use of anti-depressants, particularly selective serotonin reuptake inhibitors (SSRIs). Though reporting of anorgasmia as a side-effect of SSRIs is not precise, it is estimated that 15-50% of users of such medications are affected by this condition. Some popular SSRIs are escitalopram (Lexapro®), paroxetine (Paxil®), fluoxetine (Prozac®), and sertraline (Zoloft®). The antiviral drug amantadine (Symmetrel®) has been shown to reverse SSRI-induced anorgasmia in some, but not all, people.

• Premature ejaculation (PE), also known as rapid ejaculation, premature climax, or early ejaculation, is the most common sexual problem in men, affecting 25%-40% of men. It is characterized by a lack of voluntary control over ejaculation.

• Sexual pain disorders: Sexual pain disorders affect women almost exclusively and are known as dyspareunia (painful intercourse) and vaginismus (an involuntary spasm of the muscles of the vaginal wall that interferes with intercourse).

• Dyspareunia may be caused by insufficient lubrication (vaginal dryness) in women. Poor lubrication may result from insufficient excitement and stimulation, or from hormonal changes caused by menopause, pregnancy, or breastfeeding. Irritation from contraceptive creams and foams can also cause dryness, as can fear and anxiety about sex. Other causes of dyspareunia include infections (candidiasis, chlamydia, trichomoniasis, urinary tract infections), endometriosis, tumors, xerosis (dryness, especially after menopause), and lichen sclerosus et atrophicus (LSEA, a fungal skin condition of the genital area). Dyspareunia may result from female genital mutilation, when the vaginal opening has become too small for normal penetration and is often worsened by scarring. Although dyspareunia is not common in the United States, it is common in other geographic locations such as Africa.

• It is unclear exactly what causes vaginismus, but it is thought that past sexual trauma (such as rape or abuse) may play a role. Another female sexual pain disorder is called vulvodynia or vulvar vestibulitis. In this condition, women experience burning pain during sex which seems to be related to problems with the skin in the vulvar and vaginal areas. The cause is unknown.

• In men, as in women, there are a number of physical factors that may cause sexual discomfort. Pain is sometimes experienced in the testicular or glans (the "head") area of the penis immediately after ejaculation. Infections of the prostate, bladder, or seminal vesicles can lead to intense burning or itching sensations following ejaculation. Men suffering from interstitial cystitis may experience intense pain at the moment of ejaculation. Gonorrheal infections are sometimes associated with burning or sharp penile pains during ejaculation. Urethritis (inflammation of the urethra) or prostatitis (inflammation of the prostate) can make genital stimulation painful or uncomfortable. Anatomic deformities of the penis, such as exist in Peyronie's disease, may also result in pain during sexual intercourse. Other causes of painful intercourse in men are the painful retraction of a too-tight foreskin and vigorous intercourse or masturbation, which may cause small tears in penile tissue.

Signs and Symptoms

• Signs and symptoms of sexual dysfunction between males and females vary.

• Men and women: Men and women with sexual dysfunction may experience: a lack of interest in sex (loss of libido); inability to feel aroused; and pain with intercourse (much less common in men than women).

• Men: Men with sexual dysfunction may experience: an inability to attain an erection; inability to maintain an erection adequately for intercourse; delayed or absent ejaculation despite adequate stimulation; and an inability to control timing of ejaculation.

• Women: Women with sexual dysfunction may experience: an inability to relax vaginal muscles enough to allow intercourse; inadequate vaginal lubrication before and during intercourse; an inability to attain orgasm; and a burning pain on the vulva or in the vagina with contact to those areas.

Complications

• Persistent sexual dysfunction may cause depression in susceptible individuals. The importance of the sexual disorder for both the individual and their partner needs to be determined. Sexual dysfunction that is not addressed adequately may lead to conflicts or potential breakups.

• When both partners have low sexual desire, the issue of sexual interest level will not be problematic in the relationship. Low sexual desire, however, may be a barometer of the emotional health of the relationship. In other cases where there is an excellent and loving relationship, low sexual desire may cause a partner to repeatedly feel hurt and rejected, leading to eventual feelings of resentment and promoting eventual emotional distance.

• Sex is something that, for most couples, either bonds their relationship closer together, or it is something that becomes a wedge that gradually drives them apart. When one partner is significantly less interested in sex than their companion, and this has become a source of conflict and friction, it is recommended by healthcare providers that professional help be sought before the relationship becomes further strained.

Diagnosis

• The majority of the time, medical evaluation and lab tests will not reveal a physical cause. However, testosterone is the hormone most responsible for creating sexual desire in both men and women. It may be useful to check testosterone levels, particularly in men who have ISD. Blood for such lab tests in men should be drawn before 10:00 a.m., when male hormone levels are at their highest. Interviews with a specialist in sex therapy are more likely to reveal possible causes.

• The diagnostic criteria (DSM-IV-TR) for female sexual arousal disorders are: persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement; the dysfunction causes marked distress or interpersonal difficulty; and the sexual dysfunction is not caused by another primary disorder (except another sexual dysfunction) and is not due exclusively to the direct effects of a substance (such a drug of abuse, a medication) or a general medical condition on the body.

• Diagnostic criteria for premature ejaculation DSM-IV-TR (American Psychiatric Association) are: persistent or recurrent ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and occurring before the person wishes it. Factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity, are taken into consideration; the disturbance causes distress or interpersonal difficulty; and the premature ejaculation is not due exclusively to the direct effects of a substance (such as withdrawal from opioids).

Treatment

• Treatment for sexual dysfunction must be individualized to the factors that may be inhibiting sexual interest, desire, and pleasure. Often, there may be several such factors. Some couples will need relationship enhancement work or marital therapy prior to focusing directly on enhancing sexual activity.

• Psychological counseling: Psychological counseling can help with sexual dysfunction in men and women caused by stress, anxiety, or depression. The individual and their partner may be instructed to visit a sex therapist, psychologist, or psychiatrist with experience in treating sexual problems. Qualified therapists work with couples to reduce tension, improve sexual communication, and create realistic expectations for sex, all of which can improve symptoms of ED. Therapists also help the individual work through issues such as sexual abuse as a child. Psychological therapy may be effective along with medical or surgical treatment.

