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TC(945).(20).Sexology Case No 98. Depression/Anxiety-related Sexual Dysfunction

Depression/Anxiety-related Sexual Dysfunction

শিক্ষামূলক/ক্লিনিক্যাল রেফারেন্স হিসেবে ব্যবহার করুন—self-medication নয়। Depression বা anxiety-র রোগী যদি suicidal thought, severe panic, chest pain, recent MI/stroke, nitrate use, priapism >4 hours, genital bleeding/discharge/pain, বা severe relationship violence জানান—urgent referral দরকার।

1. Definition / সংজ্ঞা

Depression/Anxiety-related Sexual Dysfunction হলো এমন যৌন সমস্যা যেখানে depression, anxiety, performance anxiety, relationship stress, বা psychiatric medicine—বিশেষ করে SSRI/SNRI—এর কারণে sexual desire, arousal/erection, lubrication, orgasm, ejaculation বা sexual satisfaction কমে যায় এবং এতে রোগীর clinically significant distress বা relationship impairment হয়।

এটি ৩ভাবে দেখা যায়:

  1. Disease-related: depression/anxiety নিজেই libido, erection, arousal, orgasm কমিয়ে দেয়।
  2. Medication-induced: antidepressant, anxiolytic, antipsychotic, beta-blocker ইত্যাদির side effect হিসেবে হয়। SSRI/SNRI-related sexual dysfunction-এ desire কমা, arousal/erection problem, delayed orgasm/ejaculation, anorgasmia বেশি দেখা যায়।
  3. Mixed: disease + drug + organic disease যেমন diabetes, hypothyroidism, hypogonadism, cardiovascular disease একসাথে থাকে।

Depression/anxiety ও sexual dysfunction-এর মধ্যে strong clinical association আছে; internalizing disorders হিসেবে depression/anxiety যৌন প্রতিক্রিয়ার desire–arousal–orgasm phase-কে প্রভাবিত করতে পারে।

2. Causes / কারণসমূহ

A. Depression-related causes

  • Anhedonia: আনন্দ অনুভবের ক্ষমতা কমে যায়, ফলে sexual interest কমে।
  • Low dopamine/serotonin imbalance: motivation, pleasure, libido কমে।
  • Fatigue ও sleep disturbance: energy কম থাকায় sexual activity এড়ায়।
  • Low self-esteem/guilt: নিজেকে unattractive মনে হওয়া, performance fear।
  • Psychomotor retardation: initiative কমে যায়।
  • Suicidal thought/hopelessness: intimacy থেকে withdrawal হয়।

B. Anxiety-related causes

  • Performance anxiety: “পারবো তো?”, “fail করলে কী হবে?”—এই fear erection/arousal নষ্ট করে।
  • Sympathetic overactivity: anxiety sympathetic tone বাড়ায়; erection/lubrication parasympathetic-dependent, তাই সমস্যা হয়।
  • Panic symptoms: palpitation, breathlessness, fear of dying—sexual activity avoid করে।
  • Generalized worry: mind distracted থাকে, sexual focus কমে।
  • Trauma/social anxiety/OCD: sexual guilt, contamination fear, intrusive thoughts হতে পারে।

C. Drug-induced causes

  • SSRI: sertraline, escitalopram, fluoxetine, paroxetine—libido কমা, delayed orgasm, erectile problem।
  • SNRI: venlafaxine, duloxetine—SSRI-এর মতো sexual side effect; venlafaxine BP বাড়াতে পারে।
  • Benzodiazepine: clonazepam/diazepam—sedation, libido কমা, dependence।
  • Antipsychotic: risperidone/amisulpride—hyperprolactinaemia → libido/erection/amenorrhea problem।
  • Beta-blocker: propranolol—performance anxiety কমায়, কিন্তু কিছু রোগীতে ED/libido problem বাড়াতে পারে।
  • Opioid, finasteride, alcohol, cannabis: libido ও erection কমাতে পারে।

D. Organic/medical causes যা বাদ দিতে হবে

  • Diabetes mellitus
  • Hypertension/CVD, dyslipidaemia
  • Hypothyroidism বা hyperthyroidism
  • Hyperprolactinaemia
  • Male hypogonadism / low testosterone
  • PCOS, premature ovarian insufficiency, menopause
  • Chronic kidney/liver disease
  • Pelvic infection, prostatitis, vaginismus, dyspareunia
  • Porn-induced performance anxiety বা compulsive sexual behavior
  • Smoking, alcohol, obesity, sedentary lifestyle

3. Symptoms / লক্ষণসমূহ

Male symptoms

  • যৌন ইচ্ছা বা libido কমে যাওয়া
  • Erection শুরু করতে বা ধরে রাখতে সমস্যা
  • Morning erection কমে যাওয়া—organic ED suspicion
  • Premature ejaculation বা delayed ejaculation
  • Orgasm হতে অনেক দেরি হওয়া বা orgasm না হওয়া
  • Sexual pleasure কমে যাওয়া
  • Performance anxiety: intercourse-এর আগে ভয়/হৃদকম্পন/ঘাম
  • Partner avoidance, shame, irritability

