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RDS Test 4 > B8.069 Big Case: Sexual Dysfunction > Flashcards

B8.069 Big Case: Sexual Dysfunction Flashcards

1
Q

5 Ps of sexual dysfunction

A 
partners (# and gender)
practices (high risk)
protection
past history of STIs
prevention of pregnancy
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2
Q

sexuality

A

complex interplay of multiple facets, including anatomical, physiological, psychological, developmental, cultural, and relational factors

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3
Q

sexual identity

A
  1. gender identity
  2. orientation
  3. intention
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4
Q

sexual function

A
  1. desire
  2. arousal
  3. orgasm
  4. emotional satisfaction
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5
Q

genital tubercle

A

male- glans penis

female- glans clitoris

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6
Q

urogenital groove

A

male- urethral opening

female- vaginal + urethral opening

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7
Q

urogenital folds

A

male- urethra

female- labia minora

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8
Q

lateral tubercle

A

male- penile shaft

female- clitoral shaft

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9
Q

genital swelling

A

male- scrotum

female- labia majora

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10
Q

importance of the glans

A

greatest concentration of sensory nerves

contiguous with corpus spongiosum

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11
Q

corpus spongiosum

A

houses the urethra

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12
Q

corpus cavernosum

A

erectile bodies

  • crus: split of the corpora over the urethra
  • tunica albuginea: fibrous wrapping of the corpora cavernosa
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13
Q

describe the tunica albuginea

A

strong, fibrous tissue
2 layers
traps blood during erection

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14
Q

what is unique about the anterior scrotal artery compared with the rest of the male vascular anatomy

A

comes off of the femoral artery
rest of arteries arise from internal pudendal
has implications in testicular cancer spread (inguinal nodes)

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15
Q

mechanisms of pelvic artery damage that can impact sexual function due to downstream effects

A

pelvic fracture

pelvic radiation

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16
Q

dorsal penile artery

A

glans filling during erection

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17
Q

cavernosal artery

A

corporal filling during erection

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18
Q

bulbar/urethral artery

A

corpus spongiosum filling during erection

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19
Q

sympathetic pathway of the penis

A

SHOOT
T10-12 fibers innervate the penis
white rami > sympathetic ganglia > inferior mesenteric and superior hypogastric plexus > hypogastric nerves > pelvic (inferior hypogastric) plexus

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20
Q

distal fibers of the penile sympathetic pathways

A

form prostatic plexus and cavernous nerves

  • responsible for detumescence
  • plays a role in emission/ejaculation
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21
Q

parasympathetic pathway of the penis

A

POINT
S2,3,4 intermediolateral cells
pelvic nerve > pelvic (inferior hypogastric) plexus, joined by sympathetic fibers > prostatic plexus and cavernous nerves

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22
Q

function of parasympathetic pathway of the penis

A

responsible for erections

plays a role in secretion of seminal fluids

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23
Q

afferent sensory nerves of the penis

A

innervate skin of glans, penile skin, urethra
dorsal nerve of the penis
-sensory branch of the internal pudendal nerve

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24
Q

efferent motor nerves of the penis

A

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
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25
Q

components of central control of sexual function

A

cerebral cortex- how we perceive sex
limbic system- how we feel about sex
hypothalamus- stimulation results in arousal

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26
Q

components of the limbic system involved in sexual function

A

amygdala: larger in men

- visual stimuli men&raquo_space;> women

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27
Q

components of the hypothalamus involved in sexual function

A 
medial preoptic area (MPOA)
-sexual stimuli are summated
>dopamine facilitates sexual behavior
>triggers autonomic pathway for erection
-gonadotropin RH cell bodies
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28
Q

phases of the male sexual response

A 
excitement (arousal)
plateau
orgasm
resolution
-contains refractory period
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29
Q

excitement phase in men

A

partial erection
elevation of scrotum
vasocongestion of the skin (sex flush)

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30
Q

plateau phase in men

A

increased HR, increased circulation, increased respiration
perspiration
secretions by Cowper’s gland
bladder neck contracts

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31
Q

orgasm phase in men

A

cyclic muscle contraction of pelvic musculature
euphoria
ejaculation

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32
Q

resolution phase in men

A

decreased tumescence to 50% of erect state
refractory period where another erection can’t be achieved (increases with age)
return to flaccid state

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33
Q

types of erections

A

psychogenic
reflexogenic
nocturnal

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34
Q

psychogenic erections

A

controlled by cerebral cortex
stimuli: sight, smell, hearing, and fantasy
thoracolumbar erection center (T10-L2)

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35
Q

reflexogenic erections

A

reflex pathway through direct genital stimulation

sacral erection center (S2-4)

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36
Q

nocturnal erections

A

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)

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37
Q

hemodynamics of flaccid penis

A

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

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38
Q

hemodynamics of erection

A
  1. cavernous nerve stimulation results in relaxation of smooth muscle
  2. arteriole dilation increased blood flow into sinusoids
  3. increased sinusoidal pressure causes venous compression and decreases venous outflow
  4. subtunical venous plexus compressed against tunica albuginea
  5. stretched tunica further compresses emissary veins
  6. ischiocavernous muscles contract to increase penile pressure (creates rigid erection phase)
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39
Q

what is the importance of the nitric oxide pathway?