• Medications for sexual arousal and desire disorders:

• Phosphodiesterase-5 inhibitors (PDE-5): Oral medications available to treat erectile dysfunction (ED) and female sexual arousal disorders include sildenafil (Viagra®), tadalafil (Cialis®), and vardenafil (Levitra®). The U.S. Food and Drug Administration (FDA) approved Viagra® in 1998, and it became the first oral medication for ED on the market. Since then, Levitra® and Cialis® have been approved, providing more options for oral therapy. These drugs are chemically known as phosphodiesterase-5 inhibitors (PDE-5). They enhance the effects of nitric oxide, a chemical messenger that relaxes smooth muscles in the penis. This increases the amount of blood flowing into the penis and allows an erection in response to sexual arousal and stimulation. These medications do not automatically produce an erection. Instead they allow an erection to occur after physical and psychological stimulation and arousal. Many men experience improvement in erectile function after taking these medications regardless of the cause of their impotence.

• Generally, these medications are absorbed and processed rapidly by the body and are usually taken 30 minutes to one hour before intercourse. Cialis® has been reported in clinical trials to stay in the body longer than the others. It promotes erection within 30 minutes and enhances the ability to achieve erection for up to 36 hours.

• Common side effects of phosphodiesterase inhibitors include headache, reddening of the face and neck (flushing), indigestion, and nasal congestion. These drugs may also cause hypotension or low blood pressure. Cialis® may cause muscle aches and back pain, which usually go away on their own within 48 hours.

• Medications prescribed for the treatment of erectile dysfunction may cause significant side effects when mixed with certain heart drugs called nitrates, including nitroglycerin (Nitrostat®, Nitro-Bid®), isosorbide mononitrate (Imdur®), and isosorbide dinitrate (Isordil®). Nitrates are often prescribed to reduce chest pain, dilate the blood vessels, and lower blood pressure. Because ED medications also reduce blood pressure, combining these two types of medication can cause a dangerous drop in blood pressure. Experts do not recommend taking sildenafil (Viagra®), vardenafil (Levitra®), or tadalafil (Cialis®) if nitrates are used. If an individual has coronary heart disease (CHD) or has had a heart attack in recent months, be sure to check with a doctor before taking any of these drugs for erectile dysfunction. These drugs should also not be used along with certain medications for high blood pressure called alpha blockers.

• Bremelanotide: Bremelanotide (formerly PT-141) is a new medication in phase 3 clinical trials for use in treating sexual dysfunction in men (erectile dysfunction or impotence) as well as sexual dysfunction in women (sexual arousal disorder). It is the only known synthetic aphrodisiac. Bremelanotide is called a melanocortin receptor agonist, and unlike Viagra® and other related medications, it does not act upon the vascular system, but directly increases sexual desire by acting on melanocortin receptors in the brain. Melanocortin receptors seem to stimulate sexual desire and arousal. Bremelanotide is a spray introduced nasally. High blood pressure is reported to be a side effect of bremelanotide in sensitive individuals.

• Eros Therapy®: Eros Therapy® is an FDA-approved device for the treatment of female sexual dysfunction. This small handheld device is used three to four times per week to increase blood flow to the clitoris and external genitalia, which improves clitoral and genital sensitivity, lubrication, and the ability to experience orgasm. It may take several weeks of conditioning before experiencing the benefits of this therapy.

• Prostaglandin E1 (alprostadil): Two treatments involve using a drug called alprostadil (Muse®, Caverject®, Edex®). Alprostadil is a synthetic version of the hormone prostaglandin E1. This hormone helps relax smooth muscle tissue in the penis (corpus cavernosum), which enhances the blood flow needed for an erection. There are two ways to use alprostadil, including needle-injection therapy and intraurethral (into the urethra) therapy. With needle-injection, a needle is used to inject alprostadil (Caverject®, Edex®) into the base or side of the penis, performed at a doctor's office or hospital. This generally produces an erection in five to 20 minutes that lasts for about an hour. Because the injection goes directly into the spongy cylinders that fill with blood, alprostadil is an effective treatment for many men. And because the needle used is so fine, pain from the injection site is usually minor. Other side effects may include bleeding from the injection, prolonged erection, and formation of fibrous tissue at the injection site. It should not be used more than three times per week, and there must be at least 24 hours (one day) between each dose. The cost per injection can be expensive. Injecting a mixture of alprostadil and other prescribed drugs (including papaverine and phentolamine) may be a less expensive and more effective option. A risk of infection exists at the injection site, especially in immunocompromised individuals such as those with human immunodeficiency virus (HIV). Healthcare professionals recommend using care to protect the individual using Caverject® and their sexual partner, as blood from the injection site after could be a carrier of sexually transmitted diseases, such as HIV or hepatitis.

• Medicated Urethral System for Erection (Muse®) is a self-administered intraurethral (into the urethra or opening in penis) therapy. It involves using a disposable applicator to insert a tiny suppository, about half the size of a grain of rice, into the tip of the penis. The suppository, placed about two inches into the urethra, is absorbed by erectile tissue in the penis, increasing the blood flow and causing an erection. Although needles are not involved, this method may be painful or uncomfortable. Side effects may include pain, minor bleeding in the urethra, dizziness, and formation of fibrous (scar) tissue. Again, bleeding may occur during the use of this drug, so care should be taken by the individual using Muse® to protect themselves and their sexual partner.

• Hormone replacement therapy (HRT): Women may benefit from hormone replacement therapy (HRT), which is aimed at restoring hormone levels affected by age (such as in menopause), surgery (such as in a hysterectomy), or hormone dysfunction (such as in premenstrual syndrome or PMS) to normal, thus restoring sexual function. Estrogen, progesterone, and testosterone levels are measured and treated by a doctor. HRT medications include conjugated estrogen (Premarin®) and estrogen/progesterone combinations (Premphase®). Complications of HRT can include an increased risk of developing ovarian and breast cancer and cardiovascular diseases such as stroke and heart attack.

• For men who have testosterone deficiency, testosterone replacement therapy may be an option. While it is fairly well established that testosterone plays a role in libido (sexual desire), its role in ED remains unclear. ED occurs in men with normal or moderately low levels of testosterone, so it cannot be concluded that testosterone is the primary modulator of erectile function. However, among men diagnosed with hypogonadism, a condition characterized by abnormally low testosterone, erections do improve after testosterone replacement. For these men with ED, testosterone therapy is recommended to restore erectile function.

