Determinants of Male Coital Difficulties among Attendees of the Gynae Clinic at a Tertiary Health Center in North-Central Nigeria

Background: Male sexual or coital difficulties are among the factors contributing to infertility in couples seeking fertility as this may result in low coital frequency. Aims/Objectives: To evaluate the causes of male sexual or coital difficulties among couples attending the infertility clinic at BSUTH, Makurdi over a 2 year period. Methodology: This was a cross-sectional study involving all males attending the infertility clinic at Benue State University Teaching Hospital (BSUTH) who consent to participate in the study. A pretested structured questionnaire was administered and analyzed with statistical package for social sciences (version 23.0) and the results were presented in simple proportions. Results: There were several factors responsible for male coital difficulties. The most common was male erectile dysfunction 33 (32.4%), vaginismus 11 (10.8%), penile pain 14 (13.7%), poor response from the female partner 8 (7.8%) and severe dyspareunia 18 (17.1%). Conclusion: Coital difficulties resulting to low frequency of sexual exposure constitutes a major cause of infertility among males attending the infertility clinic at BSUTH, Makurdi. Therefore efforts should be made to evaluate these factors while assessing infertility couples in order to mitigate the effect.


Introduction
Infertility is common in our environment and is one of the commonest reasons why a couple may present to the Gynaecologist [1] [2] [3].Some studies have revealed that coital difficulties may be a contributory factor in up to 5% of some cases of infertility [4] [5] [6].Despite the literatures, coital difficulties are still frequently over looked as a primary cause or as contributory cause of infertility in many societies.
This may result in reduced coital frequency or cessation of intercourse, ironically, in a couple seeking conception.This further worsens the couples' situation and can result in serious marital disharmony, divorce or domestic violence [3] [7] [8].
Coital or sexual difficulties may be due to poor sexual knowledge or attitudes, poor self-esteem, emotional difficulties or sexual abuse.Other causes include unresolved marital problems, ineffective communication, sexual orientation, chronic illnesses and disabilities, medication effects and negative childhood sexual learning or education [3] [4] [9] [10] [11] [12].Empirical studies on the concept is scanty therefore, this study was carried out to evaluate the causes of male sexual or coital difficulties among couples attending the infertility clinic at BSUTH, Makurdi.

Methods
This was a cross-sectional study involving all males attending the Infertility Clinic at the Gynaecology Department, Benue State University Teaching Hospital (BSUTH), Makurdi, Nigeria.BSUTH is a newly established government owned tertiary hospital, located in Makurdi, North-Central Nigeria.Makurdi is an urban centre and the capital of Benue State located in North-Central, Nigeria.The hospital serves as a referral centre for secondary and primary care hospitals in the public and private sectors and covers a wide area in the region.The obstetric department has several consultants and registrars and serves as a postgraduate training centre for obstetrics and gynecology.The study was conducted between 1 st May 2013 and 31 st April 2015.A total of 102 males participated in the study.The study population was couples attending the infertility clinic.However, the females were excluded from the study because the male perspective on the causes of coital difficulties was what was been sought.Males who refused to consent for the study were also excluded.The outcome measure in this study (coital difficulty) is defined as the inability to achieve satisfactory penetrative vaginal intercourse with ejaculation of semen.
A pretested structured questionnaire was administered by the investigators and the results were analyzed using simple proportions, charts and tables.Information obtained includes: the socio-demographic characteristics of the respondents, causes of coital difficulties, co-morbid conditions and treatment received.The instrument for data collection was pretested on male couples attending fertility clinic in Federal Medical Centre, Makurdi, a tertiary health facility located in Makurdi where the study was conducted for validity and reliability and necessary adjustments were made on the tool before the final administration in BSUTH.Approval for the study was obtained from the relevant re-search ethics committee before the commencement of the study.Informed consent was also obtained from the participants after carefully explaining the nature and scope of the study to them.

Results
Majority of patients are above 41 years (79.4%) as seen in Table 1.Diabetes mellitus and high blood pressure are the diseases most associated with coital difficulties (Table 2).Figure 1 presents the causes of coital difficulties.Erectile dysfunction (ED) and severe dyspareunia are the most frequent cause (32.0% and 17.0% respectively).Predominant co-morbid condition seen amongst the respondents was High blood pressure (32.4%), followed by Diabetes Mellitus (23.5%), chronic back pain (9.8%), Chronic liver Disease (5.9%) and the least was renal disease (2.9%).Excessive alcohol consumption and smoking are the prevalent social factors contributing to the respondent's problem as seen in Table 2. Majority of the respondents had used aphrodisiacs to treat themselves before coming to the hospital (Table 3).

Discussion
The recommended coital frequency among couples seeking conception by natural means is 3 -4 times in a week, preferably on alternate days [1] [2].Inability to achieve this frequency of coitus may result in failure of conception in the absence of other more serious pathologies [3] [5] [6] [7].Difficulties encountered during the act of coitus may result in low coital frequency [8] [9].
In this study, the most commonly affected age group is the 41 -45 and 46 -50 years, which together constitute 56.9% of the study population (Table 1).Other studies have reported similar figures [6] [8].
This may be due to the fact that the same age group is most likely to be affected by the medical conditions that indirectly contribute to erectile dysfunction (Table 2) such as diabetes mellitus (DM), high blood pressure (HBP), chronic renal failure and low back pain, which leads to physical difficulties in the act of having coitus (Table 3).Several other studies have shown that chronic pain is a frequent cause of coital difficulty [6] [9] [13] [14] [15].
Other major causes of coital difficulties among the study population include vaginismus in the female partner which may result in the male partner losing interest in coital activity with the female partner, penile pain on penetration which may result from inadequate lubrication, bruises on the penis from previous encounters or severe vaginismus [10] [13] [14] [15] [16] [17].
In order to overcome this problem, majority of the respondents engaged in social vices such as excessive alcohol consumption (56.8%), smoking (23.5%), use of social drugs (9.8%) such as marijuana and native or herbal preparations.
However, another 9.8% of the respondents did not engage in any of these social vices (Table 4).
Coital difficulties in a marital relationship are usually seen as a major problem and couples will quickly seek solutions.It is not surprising then that at least 68% of the respondents have sought treatment before presenting to the fertility clinic (Table 4) with majority of them (60%) resorting to using aphrodisiacs, 25.7% used traditional preparations and herbs while 11.7% tried using alcohol with various degrees of success been ascribed to such methods.Majority have used aphrodisiacs to treat themselves.

Conclusion
Coital difficulties results in low coital frequency and constitutes a major contributory factor in the aetiology of infertility.Efforts should be made to elucidate any factors that may result in inadequate sexual exposure while evaluating couples for infertility.The male partner should be discouraged from resorting to self-help while seeking solution to their coital difficulties as such measures may not only be counter-productive, but could actually be harmful in the long term.
Excessive alcohol consumption and smoking are prevalent.