Female symptoms

  • যৌন ইচ্ছা কমে যাওয়া
  • Arousal/lubrication কমে যাওয়া
  • Orgasmic difficulty বা anorgasmia
  • Dyspareunia বা painful intercourse
  • Vaginismus/pelvic floor tightening
  • Intimacy avoidance
  • Body image concern, guilt, sadness
  • Relationship conflict

Common psychological symptoms

  • Depression: low mood, anhedonia, fatigue, poor sleep/appetite, guilt, suicidal thought
  • Anxiety: excessive worry, panic, restlessness, muscle tension, sleep problem
  • Sexual dysfunction নিয়ে shame, guilt, low confidence
  • Antidepressant non-adherence—রোগী ওষুধ বন্ধ করে relapse করতে পারে
  • Marital/relationship dissatisfaction

4. Clinically Diagnosis / ক্লিনিক্যাল ডায়াগনোসিস

Diagnosis clinical। Lab test sexual dysfunction “confirm” করে না; বরং organic cause exclude/identify করে।

A. History নিতে হবে

  1. Problem type: libido, erection, ejaculation, orgasm, pain—কোন phase?
  2. Onset: depression/anxiety-এর আগে, পরে, নাকি medicine শুরু করার পর?
  3. Course: sudden/situational হলে psychogenic বেশি; gradual/global হলে organic বেশি।
  4. Morning/nocturnal erection: preserved থাকলে psychogenic ED support করে।
  5. Medication history: SSRI/SNRI, antipsychotic, beta-blocker, finasteride, opioid, alcohol।
  6. Relationship/sexual context: partner conflict, performance fear, trauma, pornography pattern।
  7. Medical history: DM, HTN, CVD, thyroid, endocrine, urogenital disease।
  8. Risk assessment: suicidal thought, bipolar history, substance use, domestic violence।

B. Validated clinical scales

  • PHQ-9: depression severity
  • GAD-7: anxiety severity
  • ASEX: Arizona Sexual Experience Scale
  • IIEF-5/SHIM: male erectile dysfunction
  • PEDT: premature ejaculation
  • FSFI: female sexual function
  • MDQ: bipolar screening, antidepressant শুরু করার আগে useful

C. Physical examination

  • BP, pulse, BMI, waist circumference
  • Thyroid signs
  • Secondary sexual characteristics
  • Gynecomastia/galactorrhea—prolactin issue
  • Genital exam: penile plaque, testicular size, phimosis, infection
  • Female pelvic exam if dyspareunia, discharge, bleeding, vaginismus suspicion
  • Neurological and peripheral vascular exam
  • Cardiovascular risk assessment before PDE5 inhibitor

5. Investigations / নির্দিষ্ট ইনভেস্টিগেশন

Basic tests

  • CBC
  • Fasting blood glucose / HbA1c
  • Lipid profile
  • TSH ± free T4
  • Serum creatinine/eGFR
  • LFT
  • Urine R/E if urinary symptoms
  • Pregnancy test if relevant

Hormonal tests

  • Morning total testosterone, 7–10 AM—male low libido/ED হলে
  • Repeat testosterone if low
  • LH, FSH, SHBG/free testosterone if testosterone low
  • Serum prolactin—low libido, ED, galactorrhea, amenorrhea, antipsychotic use
  • Estradiol/FSH/LH in female menopause/POI suspicion

Specific tests based on symptoms

  • STI screening: VDRL/RPR, HIV, HBsAg, HCV, NAAT for chlamydia/gonorrhea if risk
  • Vaginal swab/culture if discharge or dyspareunia
  • ECG/CVD workup if ED + cardiac risk
  • Penile Doppler / nocturnal penile tumescence test if refractory or medico-legal/unclear ED
  • Pelvic ultrasound if gynecologic pathology suspected

6. Complications / জটিলতা

  • Depression/anxiety relapse or worsening
  • Suicidal ideation বেড়ে যেতে পারে
  • Relationship breakdown, marital conflict
  • Infertility concern বা planned pregnancy difficulty
  • Antidepressant non-adherence → relapse
  • Substance misuse: alcohol, sedative, illegal sexual stimulant
  • Low self-esteem, shame, social withdrawal
  • Undiagnosed diabetes, thyroid disease, CVD, hypogonadism missed হতে পারে
  • Unsafe PDE5 use করলে hypotension, syncope, cardiac risk
  • Rarely SSRI বন্ধ করার পরও persistent sexual symptoms থাকতে পারে; NICE antidepressant continuation/discontinuation আলোচনায় long-term sexual function effect বিবেচনা করতে বলে।