• Testosterone replacement therapy has also been recommended as a second-line approach to treatment of ED when prescription medications alone have failed and when prostate cancer has been ruled out. However, testosterone may increase the growth of prostate cancer and is not used in individuals with this disease or an enlarged prostate (benign prostatic hyperplasia or BPH).

• Vacuum devices: This treatment involves the use of an external vacuum and one or more rubber bands (tension rings). To begin, a hollow plastic tube is placed over the penis. This tube is available by prescription or through various vendors. Then a hand pump is used to create a vacuum in the tube that pulls blood into the penis. Once an adequate erection is achieved (usually one to three minutes), a tension ring is slipped around the base of the penis to maintain the erection. The vacuum device is then removed. The erection typically lasts long enough for a couple to have sexual intercourse. The ring can be left in place for 25-30 minutes. The tension ring is removed after intercourse.

• Vascular surgery: This treatment is usually reserved for men whose blood flow has been blocked by an injury to the penis or pelvic area. Surgery may also be used to correct erectile dysfunction caused by vascular blockages such as atheroslerosis (hardening of the arteries) or tumors. The goal of this treatment is to correct a blockage of blood flow to the penis so that erections can occur naturally; however, long-term success of this surgery is unclear. Complications are minimal and include abdominal or scrotal pain/swelling and occasional temporary numbness on the top surface of the penis. Abstinence from sexual activity involving the erect penis is recommended for the first six weeks after the operation.

• Penile implants: This treatment involves surgically placing a device into the two sides of the penis, allowing erection to occur as often and for as long as desired. These implants consist of either an inflatable device or semi-rigid rods made from silicone or polyurethane. This treatment is often expensive and is usually not recommended until other methods have been considered or tried first. Penile implants are also sometimes used to treat Peyronie's disease, a disorder that causes bent or painful erections. As with any surgery, there is a risk of complications such as infection. Most men go home within 24 hours of surgery. Although new penile implant designs are very reliable and may last a lifetime, they can malfunction. For example, in some semi-rigid devices, internal parts can break down over time, leading to a prosthesis malfunction. In inflatable devices, fluid can leak or the valve or pump device can fail. Surgery is necessary to repair or replace a broken implant. Penile implants do not usually affect urination, sex drive, orgasm, or ejaculation.

• Treatment for sexual pain disorders:

• Dyspareunia: Dysparenunia is treated by doctors using the following steps: carefully taking a history; carefully examining the pelvis to duplicate as closely as possible the discomfort and to identify a site or source of the pelvic pain; removing the source of pain when possible; and prescribing very large amounts of water-soluble sexual or surgical lubricant during intercourse. Petroleum jelly is discouraged. Moisturizing skin lotion may be used as an alternative lubricant, unless the individual is using a condom or other latex product (lotion may degrade the condom). Lubricant should be liberally applied to both the penis and the orifice to receive the penis. A folded bath towel under the receiving partner's hips helps prevent spillage on bedclothes.

• It is recommended by healthcare providers to instruct the receiving partner to take the phallus of the penetrating partner in their hand and control insertion, rather than letting the penetrating partner do it.

• Couples may add pleasant, sexually exciting experiences to their regular interactions, such as bathing together (in which the primary goal is not cleanliness), mutual caressing without intercourse, and using sexual books, pictures, or videos. In couples where a woman is preparing to receive vaginal intercourse, such activities tend to increase both natural lubrication and vaginal dilation, both of which decrease friction and pain.

• Healthcare providers recommend changing coital positions to one admitting less penetration. In women receiving vaginal penetration, this is recommended for those who have pain on deep penetration because of pelvic injury or disease. Maximum vaginal penetration is achieved when the receiving woman lies on her back with her pelvis rolled up off the bed, compressing her thighs tightly against her chest with her calves over the penetrating partner's shoulders; and minimal penetration occurs when a receiving woman lies on her back with her legs extended flat on the bed and close together while her partner's legs straddle hers. If no penetration is tolerable, the couple may substitute oral sex and masturbation for intercourse.

• Vaginismus: Physical treatment of the internal spasms may include sensate focus exercises, exploring the vagina through touch, and desensitization with vaginal dilators. Dilating involves inserting objects, usually phallic in shape, into the vagina. In treating the spasms through dilation, the objects used gradually increase in size as the woman progresses. Medical dilators may be obtained online, though they may be expensive. Other options include sex toys (such as dildos or vibrators), peeled cucumber, or simply the individual's own fingers. The addition of personal lubricant can ease insertion.

Integrative Therapies

• Good scientific evidence:

• Cranberry: Cranberry seems to work for urinary tract infection prophylaxis by preventing bacteria from sticking to cells that line the bladder. Contrary to prior belief, urine acidification (urine that is concentrated and has a lower-than-normal pH) does not appear to play a role. Notably, many studies have been sponsored by the cranberry product manufacturer Ocean Spray®. Additional research is needed in this area before a conclusion can be made.

• Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.

• Lactobacillus acidophilus: Multiple human studies report that Lactobacillus acidophilus vaginal suppositories are effective in the treatment of bacterial vaginosis. Additional research is necessary before a firm conclusion can be reached. Patients with persistent vaginal discomfort are advised to seek medical attention.

• It may be difficult to tolerate Lactobacillus acidophilus if allergic to dairy products containing Lactobacillus acidophilus. Avoid with history of an injury or illness of the intestinal wall, immune-disease or heart valve surgery. Avoid with prescription drugs, like corticosteroids, because of the risk of infection. Use cautiously with heart murmurs. Antibiotics or alcohol may destroy Lactobacillus acidophilus. Therefore, it is recommended that Lactobacillus acidophilus be taken three hours after taking antibiotics or drinking alcohol. Some individuals can use antacids (like famotidine (Pepcid®), esomeprazole (Nexium®)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

• Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). Its purpose is the exploration of thoughts, feelings, and behavior for the purpose problem solving or achieving higher levels of functioning. Psychotherapy may be helpful for sexual abuse in both child and adult survivors. Group therapy and individual therapy may be equally effective, although individual therapy may address post-traumatic stress symptoms more effectively.

• Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may worsen if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression.

• Vitamin C: Vitamin C may decrease the risk of developing a urinary tract infection during pregnancy. Further research is needed to confirm early study findings.

• Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding. It is not clear if vitamin C supplements in doses higher than Dietary Reference Intake recommendations are safe for pregnant or breastfeeding women. Vitamin C is naturally found in breast milk.

• Unclear or conflicting scientific evidence:

• Acupressure, shiatsu: Results from preliminary study suggest a benefit of vaginal acupressure/pelvic massage in the treatment of sexual dysfunction. Additional studies are needed.

• With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. Serious long-term complications have not been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

• Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Today it is widely used throughout the world and is one of the main pillars of Chinese medicine. It involves the insertion of needles in various point of the body to help move the "chi" or energy. A few clinical studies have suggested that acupuncture may help individuals suffering from erectile dysfunction (ED). The results found that acupuncture can be an effective treatment option in more than two-thirds of patients with ED caused by psychological factors including stress, anxiety, and depression. Subjective observations in limited available study suggest a possible role of acupuncture in the treatment of vulvodynia symptoms (chronic burning or stinging sensation of the vulva in the vagina). However, there is currently insufficient evidence on which to base recommendations. There is also insufficient available evidence to recommend either for or against the use of acupuncture in prostatitis. Early study in women with a urinary tract infection suggests a reduced recurrence over six months and reduced residual urine (urine retained in the bladder after urination). Better-designed studies are needed to determine recommendations.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, medical conditions of unknown origins, or infections. Acupuncture should not be applied to the chest in patients with lung diseases or on any area that may rely on muscle tone to provide stability. Avoid use in infants, young children, or in patients with needle phobias. Use cautiously with bleeding disorders, neurological disorders, seizure disorders, or diabetes. Use cautiously in elderly or medically compromised patients. Use cautiously in patients who will drive or operate heavy machinery after acupuncture. Use cautiously if taking anticoagulants. Avoid if pregnant.

• Arginine: L-arginine, or arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. Early studies found that men with low nitrate levels (a cause of erectile dysfunction) in their blood or urine may find arginine supplements to be useful for managing erectile dysfunction. A randomized, controlled clinical trial reported improvements in patients with ED following use of a combination of L-arginine, glutamate, and yohimbine hydrochloride. Notably, yohimbine hydrochloride is an U.S. Food and Drug Administration (FDA) approved drug therapy for ED, and the effects caused by arginine alone in this combination therapy are difficult to determine. It is not clear what doses of arginine may be safe or effective in treating this condition, and comparisons have not been made with other agents used for ED. Larger, high-quality studies are needed.

• L-arginine is generally safe in recommended dosages, although drug interactions may be seen, especially with drugs to lower high blood pressure. Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

• Boron: Boron is a trace element, which is found throughout the global environment. Inorganic boron (boric acid, borax) has been used as an antiseptic based on proposed antibacterial and antifungal properties. It is proposed that boric acid may have effects against candidal and non-candidal vulvovaginitis. A limited amount of poor-quality research reports that boric acid capsules used in the vagina may be effective for vaginitis. Further evidence is needed before a recommendation can be made.

• Avoid if allergic or sensitive to boron, boric acid, borax, citrate, aspartate or glycinate. Avoid with a history of diabetes, seizure disorder, kidney disease, liver disease, depression, anxiety, high blood pressure, skin rash, anemia, asthma, or chronic obstructive pulmonary disease (COPD). Avoid with hormone-sensitive conditions like breast cancer or prostate cancer. Avoid if pregnant or breastfeeding.

• Bromelain: Bromelain is an herb that contains a digestive enzyme, which comes from the stem and the fruit of the pineapple plant. Additional research is needed to determine if bromelain can help treat urinary tract infections (UTIs).

• Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceaefamily. Use cautiously with a history of bleeding disorders, stomach ulcers, heart disease, liver disease, or kidney disease. Use cautiously two weeks before and immediately after dental or surgical procedures. Use cautiously while driving or operating machinery. Avoid if pregnant or breastfeeding.

• Chamomile: Chamomile douche may improve symptoms of vaginitis with few side effects. Better research is needed before a conclusion can be drawn regarding the role of chamomile in the management of this condition. Because infection (including sexually transmitted diseases), poor hygiene, or nutritional deficiencies can cause vaginitis, medical attention should be sought by patients with this condition.

• Avoid if allergic to chamomile or any related plants, such as aster, chrysanthemum, mugwort, ragweed, or ragwort. Avoid with heart disease, breathing disorders, hormone-sensitive conditions, or central nervous system disorders. Avoid if taking cardiac depressive agents, central nervous system depressants, respiratory depressive agents, or anticoagulants. Use cautiously if taking benzodiazepines, anti-arrhythmic medications, calcium channel blockers, alcohol, sedative agents, anxiolytic medications, spasmolytic drugs, oral medications, or agents that are broken down by the liver. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.

• Clove: A small amount of human research reports that a combination cream with clove and other herbs may be helpful in the treatment of premature ejaculation. However, well-designed studies of the effectiveness of clove alone are needed before a conclusion can be drawn.

• Avoid if allergic to Balsam of Peru, clove, eugenol, or some licorice and tobacco (clove cigarette) products. Avoid with bleeding disorders and in pediatric patients. Avoid use of undiluted clove oil on the skin. Use cautiously with seizure disorders and kidney or liver dysfunction. Avoid if pregnant or breastfeeding.

• Coenzyme Q10: There is early evidence that supports the use of CoQ10 for increasing sperm count and motility in patients with idiopathic asthenozoospermia. Better studies are needed before a conclusion can be made.

• Allergy associated with Coenzyme Q10 supplements has not been documented in the available literature, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin), or blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.

• Coleus: Coleus (Coleus forskohlii) has been used in Asian traditional medicine for over 2,000 years. A component of coleus, called forskolin, was studied in humans in addition to prostaglandin E1, a drug commonly used in erectile dysfunction. Positive effects were seen with forskolin and progstaglandin when the prostaglandin alone did not work for erectile dysfunction.

