23. Sexe Flashcards
broad topics about sex
normal sexuality,
safe sex,
contraception,
sexual orientation,
sexual dysfunction
which pt are high risk for sexual dysfunction
post infarctus
pt diabétiques
pt aevc maladies chorniques
définition dysfonction érectile
Incapacité persistante ou récurrente d’obtenir et de maintenir une érection pénienne suffisamment rigide pour permettre une activité sexuelle satisfaisante pendant au moins 3 mois.
Sexual hx taking (5)
Partner/preferences/contraception
Desire/libido
Opportunity
Obtaining/maintaining erections
Orgasm, Ejaculation, Pain
Cardiac risk factors 5
smoking, diabetes, hypertension, obesity, hyperlipidemia
Other hx elements (medical)
Rx: ROH cocaine
Rx: antidepressants, antihypertensives
past Mhx
spinal cord injuries, pelvic and prostate surgery, trauma or radiation
premature ejaculation
hypogonadism
peyronie’s disease (fibrosis of penis)
Psychogenic factors 7
Nocturnal/morning erections
Erections during masturbation or with alternate partners
Situational variability (eg. improved while on vacation)
Psychosocial stressors, partner relationship
Concern about poor sexual function (performance anxiety)
Previous traumatic sexual experience
Depression
Physical exam (5 categories)
Vitals (blood pressure)
ABI
Gynecomastia
Genital exam
Decreased male hair distribution
Peyronie’s disease
Small testes
Peripheral vascular exam
Abdominal, femoral bruits
Peripheral pulses
Neurologic
Pelvic sensation
Anal sphincter tone
Prostate Exam
investigations cardiac risks
A1C
lipid profile
when to monitor testosterone
hypogonadism, young age, or suspect libido/ejaculatory disorder
what to do if low testosterone
ask for:
free testosterone
sex hormone binding globulin (SHBG) levels
prolactin (pituitary)
LH, FSH (testicular failure)
prolactin high - what to do
imaging of pituitary
testicular failure definition and what to give
High LH and FSH (aka pituitary works well)
Low T (aka testicules do not produce it)
testosterone replacement therapy if no prostate cancer (consider DRE and PSA in age >45yo)
ED tx (5)
Treat underlying medication condition (medication adherence)
Lifestyle modification (stop smoking, weight loss if overweight)
Medication review
If psychogenic cause suspected consider sex therapy/psychiatric referral AND/OR trial of medical therapy
If neurogenic or vasculogenic causes suspected consider trial of medical therapy
Rx contraindications to PDE-5 inhibitors (5)
nitrates (eg. nitroglycerin)
severe CHF
unstable angina
hypotension
recent stroke/MI
Phosphodiesterase type-5 inhibitors (PDE5-inhibitors) examples
Sildenafil (Viagra) 25, 50, 100 mg once daily 1 hour before sexual activity PRN
Tadalafil (Cialis) 5, 10, 20mg PO PRN or daily (longer half life)
Vardenafil (Levitra)
other options besides PDE-5 inhibitors
intracavernosal vasodilator injection,
vacuum erection pump device
testosterone monitoring
Surveillance for prostate cancer (yearly rectal examinations and PSA)
Detection of polycythemia (measuring hematocrit every six to 12 months)
Decrease testosterone dose if hematocrit rises above the normal range
Dyspareunia ddx 9
genitourinary syndrome of menopause
vaginismus - pelvic floor muscles contraction/dysfunction
vulvodynia - discomfort around the outer part of the female genitals
vulvar vestibulitis
PID
endometriosis
vulvar fissures
dermatose
pudendal neuralgia (dommage au nerf innervant la region)
what is vulvar vestibulitis
Type of vulvodynia
severe pain during attempted vaginal entry (intercourse or tampons insertion)
tenderness to pressure localized to the vulvar vestibule
redness of the vulvar vestibule
investigations - female
PRN
Pelvic ultrasound
STI screen
CBC, TSH, prolactin
Tx - female
Pelvic physical therapists
Sex therapist, CBT
vaginal lubricants or local estrogen
directed masturbation if anorgasmia
change Rx / adjunct
age of consent
18 years for exploitative (prostitution, pornography or relationship of trust, authority or dependency)
16 years for non-exploitative
14 years up to 5 years older
12 years up to 2 years older