7. Treatment Management / চিকিৎসা ব্যবস্থাপনা

A. Non-pharmacological management

  • Psychoeducation: রোগীকে বুঝাতে হবে—এটি common, treatable, shameful নয়।
  • Depression/anxiety treat করা: CBT, mindfulness, relaxation, exposure therapy। WHO depression management-এ psychological treatment-কে first-line হিসেবে গুরুত্ব দেয়; moderate/severe depression-এ antidepressant যুক্ত হতে পারে।
  • Couple/sex therapy: communication, sensate focus, performance pressure কমানো।
  • Sleep, exercise, weight loss, smoking cessation, alcohol reduction।
  • Pornography overuse থাকলে stimulus control।
  • Medicine review: SSRI/SNRI-induced হলে dose reduction/switch/augmentation consider।
  • NICE anxiety/panic guideline CBT ও antidepressant-based structured care recommend করে।
  • ED হলে lifestyle/risk-factor modification এবং PDE5 inhibitor first-line হিসেবে EAU guideline recommend করে।

8. Pharmacological Drugs — Bangladesh Context

নোট: নিচের dose adult usual dose। Pregnancy, lactation, elderly, hepatic/renal disease, bipolar disorder, seizure disorder, cardiac disease, nitrate use—সব ক্ষেত্রে dose/choice পরিবর্তন করতে হয়। Bangladesh brand availability সময়ের সাথে বদলাতে পারে; prescription-এর আগে DGDA/BNF/updated medicine index যাচাই করা উচিত। Bangladesh tertiary hospital prescription pattern study-তে antidepressant prescription-এর মধ্যে SSRI সবচেয়ে বেশি ব্যবহৃত হয়েছে; sertraline ও escitalopram common ছিল।

1) Generic name: Sertraline

  • Therapeutic category: Antidepressant / anxiolytic
  • Pharmacological class: SSRI
  • কেন used হয়: Depression, GAD/panic symptoms, social anxiety, OCD, PTSD; sexual dysfunction যদি depression/anxiety-driven হয়, core illness treat করতে ব্যবহৃত।
  • Dose:
    • Depression: 50 mg once daily; increase by 25–50 mg weekly
    • Panic/social anxiety: start 25 mg daily, then 50 mg
    • Usual range: 50–200 mg/day
  • Duration: response 4–8 weeks; remission হলে সাধারণত 6–12 months continue; recurrent case-এ longer।
  • Important side effects: nausea, diarrhea, insomnia, sweating, headache, sexual dysfunction, delayed ejaculation/anorgasmia, hyponatraemia, bleeding risk।
  • Interactions: MAOI/linezolid/tramadol/triptan/St John’s wort → serotonin syndrome risk; NSAID/warfarin → bleeding risk; alcohol avoid।
  • Bangladesh available brand names: Andep 25/50/100 mg, Chear 25/50/100 mg, Mudiral 25/50 mg, Repose 25/50/100 mg, Sartra 50 mg, SB-Serta 50 mg, Selotin 50 mg, Sera 50 mg, Serofit 25/50 mg, Serolux 25/50/100 mg, Seronex 25/50/100 mg, Sertal 25/50/100 mg, Sertlin 25/50/100 mg, Setra 25/50/100 mg, Stalin 50 mg, Tralin 25/50/100 mg, Zosert 25/50/100 mg।

2) Generic name: Escitalopram

  • Therapeutic category: Antidepressant / anxiolytic
  • Pharmacological class: SSRI
  • কেন used হয়: Depression + anxiety symptoms; tolerability ভালো হওয়ায় Bangladesh-এ commonly prescribed।
  • Dose: 5–10 mg once daily; usual 10–20 mg/day।
  • Duration: 6–12 months after remission; relapse/recurrent case-এ longer।
  • Side effects: nausea, insomnia/somnolence, headache, sweating, QT prolongation risk at higher dose, sexual dysfunction।
  • Interactions: MAOI, linezolid, other serotonergic drugs; QT-prolonging drugs; NSAID/anticoagulant bleeding risk।
  • Bangladesh available brand names: Acipam 5/10 mg, Andepram 5/10 mg, Citalam 5/10 mg, Citalex 5/10 mg, Citalon 5/10 mg, Desital 5/10 mg, Elodep 5/10 mg, Elopram 5/10 mg, Epram 5/10 mg, Escilex 5/10/20 mg and oral solution 5 mg/5 ml, Esipram 5/10 mg, Esita 5/10 mg, Esitanaaf 5/10 mg, Estarex 5/10 mg, Expres 5/10 mg, Lexapro 5/10 mg, Losita 5/10 mg, Meliva 10 mg, Nexcital 5/10 mg, Nexito 5/10/20 mg, Oxapro 5/10 mg, Recita 5/10 mg, Redep 5 mg, S-Citapram 5/10 mg, Sencital 10 mg, Seropam 5/10 mg, Serotal 5/10 mg, Talopram 5/10 mg, Ventus 5/10 mg।

