Sexual dysfunction resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[2]

Synonyms and keywords: Approach to sexual dysfunction, Approach to dyspareunia

Sexual dysfunction Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Overview

Sexual dysfunction is defined as recurrent and persistent issues with sexual response, desire, experience of pain or achieving orgasm. Sexual dysfunction often causes distress to the partners in a relationship. Sexual dysfunction conditions are broadly classified into disorders of sexual desire, arousal, orgasm and pain disorders. Treatment often includes identifying the underlying cause and treatment along with counselling and supportive care.

Causes

Disorders of sexual desire

• Psychological disorders or stress
• Advanced age
• Menopause
• Emotional distress
• Medications such as antidepressants, anxiolytics, antihypertensives

Disorders of sexual arousal

• Trauma
• Chronic disorders such as diabetes, multiple sclerosis
• Neuropathy
• Stroke
• Previous genital surgery

Disorders of orgasm

• History of sexual or emotional abuse
• Medication such as antihypertensives, anxiolytics
• Previous trauma or surgery

Disorders of sexual pain

• Endometriosis
• Pelvic inflammatory disease
• Decreased vaginal lubrication
• Sexually transmitted infections
• Vaginismus

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Sexual dysfunction according the the Journal of Sexual Medicine 2017 Opinion paper on The Diagnosis/Classification of sexual arousal concerns in women and the American College of Obstetricians and Gynecologists' Committee Practice Bulletin Summary on Sexual Dysfunction.

❑ Seek proper history, ask patients to describe in their own words, what do they mean by sexual dysfunction? ❑ This will help distinguish the various causes of sexual dysfunction. ❑ The history should also determine the characteristics, severity, and frequency of dysfunction: ❑ Onset – Abrupt or gradual, relationship to illness or life event ❑ Course – Stable, improving, or worsening <be> ❑ Duration and pattern ❑ Factors that alleviate or exacerbate it ❑ Impact on life – Causing emotional or psychological distress, marital discord? ❑ Any recent changes that the patient has made such as change in contraceptive, any other medication <be> ❑ Menstrual history including menopausal status

Rule out medical conditions such as ❑ Chronic diabetes mellitus ❑ Hypertension ❑ Hypothyroidism ❑ Depression ❑ Psychosis

Persistent lack of interest in sexual arousal

Difficulty in becoming sexually aroused or maintaining sexual arousal

Diminished ability in achieving orgasm

Pain associated with sexual activity

Other sexual concerns

Difficulty in maintaining sexual excitement

Vaginal dryness/difficulty with lubrication

Proper sexual education and counselling

Subjective Arousal disorder

Genital Sexual Arousal disorder

Painful intercourse

Pain associated with sexual stimulation

Pain with vaginal entry

Does nongenital stimulation (visual, mental) cause sexual arousal?

Dyspareunia

Non coital pain disorder

Vaginismus

High arousal but no orgasm/very delayed orgasm

Poor arousal and no orgasm

Orgasm present but minimal/low intensity

Yes

No

Genital female sexual arousal disorder

Missed diagnosis of female sexual arousal disorder

Female orgasmic disorder

Female sexual arousal disorder

Consider other investigations/diagnoses

Lack of sexual desire in response to sexual stimulation

Lack of spontaneous sexual desire

Sexual desire or Sexual interest disorder

May be normal under certain circumstances

Treatment

Shown below is an algorithm summarizing the treatment of sexual dysfunction.

Identify the cause of sexual dysfunction with thorough history and physical exam

Disorders of sexual desire

Disorders of orgasm

Disorders of sexual arousal

Disorders of sexual pain

Sexual interest/Sexual desire disorder

Genital female sexual arousal disorder

❑ Encourage communication among partners ❑ Educate patients about healthy lifestyle choices ❑ Counselling sessions with therapists who specialize in sexual dysfunction ❑ Flibanserin can be used in cases of low sexual desire/interest

❑ Hormone therapy in cases of low estrogen ❑ If the patient is on an antidepressant, changing the dose might help ❑ Counselling with the help of a sex-therapist ❑ Bremelanotide is a nasal spray which is used in sexual arousal disorder

Female orgasmic disorder

Female orgasmic disorder +/- arousal disorder

❑ Cognitive behavioural therapy ❑ Psychodynamic sex therapy ❑ Estrogen therapy in post menopausal women ❑ Testosterone therapy is experimental and has been used in some

Cognitive behavioural therapy ❑ Hormone therapy with estrogen ❑ Review of medication list, change in dosage of antidepressants ❑ Counselling ❑ Bremelanotide

Dyspareunia

Non coital pain disorder

Vaginismus

❑ Cognitive behavioural therapy ❑ Topical anesthetic creams ❑ Tricyclic antidepressants ❑ Kegel exercises

❑ Sex therapy and counselling ❑ Vaginal dilators ❑ Kegel exercises

❑ Mulitmodal approach involving a * Gynecologist * Expert in pain management * Mental health professional ❑ Tricyclic antidepressants ❑ Hormone replacement ❑ Cognitive behavioural therapy ❑ Vaginal dehydroepiandrosterone in post-menopausal patients ❑ Dyspareunia in post partum patients can be treated with * vaginal lubricants and * scar tissue massage ❑ Botulinum toxin injection ❑ Physical therapy of pelvic floor ❑ Adesiolysis in cases of adhesions

Do's

• Encourage patients to discuss sexual health with their primary care provider or obgyn.
• Referral to a psychiatrist may be needed to alleviate patient distress.
• Pelvic floor rehabilitation must be done in patients with dyspareunia.
• Encourage non coital behaviours such as massages to improve communication and understanding between partners.
• Education about sexually transmitted infections must be done to all patients.
• Early identification and treatment can help prevent PID and associated cervical motion tenderness, dyspareunia and even subsequent infertility.

Don'ts

• Don't forget to do an endocrine/hormonal evaluation in patients with sexual dysfunction.
• Oral contraceptive use can cause vaginal dryness which leads to sexual dysfunction. Don't treat patients without taking a proper and thorough drug history.
• Do not do counselling on patients alone, both involved partners must be encouraged to undergo sex education and counselling.
• Do not proceed to genital examination without properly explaining to the patient about the procedure to be done. Some patients might have severe discomfort due to vaginismus or prior trauma.

References

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