Sexual Dysfunction: Diagnosis & Treatment

General Objective

• Patients experiencing sexual dysfunction, including delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain disorder, male hypoactive sexual desire disorder, premature ejaculation, or substance/medication-induced disorder can be diagnosed.
• Recommend initial treatment intervention as it applies to general medical practice.

Specific Objectives

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

Sexual Human Response

• The desire phase lasts minutes to hours where sexual fantasies and a desire for sexual intimacy occur.
• The excitement phase consists of a subjective sense of pleasure and accompanying physiological changes.
• The orgasm phase consists of a peaking of sexual pleasure, with release of sexual tension and rhythmic contractions of the perineal muscles and reproductive organs.
• The resolution phase consists of a sense of muscular relaxation and general well-being.

Epidemiology of Sexual Dysfunction

• Desire and arousal dysfunctions are the most frequent sexual dysfunctions for women.
• A large proportion of women experience multiple sexual dysfunctions.
• Premature ejaculation and erectile dysfunction are the most common sexual dysfunctions for men.
• Sexual dysfunction has less comorbidity in men compared with women.
• Female sexual dysfunction rates of 38%
• Male sexual dysfunction rates of 29%
• Male who have sex with male (MSM) 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

• Types of sexual dysfunctions include delayed ejaculation disorder, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito pelvic pain disorder, male hypoactive sexual disorder, premature ejaculation (early), and substance medication-induced sexual disorder.
• Sexual human response disorders by phase.
• Desire: Male hypoactive sexual disorder and female sexual interest/arousal disorder.
• Excitement: Erectile dysfunction and female sexual interest/arousal disorder.
• Orgasm: Female orgasmic disorder, and premature ejaculation
• DSM 5 criteria for all include these factors.
• Symptoms have persisted for 6 months or longer.
• The disorder causes clinically significant distress.
• The disorder is not due to severe relationship stress, to another mental disorder, or to the effects of a substance, medication, or medical condition such as diabetes mellitus.
• Two 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 with the individual desiring delay.

Delayed Ejaculation

• Requires two symptoms experienced on almost all or all occasions, about 75%-100%, of partnered sexual activity and without the individual delaying
• The diagnostic criteria require either marked delay in ejaculation or marked infrequency or absence of ejaculation.
• Specifiers include:
  • Lifelong: Disturbance has been present since the individual became sexually active.
  • Acquired: 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: Mild, moderate, or severe based on distress related to symptoms in Criterion A.

Erectile disorder

Diagnostic criteria include at least one of the following:

• 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.
• Requires at least one of the symptoms experienced should be on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts). Specifiers include:
  • Lifelong: Disturbance has been present since the individual became sexually active.
  • Acquired: 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: Mild, moderate, or severe based on distress related to symptoms in Criterion A.

Female Orgasmic Disorder

• Diagnostic criteria includes presence of either the following symptoms on almost all or all (approximately 75%-100%) occasions of sexual activity
  • Marked delay in, marked infrequency of, or absence of orgasm is a sign
  • Markedly reduced intensity of orgasmic sensations are also indicative Specifiers include:
  • Lifelong: Disturbance has been present since the individual became sexually active.
  • Acquired: 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.
  • If applicable, specify if never experienced an orgasm under any situation.
  • Current severity: Mild, moderate, or severe based on distress related to symptoms in Criterion A.
• Female orgasmic disorder facts:
  • It is better known as anorgasmia
  • The experience or orgasm is diminished, delayed, or even absent on almost all occasions of sexual activity
  • The disorder is difficult to assess because experiences are extremely varied
  • 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 achieving orgasm.

Female Sexual Interest/Arousal Disorder

• Diagnosis includes if at least three of the following occur
  • Lack of or significantly reduced, sexual interest/arousal.
  • Manifested by 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%) of sexual encounters
  • 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. Specifiers include:
  • Lifelong: Disturbance has been present since the individual became sexually active.
  • Acquired: 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: Mild or moderate.
• Female sexual interest/arousal disorder facts:
  • It occurs in 1/3 of married females.
  • Women may experience painful intercourse, sexual avoidance, and unsatisfying sexual relationships.
  • Temporary low sexual interest can result from stressful situations, such as overwork or lack of privacy.