3) Generic name: Fluoxetine

  • Therapeutic category: Antidepressant
  • Pharmacological class: SSRI
  • কেন used হয়: Depression, OCD, panic; long half-life থাকায় withdrawal কম, কিন্তু sexual side effect হতে পারে।
  • Dose: 20 mg once daily morning; usual 20–60 mg/day।
  • Duration: 6–12 months after remission।
  • Side effects: insomnia, anxiety activation, GI upset, sweating, sexual dysfunction।
  • Interactions: MAOI contraindicated; strong CYP2D6 inhibition; tramadol/triptan/linezolid risk; NSAID/warfarin bleeding risk।
  • Bangladesh available brand names: Modipran 20 mg, Nodep 20 mg, Nodepress 20 mg, Oxetin 20 mg; some oral solution forms also available in Bangladesh market listings।

4) Generic name: Paroxetine

  • Therapeutic category: Antidepressant / anxiolytic
  • Pharmacological class: SSRI
  • কেন used হয়: Panic disorder, GAD, social anxiety, PTSD, depression; কিন্তু sexual dysfunction ও withdrawal risk তুলনামূলক বেশি—তাই sexual complaint থাকলে cautious।
  • Dose: 10–20 mg daily start; usual 20–50 mg/day depending indication।
  • Duration: 6–12 months after remission; taper slowly।
  • Side effects: sexual dysfunction, delayed ejaculation, weight gain, sedation, anticholinergic effects, withdrawal symptoms।
  • Interactions: MAOI contraindicated; CYP2D6 inhibition; warfarin/NSAID bleeding risk; alcohol avoid।
  • Bangladesh available brand names: Melev 20 mg, Oxat 20 mg, Panirid 20 mg।

5) Generic name: Duloxetine

  • Therapeutic category: Antidepressant / anxiolytic
  • Pharmacological class: SNRI
  • কেন used হয়: Depression + GAD, neuropathic pain/fibromyalgia থাকলে helpful; তবে sexual side effect হতে পারে।
  • Dose: 30 mg daily start; usual 60 mg/day; max 120 mg/day in selected cases।
  • Duration: 6–12 months after remission।
  • Side effects: nausea, dry mouth, sweating, insomnia, BP rise, sexual dysfunction, withdrawal if abrupt stop।
  • Interactions: MAOI, serotonergic drugs; CYP1A2/CYP2D6 interactions; liver disease/alcohol misuse-এ caution।
  • Bangladesh available brand names: Diliner DR 20/30/60 mg, Dulox 20/30 mg, Duloxen 20/30 mg, Duzela 20 mg, Stresin 20 mg।

6) Generic name: Venlafaxine

  • Therapeutic category: Antidepressant / anxiolytic
  • Pharmacological class: SNRI
  • কেন used হয়: Depression, GAD, panic; SSRI inadequate হলে।
  • Dose: 37.5–75 mg/day start; usual 75–225 mg/day।
  • Duration: 6–12 months after remission; taper slowly।
  • Side effects: nausea, sweating, insomnia, BP rise, sexual dysfunction, discontinuation syndrome।
  • Interactions: MAOI/serotonergic drugs; BP monitoring needed; alcohol avoid।
  • Bangladesh available brand names: Veniz XR 75 mg, Venlax 37.5/75 mg।

7) Generic name: Mirtazapine

  • Therapeutic category: Antidepressant
  • Pharmacological class: NaSSA / noradrenergic and specific serotonergic antidepressant
  • কেন used হয়: Depression with insomnia, poor appetite, weight loss; SSRI-induced sexual dysfunction থাকলে switch option হিসেবে ব্যবহার করা হয় কারণ sexual side effect তুলনামূলক কম।
  • Dose: 15 mg at night start; usual 15–45 mg nocte।
  • Duration: 6–12 months after remission।
  • Side effects: sedation, increased appetite, weight gain, dry mouth, dizziness।
  • Interactions: alcohol/benzodiazepine sedation বাড়ায়; MAOI contraindicated; other serotonergic drugs with caution।
  • Bangladesh available brand names: Amiron 7.5/15/30 mg, Azapin 15 mg, Miramind 7.5/15 mg, Mirapin 15 mg, Mirapro 7.5/15 mg, Mirez 7.5/15/30 mg, Mirtaz 7.5/15/30 mg, Mirzalux 15/30 mg, Mitadip 7.5/15/30 mg, Mitaprex 7.5/15/30 mg, Mitazapine 7.5/15/30 mg, Mitrazin 7.5/15/30 mg, Rapine 7.5/15 mg, Rejoy 7.5/15/30 mg, Resant 15 mg, Trazapin 7.5/15/30 mg, Zispin 7.5/15/30 mg।

