Sexual Dysfunction: Diagnosis & Treatment

General Objective

• Diagnosis of sexual dysfunctions including delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain disorder, male hypoactive sexual desire disorder, premature ejaculation, and substance/medication-induced disorder is key
• Recommendation of initial treatment intervention as applicable to general medical practice is important

Specific Objectives

• Understanding the common causes of sexual dysfunctions is important, including medical and psychological etiologies
• Diagnosis is based on DSM 5 criteria for all disorders listed
• Specifiers for sexual dysfunction disorders should be described
• Manifestations and differential diagnoses of the specified disorders should be compared/contrasted
• Treatment plans based on the diagnoses should be recommended

Sexual Human Response

• By Masters and Johnson, includes:
• The desire phase which can last from minutes to hours, where sexual fantasies and the desire for sexual intimacy occur
• The excitement phase which involves a subjective sense of pleasure and accompanying physiological changes
• The orgasm phase which consists of a peaking of sexual tension, the release of sexual tension and rhythmical contractions of the perineal muscles and reproductive organs
• The resolution phase, which consists of muscular relaxation and a general sense of well-being

Epidemiology of Sexual Dysfunction

• There are more studies on the incidence and prevalence for sexual dysfunctions in men, and more studies on the prevalence than the incidence for women
• The most frequent sexual dysfunctions for women are desire and arousal dysfunctions
• A large proportion of women experience multiple sexual dysfunctions
• Premature ejaculation and erectile dysfunctions are the most common sexual dysfunctions in men
• There is less comorbidity across sexual dysfunctions for men compared with women

Sexual Dysfunction in Females

• The PRESIDE (Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking) study found that, of 50,001 US women (aged 18-102):
  • Low sexual desire was the most common problem, reported in 37.7% of participants
  • Hypoactive sexual desire disorder (HSDD) was present in about 10% of women
  • Low desire with distress was more common than distressing arousal or orgasm difficulties
• Globally, female sexual dysfunction rates are around 38%

Sexual Dysfunction in Males

• The crude incidence rate for erectile dysfunction is 25.9 cases per 1,000 man-years (95% confidence interval [CI] 22.5 to 29.9)
• The annual incidence rate increases with each decade of age; cases per 1,000 man-years:
  • Ages 40-49= 29.8 (24.0 to 37.0)
  • Ages 50-59= 29.8 (24.0 to 37.0)
  • Ages 60-69= 46.4 (36.9 to 58.4)
• The age-adjusted risk of erectile dysfunction is higher for men with lower education, diabetes, heart disease, and hypertension
• Population projections of men aged 40-69 suggest that 17,781 new cases of erectile dysfunction in Massachusetts and 617,715 in the US are expected annually
• The global study on sexual attitudes and behaviors found that the male sexual dysfunction rate is 29%
• Male who have sex with male 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

Sexual Dysfunctions

• Delayed ejaculation
• Erectile disorder
• Female orgasmic disorder
• Female sexual interest/arousal disorder
• Genito-Pelvic Pain Disorder
• Male hypoactive sexual disorder
• Premature (early) ejaculation
• Substance/medication induced sexual disorder

Disorders by Phase

• Desire Phase:
  • Male hypoactive sexual disorder
  • Female sexual interest/arousal disorder
• Excitement Phase:
  • Erectile dysfunction
  • Female sexual interest/arousal disorder
• Orgasmic Phase:
  • Female orgasmic disorder
  • Premature ejaculation
• Resolution Phase:
  • No disorders listed

DSM 5 Criteria for All Sexual Dysfunction Diagnoses

• Symptoms have persisted for 6 months or longer
• The disorder causes clinically significant distress
• The disorder is not due to:
  • Sever relationship stress
  • Another mental disorder
  • The effects of a substance, medication, or medical condition (e.g. diabetes mellitus)

Delayed Ejaculation Diagnostic Criteria

• At least one symptom must be experienced on almost every occasion. (75%-100%) of partnered sexual activity, is the individual does not desire to delay:
  • Marked delay in ejaculation
  • Marked infrequency or absence of ejaculation

Specifications For Delayed Ejaculation

• Lifelong vs. Acquired:
  • Lifelong= present since person was sexually active
  • Acquired= began after a period of relatively normal sexual function
• Generalized vs. Situational:
  • Generalized= Not limited to certain types of stimulation, situations, or partners
  • Situational= Only occurs with certain types of stimulation, situations, or partners
• Current severity:
  • Mild= there is mild distress over the symptoms in Criterion A.
  • Moderate= there is moderate distress over the symptoms in Criterion A.
  • Severe= there is severe or extreme distress over the symptoms in Criterion A.

