Updated: 1/29/2019

Sexual Dysfunctions

Topic
Review Topic
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Questions
4
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Evidence
5
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Overview
  •  Sexual dysfunction of some form is very common
    • not a linear and uniform process and there are not absolute phases (desire, arousal)
    • prevalence is approximately 30% of general population
    • causes include
      • biological factors
      • psychological factors
        • sexual masochism 
      • pharmacologic factors
      • idiopathic
  • Subtypes (DSM-V): lifelong vs. acquired, generalized vs. situational
    • Types of sexual dysfunction include
      • impotence
      • premature ejaculation 
      • genito-pelvic pain/penetration disorder
      • medication induced sexual dysfunction
      • female sexual interest/arousal disorder
    • influencing factors (DSM-V)
      • partner
      • relationship
      • individual vulnerability
      • cultural/religious
      • medical

Snapshot
  • A 55-year-old main comes to his physician for an annual physical. A physical exam was within normal limits. At the conclusion of the encounter, the patient hesitates and asks for help for "an embarrassing problem" which he describes as an inability to maintain an erection during sexual intercourse with his wife.
Impotence
  • Introduction
    • clinical definition
      • persistent inability to attain or maintain an erection
  • Presentation
    • symptoms
      • inability to attain or maintain an erection
  • Evaluation
    • rule out any medical or pharmacologic causes
    • consider disease that could cause vascular pathology
      • diabetes
      • dyslipidemia
      • atherosclerosis
    • best initial test: check for nighttime erections (postage stamp test)
      • if erection achieved, tends to rule out organic and suggest psychiatric etiology
  • Treatment
    • pharmacologic - if organic etiology
      • PDE5 inhibitors - do not take with nitrates or venodilators
        • sildenafil
    • other therapies
      • vaccuum device
      • penile prosthesis - ultimate therapy, once this device is installed can never achieve erection again organically
    • psychotherapy - if organic etiology is ruled out
      • couples sex therapy
Snapshot
  • A 33-year-old man presents to his primary care physician with a complaint that he is very anxious about "certain things." When you probe these feelings, he reluctantly describes a problem with "sexual performance," in that he ejaculates immediately when intercourse begins.
Premature Ejaculation
  • Introduction
    • clinical definition
      • persistent ejaculation before or just following vaginal penetration
      • most commonly a result of anxiety
  • Presentation
    • symptoms
      • ejaculation before or just following vaginal penetration
  • Treatment
    • pharmacologic
      • SSRIs 
    • psychotherapy
      • couples sex therapy
    • behavioral modification 
      • stop-and-go and squeeze techniques

Genito-Pelvic Pain/Penetration Disorder (Dyspareunia and Vaginismus - DSM IV)
  • This DSM V diagnosis contains the previous DSM IV diagnosis of dysparuenia and vaginismus (below)
  • Sexual aversion disorder has been removed from the DSM V - it was a rare and often unused diagnosis
Snapshot
  • A 29-year-old woman presents to her OBGYN for her annual Pap smear. When asked if she was experiencing any other gynecological issues, she mentioned that recently she has become sexually active with a new partner and has been experiencing pain with intercourse. A Pap smear and STD workup is negative.
Dyspareunia
  • Introduction
    • clinical definition
      • pain with intercourse not due to a medical condition
  • Presentation
    • symptoms
      • recurrent pain with intercourse
  • Evaluation
    • essential to rule out a medical cause
      • including cervical and endometrial cancers, PID, estrogen deficiency (menopause), endometriosis, and other STDs
  • Treatment
    • psychotherapy
      • couples sex therapy and cognitive therapy
Snapshot
  • A 23-year-old woman presents to her gynecologist after becoming sexually active for the first time. She was distressed because despite several attempts, she described the act as impossible because of vaginal "contractions."  The patient's only medical history was rape that occurred when she was a senior in high school.
Vaginismus
  • Introduction
    • clinical definition
      • difficulty with penile insertion as a result involuntary constriction of the outer third of the vagina
    • associated with childhood sexual abuse or strict moral upbringing
  • Presentation
    • symptoms
      • vaginal constriction during intercourse
  • Treatment
    • psychotherapy
      • couples sex therapy, cognitive therapy
    • physical therapy
      • dilator therapy, kegel exercises