8) Generic name: Bupropion

  • Therapeutic category: Antidepressant / smoking cessation aid
  • Pharmacological class: NDRI—norepinephrine-dopamine reuptake inhibitor
  • কেন used হয়: Depression with low energy, hypersomnia, sexual dysfunction; SSRI-induced libido/orgasm problem-এ switch বা augmentation হিসেবে ব্যবহৃত হয়।
  • Dose: SR 150 mg morning; after 3–7 days 150 mg twice daily if needed; max usually 300 mg/day SR।
  • Duration: 6–12 months after remission; augmentation হলে 4–8 weeks response review।
  • Side effects: insomnia, anxiety, dry mouth, tremor, BP rise, seizure risk।
  • Contraindications: seizure disorder, eating disorder, abrupt alcohol/benzodiazepine withdrawal।
  • Interactions: MAOI contraindicated; CYP2D6 interactions; other seizure-threshold-lowering drugs caution।
  • Bangladesh available brand names: Depnox SR 150 mg, Zybex SR 150 mg; Bupro-D 45/105 mg is dextromethorphan+bupropion combination, not pure bupropion।

9) Generic name: Vortioxetine

  • Therapeutic category: Antidepressant
  • Pharmacological class: Serotonin modulator and stimulator
  • কেন used হয়: MDD; cognitive symptoms ও sexual side effect concern থাকলে SSRI alternative হিসেবে consider করা হয়।
  • Dose: 5–10 mg once daily start; usual 10–20 mg/day।
  • Duration: 6–12 months after remission।
  • Side effects: nausea, vomiting, headache, dizziness; sexual dysfunction তুলনামূলক কম হতে পারে কিন্তু possible।
  • Interactions: MAOI contraindicated; serotonergic drugs—SSRI/SNRI/tramadol/triptan/buspirone—serotonin syndrome risk; strong CYP2D6 inhibitors dose adjustment দরকার।
  • Bangladesh available brand names: Brintexa 5/10 mg, Nytenso 5/10/20 mg, Vintelix 5/10 mg, Vortiox 5/10/20 mg, Vortixen 5/10 mg, Vorton 5/10/15 mg।

10) Generic name: Buspirone

  • Therapeutic category: Anxiolytic
  • Pharmacological class: 5-HT1A partial agonist
  • কেন used হয়: GAD; SSRI-induced sexual dysfunction-এ orgasm/libido issue কমাতে off-label augmentation হিসেবে কিছু ক্ষেত্রে ব্যবহার করা হয়।
  • Dose: 5 mg TID or 7.5 mg BID start; increase every few days; usual 20–30 mg/day; max 60 mg/day।
  • Duration: onset 2–4 weeks; anxiety stable হলে months-based continuation।
  • Side effects: dizziness, nausea, headache, nervousness।
  • Interactions: MAOI contraindicated; CYP3A4 inhibitors, grapefruit; serotonergic drugs with caution।
  • Bangladesh available brand name: Busper 5 mg tablet reported available in Bangladesh medical country-of-origin information; current local availability should be verified before prescribing।

11) Generic name: Sildenafil

  • Therapeutic category: Drug for erectile dysfunction
  • Pharmacological class: PDE5 inhibitor
  • কেন used হয়: Depression/anxiety-related ED বা SSRI-induced ED-তে erection improve করতে। Desire বাড়ায় না; sexual stimulation দরকার।
  • Dose: 25–50 mg orally 30–60 min before intercourse; max 100 mg; max once/day।
  • Duration: PRN; 4–8 weeks পরে response/side effect review।
  • Side effects: headache, flushing, dyspepsia, nasal congestion, dizziness, visual disturbance।
  • Dangerous interactions: nitrate/GTN/isosorbide absolutely contraindicated; riociguat contraindicated; alpha-blocker/antihypertensive/alcohol → hypotension; recent MI/stroke/unstable angina হলে avoid until cardiology clearance।
  • Bangladesh available brand names: Acmegra 25/50/100 mg, Activa 50/100 mg, Adegra 25/50/100 mg, Aggra 50/100 mg, Charm 50/100 mg, Danafil 50/100 mg, Edegra 50/100 mg, Enegra 50 mg, Enigma 50/100 mg, Enjofil 50/100 mg, Eurofil 50/100 mg, Exifil 25/50/100 mg, Fulfeel 50/100 mg, Immense 50 mg, kX 50/100 mg, Medigra 50 mg, Niagra 100 mg, Novagra 25/50/100 mg, Panagra 50/100 mg, Performax 50/100 mg, SB-Sild 50 mg, Senegra 50/100 mg, Silagra 50/100 mg, Silfil 50/100 mg, Sngra 50/100 mg, Starfil 100 mg, Trigger 50 mg, Veagra 25/50/100 mg, Vegara 50/100 mg, Verigra 50 mg, Viagrex 25/50/100 mg, Viamax 25/50/100 mg, Viax 50/100 mg, Vigorex 25/50/100 mg, X-Cite 100 mg, X-Fil 50/100 mg, Yogra 100 mg।