• Caution is advised when taking coleus supplements, as numerous adverse effects including drug interactions with blood pressure lowering medications are possible. Coleus should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.

• Cordyceps: Cordyceps sinensis is a fungus found mainly in China, Nepal, and Tibet. There is currently not enough available scientific evidence regarding the use of Cordyceps for sexual dysfunction. High quality clinical research is needed in this area.

• Avoid if allergic or hypersensitive to cordyceps, mold, or fungi. Use cautiously with diabetes, prostate conditions, bleeding disorders, or if taking anticoagulant medications, immunosuppressive medications, or if on hormonal replacement therapy or oral contraceptives. Avoid with myelogenous-type cancers. Avoid if pregnant or breastfeeding.

• Cranberry: Well-designed human studies of cranberry for urinary tract infection treatment are currently lacking. Laboratory research suggests that cranberry may not be an effective treatment when used alone, although it may be helpful as an adjunct to other therapies such as antibiotics. In large quantities, cranberry juice may lower urine pH, making it more acidic.

• Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.

• Danshen: Danshen (Salvia miltiorrhiza) is widely used in traditional Chinese medicine (TCM), often in combination with other herbs. Early studies have found that danshen in combination with routine western medicine was not as effective as warming needle moxibustion for prostatitis. More studies are warranted in this area.

• Avoid if allergic or hypersensitive to danshen. Use cautiously if taking sedatives, hypolipidemics, cardiac glycosides, CYP-metabolized agents, nitrate ester, steroidal agents, or some anti-inflammatories (e.g. ibuprofen). Use cautiously with altered immune states, arrhythmia, compromised liver function, or a history of glaucoma, stroke, or ulcers. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin, or hypotensives, including ACE inhibitors (e.g. captopril), or Sophora subprostrata root or herba serissae. Avoid use after cerebral ischemia.

• DHEA (dehydroepiandosterone): DHEA is an endogenous hormone (made in the human body) secreted by the adrenal gland. DHEA serves as forerunner to male sex hormones (androgens) and female sex hormones (estrogens). DHEA levels in the body begin to decrease after age 30. Although some human studies report positive benefits on erectile dysfunction and sexual function while using DHEA in both men and women, better research is necessary before a clear conclusion can be drawn. Preliminary evidence suggests that DHEA may offer some benefit for increasing libido in premenopausal women. Well designed clinical trials are required before recommendations can be made.

• Caution is advised when taking DHEA supplements, as numerous adverse effects including drug interactions are possible.

• Echinacea: When echinacea is used at the same time as the prescription cream econazole nitrate (Spectazole®), vaginal yeast infections (Candida) may occur less frequently. However, further research is needed to confirm this.

• Caution is advised when taking echinacea supplements, as numerous adverse effects including drug interactions are possible. Echinacea should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.

• Ephedra: Early small studies suggest that ephedra may increase sexual arousal in women. Further well-designed research is needed to confirm these results.

• The U.S. Food and Drug Administration (FDA) has collected more than 800 reports of serious toxicity, including more than 22 deaths from the use of ephedra and/or ephedra containing products. Avoid use in individuals younger than 18 years old. Avoid use for prolonged periods (longer than seven days) due to risk of abuse or toxicity. Discontinue use at least one week prior to major surgery or diagnostic procedures. Use cautiously with cardiovascular disease, including structural heart disease, arrhythmia, coronary artery disease, high blood pressure, cerebrovascular disease, and a history of stroke or transient ischemic attack. Use cautiously with depression, anxiety disorders, anorexia/bulimia, a history of suicidal ideation, insomnia, tremors, urinary retention, enlarged prostate, diabetes, kidney disease, glaucoma, thyroid disease, and peptic ulcer disease. Use cautiously with monoamine oxidase inhibitor (MAOI) or stimulant use. Avoid if pregnant or breastfeeding.

• Ginkgo: Ginkgo (Ginkgo biloba) has been used medicinally for thousands of years, and is one of the top selling herbs in the United States. Ginkgo is commonly used for decreased blood flow. Ginkgo has been reported in animal and human models as having vascular (blood vessel) relaxant properties, which may act on corpus cavernosum tissue of the penis and improve penile blood flow in patients with ED. Ginkgo has also been reported to be effective in treating antidepressant-induced decreased libido and erectile dysfunction.

• Ginkgo may increase the chances of bleeding in sensitive individuals, such as those taking blood thinning drugs like warfarin (Coumadin®). Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, poison sumac, poison ivy, poison oak, or cashews, then allergy to ginkgo is possible. Ginkgo should be stopped two to three weeks before surgical procedures. Use cautiously with seizures or in children. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding.

• Ginseng: Asian ginseng, or Panax ginseng, has been used for more than 2,000 years in Chinese medicine for various health conditions. Preliminary evidence indicates that ginseng may be effective in improving the signs and symptoms of erectile dysfunction (ED). Early studies suggest that applying an herbal combination containing Panax ginseng on the penis may help treat premature ejaculation. However, because ginseng was tested with other herbs, its individual effects on sexual function and libido are unclear. Early studies also suggest that a product containing Panax ginseng, L-arginine, Ginkgo biloba, damiana, and multivitamin/minerals may improve sexual arousal in women with decreased sex drives and menopausal women. Studies with Panax ginseng alone are needed before strong conclusions can be made.

• Avoid ginseng with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

• Horny goat weed: Horny goat weed has been traditionally used to increase fertility. Early study suggests that horny goat weed may be of benefit for sexual dysfunction in renal failure patients. Additional study is needed in this area.

• Avoid if allergic/hypersensitive to horny goat weed (Epimedium grandiflorum), its constituents, or related plants in the Berberidaceae family. Use cautiously with tachyarrhythmia, decreased blood pressure, frequent nosebleeds, musculoskeletal disorders, bipolar disorder, immune function disorders, homocysteine disorders, hypothyroid conditions, and cardiovascular disease. Use cautiously if taking anticoagulant or antiplatelet (blood thinning) medications, antihypertensive (blood pressure) medications, antidepressants (MAOIs), interleukins, or cholesterol-lowering medications. Avoid with hormone-sensitive conditions or if taking estrogen or oral contraception. According to traditional Chinese medicine (TCM), avoid in patients with "fire from yin deficiency" (people with too much "yang" or heat, masculinity, and activity, based on Chinese philosophy). Avoid if pregnant or breastfeeding.

