Figure 9: Management algorithm for haemospermia [959, 962, 977, 978]

Presentaon of haemospermia

• History and detailed physical examinaon

• Blood pressure
• Urinalysis
• Urine culture
• Complete blood count
• Serum coagulaon assessment
• Serum chemistry panel
• Semen analysis
• STI screening
• Condom test

Low risk High risk

Men < 40 years old, isolated Men ≥ 40 years old or man of any
haemospermia, and no other age with persistent haemospermia,
symptoms or signs of disease or haemospermia associated with
symptoms or signs of disease

Cure the aeology that can be

Conservave treatment and idenfied with roune clinical
watchful waing evaluaon (anbiocs, an-
Reassure the paent inflammatory drugs, etc.)
TRUS, pelvic MRI
Recurrence Prostate cancer screening with PSA
and DRE (in men ≥ 40 years old)
Rule out tescular tumour by US
(in men < 40 years old)
Cystourethroscopy ± biopsy

STI = Sexually transmitted infections; PSA = Prostate specific antigen; DRE = Digital rectal examination;
US = Ultrasonography; TRUS = Transrectal ultrasonography; MRI = Magnetic resonance imaging.

6.9 Recommendations for the management of recurrent haemospermia

Recommendations Strength rating

Perform a full medical and sexual history with detailed physical examination. Strong
Men aged > 40 years with persistent haemospermia should be screened for prostate Weak
cancer.
Consider non-invasive imaging modalities (TRUS and MRI) in men aged > 40 years or men Weak
of any age with persistent or refractory haemospermia.
Consider invasive methods such as cystoscopy and vesiculoscopy when the non-invasive Weak
methods are inconclusive.

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7. LOW SEXUAL DESIRE AND MALE
HYPOACTIVE SEXUAL DESIRE DISORDER
7.1 Definition, classification and epidemiology
It has always been a challenge to define sexual desire properly because it has a complicated nature and it
can be conceptualised in many different ways. According to the International Classification of Diseases 10th
edition (ICD-10), lack or loss of sexual desire should be the principal problem and not other sexual problems
accompanying it such as ED [979]. In the DSM-V, male hypoactive sexual desire disorder (HSDD) is defined
as “the persistent or recurrent deficiency (or absence) of sexual or erotic thoughts or fantasies and desire for
sexual activity”. The judgment of deficiency is made by the clinician, taking into account factors that affect
sexual functioning, such as age and general and socio-cultural contexts of the individual’s life [216]. According
to the fourth International Consultation on Sexual Medicine (ICSM), the definition of male HSDD was proposed
as a “persistent or recurrent deficiency or absence of sexual or erotic thoughts or fantasies and desire for
sexual activity (clinical principle)” [980]. Although the exact prevalence of low sexual desire (LSD) is unknown,
a prevalence of 4.7% was reported in a survey of a population-based sample of middle-aged German men
(n = 12,646) [981].

7.2 Pathophysiology and risk factors

Several aetiological factors are considered to contribute to the pathophysiology of LSD. Levine proposed
three components of sexual desire as drive (biological), motivation (psychological) and wish (cultural) [982].
However, it is believed that both in the surveys and clinical practice those three components are usually found
interwoven [983].

7.2.1 Psychological aspects

The endorsement of negative thoughts during sexual intercourse (i.e., concerns about erection, lack of erotic
thoughts, and restrictive attitudes toward sexuality) predicts LSD in men [984, 985]. Furthermore, feeling
shame during sexual intercourse, because of negative sexual thoughts (e.g., concern about achieving erection),
characterises men with LSD as opposed to women with the same condition [986]. Psychopathological
symptoms steaming from a crisis context negatively impacted male sexual desire [453], as well. In addition,
dyadic male sexual desire was best accounted by sexual satisfaction [987]. It is worth noting that, despite
LSD being less common in men than in women [980], it is the most frequent complaint in couples’ therapy
[988]. Therefore, the role of relationship factors must be addressed. In addition, anxiety proneness has been
associated with LSD in men and is expected to shift men’s attention from erotic cues to worrying thoughts,
thereby decreasing sexual desire [989]. Finally, is worth noting that current approaches focus on sexual desire
discrepancies between partners; the focus on discrepancies rather than on the partner who presents low desire
not only reduces stigma, but also provides new opportunities for the management of desire in the relationship
context [990].

7.2.2 Biological aspects

Testosterone seems to be essential for a man’s sexual desire; however, sexual desire does not directly
relate to the circulating level of testosterone, especially in older men [991]. The biological and psychological
components that take place in the pathophysiology of LSD are shown in Table 24 [983, 992]. In addition to
these factors, there is some speculation about the role of thyroid and oxytocin hormones [720, 993].