12) Generic name: Tadalafil

  • Therapeutic category: Drug for erectile dysfunction / BPH
  • Pharmacological class: PDE5 inhibitor
  • কেন used হয়: ED; longer action up to 36 hours, performance anxiety-related timing pressure কমাতে useful।
  • Dose:
    • PRN: 10 mg before intercourse; adjust 5–20 mg
    • Daily: 2.5–5 mg once daily
  • Duration: PRN or daily course; 4–8 weeks review।
  • Side effects: headache, flushing, dyspepsia, back pain, myalgia, nasal congestion।
  • Interactions: nitrate/riociguat contraindicated; alpha-blocker/antihypertensive/alcohol caution; strong CYP3A4 inhibitors dose adjustment। MedEx tadalafil page also lists nitrate, alpha-blocker, antihypertensive, alcohol and CYP3A4 interaction cautions।
  • Bangladesh available brand names: Adafil 10/20 mg, Celeste 10/20 mg, Ciafil 10/20 mg, Cialix 10 mg, Ciaton 5/10/20 mg, Durevolis 5/10/20 mg, Edysta 2.5/5/10/20 mg, Erectomed 10/20 mg, Erectus 10/20 mg, Extrafeel 20 mg, Feel 5/10/20 mg, Intimate 2.5/5/10/20 mg, kTx 5/10/20 mg, Manlee 10/20 mg, Megafil 10/20 mg, Nirvana 5/10/20 mg, Penfil 10/20 mg, Prolonga 10/20 mg, SB-Tad 5/10 mg, Tada 5/10/20 mg, Tadafil 5/10 mg, Tadalis 10 mg, Tealis 5/10/20 mg, Tiagra 5/10 mg, TopUp 5/10/20 mg, Triptimate 20 mg, Vgofil 10 mg, Viev 10/20 mg।

13) Generic name: Dapoxetine

  • Therapeutic category: Premature ejaculation drug
  • Pharmacological class: Short-acting SSRI
  • কেন used হয়: Premature ejaculation; anxiety-related PE থাকলে PRN ব্যবহার করা হয়।
  • Dose: 30 mg 1–3 hours before intercourse; if inadequate and tolerated, 60 mg; max once/day।
  • Duration: PRN; 4 weeks or 6 doses পরে review।
  • Side effects: nausea, dizziness, headache, diarrhea, insomnia, syncope।
  • Important interactions/contraindications: SSRI/SNRI/TCA/MAOI/tramadol/linezolid/St John’s wort-এর সাথে ব্যবহার করা উচিত নয়—serotonin syndrome/syncope risk; significant heart disease, severe hepatic impairment এ avoid।
  • Bangladesh available brand names: Daporex 30/60 mg, Dapotin 30 mg, Dapoxen 30/60 mg, Daxetin 30/60 mg, Dejac 30 mg, Dulong 30 mg, Dumax 30/60 mg, Ejalong 30/60 mg, Extreme 30 mg, Impreja 30 mg, Maturex 30/60 mg, Plezer 30 mg, Prolong 30/60 mg, Susten 30 mg, X-Ride 30/60 mg।

14) Generic name: Lidocaine + Prilocaine topical cream / Lidocaine spray

  • Therapeutic category: Local anaesthetic for premature ejaculation, off-label sexual medicine use
  • Pharmacological class: Amide local anaesthetic
  • কেন used হয়: Glans sensitivity কমিয়ে PE delay করতে।
  • Dose/use: Thin layer 5–20 min before intercourse; intercourse-এর আগে wipe/wash করে নিতে হবে, না হলে partner numbness হতে পারে।
  • Duration: PRN।
  • Side effects: local irritation, numbness, burning, partner numbness; prilocaine-related methemoglobinaemia rare।
  • Interactions/caution: other local anaesthetic, methemoglobinaemia-prone drugs; condom integrity/product instruction check।
  • Bangladesh available brand names: Emprila 2.5% + 2.5% cream, Skisia 2.5% + 2.5% cream; lidocaine spray: Jasocaine 10 mg/spray, Lido 10 mg/spray, Xyloken 10 mg/spray।