• Horseradish: Horseradish (Armoracia rusticana) is a hardy perennial plant of the Brassicaceae family, which includes mustard and cabbage. Several laboratory studies suggest that horseradish has antibiotic activity. Limited available human study used a combination product made from horseradish root and nasturtium herb to treat common bacterial infections, including urinary tract infections. Researchers found that the combination product was as effective as standard antibiotic therapy. However, further studies evaluating horseradish alone are needed.

• Intravenous horseradish should be used cautiously. Use cautiously with bleeding disorders, high blood pressure, thyroid disorders, kidney disorders, gastrointestinal conditions, or ulcers. Use cautiously if taking anticoagulants, anti-platelet drugs, blood pressure drugs, anti-inflammatories, thyroid hormones, or if receiving cancer treatment. Avoid medicinal amounts of horseradish if pregnant or breastfeeding.

• Hydrotherapy: There is currently insufficient evidence to determine the safety or effectiveness of hydrotherapy for treatment of pelvic inflammatory disease (PID). PID is a potentially serious medical condition that should be evaluated by a qualified, licensed healthcare provider.

• Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, or saunas, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.

• Hypnotherapy, hypnosis: There is inconclusive evidence from preliminary research on the use of hypnotherapy for erectile dysfunction. Additional study is needed before a firm conclusion can be drawn.

• Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.

• Lactobacillus acidophilus: Lactobacillus acidophilus taken by mouth or as a vaginal suppository has not been adequately assessed for the prevention or treatment of vaginal candidiasis. More research is needed in this area a before a conclusion can be drawn.

• It may be difficult to tolerate Lactobacillus acidophilus if allergic to dairy products containing Lactobacillus acidophilus. Avoid with history of an injury or illness of the intestinal wall, immune-disease or heart valve surgery. Avoid with prescription drugs, like corticosteroids, because of the risk of infection. Use cautiously with heart murmurs. Antibiotics or alcohol may destroy Lactobacillus acidophilus. Therefore, it is recommended that Lactobacillus acidophilus be taken three hours after taking antibiotics or drinking alcohol. Some individuals can use antacids (like famotidine (Pepcid®), esomeprazole (Nexium®)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

• L-carnitine: L-carnitine, carnitine, or acetyl-L-carnitine, is an amino acid (building block for proteins). High concentrations of carnitine are found in muscle tissue. Preliminary studies suggest that addition of acetyl-L-carnitine (in combination with propionyl-L-carnitine, another form of carnitine) helped sildenafil (Viagra®) work better for patients with erectile dysfunction (ED). However, more rigorous trials should be performed. Additionally, although early evidence is promising, more study is needed before a firm recommendation can be made for Peyronie's disease.

• Caution is advised when taking L-carnitine supplements, as adverse effects including drug interactions are possible. Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

• Lingonberry: Cranberry juice is commonly used to prevent and treat urinary tract infections. Clinical study using a combination of cranberry and lingonberry juice found that this was more effective than cranberry juice alone. Higher quality research comparing lingonberry juice or cranberry-lingonberry juice to cranberry juice alone is needed before a recommendation can be made for the use of lingonberry for urinary tract infection prevention.

• Avoid if allergic or hypersensitive to lingonberry (Vaccinium vitis-idaea), its constituents, or members of the Ericaceae family. Use cautiously in male patients in couples who are trying to become pregnant. Avoid if pregnant or breastfeeding.

• Maca: Maca (Lepidium meyenii) is a vegetable that has been cultivated as a root crop for at least 2,000 years. It can be found wild in Peru, Bolivia, Paraguay, and Argentina, but has primarily been cultivated in the highlands of the Peruvian Andes. Traditionally in Peru, maca has been used as a male aphrodisiac to increase sexual desire. Maca may improve sexual desire in healthy men independent of changes in mood, or serum testosterone (male hormone), and estradiol (female hormone) levels. Higher quality studies are needed in this area, in both men and women.

• Avoid if allergic/hypersensitive to maca (Lepidium meyenii), any of its constituents, or other members of the Brassicaceae family, formerly Cruciferae (broccoli, brussel sprouts, cabbage, or cauliflower). Use cautiously with anticoagulation therapy, hypertension, hormone responsive cancers such as breast cancer, or prostate cancer, and if using oral contraceptives or stimulants. Avoid if pregnant or breastfeeding.

• Moxibustion: There is preliminary evidence suggesting that moxibustion combined with acupuncture may help reduce urological symptoms in women with urethritis. However, more studies are needed before definitive recommendations for or against this approach can be made.

• Avoid with aneurysms, any kind of "heat syndrome," heart disease, convulsions, cramps, diabetic neuropathy, extreme fatigue, anemia, fever, or inflammatory conditions. Avoid over allergic skin conditions, ulcerated sores, skin adhesions, or inflamed areas or organs. Do not use over the face, genitals, head, or nipples. Use cautiously over large blood vessels and thin or weak skin. It is not advisable to bathe or shower for up to 24 hours after a moxibustion treatment. Avoid if pregnant or breastfeeding.

• Muira puama: Muira puama (Ptychopetalum olacoides) has been used historically for enhancement of libido and as a treatment for erectile dysfunction by Brazilian native people. Well-designed human trials of muira puama, as well as safety data, are necessary. Additional study is also needed regarding the use of muira puama for female sexual dysfunction.

• Use cautiously with steroidal drug therapy, hormone-sensitive conditions (breast cancer, endometriosis, ovarian cancer, prostate cancer), high blood pressure, or heart disease. Use cautiously if taking medications acting on the central nervous system (CNS). Avoid if allergic/hypersensitive to muira puama (Ptychopetalum olacoides), any of its components or any related members of the Olacaeae family. Avoid if pregnant or breastfeeding.

• Para-aminobenzoic acid: Potassium para-aminobenzoate may be useful in the treatment of Peyronie's disease. High quality clinical research is needed to make a conclusion.

• Avoid oral use in children and pregnant or nursing women. PABA must be used with caution in patients with renal disease. Abnormalities of liver function tests have been noted in patients taking PABA. Discontinue use if rash, nausea, or anorexia occurs. PABA should not be given concurrently with sulfonamides. Anyone with known hypersensitivity to PABA or its derivatives. Use cautiously in patients with bleeding disorders or taking anticoagulants. Use cautiously in patients with diabetes or hypoglycemia.

