L23 Sexual dysfunction

Question 1

What are the 3 main models of sexual function and their main points

Answer 1

1. Sexual response cycle: Masters and Johnson: 5 stages (excitement, plateau, orgasm, resolution, refractory) with corresponding physiological changes- bell curve of arousal over time with orgasm the nipple
2. 3 phase model: Kaplan: Desire ->Arousal ->orgasm. Includes consideration of factors which influence sexual desire and therefore individual response
3. Non-linear model of female sexual response - Basson: Acknowledges how emotional intimacy, sexual stimuli and relationship satisfaction affect female sexual response: desire can be secondary for women, spontaneous sexual drive not needed but willingness to engage is important

Question 2

What are the organic vs psychological etiological factors that affect sexual function

Answer 2

Organic: Chronic illness/ pain, Depression, CNS conditions, Diabetes, CVS, post surgery, Meds, rec drugs.

Psychological: self perception, capacity for intimacy/relationship building, Anxiety, education/cultural beliefs, Past experiences, life circumstances, quality of relationship, communication, sexual and non sexual touch and sex politics.

Question 3

How does sexual function change over time with age (50+) for both sexes

Answer 3

For both; decline in estrogen/androgen->wane in libido,
menopause for women, tissue atrophy, more time required for arousal.
Loss of erectile security, longer refractory period, changes in ejaculation, fewer spontaneous erections for males.

Question 4

What are the DSM categories of sexual dysfunction for men and women

Answer 4

1. Female/Male hypoactive sexual desire disorder, + sexual aversion disorder for fem
2. Female orgasmic disorder
3. Genito-pelvic pain penetration disorder
4. Erectile disorder
5. Delayed or premature ejaculation

Question 5

What are important things to know for sexual function history

Answer 5

1. History of presenting problem: what, always or new, when
2. Sexual history: partners, relationship length, STI
3. Medical history, rec drugs, medicines
4. Social and relationship history: cultural, living situation etc

Question 6

What are 3 main treatments for the psychological component of sexual dysfunctions

Answer 6

1. CBT/ Mindfulness: coping with pain, fear, anxiety and increasing self esteem
2. Plissit model- counselling at 4 levels of intervention: permission to talk about sexual matters, limited information, specific suggestions, intensive therapy.
3. Sensate focus: M&J: Moving away from performance goals to enhance pleasure, improve communication, and awareness of sensation. 4 stages of touch with ban on intercourse

Question 7

What gets in the way of sexual desire and how is Low sexual desire managed

Answer 7

• unrealistic expectations, performance focus rather than closeness and pleasure, emotional isolation and inability to be open .

Doctors need to listen, reassure, manage medical issues then refer to therapist

Question 8

What is premature ejaculation and how is it treated

Answer 8

Lack of control or inability to delay ejaculation- for Lifetime may be some genetic impairment of inhibitory serotinergic pathways.
Treated by sensate focus with squeeze/ stop-start technique to delay ejac. ~Local anaesthetic spray, Antidepressants: SSRI or clomipramine with daily or dose prior to sex
+ sex therapy

Question 9

How is delayed/ anejaculation, Anorgamsia treated

Answer 9

It is generalised or situational due to effects of aging, psychogenic- lack of education/experimentation, induced by SSRI
Treatment is Sex therapy. modify risk factors, self help books.

Question 10

What are the biomechanical mechanisms of penile erection

Answer 10

1. Sexual signals in the brain from sensory stimulation (even imaginary) stimulate NO release which increases cGMP levels in areas of the penis
2. cGMP causes SM relaxation of erectile tissues and arterial expansion which allow increased blood flow into the corpus cavernosum where veins are compressed and leading to an erection
3. PDE 5 enzyme destroys cGMP and limits the erection after time without sexual stimulation

Question 11

What is Erectile dysfunction, the mix of organic (older) and pyschogenic (younger) causes

Answer 11

Persistent inability for 3mo + to obtain and maintain erection sufficient for satisfactory sexual performance

Psychogenic factors: Central inhibition of erectile mechanism without physical insult/injury. Performance anxiety related to situation/relationship.

Organic factors: Mechanism of failure-chronic illness, peyronies disease which bends penis. Alcohol, meds, cigs, re drugs, obesity

Question 12

What is treatment of Erectile dysfunction

Answer 12

-From couples wants
adjust the medication
based on diagnosis and comorbidities:
PDE5 inhibitors : sildenafil, tadalafil (long duration), Vardenafil
, lifestyle modification, education and tailored treatment, interrupt performance anxiety cycle with sensate/mindfulness.

Question 13

What is Vulvodynia and what is it caused by

Answer 13

Vulvar pain of 3mo+ without clear identifiable cause which may be multifactorial. This can be triggered by infections, trauma and is neuropathic pain- with pelvic floor dysfunction involved and psychological aspects causal or exacerbating.

Question 14

What does central sensitization in Chronic pain mean (related to Vulvodynia)

Answer 14

Central and peripheral changes in nervous system result in amplification of neuronal response and a failure to activate descending inhibition, mediated by cognitive emotional factors

Question 15

Compare the symptoms of Localised provoked vulvodynia vs General unprovoked vulvodynia

Answer 15

LPV: Usually no symptoms unless pressure on the area, sex or tampon use. May experience pain with sitting, tight clothing.

GUV: usually in older women, Constant vulval burning/stinging soreness. With or without exacerbations, sex may be ok.

Question 16

How is Vulvadynia diagnosed and treated

Answer 16

Diagnosis is done by exclusion of other specific causes.
MDT: gyn, counselling, pelvic floor physiology, tricyclics/anti epileptics for neuropathic pain.
Surgery: vestibulectomy only for LPV (careful).
Include partner but ensure patient is also seen on her own.

Question 17

What is Apareunia and the causes

Answer 17

Inability to achieve penetrative intercourse w/wout pain- due to fear, primary LPV, Vaginismus- complete spasm of pelvic floor or anatomical abnormalities-eg. hymenal band-