15) Generic name: Testosterone

  • Therapeutic category: Androgen replacement
  • Pharmacological class: Androgen/anabolic steroid hormone
  • কেন used হয়: শুধুমাত্র confirmed male hypogonadism—low morning testosterone + symptoms—থাকলে libido/ED improve করার জন্য; depression/anxiety sexual dysfunction-এ routine নয়।
  • Dose examples:
    • Testosterone undecanoate capsule: commonly 40 mg capsule-based dosing, specialist-guided
    • Testosterone ester injection 250 mg/ml: IM regimen formulation-specific, specialist-guided
  • Monitoring: testosterone level, hematocrit, PSA/prostate assessment, LFT/lipid, sleep apnoea, fertility desire।
  • Side effects: acne, oily skin, edema, mood change, erythrocytosis, prostate symptom worsening, infertility/spermatogenesis suppression।
  • Contraindications/caution: prostate/breast cancer, high hematocrit, untreated severe OSA, severe LUTS, recent cardiovascular event।
  • Interactions: warfarin effect may increase; insulin/oral hypoglycaemic adjustment may be needed।
  • Bangladesh available brand names: Androcap 40 mg, Andriol TestoCaps 40 mg, Androjet 250 mg/ml, Sustogen 250 mg/ml, Testanon 250 mg/ml, Testoren 250 mg/ml।

16) Generic name: Propranolol

  • Therapeutic category: Beta-blocker / anxiolytic symptom control
  • Pharmacological class: Non-selective beta-adrenergic blocker
  • কেন used হয়: Performance anxiety-এর physical symptoms—palpitation, tremor, sweating—কমাতে selected short-term/off-label use; কিন্তু ED/libido issue বাড়াতে পারে, তাই sexual dysfunction রোগীতে cautious।
  • Dose: 10–20 mg 30–60 min before performance situation; routine anxiety managementে long-term first-line নয়।
  • Side effects: bradycardia, hypotension, fatigue, cold extremity, bronchospasm, sleep disturbance, sexual dysfunction।
  • Contraindications/interactions: asthma/COPD bronchospasm, bradycardia/heart block, decompensated HF; verapamil/diltiazem/digoxin with caution।
  • Bangladesh available brand names: Adlock 10/40 mg, Betacap TR 40 mg, Indever 10/20/40 mg, Propranol 10/20/40 mg।

17) Generic name: Clonazepam

  • Therapeutic category: Anxiolytic/sedative
  • Pharmacological class: Benzodiazepine
  • কেন used হয়: Severe acute anxiety/panic with insomnia—short-term bridging only; sexual dysfunction-এর primary treatment নয় এবং libido/erection worsen করতে পারে।
  • Dose: 0.25–0.5 mg at night or BID short-term; elderly/liver disease-এ lower dose।
  • Duration: ideally 2–4 weeks maximum; taper required।
  • Side effects: sedation, cognitive slowing, falls, dependence, withdrawal, respiratory depression।
  • Interactions: alcohol, opioid, sedative, antihistamine—dangerous CNS/respiratory depression।
  • Bangladesh available brand names: Lonazep 0.5/1/2 mg forms listed in Bangladesh medicine index।

9. Bangladesh Doctors’ Practical Prescription Pattern — রোগীভেদে কী ব্যবহার হয়

  1. Depression/anxiety core treatment:
    • Sertraline, escitalopram commonly used। Bangladesh tertiary hospital study-তে SSRI ছিল most common antidepressant group; sertraline ও escitalopram সবচেয়ে বেশি ব্যবহৃত SSRIগুলোর মধ্যে ছিল।
    • কেন: depression/anxiety remission হলে sexual dysfunction নিজে থেকেই improve হতে পারে।
    • Problem: SSRI sexual dysfunction বাড়াতে পারে—follow-up জরুরি।
  2. SSRI-induced sexual dysfunction হলে:
    • Dose reduction, switch to mirtazapine/bupropion/vortioxetine, বা add-on bupropion/buspirone selected case।
    • কেন: libido/orgasm dysfunction কমানো এবং depression control রাখা।
  3. Male ED থাকলে:
    • Sildenafil বা tadalafil।
    • কেন: erection physiology improve করে; anxiety-driven ED-তে confidence restore করতে সাহায্য করে। AUA/EAU guidelines PDE5 inhibitors-কে ED treatment-এর major first-line option হিসেবে রাখে।
  4. Premature ejaculation থাকলে:
    • Dapoxetine PRN বা topical lidocaine/prilocaine।
    • কেন: ejaculation latency বাড়ানো।
    • Important: dapoxetine + SSRI/SNRI একসাথে দেওয়া যাবে না।
  5. Confirmed hypogonadism হলে:
    • Testosterone replacement specialist-supervised।
    • কেন: low testosterone-driven libido/ED correct করা।
  6. Performance anxiety prominent হলে:
    • CBT/sex therapy first; propranolol selected situational case।
    • কেন: palpitations/tremor কমানো; কিন্তু ED risk থাকলে cautious।