• Peppermint: Peppermint is a flowering plant that grows throughout Europe and North America. Peppermint is most often grown for its fragrant oil. Peppermint tea added to other therapies has been used in the treatment of urinary tract infection. It is not clear if this is an effective treatment, and it is not recommended to rely on peppermint tea alone to treat this condition.

• Avoid if allergic or hypersensitive to peppermint or menthol. Peppermint is generally considered safe in non-allergic adults when taken in small doses. Use cautiously with G6PD deficiency or gallbladder disease. Menthol, a constituent of peppermint oil, is generally considered safe in non-allergic adults. However, doses of menthol greater than 1 gram per kilogram of body weight may be deadly in humans. Avoid if pregnant or breastfeeding.

• Physical therapy: The goal of physical therapy, or physiotherapy, is to improve mobility, restore function, reduce pain, and prevent further injury. There is currently insufficient available evidence to support the use of physical therapy for chronic prostatitis. Additional studies are needed before a conclusion can be made.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist; however, complications are possible. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature, although causality is unclear. Erectile dysfunction has also been reported.

• Pomegranate: Pomegranate juice has been studied in the treatment of mild to moderate erectile dysfunction. Early study is unclear, and more studies are needed to make a firm conclusion.

• Avoid if allergic or hypersensitive to pomegranate. Avoid with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root/stem bark should only be used under supervision of a qualified healthcare professional. Use cautiously with liver damage or disease. Pomegranate supplementation can be unsafe during pregnancy when taken by mouth. The bark, root and fruit rind can cause menstruation or uterine contractions. Avoid if breastfeeding due to a lack of scientific data.

• Probiotics: Vaginal suppositories containing probiotics may be effective in the treatment or prevention of bacterial vaginosis. Eating yogurt enriched with Lactobacillus acidophilus may also be beneficial. However, not all applications of probiotics show benefit. Additional research is necessary before firm conclusions can be reached regarding what probiotics and what methods may lead to reliable results.

• Probiotics have not been adequately studied for the prevention or treatment of vaginal candidiasis. More research is needed in this area before a conclusion can be drawn.

• Additionally, studies of Lactobacillus preparations for urinary tract infections have had mixed results. Evidence suggests that a combination of Lactobacillus rhamnosus GR-1 and L. fermentum RC-14 may reduce potentially harmful vaginal bacteria and yeast in healthy women. Other studies have found no benefit for women or pre-term infants. More studies are needed to determine the effectiveness of probiotics in the prevention of urogenital and urinary tract infections.

• Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

• Propolis: Several studies suggest that using propolis as a cream or ointment may help heal acute cervicitis (inflamed cervix). These studies, however, have been small, low quality, and not fully convincing. Better studies are needed. Propolis may also be an effective treatment for vaginitis (vaginal inflammation). However, more research is needed before propolis can be recommended for this use.

• Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, or Balsam of Peru. Severe allergic reactions have been reported. Kidney failure that improved upon discontinuing propolis and deteriorated with re-exposure has been reported. Avoid if pregnant or breastfeeding because of the high alcohol content in some propolis products.

• Psychotherapy: Individual, couples, or group psychotherapy may be helpful for men with erectile dysfunction. However, prescription medication may be needed to alleviate symptoms.

• Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases symptoms may worsen if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression.

• Pycnogenol: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster ssp. atlantica), which is grown in coastal south-west France. Pycnogenol® has protective effect on blood vessels. Pycnogenol®, in combination with L-arginine, may cause an improvement in sexual function in men with erectile dysfunction (ED). It is not known what effect each of the individual compounds may have directly on this condition. Further research is needed.

• Caution is advised when taking Pycnogenol®, as it may increase the chances of bleeding in sensitive individuals, such as those taking blood thinning drugs like warfarin (Coumadin®). Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Avoid if pregnant or breastfeeding.

• Quercetin: Quercetin is one of the almost 4,000 bioflavonoids (antioxidants) that occur in foods of plant origin, such as red wine, onions, green tea, apples, berries, and brassica vegetables (cabbage, broccoli, cauliflower, turnips). There is some evidence that quercetin may be useful for the treatment of chronic prostatitis.

• Quercetin is generally considered safe when taken at doses normally found in foods. Avoid if allergic or hypersensitive to quercetin. Possible eye, skin, gastrointestinal and/or respiratory tract infection can occur.

• Saw palmetto: A prospective, randomized, open label, one-year study was designed to assess the safety and efficacy of saw palmetto and finasteride in the treatment of men diagnosed with category III prostatitis/chronic pelvic pain (CP/CPPS). CP/CPPS treated with saw palmetto had no appreciable long-term improvement. In contrast, patients treated with finasteride had significant and durable improvement in multiple parameters except for voiding.

• Avoid if allergic or hypersensitive to saw palmetto. Use cautiously with a history of health conditions involving the stomach, liver, heart, or lungs; hormone-sensitive conditions; or bleeding disorders. Use cautiously with drugs that thin the blood or hormonal drugs.

• Selenium: Commercially available 1% selenium sulfide shampoo has been reported as equivalent to sporicidal therapy in the adjunctive treatment of tinea capitis and tinea versicolor infections, although further high quality evidence is warranted regarding yeast infections.

• Avoid if allergic or sensitive to products containing selenium. Avoid with history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

• Tea tree oil: In laboratory studies, tea tree oil has been shown to kill yeast and certain bacteria. However, at this time there is not enough information available from human studies to make recommendations for or against the use of tea tree oil for vaginal yeast infections or vaginal bacterial infections. Although tea tree oil may reduce itching caused by yeast or bacteria, it may cause itching from dry skin or allergy.

• Avoid if allergic to tea tree oil or plants of the Myrtle (Myrtaceae) family, Balsam of Peru, or banzoin. Use cautiously with a history of eczema. Avoid taking tea tree oil by mouth because reports of toxicity have been reported. Avoid if pregnant or breastfeeding.