Table 24: Common causes of low sexual desire in men [983, 992]

Androgen deficiency
Hyperprolactinaemia
Anger and anxiety
Depression
Relationship conflict
Stroke
Antidepressant therapy
Epilepsy
Post-traumatic stress syndrome
Renal failure
Coronary disease and heart failure
Ageing

SEXUAL AND REPRODUCTIVE HEALTH - LIMITED UPDATE 2022 89

HIV infection
Body-building and eating disorders
Erectile dysfunction
Prostatitis/chronic pelvic pain syndrome

7.2.3 Risk factors

In an international survey aimed at estimating the prevalence and correlates of sexual problems in 13,882
women and 13,618 men from 29 countries (Global Study of Sexual Attitudes and Behaviours), risk factors for
male LSD were age 60-69 and 70-80 years, poor overall health, vascular diseases, being a current smoker,
belief that ageing reduces sex, divorce in the past 3 years, financial problems in the last 3 years, major
depression, being worried about the future of a relationship and less than one sexual relation in a week [209]. In
a recent study that determined the factors associated with LSD in a large sample of middle-aged German men,
PE, ED, and lower urinary tract symptoms were associated with LSD [981]. In contrast, men having more than
two children, higher frequency of solo-masturbation, perceived importance of sexuality, and higher sexual self-
esteem were less likely to have LSD [981].

7.3 Diagnostic work-up

7.3.1 Assessment questionnaires
Sexual Desire Inventory (SDI) evaluates different components influencing the development and expression
of sexual desire [994]. This self-administered questionnaire consists of 14 questions that weigh the strength,
frequency, and significance of an individual’s desire for sexual activity with others and by themselves. The SDI
suggests that desire can be split into two categories: dyadic and solitary desire. While dyadic desire refers to
“interest in or a wish to engage in sexual activity with another person and desire for sharing and intimacy with
another”, solitary desire refers to “an interest in engaging in sexual behaviour by oneself, and may involve a
wish to refrain from intimacy and sharing with others” [994].

Physical examination and investigations

Similar to other forms of sexual dysfunctions, a thorough medical and sexual history must be obtained from
men who complain of LSD. The depressive symptoms of the patients must be assessed [995] and relationship
problems (e.g., conflict with the sexual partner) must be questioned. In the presence of accompanying
symptoms suggestive of endocrinological problems, circulating total testosterone [996], prolactin [997] and
thyroid hormones [720] levels can be evaluated.

7.4 Disease management

Treatment of LSD should be tailored according to the underlying aetiology.

7.4.1 Psychological intervention

Data on efficacy of psychological interventions for LSD are scarce. Accordingly, recommendations must be
interpreted with caution. Psychological interventions with a focus on cognitive and behavioural strategies
may be beneficial for LSD in men [460, 998] (Figure 10). Mindfulness treatments may be a strong candidate,
as well [998]. Since both members of a couple may experience age-related changes concurrently and
interdependently, it could be helpful to address the sexual health needs of the ageing couple (including LSD)
as a whole rather than treating the individual patient [999]. Indeed, psychologists are putting more emphasis on
the concept of sexual desire discrepancy. Sexual desire discrepancy is often found in couples or partners, and
mirror a natural part of life and partners’ dynamics. Clinical approaches based on this lens are less stigmatising
as they consider the normal variations in sexual desire that occur throughout the lifespan. This intervention
option targets couples distressed by sexual desire discrepancies rather than a single individual targeted as the
one presenting low sexual desire [990].

90 SEXUAL AND REPRODUCTIVE HEALTH - LIMITED UPDATE 2022

Figure 10: Flow-diagram of psychological evaluation of patients with low sexual desire

Evaluate psychosexual history and

development

Evaluate dysfunctional thinking style and Consider role of partner

expectations regarding sexuality and man’s
Consider whether lack of
sexual performance
desire is dyadic (desire
to engage in sexual
behaviour with the partner)
or solitary (desire to
Collect evidence for specific anxiety triggers engage in sexual behaviour
with one’s self)

Decide on referral to (sexual)psychotherapy

or psychological intervention

7.4.2 Pharmacotherapy
Low sexual desire secondary to low testosterone levels can be treated with different formulations of
testosterone. The favourable effect of testosterone therapy on sexual motivation and the presence of sexual
thoughts was shown in a meta-analysis [996]. The aim of treatment should be to reach the physiological range
of testosterone (see Section 3.5).

Hyperprolactinaemia can also cause LSD and one of the most relevant aetiological factors is prolactin-
secreting pituitary adenomas. These adenomas can be easily diagnosed with MRI of the pituitary gland and
can be treated with dopamine agonist agents [1000]. The other accompanying endocrine disorders, such as
hypothyroidism, hyperthyroidism and diabetes, should be treated accordingly.

Pharmacotherapy can also be used to treat major depression; however, it should be remembered that
antidepressants may negatively affect sexual functioning; therefore, antidepressant compounds with less effect
on sexual function should be chosen. Psychotherapy can increase the efficacy of pharmacotherapy, especially
for patients whose LSD is due to depression [1001].

7.5 Recommendations for the treatment of low sexual desire

Recommendations Strength rating

Perform the diagnosis and classification of low sexual desire (LSD) based on medical and Weak
sexual history, which could include validated questionnaires.
Include physical examination in the initial assessment of LSD to identify anatomical Weak
abnormalities that may be associated with LSD or other sexual dysfunctions, particularly
erectile dysfunction.
Perform laboratory tests to rule out endocrine disorders. Strong
Modulate chronic therapies which can negatively impact toward sexual desire. Weak
Provide testosterone therapy if LSD is associated with signs and symptoms of testosterone Strong
deficiency.

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