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Updated: Dec 29 2021

Sexual Dysfunctions

  • 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 her genitals
      • associated with sexual abuse
    • Sexual assault
      • Increases risk of developing many psychiatric conditions, especially post-traumatic stress disorder (PTSD), major depressive disorder, substance use disorders, and suicide
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