B8.069 Big Case: Sexual Dysfunction Flashcards
5 Ps of sexual dysfunction
partners (# and gender) practices (high risk) protection past history of STIs prevention of pregnancy
sexuality
complex interplay of multiple facets, including anatomical, physiological, psychological, developmental, cultural, and relational factors
sexual identity
- gender identity
- orientation
- intention
sexual function
- desire
- arousal
- orgasm
- emotional satisfaction
genital tubercle
male- glans penis
female- glans clitoris
urogenital groove
male- urethral opening
female- vaginal + urethral opening
urogenital folds
male- urethra
female- labia minora
lateral tubercle
male- penile shaft
female- clitoral shaft
genital swelling
male- scrotum
female- labia majora
importance of the glans
greatest concentration of sensory nerves
contiguous with corpus spongiosum
corpus spongiosum
houses the urethra
corpus cavernosum
erectile bodies
- crus: split of the corpora over the urethra
- tunica albuginea: fibrous wrapping of the corpora cavernosa
describe the tunica albuginea
strong, fibrous tissue
2 layers
traps blood during erection
what is unique about the anterior scrotal artery compared with the rest of the male vascular anatomy
comes off of the femoral artery
rest of arteries arise from internal pudendal
has implications in testicular cancer spread (inguinal nodes)
mechanisms of pelvic artery damage that can impact sexual function due to downstream effects
pelvic fracture
pelvic radiation
dorsal penile artery
glans filling during erection
cavernosal artery
corporal filling during erection
bulbar/urethral artery
corpus spongiosum filling during erection
sympathetic pathway of the penis
SHOOT
T10-12 fibers innervate the penis
white rami > sympathetic ganglia > inferior mesenteric and superior hypogastric plexus > hypogastric nerves > pelvic (inferior hypogastric) plexus
distal fibers of the penile sympathetic pathways
form prostatic plexus and cavernous nerves
- responsible for detumescence
- plays a role in emission/ejaculation
parasympathetic pathway of the penis
POINT
S2,3,4 intermediolateral cells
pelvic nerve > pelvic (inferior hypogastric) plexus, joined by sympathetic fibers > prostatic plexus and cavernous nerves
function of parasympathetic pathway of the penis
responsible for erections
plays a role in secretion of seminal fluids
afferent sensory nerves of the penis
innervate skin of glans, penile skin, urethra
dorsal nerve of the penis
-sensory branch of the internal pudendal nerve
efferent motor nerves of the penis
Onuf’s nucleus of S2,3,4
- motor branch of the internal pudendal nerve
- ischiocavernosus muscles (rigid erection phase)
- bulbospongiosus muscle = rhythmic contraction in ejaculation
components of central control of sexual function
cerebral cortex- how we perceive sex
limbic system- how we feel about sex
hypothalamus- stimulation results in arousal
components of the limbic system involved in sexual function
amygdala: larger in men
- visual stimuli men»_space;> women
components of the hypothalamus involved in sexual function
medial preoptic area (MPOA) -sexual stimuli are summated >dopamine facilitates sexual behavior >triggers autonomic pathway for erection -gonadotropin RH cell bodies
phases of the male sexual response
excitement (arousal) plateau orgasm resolution -contains refractory period
excitement phase in men
partial erection
elevation of scrotum
vasocongestion of the skin (sex flush)
plateau phase in men
increased HR, increased circulation, increased respiration
perspiration
secretions by Cowper’s gland
bladder neck contracts
orgasm phase in men
cyclic muscle contraction of pelvic musculature
euphoria
ejaculation
resolution phase in men
decreased tumescence to 50% of erect state
refractory period where another erection can’t be achieved (increases with age)
return to flaccid state
types of erections
psychogenic
reflexogenic
nocturnal
psychogenic erections
controlled by cerebral cortex
stimuli: sight, smell, hearing, and fantasy
thoracolumbar erection center (T10-L2)
reflexogenic erections
reflex pathway through direct genital stimulation
sacral erection center (S2-4)
nocturnal erections
REM sleep dreaming
-reduction of sympathetic activity
-increased parasympathetic activity
useful to determine psychogenic ED vs. physiological ED (if person still gets morning erections, machinery is working ok)
hemodynamics of flaccid penis
sympathetic input: smooth muscle in cavernosal tissue is contracted
reduced arterial blood blow
blood flow to penis is minimal (must keep tissue alive)
flaccid penis length variable
-not predictive of overall erectile length
-influenced by temperature and emotion
hemodynamics of erection
- cavernous nerve stimulation results in relaxation of smooth muscle
- arteriole dilation increased blood flow into sinusoids
- increased sinusoidal pressure causes venous compression and decreases venous outflow
- subtunical venous plexus compressed against tunica albuginea
- stretched tunica further compresses emissary veins
- ischiocavernous muscles contract to increase penile pressure (creates rigid erection phase)
what is the importance of the nitric oxide pathway?