Erectile Disorder Diagnostic Criteria

• Experiencing at least one of the following symptoms on almost all or all (75%-100%) occasions of sexual activity:
  • 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

Specifications For Erectile Disorder

• Lifelong vs. Acquired:
  • 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 vs. Situational:
  • Generalized: Not limited to certain types of stimulation, situations, or partners
  • Situational: Only occurs with certain types of stimulation, situations, or partners Current severity:
  • Mild: Evidence of mild distress over the symptoms in Criterion A
  • Moderate: Evidence of moderate distress over the symptoms in Criterion A

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

Specifications For Female Orgasmic Disorder

• Lifelong= the disturbance has been present since the individual became sexually active
• Acquired= the disturbance began after a period of relative 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
• Never experienced an orgasm under any situation
• Severity is based distress over the symptoms in Criterion A.

Additional Info on Female Orgasmic Disorder

• Known as anorgasmia
• This disorder is difficult to asses since woman's perception, orgasm and experience are extremely varied
• Many women require clitoral stimulation to reach orgasm and a relatively small proportion of women report that they always experience orgasm during vaginal intercourse
• Many women report high levels of sexual satisfaction despite achieving orgasm

Female Sexual Interest/Arousal Disorder Diagnostic Criteria

• Lack of, or significant 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 nongenital sensations during sexual activity in almost all or all (approximately 75%- 100%) sexual encounters (in identified situational contexts, or, if generalized, in all contexts)

Specifications For Female Sexual Interest/Arousal Disorder

• 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
• Severity current is based on evidence of mild distress over the symptoms in Criterion A

Additional Info on Female Sexual Interest/Arousal Disorder

• Occurs in 1/3 of married females
• Women experience painful intercourse, sexual avoidance unsatisfying marital and sexual relationships
• 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 tension or tightening of the pelvic floor muscles during attempted vaginal penetration

Specification for Genito pelvic pain/ Penetration Disorder

• Lifelong= the disturbance has been present since the individual became sexually active
• Acquired= the disturbance began after a period of relatively normal sexual function
• Severity current is based on evidence of mild distress over the symptoms in Criterion A

Additional Info on Genito pelvic pain/ Penetration Disorder

• Women may have sufficient desire and interest in sexual activity, but only for those activities that are not painful or do not require penetration (ex: (oral sex))
• It's not unusual for women to seek treatment only when they wish to conceive
• Women experiencing superficial pain during sexual intercourse often have history of vaginal infections
• Religious and cultural factors also predispose to the disorder

Male Hypoactive Sexual Desire Disorder Diagnostic Criteria

• Persistently or recurrently deficient; Absent sexual/erotic thoughts or fantasies and desire for sexual activity
• Judgement of deficiency is made by the clinician, taking into account factors that affect sexual functioning (ex: age and general and sociocultural contexts)

Specifications For Male Hypoactive Sexual Desire Disorder

• 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
• Severity is based on evidence of mild distress over the symptoms in criterion A

Additional Info on Male Hypoactive Sexual Desire Disorder

• May occur with erectile problems or abnormal ejaculation
• They 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

Specifications For Premature Ejaculation

• 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
• Severity based on mild, moderate or severe ejaculations during vaginal penetration.

Additional Info on Premature Ejaculation

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

Substance/Medication Induced Sexual Dysfunction Diagnostic Criteria

• Clinically significant dysfunction is predominant in the clinical picture
• Hst PE and labs consistent with: develops during or soon after substance intoxication or withdrawal exposure to a medicine
• Not better explained by a sexual dysfunction that is no substance induced
• Does no preceede onset of substance use; Sx persistent after one month after dessation of acute withdrawal or severe intoxation; No evidence of hx of depressive

Additional Info on Substance/Medication Induced Sexual Dysfunction

• Decreased interest and arousal difficulties or interfere with orgasm:(Cocaine, opiates, amphetamines, sedatives, hypnotics)
• Decrease in sexual interest, cause erectile difficulties, or interfereWith orgasm. ( Antihypertensives, histamine h2 receptor Antagonist, antidepressants, anabolic steroids, stimulants, anxiolytics)
• Symptoms developed during or soon after substance intoxication or withdrawal, and after exposure to medication