A

causes cavernous smooth muscle relaxation = erection

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40
Q

release of NO in cavernous smooth muscle

A

parasympathetic cavernosal nerves allow for:

  • direct NO release
  • release of ACh, which stimulates endothelial cells to release more NO
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41
Q

steps of the NO pathway

A
  1. NO > cGMP production
  2. protein kinase G activated
  3. K+ channels open, Ca2+ channels close
  4. decreased intracellular Ca2+ levels
  5. smooth muscle relaxation
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42
Q

mechanisms of PDE5 inhibitors

A

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

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43
Q

unique characteristics of sildenafil

A

viagra

blue visual hue due to cross reactivity with PDE6 in retina

44
Q

unique characteristics of tadalafil (cialis)

A

longest half life (17.5 hrs)
“weekend pill”
muscle leg/back aches in 9%

45
Q

avanafil (stendra)

A

fastest onset of 15 min

can take with alcohol

46
Q

general side effects of PDE5 inhibitors

A

mostly vasodilation

  • headache (16%)
  • flushing (10%)
  • heart burn
  • visual effects (3%); generally transient and mild to moderate
  • sinus pressure
47
Q

contraindications for PDE5 inhibitors

A

a blockers
nitrates
will cause a drop in BP when combined

48
Q

injectable ED meds

A

papaverine: general PDE inhibitor
-increased cGMP and cAMP
prostaglandin PGE1
-increases cAMP

49
Q

what is priapism

A

erection lasting more than 4 hours
blood becomes trapped in the penis
-lack of circulation causes ischemic damage of the cavernosal issue

50
Q

priapism from ED drugs

A

rare with PDE5 inhibitors

more common with injectables

51
Q

treatment of priapism

A

irrigation of corpora with normal saline
injection of sympathomimetics (phenylephrine)
-a adrenergic agonist

52
Q

main physical causes of ED

A
  1. vascular
  2. diabetes
  3. meds
  4. pelvic surgery, radiation, or trauma
  5. neurologic causes
  6. endocrine problems
53
Q

relationship between ED and CAD

A

men with ED have higher prevalence of CAD risk factors than men without ED

54
Q

phases of erection

A
  1. flaccid
  2. latent (filling) phase
  3. tumescent phase
  4. full erection phase
  5. rigid erection phase
  6. detumescence
55
Q

flaccid phase

A

cavernosal smooth muscle contracted
sinusoids empty
minimal arterial flow

56
Q

latent (filling) phase

A

increased pudendal artery flow, penile elongation

57
Q

tumescent phase

A

rising intracavernosal pressure; erection forming

58
Q

full erection phase

A

increased cavernosal pressure (100 mmHg) causes penis to become full erect

59
Q

rigid erection phase

A

further increases in pressure (several hundred mmHg) + ischiocavernosal muscle contraction

60
Q

detumescence phase

A

following ejaculation, sympathetic discharge resumes
smooth muscle contraction and vasocontriction
reduced arterial flow
blood is expelled from sinusoidal spaces

61
Q

emission

A

secretion of seminal components by seminal vesicles, prostate, ampulla
-stimulated by parasympathetics

62
Q

expulsion

A

forceful propulsion of semen out the urethra

  • bladder neck contracts to prevent retrograde flow (sympathetic)
  • contraction of bulbospongiosus (pudendal motor neurons, S2-4)
63
Q

orgasm

A

cerebral processing of pudendal nerve sensory stimuli

64
Q

dopamine and ejaculation

A

promotes

65
Q

serotonin and ejaculation

A

inhibits

66
Q

ejaculation disorders

A

premature ejaculation
anejaculation
retrograde ejaculation

67
Q

premature ejaculation

A

ejaculation occurs sooner than desires by him or partner

  • low serotonin plays a role (can use SSRI)
  • behavior modification
  • numbing cream or spray
68
Q

anejaculation

A

failure of ejaculation

  • spinal cord injury, diabetes
  • surgical resection
69
Q

retrograde ejaculation

A

ejaculation into the bladder

  • prostate surgery and BPH treatments
  • a blockers- relax bladder neck
70
Q

meds that can cause male sexual dysfunction

A

anti psychotics (increased prolactin, decreased dopamine)
B blockers
anti depressants (SSRIs)
narcotics (suppress GnRH, decrease T)

