L21 - Sexual dysfunction

Question 1

examples of sexual dysfunction problems?

Answer 1

low desire
arousal problems
lack of orgasm
pain during sex

Question 2

define erectile dysfunction?

Answer 2

The persistent inability to attain and /or maintain an erection sufficient for sexual performance >3-6 months

Question 3

Organic causes of erectile dysfunction ?

Answer 3

cardiovascular 40%
diabetes 30%
medicinal 15%
5% neuro

Question 4

Aetiology and risk factors for erectile dysfunction

Answer 4

Lifestyle - 
sedentary lifestyle 
nicotine 
alcohol abuse 
drug addictions 
age

CV risk -
hypertension
dyslipidemia
CAD

Diabetes mellitus -
type 1 and 2

Endocrine factors -
hypogonadism
hyperprolactinemia
thyroid disorders

Iatrogenic - drug induced
post op

medical disorders -
liver diesease
resp disorders - sleep apnoea

Question 5

what drugs have a negative impact on erectile dysfunction ?

Answer 5

Antihypertensives - thiazide diuretics, BB, CCB

Antidepressants/neuroleptics
SSRIs

Anti-arrhytmics
Tamsulosin

Recreational substances - 
Marijuana 
opiates 
cocaine 
nicotine 
alcohol

Question 6

Mechanism of erection

Answer 6

1 - erotic stimuli
2- neural initiation
3- cellular activation
GMP mediated relaxation of smooth muscle
4 - relaxation of cavernous smooth musculature

reduce your a-sympathetic tone of cavernous muscles
increase parasympathetic tone
dilation of arterioles
corpus cavernosum fills with blood
stretching of tunica albuginea causing hard penis
5 - Erection

Nitric oxide causes erection. by dilating blood vessels

may also need genital stimulation with increasing age for contraction of pelvic floor and increases venous pressure to get rigid erection

Question 7

Effect of stress on ED

Answer 7

STRESS = increased sympathetic tone = adenaline

which causes erectile dysfunction

Question 8

Coronary artery disease and ED

Answer 8

Arteriosclerosis in coronary arteries relates to arteriosclerosis in penile arteries
they share the same risk factors as well as obesity, low testosterone and depression

Question 9

Factors contributing to ED in diabetes?

Answer 9

Angiopathy - reduced blood flow
polyneuropathy - reduced sensation, motor drive
impairment of neurotransmitter synthesis/release
Endothelial and SM cell dysfunction = limited muscle relaxation and poor blood flow

Impairment of cavernous tissue architecture = limited inflow of blood and poor swelling

Lack of use causes smooth muscle apoptosis =
Reduction in length and fibrosis  poor function

Question 10

Therapy for ED

Answer 10

diabetes control

cardio-resp fitness

Question 11

What is the PLISSIT model for approaching sexual health problems?

Answer 11

PERMISSION - to discuss sex with the patient and for pt to discuss concerns

LIMITED INFORMATION - clarify misinformation, dispel myths and provide factual information

SPECIAL SUGGESTIONS -
directly related to particular problem, practical

INTENSIVE TREATMENT
provide referral/therapy for complex issues

Question 12

ED treatments

Answer 12

Alprostadil- Injection therapy.
Intra urethral Alprostadil – Muse
Vitaros – topical alprostadil
Vacuum pump.
Combined PDE5 and Vacuum therapy. 
Therapeutic Support for individual and couple.
Lubricants  
Testosterone
(Dapoxetine for PE)
    Must use at least 8 X 

Contraindication with PDE5-is + nitrates

Androgens for men - total testosterone below 8nmol/l

between 8-12nmol/l repeat test with prolactin

Intracavernous auto injection therapy - injection of Alprostadil into the cavernous body

Question 13

Who should you NOT treat with testosterone replacement therapy?

Answer 13

breast cancer 
liver tumour 
severe cardiac failure 
untreated sleep apnoea 
untreated prostate cancer 
moderate or severe BPH

Question 14

Vacuum device

Answer 14

use everyday
shave pubic hair at penis root
use lubricant for ring
use the smallest ring that you can tolerate

Question 15

Classification of Female Sexual Dysfunction in diabetes

Answer 15

FEMALE AROUSAL DISORDER
because of problem with lubrication. if you have problems with your nerves or blood vessels will not get the lubrication.

FEMALE ORGASMIC DISORDER

PAIN DISORDERS -

DYSPAREUNIA - genital pain associated with sexual intercourse

VAGINISMUS - Involuntary contraction of the perineal muscles preventing vaginal penetration

Question 16

What causes female sexual dysfunction?

Answer 16

INTERPERSONAL RELATIONSHIPS
partner performance
lack of partner
relationship quality and conflict

PHYSIOLOGICAL 
neurological problems 
CVD 
cancer 
medications 
Fatigue 
urogenital disorders

SOCIOCULTURAL INFLUENCES 
inadequate education
conflict with religion 
family values 
societal taboos 

PSYCHOLOGICAL 
depression anxiety 
prior sexual abuse 
stress 
alcohol/substance misuse

Question 17

causes of inhibited desire?

Answer 17

fear of pregnancy 
medication side effects 
hormonal issues 
depression 
sexual phobias 
gender identity isssues 
religious beliefs
lack of attraction to partner 
partners poor sexual skills
fear of closeness and vulnerability 
intimacy issues

Question 18

What is Atrophic Vaginitis

Answer 18

Vaginal atrophy (atrophic vaginitis) is thinning, drying and inflammation of the vaginal walls due to your body having less estrogen.

Question 19

What can atrophic vaginitis cause?

Answer 19

Can lead to :  
Avoidance of sexual relationships due to dyspareunia .
Performance anxiety.
Loss of sexual desire
Relationship distress.

Question 20

why do women become dry in atrophic vaginitis?

Answer 20

less vaginal folds when women get older and less lubrication

Question 21

Treatments for post hysterectomy or post menopausal female sexual dysfunction

Answer 21

foreplay + genital stimulation to inc blood flow and lubrication
pelvic floor exercises - inc conctractions can mean better orgasms
use of a vibrator
HRT?
estradiol (vagifem) pessary 10mcgs restores vaginal mucosa
testosterone