Female/male psychosex (ED/premature ejaculation)

Question 1

4 phases of sexual response cycle?

Answer 1

Excitement, plateau, orgasm, resolution

Question 2

Ix for erectile dysfunction?

Answer 2

Full medical hx inc drugs, neuro assessment, bloods for glucose, testosterone, cholesterol, U&E, LFT, prolactin, TSF (esp if <50yo and sudden onset), BP, Udip, consider USS to assess blood flow and atherosclerosis.

Question 3

Which nerve system is responsible for erection?

Answer 3

Parasympathetic (point and shoot mnemonic)

Question 4

Which nerve system is responsible for ejaculation?

Answer 4

Sympathetic (point and shoot mnemonic)

Question 5

Causes of erectile dysfunction?

Answer 5

Vascular (inadequate blood supply – HTN, atherosclerosis, DM),

Nerve (trauma, surgery, stoke),

endocrine (reduced testosterone, reduced nitric oxide synthase and smooth muscle relaxation resulting in erection)

medications (thiazide, SSRI, b-blockers, antiepileptics, levodopa, LHRH analogues),

psychological

Question 6

Tx for erectile dysfunction?

Answer 6

Lifestyle modifications, stop trigger drugs if possible, information about it, PDE-5 inhibitors, vacuum pumps, surgical implants.

Question 7

1st line medical tx for erectile dysfunction?

Answer 7

PDE-5 inhibitors, Sildenifil

Question 8

Contraindications for sildenafil?

Answer 8

Hypotension <90/50

unstable angina or arrhythmia

MI <90/7 ago

concomitant use of nitrate or nicorandil,

uncontrolled HTN,

hyportension on alpha blockers,

retinitis pigmentosa

serve hepatic impairment.

Question 9

How long after a MI or stoke is vardenafil CI?

Answer 9

6/12

Question 10

Risks/SE of PDE-5 inhibitors?

Answer 10

Hypotension, flushing, nausea, dizzy priapism, visual disturbance, hearing disturbance, myalgia

Question 11

What % will PDE-5 inhibitors work in for erectile dysfunction?

Answer 11

80%

Question 12

Prevalence of premature ejaculation?

Answer 12

1-3%

Question 13

Definition of premature ejaculation?

Answer 13

<1min from entry to vagina or clinically significant time (typically <3min)

Question 14

Risk factors for premature ejaculation?

Answer 14

Obesity, poor health, psychological ED, varicocele, sexual trauma, MS, peripheral neuropathy, thyroid disorder, drugs (dopaminergics amphetamine, cocaine) prostatitis

Question 15

Mx of premature ejaculation?

Answer 15

Info giving, condoms or women on top, squeeze and go learning to stop just before ejaculation, psychosexual counselling, SSRI (needs to be daily) or Dapoxetine is licenced SSRI on demand, anaesthetic creams, PDE-5 inhibitors.

Question 16

Hx taking for premature ejaculation?

Answer 16

Every time, sometimes, situational, masturbation, lifelong or new, time to ejaculation, any ED, impact on them, PMhx/medications

Question 17

Dapoxetine for tx of premature ejaculation how to take?

Answer 17

1-3hrs before needed

Question 18

Age cut of for Dapoxetine for tx of premature ejaculation?

Answer 18

<65 is ok, gives ~1-4mins extra

Question 19

A 22 yo presents with genital pain, she was seen by a colleague 2/52 ago who examined her and could not find any abnormalities, STI screening, udip and MS&C were negative.
Skin care is good.
The pain is on touching and she find sex painful particularly on initial penetration, you suspect provoked valval pain syndrome.
What are the treatment options.

Answer 19

Information giving
Examine for trigger points, teach about self massage and pelvic floor relaxation/consider physio referral
Topical analgesia
Consider tricyclics (amitriptyline 10mg increasing as required), gabapentin can also be considered
Explore sexual hx, any abuse/triggers for the pain
Consider psychosexual referral.

Question 20

What types of vulval pain conditions are there

Answer 20

provoked and unprovoked
localised and generalised 
cliterodynia
vestibulodyina
vaginismus 
hemivulvodynia

Question 21

When suspecting vulvodynia what steps in hx/exam/ix should be done

Answer 21

Full hx (SCORATES for pain and specific enquiry for o&g hx, traumatic birth/preg loss, dyspareunia, sexual hx inc assault/non-consensual SI)

Examine - skin, trigger points, hypooestrogenic, provoked pain

Swabs STI and MS&C

Udip if urinary sx.

Then dx of clinical suspicion and exclusion

Question 22

Differnential for vulval pain

Answer 22

Infection (eg candida/HSV)
Inflammation (eg lichen)
Neoplasm (eg VIN)
Neurological (eg spinal damage/post HSV neuralgia)