71
Q

effects of aging on male sexual function

A

increased refractory period, decreased recurrent sex
increased rates of ED
decreased GnRH > decreased T > less libido

72
Q

internal pudendal vessels of the female

A

supply the distal 1/3 of the vagina

73
Q

vulvar vascular anatomy

A 
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
74
Q

neuroanatomy of female pelvis

A

pudendal nerve supplies clitoris and erectile bodies

S2-4 somatic nerve

75
Q

indications for pudendal nerve blocks

A

2nd stage of labor
episiotomy repair
minor surgery of lower vagina and perineum

76
Q

function of pudendal nerve blocks

A

reduces sensation in the genitalia, urethra, anus, and perineum
largely replaced in modern era by spinal anesthesia

77
Q

technique for pudendal block

A
  1. lithotomy position
  2. palpate ischial spine transvaginally
  3. needle guide used to prevent over injection; place at tip of ischial spine
  4. 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
78
Q

function of ischiocavernosus in females

A

increases pressure in the clitoris

79
Q

variations in the female sexual response

A

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

80
Q

components of the female sexual response

A

willingness to become aroused
sensation of desire
vascular and neuro structures are analogous to erectile tissue in the male

81
Q

excitement phase in women

A

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

82
Q

plateau phase in women

A

breast enlargement continues
clitoris elevates, retracting under the hood
tenting of uterus to allow sperm entry
more increase in HR, breathing, and BP

83
Q

orgasmic phase in women

A 
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
84
Q

resolution phase in women

A 
sex flush resolves
vitals return to normal
breasts and vulva return to normal size
no refractory period
-multiple orgasms can occur in some women
85
Q

definition of female sexual dysfunction

A

failure of 1 or more phases of sexual response
-generally must include distress
up to 32% of women in a year

86
Q

subtypes of female sexual dysfunction

A
  • primary (lifelong) vs secondary (acquired)
  • generalized vs situational
  • origin: organic, psychogenic, mixed, unknown
87
Q

classes of female sexual dysfunction

A 
sexual desire disorders
-hypoactive sexual desire disorder
-sexual aversion disorder
sexual arousal disorder
orgasmic disorder
sexual pain disorders
-dyspareunia
-vagismus
88
Q

hypoactive sexual desire disorder (HSDD)

A

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

89
Q

treatment of HSDD

A

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

90
Q

medical conditions than can cause sexual disorders

A 
hypothyroidism
CAD > fear of triggering an MI
renal failure (high prolactin)
incontinence
neuro disease > direct damage to areas responsible for processing stimuli
menopause
91
Q

sexual aversion disorder (SAD)

A 
rare
severe aversion to genital contact
must have associated pscyhophysiological diagnosis
-anxiety
-often associated with trauma
personal aversion (poor self worth)
92
Q

treatment of SAD

A

counseling

antidepressants

93
Q

general treatment strategies in desire disorders

A

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

94
Q

what is Filbanserin

A

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

95
Q

sexual arousal disorder

A

inability to maintain sufficient sexual excitement to complete sexual activity

96
Q

causes of sexual arousal disorder

A
  • depression, low self esteem, stress, anxiety
  • medication, low E
  • postmenopausal atrophic vaginitis
  • skin disorder of the genital skin
97
Q

treatment of sexual arousal disorder

A 
psychogenic causes
-cognitive behavioral therapy
-improving relationship stressors
-stopping SSRI, SNRI
vaginal atrophy
-topical estrogen
sildenafil
-conflicting results
98
Q

orgasmic disorder

A

persistent delay or absence attaining orgasm with sufficient stimulation and arousal

primary: associated with trauma or abuse
secondary: associated with HSDD, pelvic surgery, drugs

99
Q

treatment of orgasmic disorder

A

cognitive behavior therapy
-benefit in symptom severity and sexual satisfaction
no pharm treatments

100
Q

dyspareunia

A

recurrent genital pain associated with intercourse

101
Q

vaginismus

A

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

102
Q

onset sexual pain disorders

A

lifelong: congenital or psychological etiology

new onset: MSK, pelvic, genital, dermatological

103
Q

causes of superficial sexual pain

A 
vulvovaginal atrophy
injury/trauma
inflammation or infection
vestibulodynia/vulvar vestibulitis
vulvar skin disease (lichen sclerosis)
104
Q

deep sexual pain disorders

A 
endometriosis
interstitial cystitis
uterine fibroids
vaginal prolapse
adnexal pathology (ovarian cyst or neoplasm)
myofascial pain
105
Q

relationship between female sexual function and menopause

A 
no clear evidence
less easily aroused and less genital sensitivity
decreased blood flow to vagina
-reduced lubrication
atrophy and stenosis of vaginal canal

RDS Test 4 (17 decks)

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