10. Prevention / প্রতিরোধ

  • Depression/anxiety early treatment করা
  • Antidepressant শুরু করার আগে baseline sexual history নেওয়া
  • SSRI/SNRI দিলে প্রথম visit-এই sexual side effect counselling করা
  • Diabetes, BP, lipid, thyroid disease control
  • Smoking বন্ধ, alcohol কমানো
  • Regular aerobic + resistance exercise
  • Sleep 7–8 hours
  • Pornography overuse/compulsive masturbation থাকলে behavioural plan
  • Partner communication ও couple therapy
  • PDE5/nitrate danger সম্পর্কে patient education
  • Antidepressant abrupt stop না করা
  • Follow-up: 2–4 weeks after starting/changing medicine, তারপর response অনুযায়ী

11. Overview / Summary

Depression/anxiety-related sexual dysfunction হলো depression, anxiety, performance fear, relationship stress, organic disease বা psychiatric medicine-এর কারণে libido, erection/arousal, orgasm/ejaculation বা sexual satisfaction কমে যাওয়া। Diagnosis মূলত history + validated scale + targeted physical exam দিয়ে করা হয়। Investigation করা হয় diabetes, thyroid, prolactin, testosterone, cardiovascular disease, infection বা gynecologic/urologic cause বাদ দিতে। Treatment হলো depression/anxiety control, psychotherapy/sex therapy, lifestyle correction, medicine review, এবং symptom-specific drug—যেমন ED-তে sildenafil/tadalafil, PE-তে dapoxetine/topical anaesthetic, SSRI-induced dysfunction-এ switch/augmentation।

12. Actionable Plan / Steps

  1. PHQ-9, GAD-7, ASEX/IIEF-5/FSFI দিয়ে baseline severity score করুন।
  2. Onset timeline লিখুন: sexual problem depression/anxiety-এর আগে, পরে, নাকি SSRI/SNRI শুরু করার পর।
  3. Basic labs: CBC, HbA1c, lipid, TSH, creatinine/eGFR, LFT।
  4. Male low libido/ED হলে morning testosterone + prolactin করুন।
  5. Depression/anxiety active হলে CBT + appropriate antidepressant; sexual complaint থাকলে SSRI choice সতর্কভাবে করুন।
  6. SSRI-induced হলে dose reduction/switch to mirtazapine/bupropion/vortioxetine বা add-on strategy consider করুন।
  7. ED হলে nitrate/cardiac risk exclude করে PDE5 inhibitor।
  8. PE হলে dapoxetine PRN বা topical lidocaine/prilocaine; SSRI/SNRI-এর সাথে dapoxetine avoid।
  9. 4–8 weeks follow-up: symptom score, side effect, adherence, relationship distress review।
  10. Suicidal thought, priapism, chest pain, severe dyspareunia/bleeding হলে urgent referral।

13. Reference List

Textbooks

  1. Kaplan & Sadock’s Synopsis of Psychiatry, 12th ed. Chapters: Depressive Disorders, Anxiety Disorders, Sexual Dysfunctions, Psychopharmacology.
  2. Harrison’s Principles of Internal Medicine, 21st ed. Sections: Depression/anxiety in medical practice, erectile dysfunction, hypogonadism, endocrine causes of sexual dysfunction.
  3. Davidson’s Principles and Practice of Medicine, 24th ed. Sections: Psychiatry, endocrinology, diabetes, cardiovascular risk and sexual health.
  4. Guyton and Hall Textbook of Medical Physiology, 14th ed. Sections: reproductive physiology, autonomic control of sexual response.
  5. DSM-5-TR, American Psychiatric Association, 2022. Sexual Dysfunctions, Depressive Disorders, Anxiety Disorders.

Guidelines / Official sources

  1. WHO. Depression fact sheet and treatment overview.
  2. NICE NG222. Depression in adults: treatment and management.
  3. NICE CG113. Generalised anxiety disorder and panic disorder in adults.
  4. EAU Guidelines: Sexual and Reproductive Health—Erectile Dysfunction.
  5. AUA Erectile Dysfunction Guideline.

Peer-reviewed journals with DOI

  1. Laurent SM, Simons AD. Sexual dysfunction in depression and anxiety: conceptualizing sexual dysfunction as part of an internalizing dimension. Clinical Psychology Review. 2009. DOI: 10.1016/j.cpr.2009.06.007.
  2. Higgins A, Nash M, Lynch AM. Antidepressant-associated sexual dysfunction: impact, effects, and treatment. Drug, Healthcare and Patient Safety. 2010. DOI: 10.2147/DHPS.S7634.
  3. Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018. DOI: 10.1016/j.juro.2018.05.004.
  4. Suma SA, Khan AH, Akhter A, et al. Patterns of antidepressant drug prescriptions in a tertiary care hospital in Bangladesh. Bangladesh Journal of Medicine. 2026. DOI: 10.3329/bjm.v37i1.84227.

Md.Rafiqul Islam Lipu,Date:-01-06-2026 Monday, Time:-06-48-37 Pm

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