Human Sexuality -- Sexual Function and Dysfunction

Question 1

Human sexual response cycle

Answer 1

Desire
Excitement
Plateau
Orgasm
Resolution

First described by Masters

Question 2

Desire phase

Answer 2

• 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

Question 3

Arousal/excitement phase

Answer 3

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

Question 4

Erection

Answer 4

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

Question 5

Plateau phase

Answer 5

heightened state of arousal

-physiologic changes stable

Question 6

Orgasm

Answer 6

• 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.

Question 7

Resolution phase

Answer 7

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

Question 8

Desire phase disorders

Answer 8

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

Question 9

Arousal/excitement phase disorders

Answer 9

• Male erectile disorder
• Female sexual arousal disorder
• Premature ejaculation
• Dyspareunia
• Vaginismus

Per DSM5 specify:
lifelong vs acquired
generalized vs situational
mild moderate or severe

Question 10

Erectile Disorder

Answer 10

1 of 3:

1. Marked difficulty in obtaining erection
2. Marked difficulty in maintaining erection until completion of sex.
3. Marked decrease in erectile rigidity.

For at least 6 mo

• Causes distress
• not explained by other stressors/med conditions

Question 11

Delayed ejaculation

Answer 11

1. marked delay in ejaculation
2. marked infrequency or absence of ejaculation

At least 6 mo

Question 12

Male Hypoactive Sexual Desire Disorder

Answer 12

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

Question 13

Premature (early) ejaculation

Answer 13

persistent or recurrent pattern of ejaculation during sex within 1 minute of penetration and before individual wishes

at least 6 mo

Question 14

Female Orgasmic disorder

Answer 14

1. Marked delay in, marked infrequency of, or absence of orgasm (normal sexual excitement phase)
2. reduced intensity of orgasmic sensations.

at least 6 mo

Question 15

Female Sexual interest/arousal disorder

Answer 15

Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three:

1. Little interest in sex
2. Few thoughts related to sex
3. Decreased start and increased rejecting of sex
4. Little pleasure during sex most of the time
5. Deceased interest in sex even when exposed to erotic stimuli
6. Little genital sensations during sex most of the time

At least 6 mo

Question 16

Genito-Pelvic Pain/Penetration disorder

Answer 16

Persistent or recurrent difficulties with one (or more):

1. Vaginal penetration during intercourse.
2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration
3. fear/anxiety about vulvovaginal/pelvic pain in anticipation or result of vaginal penetration.
4. tensing or tightening of the pelvic floor muscles during vaginal penetration.

At least 6 mo

Question 17

Vaginismus

Answer 17

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

Question 18

Dyspareunia

Answer 18

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)

Question 19

Plateau phase disorders

Answer 19

Female orgasmic disorder

Delayed ejaculation/ Male orgasmic disorder

Question 20

Most sexual dysfunctions are due to

Answer 20

performance anxiety

Question 21

Types of sex therapy

Answer 21

Sensate Focus exercises
Bibliotherapy
Marital therapy
Pharmacotherapy

Question 22

Sensate focus

Answer 22

A series of defined behaviors/exercises
Focus on sensations and emotions
“I” language

12-16 visits
Behavioral modification
involves marital therapy

Question 23

Bibliotherapy (and when is it most successful?)

Answer 23

assign readings to patients

-most successful in orgasmic dysfunction

Question 24

Drug therapy for sexual dysfunction

Answer 24

PDE5 inhibitors
Estrogen
Flibanserin
Testosterone
Antidepressants
Other drugs

Question 25

PDE5 (phosphodiesterase) inhibitors (male)

Answer 25

• 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

Question 26

Estrogen and sexual function

Answer 26

high correlation between serum estradiol levels and sexual function in women
-can improve sexual symptoms, dyspareunia, and vaginal pH

Question 27

Flibanserin

Answer 27

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

Question 28

Bupropion

Answer 28

antidepressant

-may have positive effect on desire and orgasm for some women, but not clear in independent of antidepressant effect

Question 29

Testosterone and female inhibited sexual desire

Answer 29

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

Question 30

Tx for vaginismus

Answer 30

Dilators (not to dilate vagina, but to learn to have something in the vagina)
-must involve partner

Question 31

Orgasmic dysfunction

Answer 31

• address stimulation
• address performance anxiety
• address spectatoring

Question 32

PLISSIT model

Answer 32

Permission giving
Limited information
Specific suggestions
Intensive therapy