Basic Psychiatry 714: Sexual Dysfunction

• This presentation covers sexual dysfunction disorders in Basic Psychiatry 714.
• Maritza Santiago M.D., a Child and Adolescent Psychiatrist, is presenting.

General Objective

• Students will be able to diagnose patients with various forms of sexual dysfunction.
• Sexual dysfunctions covered include: delayed ejaculation, erectile disorder, and female orgasmic disorder
• Also covered are: female sexual interest/arousal disorder, genito-pelvic pain disorder, and male hypoactive sexual desire disorder
• Also included are: premature (early) ejaculation disorder, and substance/medication-induced disorder
• Students should recommend initial treatment interventions.

Specific Objectives

• List common causes of sexual dysfunctions, including general medical and psychological etiologies
• Diagnose based on DSM 5 criteria for various disorders including: delayed ejaculation, erectile disorder, and female orgasmic disorder
• Diagnose also includes: female sexual interest/arousal disorder, genito-pelvic pain disorder, male hypoactive sexual desire disorder, premature (early) ejaculation disorder, and substance/medication induced disorder
• Describe the specifiers for sexual dysfunction disorders.
• Compare and contrast the manifestations and differential diagnoses of the above disorders
• Recommend a treatment plan for patients with sexual dysfunction

Sexual Human Response (Masters and Johnson)

• Desire phase: lasts minutes to hours; sexual fantasies and desire for sexual intimacy occur
• Excitement phase: consists of a subjective sense of pleasure and accompanying physiological changes
• Orgasm phase: consists of a peaking of sexual pleasure, with release of sexual tension and rhythmic contractions of the perineal muscles and reproductive organs
• Resolution phase: consists of a sense of muscular relaxation and general well-being

Epidemiology of Sexual Dysfunction

• Studies show more research on incidence and prevalence in men than in women
• Desire and arousal dysfunctions are the problems reported most frequently by women
• A large proportion of women experience multiple sexual dysfunctions
• Premature ejaculation and erectile dysfunction are the most common sexual dysfunctions in men
• Men have less comorbidity across sexual dysfunctions compared to women

Sexual Dysfunction in Females

• The PRESIDE study surveyed 50,001 US women aged 18-102 years, with a 63% response rate
• Low desire was the most common sexual problem, reported in 37.7% of participants
• Low desire with distress (HSDD) was present in approximately 10% of women
• Low desire with distress was more common than distressing arousal or orgasm difficulties.
• Global study shows female sexual dysfunction rates of 38%.

Sexual Dysfunction in Males

• The crude incidence rate for erectile dysfunction was 25.9 cases per 1,000 man-years (95% CI: 22.5 to 29.9)
• The annual incidence rate increased with each decade of age -For men age 40-49 it was 12.4 cases per 1,000 man-years (95% CI: 9.0 to 16.9) -For men age 50-59 it was 29.8 (24.0 to 37.0) -For men age 60-69 it was 46.4 (36.9 to 58.4)
• The age-adjusted risk of erectile dysfunction was higher for men with lower education, diabetes, heart disease, or hypertension
• Population projections estimate 17,781 new cases of erectile dysfunction in Massachusetts and 617,715 in the United States annually for white males
• Global study shows male sexual dysfunction rates of 29%.
• Males who have sex with males have higher rates of erectile dysfunction than non-MSM counterparts
• MSM have unique activators of sexual pathologies, such as insertive anal intercourse for Peyronie's disease

Diagnosis of Sexual Dysfunctions

• Common disorders to diagnose include: Delayed ejaculation disorder, Erectile disorder, Female orgasmic disorder, and Female sexual interest/arousal disorder
• Also: Genito-pelvic pain disorder, Male hypoactive sexual disorder, Premature (early) ejaculation disorder, and a Substance-induced sexual disorder

Disorders by Phase

• Desire phase disorders include Male hypoactive sexual disorder and Female sexual interest/arousal disorder
• Excitement phase disorders include Erectile dysfunction and Female sexual interest/arousal disorder
• Orgasm phase disorders include Female orgasmic disorder and Premature ejaculation.

DSM 5 Criteria for All Sexual Dysfunction Diagnoses

• Symptoms must have persisted for 6 months or longer
• The disorder must cause clinically significant distress
• The disorder must not be due to severe relationship stress, another mental disorder, use of a substance, medication, or medical condition (e.g., diabetes mellitus).

