Human Sexuality: Function and Dysfunction

Question 1

Phases of Sexual Response Cycle

Answer 1

• Desire (Phase I): circumstance-dependent
• Excitement (Phase II): first amount of measurable physiologic responses
• Plateau Phase (Phase III): Physiology remains unchanged for some time
• Orgasm Phase (Phase IV): Involuntary contractions, EEG changes
• Resolution Phase (Phase V): Obligatory or non-obligatory physiologic changes to baseline

Question 2

Components of desire phase

Answer 2

• Desire for intercourse is a primary desire like that for food, water, or air.
• Some degree of sexual desire is always present.
• Like all appetites, sexual desire can be whetted or inhibited by circumstances.
• Sexual desire is not lust

Question 3

Physiologic components of excitement phase

Answer 3

• Vasocongestion of the pelvis
• ↑ heart rate and respiration.
• Skin “mottling” + warmth from increased blood flow to the skin
• Nipple erection occurs in both sexes.
• male: penile erection
• female: vaginal lubrication and expansion

Question 4

Major mechanism of penile erection (excitment phase)

Answer 4

• caused by distension of the corpus callosum with blood
• parasympathetic nervous system
• Scrotal shortening occurs late in the excitement phase

Question 5

Major mechanism of vaginal lubrication/increase in clitoral size (excitement phase)

Answer 5

• vaginal lubrication and expansion both result from increased blood flow to the pelvis.
• Clitoral vasocongestion leads to increase in clitoral size.
• Vaginal lubrication results from direct transudation across the vaginal wall and not from secretion of any glands

Question 6

Physiologic components of plateau phase

Answer 6

• more advanced stage of arousal.
• Physiology remains unchanged for some time with no further increase in heart rate and respiration, and no blood flow shifts.

Question 7

Physiologic components of orgasm phase

Answer 7

• Accompanied by a series of rhythmic contractions of the perineal muscles occurring every 0.8 seconds.
• In the male it is accompanied by 3 to 7 ejaculatory spurts of seminal fluid.
• In the female it is accompanied by elevation of the “orgasmic platform.”
• In both sexes there are involuntary contractions of skeletal muscles and EEG changes.

Question 8

Physiologic components of resolution phase

Answer 8

• males: orgasm is followed by an obligatory resolution phase
  
  • physiologic changes return to baseline & further stimulation cannot produce excitement
  • length of the resolution phase varies with age
• In females, resolution is not always obligatory—women may have repeated orgasm without resolution to a basal state, but some women do have an obligatory resolution phase.

Question 9

Approach to tx of sexual dysfxn

Answer 9

• Accept the patient’s problem as real
• Assure patient that others have the problem
• Assure patient that there is therapy available
• Address anxiety
• Address anger

Question 10

Tx paradigms for sexual dysfxn

Answer 10

• Most sexual dysfunctions are due to performance anxiety
• Anxiety, pain, and anger interfere with sexual function
• The same underlying issue may exhibit at different points in the sexual response cycle and may manifest as different disorders

Question 11

Types of treatments for sexual dysfxn

Answer 11

• sensate focus exercises
• marital therapy
• bibliotherapy
• pharmacotherapy
• vaginismus

Question 12

Characteristics of sensate focus excerises

Answer 12

• A series of defined behaviors and exercises; whole goal is to break the script
• Focus on sensations and emotions
  
  • engage w/senses and associated emtiones
• Training methods
  
  • Typically 12 - 16 visits
  • Involves behavioral modification
  • Involves marital therapy

Question 13

Characteristics of marital therapy and bibliotherapy

Answer 13

• Marital therapy - usually a part of sex therapy
• Bibliotherapy - give patient something to read
  
  • Most successful in female orgasmic dysfunction

Question 14

Pharmacotherapy tx for sexual dysfxn

Answer 14

• PDE5 inhibitors = males for ED dysfxn
  
  • ↑ cGMP; add sexual stimulation and local release of NO
• Estrogen
  
  • High association of sexual dysfunction and ↓ E2 levels in women
• Testoterone
  
  • Transdermal testosterone has small effect on ↑ sexual desire
  • Not FDA approved

Question 15

Antidepressants and sexual dysfxn

Answer 15

• SSRIs ==> treatment emergent dysfunction
• Bupropion can improve hypoactive sexual desire associated with SSRI
  
  • Generally helps women, can improve desire and orgasm, but which women is unclear
  • Also not sure if just treating depression is what is fixing the problem

Question 16

Common etiologies of sexual dysfxn

Answer 16

• most common = pain (physical or psychic)
• True lack of desire is often associated with a chronic disease
  
  • depression, hyperprolactinemia, hypogonadism, malignancies, substance abuse
• Inhibited desire is a learned behavior or a conditioned response.
  
  • may be secondary to another dysfunction, pain, boredom, anger, or marital discord.

Question 17

Important questions for sexual history

Answer 17

• How often do you have intercourse?
• Do you have pain with intercourse?
• How often do you have orgasms with intercourse? (females)
• Do you ever have orgasm before you want to? (males)
• Do you ever have trouble getting or keeping an erection? (males)
• Are you generally satisfied with your sex life?

Question 18

Common sexual dysfxn in desire phase

Answer 18

• Hypoactive Sexual Desire Disorder
  
  • Low libido
    
    • often w/underlying dz state
• Inhibited sexual desire
  
  • Sexual Aversion - persistent or recurrent extreme aversion and avoidance to all (or almost all) genital contact with a sexual partner
  • Result of pain or other dysfunction

Question 19

Common sexual dysfxn of excitement phase

Answer 19

• Arousal disorder
• Vaginismus
• Premature ejaculation

Question 20

Characteristics of Arousal disorder

Answer 20

• Male erectile disorder - inability to attain or maintain an erection
• Female sexual arousal disorder - inability to maintain lubrication, soiling
• disconnect between objective measures of vasocongestion and subjective arousal

Question 21

Characteristics of vaginismus

Answer 21

• Recurrent or persistent involuntary spasm of the musculature of the outer ⅓ of the vagina
• Can make penetration impossible
• Caused by severe religious orthodoxy, pain, severe negative parental attitudes
• Patients are often hyper feminine, have bizarre images of their genitals, have a partner that supports their dysfunction
• Primary: occurs at first try
• Secondary: occurs later due to some other reason

Question 22

Tx of vaginismus

Answer 22

• Treat with dilators → best done with a female practitioner
• Learn to have something in vaginal canal
• Must involve partner

Question 23

Characteristics of premature ejaculation

Answer 23

• Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after the penetration and before the person wishes it
• “Failure of excitement”

Question 24

Characteristics of sexual dysfxn during orgasm phase

Answer 24

• Orgasmic disorders
• Male
• Female
• Etiologies
  
  • Boredom
  • Performance anxiety
  • Fear of loss of control