Dr. Kirloskar Santosh V

Definition

Inability or absence of successful peno- vaginal intercourse in a couple.

Prevalence

About 15% of couple have problem of Unconsummation though they can have orgasm by masturbation or by oral stimulation of the genitals. It is not so common in the west, be for social and cultural reasons. The longest duration of Unconsummation seen was for 9 years.

Etiology

The commonest cause of Unconsummation is ignorance about the sexual act, though sexual aversion, rigid hymen, atresia of vagina, trauma, infection and sexual dysfunctions like impotence, premature ejaculation vaginismus, dyspareunia, etc. and up in Unconsummation of marriage.

Attention is mainly focused here on the Unconsummation due to ignorance about the sexual act. The other conditions responsible for Unconsummation are managed by treating the cause. 

Why Unconsummation?

1. sexuality is a basic instinct in the animals for reproduction and propagation life. Unlike the other animals, sexual behavior in the human being is the outcome of learning and conditioning. Sex being a very private issue and considered as a taboo, there is hardly any opportunity for learning the intercourse. therefore ignorance, myths and misconceptions about sexual act prevail.

2. All the quadruped and biped animals perform coitus by the rear entry, while human being is the only animal doing intercourse in a face –to – face position.

3. the act is done in the dark.

4. the vaginal opening and its direction are not visible externally.

How the problem presents?

Unconsummation is more common in urbanized and well- educated clients. They are normal in every respect except for their ignorance about the sexual act.

1. The client complaint may come for the guidance saying, I don’t know how to do intercourse. Please help me.

2. The chief complaint may be, I can’t penetrate.

Perhaps he tries at the wrong site or in a wrong direction; or she may be having vaginismus.

3. Some men may not know that they have to do pelvic movements after penetration.

4. Woman keeps her legs straight

This can be an important statement by the client giving a clue to the diagnosis. This COITAL position there is no proper alignment between the direction of penis and vagina; therefore penetration  is not possible.

5. My penis is not hard enough for penetration this could be the complaint. The female might not have been sufficiently stimulated through foreplay. Nature has designed the structure of the vagina in such a way that man gets maximum rigidity of penis in the vagina and then only he can ejaculate.

6. Man may lose erection after trying at a wrong site ( at urethra or at clitoris) for a long time and blame himself. In such case, woman may complain of pain during the coital act.

7. If the women has vaginismus, man may not be able to penetrate. He may lose erection and label himself as impotent.

8. All the semen comes out

This is the complaint by the women when the man ejaculates on the vulva instead of in the vagina.

9. Women complaint of primary infertility. To the surprise of the examiner, the hymen may found to be in fact proving Unconsummation. Till this fact is brought their notice, they feel that they are doing the coitus in a perfect way.

Consequences:

1. The couple may continue  to do intercourse in a wrong way without being aware about Unconsummation.

2. Women may complain of pain during the intercourse

3. Man way lose the erection after trying intercourse unsuccessfully at a wrong site for sufficient length of time. He may think himself suffering from impotence.

4. Infertility

5. Anxiety/ depression

6. Marital conflict/ divorce

7. Suicide

Diagnosis:

1. history is most important.

Foreplay : yes/no

Erection of penis in man and lubrication of vagina in women : Yes/No

Women flexing her hips during coitus in missionary position : Yes/No

Site & direction of penetration : Right/ Wrong

Pelvic movements: Yes/No

Illumination in the room: Yes/No

2. In every case of impotence and infertility, Unconsummation should be ruled out.

3. Women sleeping in the supine position with legs straight on the bed during the intercourse should make the clinician suspect Unconsummation.

4. Genital Examination:

Presence of hymen in the married female .

Only one finger dilatation of vagina

Presence of smegma on the glans/coronal sulcus in the male

Painful retraction of prepuce (or phimosis) may be an accidental finding.

5. Post-coital Test: Absence of sperms in the sample.

Management

1. Both the partners should attend the counselling session.

2. Anatomy of male & Female genitals should be explained to them with the help of clay model, charts or slides.

3. Examination of the genitals:

One finger PV examination of the females should be done in the presence of the male to enable him to understand the site and the direction of the vaginal barrel.

4. The following instructions will help the couple  in overcoming Unconsummation.

For the couples who sleep on the floor.

Lights should be on or the coitus should be done during the day.

The couple should engage in foreplay till he gets erection  of penis and she gets lubrication of vagina.

The female should be in a supine position on the bed, with a pillow under her buttocks, and with her thighs flexed and abducted at her hips. This rotates her pelvis and brings her vaginal opening accessible for the penetration by the male.

The male should squat on his heels ( vajrasan or Namaaz  Position)

Between her thighs. In this position he being perpendicular to her body is in a position to locate and align his penis with the vagina which is at the lower end of vertical cleft, and in upward and backward direction.

Then he advances towards her that his right thigh is under her left one , and his left thigh is her right one. On reaching near her vulva, he separates the labia by his left hand and inserts his penis by his right hand. In the event of difficulty, the female should help him with her hand in guiding the insertion penis.

Supporting his body on the knees and holding her thighs by his hands he makes to and for movements of his pelvis till he ejaculates in the vagina.

For the couples who sleep on the cot: (T position )

Light should on or the coitus should be done during the day. The female sleeps on the cot in a supine and slide down till buttocks are on the foot end the bed.

She flexes and abducts her thighs, and the male kneels on the floor between her thighs, supporting his knee on the pillows so as to align his penis with her vaginal opening. In this position the male is perpendicular to the female.

The advantages are that he can see the external genitals of both and maneuver the penetration, can make pelvic movements by holding her thighs, and can stimulate the clitoris simultaneously while doing intercourse.

Outcome

The success rate is high. once the couples learn the coital act they simply wonder as to how they could miss such a simple and universal procedure