Delayed Ejaculation Diagnostic Criteria

• Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity (in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay: -Marked delay in ejaculation -Marked infrequency or absence of ejaculation

Specifiers for Sexual Dysfunction

• Lifelong: The disturbance has been present since the individual became sexually active
• Acquired: The disturbance began after a period of relatively normal sexual function
• Generalized: Not limited to certain types of stimulation, situations, or partners
• Situational: Only occurs with certain types of stimulation, situations, or partners
• Current severity: Ranges from Mild to Moderate to Severe

Erectile Disorder Diagnostic Criteria

• At least one of the symptoms below must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts): -Marked difficulty in obtaining an erection during sexual activity -Marked difficulty in maintaining an erection until the completion of sexual activity -Marked decrease in erectile rigidity

Female Orgasmic Disorder Diagnostic Criteria

• Presence of either of the following symptoms and experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts): -Marked delay in, marked infrequency of, or absence of orgasm -Markedly reduced intensity of orgasmic sensations

Female Orgasmic Disorder

• It is also known as anorgasmia
• It can be difficult to assess
• Many women require clitoral stimulation to reach orgasm
• A relatively small proportion of women report that they always experience orgasm during vaginal intercourse
• Many women report high levels of sexual satisfaction despite not achieving orgasm

Female Sexual Interest/Arousal Disorder Diagnostic Criteria

• Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following: -Absent/reduced interest in sexual activity -Absent/reduced sexual/erotic thoughts or fantasies -No/reduced initiation of sexual activity, and typically unreceptive to a partner's attempts to initiate -Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts) -Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual) -Absent/reduced genital or non-genital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts)

Female Sexual Interest/Arousal Disorder

• Occurs in 1/3 of married females
• Women may experience painful intercourse, sexual avoidance, and an unsatisfying marital and sexual relationship
• Temporary low sexual interest can result from stressful situations such as overwork or lack of privacy

Genito-Pelvic Pain/Penetration Disorder Diagnostic Criteria

• Persistent or recurrent difficulties with one (or more) of the following: -Vaginal penetration during intercourse -Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts -Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration -Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

Genito-Pelvic Pain/Penetration Disorder

• A woman may have sufficient desire and interest in sexual activity, but only for those activities that are not painful or do not require penetration such as oral sex
• It is not unusual for women who have not succeeded in having sexual intercourse to seek treatment only when they wish to conceive
• Women experiencing superficial pain during sexual intercourse often have a history of vaginal infections
• Religious and cultural factors also predispose individuals to this disorder

Male Hypoactive Sexual Desire Disorder Diagnostic Criteria

• Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity
• The judgment is made by the clinician, taking into account factors such as age and general and sociocultural context

Male Hypoactive Sexual Desire Disorder

• May co-occur with erectile problems or abnormal ejaculation
• Individuals often no longer initiate sexual activity and are minimally receptive to a partner's attempt to initiate sexual activity

Premature Ejaculation Diagnostic Criteria

• A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it
• Premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities

Premature Ejaculation

• From 20% to 30% of men age 18-70 express concern about how rapidly they ejaculate
• Some men develop the disorder only during their initial sexual encounters but gain ejaculatory control over time

Diagnostic criteria for Substance/Medication-Induced Sexual Dysfunction Disorder:

• Clinically significant dysfunction is predominant in the clinical picture
• History, PE and labs consistent with: -Symptom in criterion A develops during or soon after intoxication or withdrawal or after exposure to a medicine
• It is not better explained by a sexual dysfunction that is not substance-induced -It does not precede the onset of substance use AND Symptoms persist after one month after cessation of acute withdrawal or severe intoxication AND There is No evidence of a history of depressive disorder The substance/medication is capable of producing the symptom
• Symptoms developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
• May decrease sexual interest and cause arousal difficulties or interfere with orgasm
• • Examples of substance/medications: Cocaine, opiates, amphetamines, sedatives, hypnotics, Antihypertensives, histamine h2 receptor Antagonist, antidepressants, anabolic steroids, stimulants, and anxiolytics

Etiology of Sexual Dysfunctions

• Sexual dysfunction can be caused by psychological factors, medical conditions, medications or substances of abuse, or a combination of several factors

Causes of Desire Phase Disorders

• Biological factors: physical illnesses, spinal cord injury, or medications that depress the central nervous system or decrease testosterone production --Examples: SSRI, or imbalance in testosterone, prolactin and estrogen
• Psychological/cultural factors: Prolonged abstinence, body image issues secondary to medical illness or surgery, cultural standards, stress, older age, chronic stress, anxiety or depression, fear of pregnancy, history of molestation or sexual abuse, lack of self esteem
• Other factors include: Erectile dysfunction, orgasmic disorders (anorgasmia, premature ejaculation), and sexual pain disorders (dyspareunia, vaginismus) Differential diagnosis includes PENIS: --Psychological (if nighttime erections still occur) --Endocrine (e.g., diabetes, low testosterone) --Neurogenic --Insufficient blood flow (e.g., atherosclerosis) --Substances (e.g., antihypertensives, antidepressants, ethanol)