Etiology of Dysfunctions

• Can be caused by factors, medications, or substances, or often happens, a combination of several factors

Etiology of Sexual Dysfunction- Causes of Desire Phase

• Physical illnesses, spinal cord injuries, or surgery
• Medications that depress the central nervous system or decrease testosterone production like SSRI's or the imbalance in testosterone, prolactin, and estrogen is not good
• Prolonged abstinence can suppress desire, or cultural standards and old age can cause issues

Psychological and Cultural Factors

• Prolonged abstinence can suppress desire
• Body image secondary to medical illness or surgery, such as mastectomy can affect sexual desire
• Cultural standards, stress, older age.
• Or lack of sexual desire- result from chronic stress, anxiety or depression, or fear or pregnancy , history of molestation or sexual abuse, depression, anxiety, lack of self esteem.

PENIS

• (Differential diagnosis acronym) Psychological, Endocrine, Neurogenic, Insufficient Blood Flow, Substances

Causes Related to Excitement Phase- Biological

• Acromegaly
• Addisons disease
• Diabetes
• Hyperthyroidism
• Hypothyroidism
• Klinefelters syndrome
• Multiple sclerosis
• Parkinson disease
• Pelvic surgery or irradiation
• Peripheral vascular disease/low blood flow
• Pituitary adenoma Spinal cord injury
• Syphilis
• Temporal lobe epilepsy
• Spinal cord injury

Causes Related to Excitement Phase- Psychological

• Anxiety disorders
• Dementia
• Major depression
• Schizophrenia

Causes Related to Excitement Phase- Medication/Drugs

• Alcohol
• Antiandrogens
• Anticholinergics
• Antidepressants
• Antihypertensives
• Antipsychotics
• Barbituates
• Finasteride
• Marijuana
• Opioids
• Stimulants

Labs to Run and Important Info

• Labs: FBS, Fasting lipid profile, Thyroid function tests, serum testosterone
• Spontaneous, natural erections occur with the mind not planning anything, like morning erections and erections with masterbation
• Noturnal penile tumescence used to measure neurogenci from psychogenic functions

Causes of Orgasic Phase-Biological

• Delayed ejaculation should be differentiated from retrograde ejaculation which the fluid travels backwards
• Effect of medication or disorders with the lumbosacral section of the spinal cord
• Medication acting in these locations affects the above
• Psychological: history of sexual abuse, guilt of pleasure in sexual relationship, depression, anxiety, relationship issues, such as unresolved conflicts or lack of trust, cultural or religious beliefs

Causes of Genito Pelvic Disorder- Biological

• This disorder creates painful sexual experiences
• Vaginal atrophy can be caused by medication, causing hormonal changes
• Or Infections such as yeast infections, pelvic issues, uterus issues, cysts, ectopic pregnancy, sex to soon after child birth/surgery, stds,
• Psychological if you have been a victim of sexual abuse, spasms, or stress and past traumas

Clinical Management of Sexual Dysfunctions

• Based on the dual-sex therapy which started in the 1960s with Master and Johnson
• Must educate the couple about how sex should function
• Look at their beliefs/ thoughts
• Awareness is key, sensate focus is the number one thing

Sensate focus- erectile disorder

• Awareness of the couple's erogenous zones must be taught

Vaginismus

• Individual therapy or medications

Premature ejaculation

• Perform the squeeze to help the men go longer.
• Start medication to help them stay hard, ssri, or the dibucaine to reduce stimulation

Medications

• Premature Ejaculation: SSRIs can be used off-label for premature (early) ejaculation
• Premenopausal women with hypoactive sexual desire disorder: Flibanserin and bremelanotide are medication to help treat
• Testosterone, used in men and women, can help increase sexual desire
• Vaginal dryness: Ospemifene (Osphena): This can help treat.

Erectile Disorder Medications

• Sildenafil, vardenafil and tadalafil are all phosphodiesterase-5 inhibitors to treat ED
• Relaxs smooth muscles that cause erections, but can also bring headaches or upset stomach
• A prostadil- used to treat erectile dyafunctuin by injecting into the pernus

Additional Medication Info

• Japan took years to register the contraceptive pill
• Two pills will cover contraception and bias