• Thymus extract: Preliminary evidence suggests that thymus extract reduces urinary tract re-infection frequency and infection persistence. Further evidence is required before recommendations can be made for the use of thymus extract for urinary tract infection.

• Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid with thymic tumors, myasthenia gravis (neuromuscular disorder), or untreated hypothyroidism. Avoid if taking immunosuppressants or hormonal therapy. Avoid if pregnant or breastfeeding. Thymic extract increases human sperm motility and progression.

• Uva ursi: Uva ursi has long been used as a folk remedy to treat urinary tract infections. The active ingredients in the herb are believed to be ursolic acid and isoquercitrin. Additional study is needed to make a conclusion in this area.

• Avoid if allergic or hypersensitive to uva ursi (Arctostaphylos uva-ursi) or to other members of the Ericaceae family. Avoid with a history of anxiety, high blood pressure, glaucoma, impaired cerebral circulation, benign prostatic tumors (with residual urine accumulation), pheochromocytoma, Grave's disease, or kidney disease. Use cautiously with liver disorders, gastrointestinal problems, or gallstones. Use cautiously if taking diuretics. Avoid if pregnant or breastfeeding.

• Vitamin C (ascorbic acid): Preliminary human study shows that vitamin C vaginal tablets given once a day may help patients suffering from non-specific vaginitis. Further research is needed to confirm these findings.

• Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding.

• Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. There is early evidence to support the use of yoga in the treatment of delayed ejaculation in males. Larger well designed and controlled trials are needed to further assess the effects of yoga for sexual health.

• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

• Yohimbe bark extract: Yohimbine hydrochloride is a prescription drug that has been shown in multiple human trials to effectively treat erectile dysfunction. Yohimbine hydrochloride has also been suggested to treat sexual side effects of selective serotonin reuptake inhibitor (SSRI) antidepressants. However, although yohimbine is present in yohimbe bark extract, levels are variable and often very low. Yohimbine has also been proposed to increase female libido. More study is needed in these areas before a conclusion can be made.

• Yohimbine is generally well tolerated in recommended doses. However, many side effects have been reported with yohimbine hydrochloride and may apply to yohimbe bark. Avoid if allergic to yohimbe, any of its components, or yohimbine-containing products. Use cautiously with peptic ulcer disease, kidney disease, high blood pressure, heart disease or if taking drugs that affect blood sugar levels. Avoid with benign prostate hypertrophy (enlarged prostate), anxiety, mania, depression, stress disorders, post-traumatic stress disorders, bipolar disorders, or schizophrenia. Avoid use in children or if pregnant or breastfeeding.

• Zinc: Early studies suggest that zinc supplements taken with antibiotics may be more effective than antibiotics alone for reducing pain, urinary symptoms, quality of life, and maximum urethra closure pressure for patients with chronic prostatitis (CP). Further research is needed to confirm these results.

• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness.

• Fair negative scientific evidence:

• Calcium: In limited available study, stopping treatment with topical hormone replacement therapy and switching to treatment with calcium plus vitamin D made vaginal atrophy worse. Increases in painful or difficult intercourse and urinary leaks were reported.

• Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, hyperparathyroidism (overgrowth of the parathyroid glands), bone tumors, digitalis toxicity, ventricular fibrillation (rapid, irregular twitching of heart muscle), kidney stones, kidney disease, or sarcoidosis (inflammatory disease). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria or irregular heartbeat. Calcium appears to be safe in pregnant or breastfeeding women. It is advised to consult with a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.

• Deer velvet: Deer velvet has a reputation as an aphrodisiac that may improve sexual energy by potentially strengthening and balancing the body and restoring overall energy. Traditionally, the tip and upper portions of the antler are considered to have the greatest medicinal value. The first published human trial to investigate these claims yielded no statistically significant effects on sexual functioning in mid-life men. However, the authors noted that these results reflected the average effect; they mentioned that some participants reported feeling benefits, although positive responses were not consistent. In addition, the quality of deer velvet products may vary considerably. Additional research is needed to determine the effect of deer velvet on sexual function, libido, and erectile dysfunction.

• Use cautiously in patients in whom an androgenic effect is contraindicated. However, deer velvet has not been shown to change male hormone levels or sexual behavior. Use cautiously in patients in whom supplemental estradiol and/or progesterone is contraindicated. Use cautiously in patients taking hepatotoxic agents. Use cautiously in patients taking sexual enhancing agents. Use cautiously in patients taking energy enhancing or muscle strengthening agents. Avoid in pregnant and lactating women.

• Vitamin E: Limited available study did not show significant improvement in pain, curvature, or plaque size in patients with Peyronie's disease (PD) treated with vitamin E, propionyl-L-carnitine, or vitamin E plus propionyl-L-carnitine compared with those treated with placebo.

• Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid above the recommended daily level in pregnant women and breastfeeding women.

Prevention

• Open, informative, and accurate communication regarding sexual issues and body image between parents and their children may prevent children from developing anxiety or guilt about sex and may help them develop a healthy understanding of sexual relationships.

• Reviewing all medications, both prescription and over-the-counter (OTC), for possible side effects that relate to sexual dysfunction is important. Healthcare professionals recommend talking to a pharmacist or doctor. Avoiding drug and alcohol abuse will also help prevent sexual dysfunction.

• Couples who are open and honest about their sexual preferences and feelings are more likely to avoid some sexual dysfunction. One partner should, ideally, be able to communicate desires and preferences to the other partner.

• Individuals who are victims of sexual trauma, such as sexual abuse or rape at any age, are urged to seek psychiatric advice. Individual counseling with an expert in trauma may prove beneficial in allowing sexual abuse victims to overcome sexual difficulties and enjoy voluntary sexual experiences with a chosen partner.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American Academy of Family Physicians. http://familydoctor.org.

2. Baldwin DS, Hutchinson J, Donaldson K, et al. Selective serotonin re-uptake inhibitor treatment-emergent sexual dysfunction: randomized double-blind placebo-controlled parallel-group fixed-dose study of a potential adjuvant compound, VML-670. J Psychopharmacol. 2007; [Epub ahead of print]. View Abstract

3. Berner MM, Hagen M, Kriston L. Management of sexual dysfunction due to antipsychotic drug therapy. Cochrane Database Syst Rev. 2007;(1):CD003546. View Abstract

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