Human Sexuality -- Sexual Function and Dysfunction Flashcards
Human sexual response cycle
Desire Excitement Plateau Orgasm Resolution
First described by Masters
Desire phase
- no measurable physiologic changes
- can be augmented/inhibited by learned responses/experiences
- paritally under hormonal control (estrogen in women, testosterone in men)
Disorders of desire phase almost always due to performance anxiety or aversion
Arousal/excitement phase
Physiologic changes occur Increased pulse and respiration Shifts in blood flow to pelvis and genitalia Erection on men Clitoral engorgement, vaginal expansion and lubrication, uterine elevation in women Shift in blood flow to skin “Flush”, feeling of warmth, sweating Nipple erection
Erection
caused by increased penile blood flow resulting from the relaxation of penile arteries and corpus cavernosal smooth muscle
-mediated by NO, stimulate synth of cGMP in smooth muscle cells
Plateau phase
heightened state of arousal
-physiologic changes stable
Orgasm
- rhythmic contractions of the perineal muscles occurring every 0.8 seconds.
- male: accompanied by 3 to 7 ejaculatory spurts of seminal fluid.
- female: accompanied by elevation of the “orgasmic platform” - posterior vaginal wall – levator ani and pubococcygeus
- involuntary contractions of skeletal muscles and EEG changes.
Resolution phase
M: obligatory resolution phase after orgasm in which physiologic changes return to baseline, further stim can’t produce excitement
-5 mins to 24 hrs (elderly men)
F: may return to plateau phase and have repeated orgasm without resolution first
Desire phase disorders
Hypoactive sexual desire disorder (low libido): chronic lack of interest in sexual activity: usally assoc w/ chronic disease, depression, hypoestrogenic states
Sexual Aversion Disorder (inhibited sexual desire): Persistent or recurrent phobic avoidance of sexual contact with a partner;
result of pain or other dysfunction
sexual aversion and HSDD are a continuum
Sexual arousal disorder: persistent or recurrent inability to attain or maintain sexual excitement
Arousal/excitement phase disorders
- Male erectile disorder
- Female sexual arousal disorder
- Premature ejaculation
- Dyspareunia
- Vaginismus
Per DSM5 specify:
lifelong vs acquired
generalized vs situational
mild moderate or severe
Erectile Disorder
1 of 3:
- Marked difficulty in obtaining erection
- Marked difficulty in maintaining erection until completion of sex.
- Marked decrease in erectile rigidity.
For at least 6 mo
- Causes distress
- not explained by other stressors/med conditions
Delayed ejaculation
- marked delay in ejaculation
- marked infrequency or absence of ejaculation
At least 6 mo
Male Hypoactive Sexual Desire Disorder
Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. Judgment made by the clinician, taking into account factors of sexual functioning, such as age/ cultural factors
For at least 6 mo
Premature (early) ejaculation
persistent or recurrent pattern of ejaculation during sex within 1 minute of penetration and before individual wishes
at least 6 mo
Female Orgasmic disorder
- Marked delay in, marked infrequency of, or absence of orgasm (normal sexual excitement phase)
- reduced intensity of orgasmic sensations.
at least 6 mo
Female Sexual interest/arousal disorder
Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three:
- Little interest in sex
- Few thoughts related to sex
- Decreased start and increased rejecting of sex
- Little pleasure during sex most of the time
- Deceased interest in sex even when exposed to erotic stimuli
- Little genital sensations during sex most of the time
At least 6 mo
Genito-Pelvic Pain/Penetration disorder
Persistent or recurrent difficulties with one (or more):
- Vaginal penetration during intercourse.
- Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration
- fear/anxiety about vulvovaginal/pelvic pain in anticipation or result of vaginal penetration.
- tensing or tightening of the pelvic floor muscles during vaginal penetration.
At least 6 mo
Vaginismus
Involuntary spasm of muscles around the outer third of the vagina May make penetration impossible Causes: Pain Religious orthodoxy Severe negative parental attitudes
Pts may be hyperfeminine, have bizarre images of genitals, have a partner that supports dysfunction
Primary: with first attempt @ intercourse
Secondary: after some event
Dyspareunia
Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female.
(Pain leads to decreased desire, leads to less excitement, leads to lack of lubrication and expansion)
Plateau phase disorders
Female orgasmic disorder
Delayed ejaculation/ Male orgasmic disorder
Most sexual dysfunctions are due to
performance anxiety
Types of sex therapy
Sensate Focus exercises
Bibliotherapy
Marital therapy
Pharmacotherapy
Sensate focus
A series of defined behaviors/exercises
Focus on sensations and emotions
“I” language
12-16 visits
Behavioral modification
involves marital therapy
Bibliotherapy (and when is it most successful?)
assign readings to patients
-most successful in orgasmic dysfunction
Drug therapy for sexual dysfunction
PDE5 inhibitors Estrogen Flibanserin Testosterone Antidepressants Other drugs
PDE5 (phosphodiesterase) inhibitors (male)
- enhance erectile func by increasing amount of cGMP
- no effect in absence of sexual stimulation
- Sildenafil, vardenafil, tadalafil
Randomized trials of PDE5 inhibitors in women
-But there is a disconnect for many women b/t objective (measured) and subjective arousal
Estrogen and sexual function
high correlation between serum estradiol levels and sexual function in women
-can improve sexual symptoms, dyspareunia, and vaginal pH
Flibanserin
Post-synaptic 5HT1A receptor agonist and 5HT2A receptor antagonist
Lowers 5-HT and raises dopamine and noradrenaline in prefrontal cortex
Approved tx for acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women
Adverse events:
hypotension, syncope
dizziness, somnolence
nausea
Overall: Minimal effect on HSDD Significant side effect profile Must be taken every day Cost approximately $800 for 30 tabs, or about $10,000 per year
Bupropion
antidepressant
-may have positive effect on desire and orgasm for some women, but not clear in independent of antidepressant effect
Testosterone and female inhibited sexual desire
Transdermal testosterone is more effective than placebo in treatment of hypoactive sexual desire disorder, but the effect is small
Not FDA approved for this indication
Tx for vaginismus
Dilators (not to dilate vagina, but to learn to have something in the vagina)
-must involve partner
Orgasmic dysfunction
- address stimulation
- address performance anxiety
- address spectatoring
PLISSIT model
Permission giving
Limited information
Specific suggestions
Intensive therapy