Genito-Pelvic Pain/Penetration Disorder

• Diagnosis includes recurrent difficulties with one or more specified factors. - Vaginal penetration during intercourse is a factor - 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 can also indicate the disorder Specifier include:
  • Lifelong: Disturbance has been present since the individual became sexually active.
  • Acquired: Disturbance began after a period of relatively normal sexual function.
  • Current severity: Mild, moderate, or severe based on distress related to symptoms in Criterion A.
  • Genito pelvic pain disorder facts: - 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 (e.g., oral sex). - 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 can also predispose toward the disorder.

Male Hypoactive Sexual Desire Disorder

• Fact: May co-occur with erectile problems or abnormal ejaculation.
• Requires a diagnosis where deficits are persistent or recurrent.
• Includes signs of deficient or absent sexual/erotic thoughts or fantasies and desire for sexual activity.
• Must be judged by the clinician, based on factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual's life. Specifier include:
  • Lifelong: Disturbance has been present since the individual became sexually active.
  • Acquired: 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: Mild or moderate based on distress related to symptoms in Criterion A.
• People with this disorder may no longer initiate sexual activity and may be minimally receptive to a partner's attempts to initiate sexual activity.

Premature Ejaculation

• The persistent or recurrent pattern of ejaculation occurs during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it.

• The diagnosis may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for those activities. Specifier include:

  • Lifelong: Disturbance has been present since the individual became sexually active.
  • Acquired: 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: Mild, moderate, or severe based on distress related to symptoms in Criterion A.

• Current Severity:

• Mild: Ejaculation occurring within approximately 30 seconds to 1 minute of vaginal penetration.

• Moderate: Ejaculation occurring within approximately 15-30 seconds of vaginal penetration.

• Severe: Ejaculation occurring prior to sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration

• Between 20%-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.

Substance/ Medication Induced Sexual Dysfunction

• Substance/medication facts:

  • Clinically significant dysfunction.
  • A sexual dysfunction is diagnosed when:
    • It is clinically significant
    • Predominates in the clinical picture
    • History, physical, and labs are consistent with symptom.
    • The condition arises from withdrawal/intoxication or from substance use.
    • The substance is known to be able to produce the symptom.
  • The condition is diagnosed when:
    • It's not better explained by an independent sexual dysfunction,
    • Intoxication symptoms do not precede substance use
    • Symptoms do not continue for a month or more after the cessation of acute withdrawal or severe intoxication

• Substances/Medications associated with this can:

  • Decrease sexual interest and cause arousal difficulties or interfere with orgasm. Cocaine, opiates, amphetamines, sedatives, hypnotics.
  • Decrease sexual interest, cause erectile difficulties, or interfere with orgasm. Antihypertensives, histamine h2 receptor antagonists, antidepressants, anabolic steroids, stimulants, and anxiolytics.
  • Symptoms develop during or soon after substance intoxication, withdrawal, or after exposure to a medication.

Etiology

• Sexual dysfunction is a multifaceted condition

• It presents with: medication use, medical use and psychological factors

• Biological causes of issues in the desire phase may include:

  • Physical illnesses
  • Spinal cord injury
  • Surgery
  • Medications that either depress the central nervous system
  • Medications that decrease testosterone production such as SSRI, imbalance in testosterone, prolactin and estrogen.

• Psychological/cultural causes include:

  • Prolonged abstinence
  • Body image secondary to medical illness or surgery such as mastectomy
  • Cultural standards -Stress
  • Older age
  • Lack of sexual desire- result from chronic stress, anxiety or depression
  • Fear or pregnancy _History of molestation or sexual abuse, depression, anxiety, lack of self esteem

• Penises causes of issues in disorders:

  • Psychological (if nighttime erections still occur)

• Endocrine (eg, diabetes, low testosterone)

  • Neurogenic (eg)
  • Insufficient blood flow (eg, atherosclerosis)
  • Substances (eg, antihypertensives, antidepressants, ethanol)

• Cases related to excitement phase causes in

  • 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)
  • Spinal cord injury
  • Syphilis
  • Temporal lobe epilepsy -Anxiety disorders -Dementia -Major depression
  • Schizophrenia -Medications and drugs causes -Alcohol -Antiandrogens -Anticholinergics -Antidepressants -Antihypertensives (especially centrally acting ones) -Antipsychotics -Barbiturates -Finasteride -Marijuana -Opioids S -Stimulants -Laboratory work up:
    • FBS
    • Fasting lipid profile
    • Thyroid function tests
    • Serum testosterone

• Important to determine whether spontaneous erections occur at times when the man does not plan to intercourse (morning erection, erections with masturbation). If erections occur at these times, the disorder is more likely to have a psychological origin.

