Sexual Dysfunction

Question 1

First line treatment dyspareunia?

Answer 1

Pelvic floor muscle training + cognitive behavioural + sexual therapy

Question 2

Topical treatment options dyspareunia? (7)

Answer 2

First line

• topical anaesthetic: lignocaine cream
• topical hormones for vaginal atrophy: oestrogen cream

Second line

• topical capsaicin cream: phenols produced by chili’s, initially burning + pain but later desensitisation of ion channels in sensory nociceptive neuron fibres.
• Vaginal prasterone: synthetic DHEA (dehydroepiandrostenedione)

Third line (no solid evidence)

• gabapentin cream
• amitriptyline topical preparations (combined with ketamine/ baclofen) : option if serious side effects from oral TCA
• cromolyn cream: mast cell stabiliser. Of use iF primary complaint pruritis

Question 3

Oral treatment options dyspareunia? (7)

Answer 3

First line

• ospemifine: SERM for dyspareunia associated with vulvar + vaginal atrophy.

Second line

• antidepressants: TCA, ssri, snri.
• neuropathic pain analgesia: antiepileptics gabapentin, pregabalin, carbamazepine

Third line

• Botox: block cholinergic innervation

Last resort

• injectable steroids
• vaginal laser therapy
• vestibulectomy

Question 4

Name 2 types and 4 broad causes dyspareunia

Answer 4

Superficial

• psychological (most common)
• vulvovaginal
  → vaginitis (atrophic, chemical, allergic, infectious)
  → vaginismus (involuntary tensing)
  → imperforate hymen
  → lichen sclerosis
  → inadequate lubrication

Deep

• Cervical
  → cervicitis
  → cervical cancer
• Pelvic
  → endometriosis
  → adenomyosis
  → fibroids
  → ASO (strep A)
  → masses
  → ovarian cyst

Question 5

Name causes superficial dyspareunia (6)

Answer 5

• psychological (most common)
• vulvovaginal

→ vaginitis (atrophic, chemical, allergic, infectious)
→ vaginismus (involuntary tensing)
→ imperforate hymen
→ lichen sclerosis
→ inadequate lubrication

Question 6

Name 8 causes deep dyspareunia

Answer 6

• Cervical

→ cervicitis
→ cervical cancer

• Pelvic

→ endometriosis
→ adenomyosis
→ fibroids
→ ASO (strep A)
→ masses
→ ovarian cyst