Causes Related to Excitement Phase Disorders

• Biological factors: Acromegaly, Addison's disease, Diabetes, Hyperthyroidism, Hypothyroidism, Klinefelter's syndrome, Multiple sclerosis, Parkinson's disease, Pelvic surgery or irradiation, Peripheral vascular disease/low blood flow (CAD), Pituitary adenoma, Spinal cord injury, Syphilis or Temporal lobe epilepsy
• Psychological/Psychiatric Illnesses: Anxiety disorders, Dementia, Major depression, Schizophrenia
• Medications/Drugs: Alcohol, Antiandrogens, Anticholinergics or Antidepressants
• -Especially centrally acting Antihypertensives, Antipsychotics, Barbiturates, Finasteride, Marijuana, Opioids or Stimulants
• Laboratory work-up should include FBS, Fasting lipid profile, Thyroid function tests and serum testosterone --Providers should determine whether spontaneous erections occur at times when the man does not plan to have intercourse --If erections occur at such times, the disorder is more likely to have a psychological origin --Nocturnal penile tumescence testing has been used to separate neurogenic from psychogenic erectile dysfunction in the past, though such results can be unreliable and misleading

Etiology of Orgasmic Phase Disorders

• Biological factors: Differentiate from retrograde ejaculation, which has a physiological cause, such as medication, genitourinary surgery, or neurological disorders involving the lumbosacral section of the spinal cord
• -May be associated with centrally acting antihypertensives, tricyclic antidepressants or antipsychotics
• Psychological/cultural factors: history of sexual abuse, guilt about pleasure in sexual relationship, depression, anxiety or relationship issues Cultural or religious beliefs

Causes of Genito-Pelvic Pain Disorder

- The disorder combines dyspareunia and vaginismus
- Vaginal atrophy and infections are biological causes
- Problems with the uterus and ovaries
- Sexually transmitted infections
- Skin disorders affecting the genitalia
- Psychological issues: Victim of sexual abuse with or without vaginismus

Clinical Management of Sexual Dysfunctions

• Masters and Johnson pioneered dual sex therapy in the 1960's
• -treatment begins educating the couple about normal sexual functioning and evaluating their ability to communicate about sex and intimacy Correction of irrational beliefs and dysfunctional thoughts Sensate focus- erectile disorder- the couple is assigned nongenital caressing to gradually increase awareness of the couple's erogenous zones in cases of female orgasmic disorder therapy may involve training the woman to first have an orgasm by masturbation, before treating the couple
• Vaginismus- individual therapy, meditation or other relaxation exercises, or the use of Hegar dilators
• Premature ejaculation- Squeeze method- when the man feels he is about to ejaculate, the partner is instructed to squeeze the penis for up to 5 second, by placing the thumb on the frenulum and the first and second fingers on the opposite side

Medications For Sexual Dysfunction

• SSRIs can be used off-label for premature (early) ejaculation . Men also can benefit from 1% dibucaine (Nupercaine) ointment applied to the coronal ridge and frenulum of the penis to reduce stimulation.
• -Examples of SSRI's: paroxe-tine, 20 mg/ day
• Premenopausal women with hypoactive sexual desire disorder:
• -Flibanserin (Addyi) and bremelanotide (Vyleesi) are FDA approved Testosterone has also been used to treat both men and women for low sexual desire but research on its use is inconsistent (except in clear cases of hypogonadism)
• For vaginal dryness, Ospemifene (Osphena) is a nonhormonal treatment that is FDA approved
• Erectile disorder medications include: sildenafil, vardenafil, and tadalafil, which are phosphodiesterase-5 inhibitors that enhance the effect of nitric oxide
• -They are also FDA approved and relax smooth muscles in the penis, increasing blood flow and allowing an erection to develop in response to sexual arousal
• -Each of these medications can cause headaches, upset stomach, nausea, and muscle aches, and in rare occasions, priapism. A prostadil (a synthetic version of the hormone prostaglandin) also is FDA approved. The drug either is injected directly into the base or side of the penis or is placed directly into the urethra with a special syringe
• Surgical treatments are also available, but these are indicated only when medication is ineffective
• -A simple alternative is a vacuum pump device that produces an erection by increasing blood flow to the penis.