• Nocturnal penile tumescence testing has been used in the past as a means of separating neurogenic from psychogenic erectile dysfunction. -If an individual with erectile dysfunction was documented attain a full erection while sleeping, a psychogenic basis for the erectile dysfunction was presumed to be present. However, it has been recognized more recently that such test results can be unreliable and even misleading.

• Causes of orgasmic phase include: -Biological: -Delayed ejaculation must be differentiated from retrograde ejaculation, in which ejaculation occurs but the seminal fluid passes backward into the bladder. -Both the delayed ejaculation and retrograde ejaculation can have a physiological cause, such as the effects of medication, genitourinary surgery or neurological disorders involving the lumbosacral section of the spinal cord. -Associated medications centrally acting antihypertensives, tricyclic antidepressants and antipsychotics. -Psychological/cultural: -History of sexual abuse -Guilt of pleasure in a sexual relationship, -Depression, anxiety, relationship issues - Such as unresolved conflicts or lack of trust, cultural or religious beliefs

• Causes of Genito Pelvic disorder:

  • Biological
    • The disorder combines dyspareunia and vaginismus, which involves painful sex and vaginal muscle spasms -Vaginal atrophy - The vaginal lining can lose its normal moisture and thickness and became dry, then and inflamed and can be caused by medication, menopause or other hormonal changes -Infections: vaginal yeast infections, pelvic inflammatory disease
    • Problems with the uterus: fibroids that can cause deep intercourse pain endometriosis problems with the ovaries
    • Ovarian cysts
    • Ectopic pregnancy
    • Intercourse too soon after surgery or childbirth
    • Sexually transmitted infections
    • Vulvodynia
    • Injury to the vulva or vagina

• Psychological issues:

  • If you have been victims of sexual abuse can contribute to pain during sex

• Vaginismus: The fear of being hurt or prior trauma, can cause a sperm of the vaginal muscles

Clinical Management of Sexual Dysfunctions

• Masters and Johnson pioneered dual-sex therapy in the 1960s.
  • Treatment begins with educating the couple about normal sexual functioning.
  • Then evaluating their ability to communicate about sex and intimacy
  • Corrections of irrational beliefs and dysfunctional thoughts are important
  • Sensate Focus-For the erectile disorder, the couple is assigned non-genital caressing to gradually increase awareness of the couple’s erogenous zones.
  • For female orgasmic disorder therapy may involve training the woman to first have an orgasm by masturbation before treating the couple.
  • Therapy and or medication help some people who experience vaginismus
    • Individual therapy
    • Meditation or other relaxation exercises,
  • 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 seconds -Place the thumb on the frenulum and two fingers on the opposite side.

Medications

• Premature Ejaculation: off-label SSRIs (e.g., paroxetine, 20 mg/day); 1% dibucaine (Nupercaine) ointment applied to the coronal ridge and frenulum of the penis.
• Premenopausal women with hypoactive sexual desire disorder:Flubaserin (Addyi) and bremelatonide (Vyleesi) are U.S. Food and Drug Administration (FDA) approved medication
  • Use in inconsistent in clear cases of hypogonadism
• Vaginal dryness: Ospemifene (Osphena), a nonhormonal treatment, is FDA approved.
• Erectile disorder: sildenafil, vardenafil, and tadalafil are all FDA approved.
  • They enhance the effects of nitric oxide (relaxes smooth muscles and increases blood flow in the penis, allowing an erection to develop in response to sexual arousal).
• Each of these medications has side effects that include these disorders and/or side effects: -Headaches -Upset stomach -Nausea, -Muscle aches -In rare occasions: -Priapism
• A synthetic prostaglandin for erectile dysfunction is applied with a special syring either at the base/side of penis or placed in the urethrea Surgical treatments:
• Surgical treatments are indicated for patients with: -Inaffective erectile disorder -vacuum pump device that produces an erection, by increasing blood flow to the penis