causes cavernous smooth muscle relaxation = erection
release of NO in cavernous smooth muscle
parasympathetic cavernosal nerves allow for:
- direct NO release
- release of ACh, which stimulates endothelial cells to release more NO
steps of the NO pathway
- NO > cGMP production
- protein kinase G activated
- K+ channels open, Ca2+ channels close
- decreased intracellular Ca2+ levels
- smooth muscle relaxation
mechanisms of PDE5 inhibitors
cGMP is degraded by PDE5 which eventually restores cell increased muscle tone
when PDE5 is INHIBITED
-decreased cGMP breakdown
-continues state of smooth muscle relaxation
unique characteristics of sildenafil
viagra
blue visual hue due to cross reactivity with PDE6 in retina
unique characteristics of tadalafil (cialis)
longest half life (17.5 hrs)
“weekend pill”
muscle leg/back aches in 9%
avanafil (stendra)
fastest onset of 15 min
can take with alcohol
general side effects of PDE5 inhibitors
mostly vasodilation
- headache (16%)
- flushing (10%)
- heart burn
- visual effects (3%); generally transient and mild to moderate
- sinus pressure
contraindications for PDE5 inhibitors
a blockers
nitrates
will cause a drop in BP when combined
injectable ED meds
papaverine: general PDE inhibitor
-increased cGMP and cAMP
prostaglandin PGE1
-increases cAMP
what is priapism
erection lasting more than 4 hours
blood becomes trapped in the penis
-lack of circulation causes ischemic damage of the cavernosal issue
priapism from ED drugs
rare with PDE5 inhibitors
more common with injectables
treatment of priapism
irrigation of corpora with normal saline
injection of sympathomimetics (phenylephrine)
-a adrenergic agonist
main physical causes of ED
- vascular
- diabetes
- meds
- pelvic surgery, radiation, or trauma
- neurologic causes
- endocrine problems
relationship between ED and CAD
men with ED have higher prevalence of CAD risk factors than men without ED
phases of erection
- flaccid
- latent (filling) phase
- tumescent phase
- full erection phase
- rigid erection phase
- detumescence
flaccid phase
cavernosal smooth muscle contracted
sinusoids empty
minimal arterial flow
latent (filling) phase
increased pudendal artery flow, penile elongation
tumescent phase
rising intracavernosal pressure; erection forming
full erection phase
increased cavernosal pressure (100 mmHg) causes penis to become full erect
rigid erection phase
further increases in pressure (several hundred mmHg) + ischiocavernosal muscle contraction
detumescence phase
following ejaculation, sympathetic discharge resumes
smooth muscle contraction and vasocontriction
reduced arterial flow
blood is expelled from sinusoidal spaces
emission
secretion of seminal components by seminal vesicles, prostate, ampulla
-stimulated by parasympathetics
expulsion
forceful propulsion of semen out the urethra
- bladder neck contracts to prevent retrograde flow (sympathetic)
- contraction of bulbospongiosus (pudendal motor neurons, S2-4)
orgasm
cerebral processing of pudendal nerve sensory stimuli
dopamine and ejaculation
promotes
serotonin and ejaculation
inhibits
ejaculation disorders
premature ejaculation
anejaculation
retrograde ejaculation
premature ejaculation
ejaculation occurs sooner than desires by him or partner
- low serotonin plays a role (can use SSRI)
- behavior modification
- numbing cream or spray
anejaculation
failure of ejaculation
- spinal cord injury, diabetes
- surgical resection
retrograde ejaculation
ejaculation into the bladder
- prostate surgery and BPH treatments
- a blockers- relax bladder neck
meds that can cause male sexual dysfunction
anti psychotics (increased prolactin, decreased dopamine)
B blockers
anti depressants (SSRIs)
narcotics (suppress GnRH, decrease T)
effects of aging on male sexual function
increased refractory period, decreased recurrent sex
increased rates of ED
decreased GnRH > decreased T > less libido
internal pudendal vessels of the female
supply the distal 1/3 of the vagina
vulvar vascular anatomy
from bottom to top: inferior rectal artery internal pudendal artery gives off: 1. perineal artery 2. artery to the vestibular bulb 3. deep artery of the clitoris
neuroanatomy of female pelvis
pudendal nerve supplies clitoris and erectile bodies
S2-4 somatic nerve
indications for pudendal nerve blocks
2nd stage of labor
episiotomy repair
minor surgery of lower vagina and perineum
function of pudendal nerve blocks
reduces sensation in the genitalia, urethra, anus, and perineum
largely replaced in modern era by spinal anesthesia
technique for pudendal block
- lithotomy position
- palpate ischial spine transvaginally
- needle guide used to prevent over injection; place at tip of ischial spine
- 3 injections
- mucosal wheel
- advance 1 cm into sacrospinous ligament (target 1cm medial and 1 cm posterior to ischial spine)
- advance 1 cm past sacrospinous ligament
function of ischiocavernosus in females
increases pressure in the clitoris
variations in the female sexual response
doesnt have a refractory period, but only about 20% can get multiple orgasms