Snapshot
  • A 38-year-old gentleman presents with a request for sildenafil to help with sex.  The patient states that he is able to achieve and maintain an erection, however he is no longer able to have an orgasm.  The patient's past medical history is unremarkable with the exception of beginning treatment for depression with a psychiatrist that began a week ago.
Medication Induced Sexual Dysfunction
  • Introduction
    • SSRIs, TCAs and MAOIs have a high incidence of inducing sexual dysfunction
  • Presentation
    • anorgasmia, delayed ejaculation, decreased libido
  • Treatment 
    • switch to or add-on buproprion
      • cross-taper medications
    • mirtazepine, vilazodone, buspirone are also alternatives
Snapshot
  • A 35-year-old woman presents with a chief complaint of trouble during intercourse.  She states that she is unable to attain or maintain sexual arousal that is affecting her current relationship with her boyfriend. 
Female Sexual Interest/Arousal Disorder
  •  Introduction
    • new DSM V diagnosis - difficult to differentiate old diagnosis between desire and arousal
    • expands that sexual interest/arousal may be related to more than just lubrication
  • Evaluation (requires ABSENCE/REDUCED of 3 of the following for 6 MONTHS that causes DISTRESS)
    • interest in sexual activity
    • sexual/erotic thoughts or fantasies
    • initiation of sexual activity/not receptive
    • excitement/pleasure
    • sexual interest/arousal in response to internal or external stimuli
    • genital or nongenital sensations
      • must rule out other medical disorders prior to making diagnosis
  • Treatment
    • psychotherapy
    • couple's therapy
    • sildenafil/taldalfil (off-label currently)
    • testosterone (off-label currently)
Others
  • Abnormal sexual behavior in a pediatric patient
    • e.g., female pediatric patient inserting inappropriate items into their sexual organ 
    • associated with sexual abuse 
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.PY.4773) An 18-year-old woman comes to see her primary care physician for a physical for school. She states she has not had any illnesses last year and is on her school's volleyball team. She exercises daily, does not use any drugs, and has never smoked cigarettes. On physical exam you note bruising around the patients neck, and what seems to be burn marks on her back and thighs. The physician inquires about these marks. The patient explains that these marks are the result of her sexual activities. She states that in order for her to be aroused she has to engage in acts such as hitting, choking, or anything else that she can think of. The physician learns that the patient lives with her boyfriend and that she is in a very committed relationship. She is currently monogamous with this partner. The patient is studying with the hopes of going to law school and is currently working in a coffee shop. The rest of the patient’s history and physical is unremarkable. Which of the following is the most likely diagnosis? Review Topic

QID: 109099
1

Domestic abuse

9%

(3/34)

2

Dependent personality disorder

0%

(0/34)

3

Avoidant personality disorder

0%

(0/34)

4

Sexual masochism

79%

(27/34)

5

Sexual sadism

12%

(4/34)

M2

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(M2.PY.4681) A 26-year-old man being treated for major depressive disorder returns to his psychiatrist complaining that he has grown weary of the sexual side effects. Which other medication used to treat major depressive disorder may be appropriate as a stand-alone or add-on therapy? Review Topic

QID: 107294
1

Paroxetine

0%

(0/0)

2

Venlafaxine

0%

(0/0)

3

Aripiprazole

0%

(0/0)

4

Buproprion

0%

(0/0)

5

Cyproheptadine

0%

(0/0)

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(M2.PY.4405) A 26-year-old man presents to his primary care physician complaining of impotence. He reports that he has a healthy, long-term relationship with a woman whom he hopes to marry, but he is embarrassed that he is unable to have an erection. Which of the following is the next best step? Review Topic

QID: 106997
1

Obtain a sperm sample

0%

(0/18)

2

Evaluate nocturnal tumescence

94%

(17/18)

3

Duplex penile ultrasound

0%

(0/18)

4

Prescribe sildenafil

0%

(0/18)

5

Prescribe vardenafil

0%

(0/18)

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