3 main outcomes:
1. multiple orgasms > resolution
2. stays at plateau and never reaches orgasm > resolution
3. reaches orgasm and has resolution right after
components of the female sexual response
willingness to become aroused
sensation of desire
vascular and neuro structures are analogous to erectile tissue in the male
excitement phase in women
central arousal due to stimuli
increased HR, breathing, BP
sex flush (more common in women)
engorgement of venous plexus of lower vagina
-erectile bulbs of the vestibule swell
-labia expands
clitoris enlarges
-NO mediated pathway
uterus elevates and vaginal lubrication begins
-transudative process, not glandular secretions
plateau phase in women
breast enlargement continues
clitoris elevates, retracting under the hood
tenting of uterus to allow sperm entry
more increase in HR, breathing, and BP
orgasmic phase in women
release of sexual tension peak HR, breathing, BP 5-10 rhythmic contractions of vaginal, uterine, anal, and abdominal musculature -2 to 4 seconds after orgasm -0.8 second interval
resolution phase in women
sex flush resolves vitals return to normal breasts and vulva return to normal size no refractory period -multiple orgasms can occur in some women
definition of female sexual dysfunction
failure of 1 or more phases of sexual response
-generally must include distress
up to 32% of women in a year
subtypes of female sexual dysfunction
- primary (lifelong) vs secondary (acquired)
- generalized vs situational
- origin: organic, psychogenic, mixed, unknown
classes of female sexual dysfunction
sexual desire disorders -hypoactive sexual desire disorder -sexual aversion disorder sexual arousal disorder orgasmic disorder sexual pain disorders -dyspareunia -vagismus
hypoactive sexual desire disorder (HSDD)
persistent or deficient sexual fantasies or desire for sexual activity
often psychosocial
-depression
-lack of time
-emotional stressors
-life changes
*rule out difference in partner’s sexual appetite
treatment of HSDD
psychotherapy, sex therapy often helpful
rule out substance induced sexual dysfunction (anti-psychotics, B blockers, anti depressants, opioids)
rule out sexual disorders due to medical condition
medical conditions than can cause sexual disorders
hypothyroidism CAD > fear of triggering an MI renal failure (high prolactin) incontinence neuro disease > direct damage to areas responsible for processing stimuli menopause
sexual aversion disorder (SAD)
rare severe aversion to genital contact must have associated pscyhophysiological diagnosis -anxiety -often associated with trauma personal aversion (poor self worth)
treatment of SAD
counseling
antidepressants
general treatment strategies in desire disorders
counseling / reduction of stressors
T therapy controversial in women
-increased fantasy, desire, and satisfaction with sex
-risk of virilization
estrogen supplementation in postmenopausal women
-increased genital sensitivity, increased libido, decreased dryness
amphetamines
-increased D2 secretion, increased desire
buproprion
-NE and D2 reuptake inhibitor
-increased dopamine
what is Filbanserin
only FDA approved med for HSDD
-multifunctional serotonin agonist and antagonist
-approved in premenopausal, unlabeled in postmenopausal
increases # of sexual satisfying events per month
avoid alcohol
sexual arousal disorder
inability to maintain sufficient sexual excitement to complete sexual activity
causes of sexual arousal disorder
- depression, low self esteem, stress, anxiety
- medication, low E
- postmenopausal atrophic vaginitis
- skin disorder of the genital skin
treatment of sexual arousal disorder
psychogenic causes -cognitive behavioral therapy -improving relationship stressors -stopping SSRI, SNRI vaginal atrophy -topical estrogen sildenafil -conflicting results
orgasmic disorder
persistent delay or absence attaining orgasm with sufficient stimulation and arousal
primary: associated with trauma or abuse
secondary: associated with HSDD, pelvic surgery, drugs
treatment of orgasmic disorder
cognitive behavior therapy
-benefit in symptom severity and sexual satisfaction
no pharm treatments
dyspareunia
recurrent genital pain associated with intercourse
vaginismus
recurrent involuntary spasm of musculature in distal 1/3 of vagina that prevents vaginal penetration
psychogenic - anticipation of pain associated with sex
rule out medical causes
onset sexual pain disorders
lifelong: congenital or psychological etiology
new onset: MSK, pelvic, genital, dermatological
causes of superficial sexual pain
vulvovaginal atrophy injury/trauma inflammation or infection vestibulodynia/vulvar vestibulitis vulvar skin disease (lichen sclerosis)
deep sexual pain disorders
endometriosis interstitial cystitis uterine fibroids vaginal prolapse adnexal pathology (ovarian cyst or neoplasm) myofascial pain
relationship between female sexual function and menopause
no clear evidence less easily aroused and less genital sensitivity decreased blood flow to vagina -reduced lubrication atrophy and stenosis of vaginal canal
