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Sita GenitoUrinary System > Lecture 26: Sexual function and Dysfunction > Flashcards

Lecture 26: Sexual function and Dysfunction Flashcards

1
Q

Sexual Response Cycle

A
  • Masters and Johnson 1966 –> observation and recordings of sex –> low levels of volunteers –> High proportion of prostitutes used for studies
    1. Excitement (Arousal phase
    2. Plateau
    3. Orgasm
    4. Resolution
    5. Refractory period
    Overall: groundbreaking research. tested and added too over the years
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2
Q

Descriptions for the phases of Sexual Response Cycle

A
  1. Excitement (arousal phase): caused by any reflexogenix or psychogenic stimulation
  2. Plateau: arousal reversible –> inevitable orgasm
  3. Orgasm
  4. Resolution: Involuntary period of tension loss (slower in woman than men)
  5. Refractory period
    - Increased HR, Change in BP, sweating, degree of dilitation
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3
Q

Sexual response cycle table

A
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4
Q

Kaplan 1979

A

Kaplan: feminist –> all about X and the Lack there of
3 phase model
1. Desire
2. Arousal
3. Orgasm
- forms basis of DSM IV classification of female sexual Dysfunction
Note: Linear models arent reality for many woman

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5
Q

Why are linear models not reality for the majority of woman?

A
  1. disconnection b/w desire and orgasm
  2. assumption: vasocongestion measures arousal
  3. assumption: Orgasm reflects satisfaction (synonymous)
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6
Q

Basson’s mode

A

Tries to separate desire and arousal –> bigger contention/problem for female sexuality (more than male sexuality)
Allows for consideration: Marital relationship –> husband more eager to have sex than female –> lack of female desire –> but becomes secondarily aroused during act

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7
Q

Categories of Sexual Problem Impairments

A
  1. Physiological impairment (sexual dysfunction)
  2. Non-Physiological impairment (human relations/difficulties in, consequences of, ways in which people conduct themselves sexually
    a) Psychological
    i) IntERsychic (Within the 2x people of the relationship/communication)
    ii) IntRAsychic (beliefs, meanings, conflicts, guilt, shame, information deficiet/distortion, past sexual trauma, depression, anxiety, aversions, phobias
    b) Social
    i) situational (environmental)
    Note: most common when have newborns/young children
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8
Q

PLISSIT model in regards to primary care of sexual dysfunction

A
  • Annon and Robinson 1978
  • Model for Sexual counselling –> interventions for common sexual dysfunctions of 4x levels of intensity
    P: ERMISSION to talk about sexual matters, fantasize, enjoy sexuality
    LI: Limited Information (response to patient’s discussion)
    SS: Specific Suggestions (e.g. retroverted uterus –> have sex ontop)
    IT: Intensive Therapy
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9
Q

What is the most common female sexual complaint

A

Lack of desire

Medication: Flibanserin (Girosa)

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10
Q

3x Main reasons for Female Sexual dysfunction

A
  1. disorder of sexual Interest or Arousal
  2. disorder of orgasm
  3. disorder of genito-pelvic pain/penatration
    - dysparenuria
    - vaginismus
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11
Q

What are the requirements for a complain of sexual dysfunction by both males and females

A
  1. atleast 6 months
  2. atleast 75-100% of time
  3. results in atleast significant distress
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12
Q

What are the potentail variations in sexual dysfunctions for both males and female?

A
  1. Lifelong or acquire
  2. Generalised vs situational
  3. Severity: mild, moderate, severe
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13
Q

Associated features of sexual dysfunction for both males and females

A

Factors:

  1. partner
  2. relationship
  3. individual vulnerability factors/ psychiatric co-morbidity / stressors
  4. cultural or religious
  5. medical factors
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14
Q

Description of Associated features of sexual dysfunction for both males and females

A

Factors:

  1. partner: partner sexual problem, partner health status
  2. relationship: poor communication, discrepancies in desire for sexual activity
  3. individual body factors: poor body image, history of sexual or emotional abuse, Psychiatric comorbidity: depression or anxiety. Stressors: job loss, bereavement
  4. Cultural or religious: inhibitions related to prohibitions against sexual activity or pleasure. attitudes towards sexuality
  5. Medical: factors relevant to prognosis, course or treatment
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15
Q

Treatment of Female Sexual Dysfunction

A
  1. Is there really a problem: If so Whose problem (which partner) and Check associate features of partner (past sexual abuse/domestic violence)
  2. Education:
  3. Counselling:
    a) Patient Couple
    b) Sensate focus (ban sex, RE-ESTABLISH INTIMACY by starting at foundation)
    c) manage medical problem
    - “menopause” –> sexual function issues:
    i) consider hormone replacement therapy –> topic oestrogen –> adds robustness to vaginal mucosa –> increased lubrication and hence decreased pain during sex
    ii) physiotherapy –> added strength to pelvic floor muscles
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16
Q

4x main reasons for Male Sexual Dysfunction

A
  1. Hypoactive sexual disorder (decreased libido)
  2. Erectile
  3. Ejaculation: Delayed (retarted) or Premature (rapid)
    Note: biased research as most researchers are men –> know more about male sexual dysfunction
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17
Q

Cuases of Hypoactive sexual disorder/Low libido in men

A
  1. Psycholocial
    a) fatigue
    b) situational
    c) depression –> treament drugs further worsen sexual dysfunction
  2. Physical
    a) hypothyroidism
    b) hypogonadism
    c) PADAM (Partial Androgen deficiency in Aging Males)
  3. Other: Medicaiton (e.g. antidepressants)
18
Q

PADAM

A

Partial Androgen Deficiency in Aging Males
–> extreme hypogonadism disproportionate to rate of male aging
Treatment: Testosterone supplementation

19
Q

What are the nerve pathways to penile erections?

A

Visual, imaginative, auditory, emotional or olfactory sex stimuli to brain –> No release –> increase in cGMP in penile areas –> increased smooth muscle/erectile tissue relaxation –> increased blood flow into corpora cavernosum (arterial expansion)–> compression of veins distended lacunae and cavernous sinuses –> erection –> PDE-5 enzyme breaks down cGMP –> acoids thrombosis + decreases erection
Note: disruption on any level can cause problems
Pelvic level: Contains reflex arch (tactile response cremasteric reflex) –> allows men with spinal cord injuries still being able to get erect –> reflex arch at pelvic level is a tactile response in nerve pathway

20
Q

What is a special loop hole in the Nerve pathway to penile erection?

A

Reflex arch at pelvic level (tactile response cremasteric reflex)
Clinically: means men with spina cord injuries are still able to get erect (tactile response nerve pathway)

21
Q

What sort of instrument is the penis

A

Penis isnt a muscle

Hydrolic instrument

22
Q

Components of Penis Flaccid –> Erect

A
  1. Circumflex vein
  2. Cavernous sinuses
  3. tunic albuginea
  4. Helicine arteries
  5. Cavernous arteries
23
Q

Erectile Difficulties requirements

A

Persisitent inability, for alteast 3 months, to obtain and maintain sufficient and satisfactory sexual performance
Note: DSM-5: 6 months

24
Q

Relating features to erectile difficulties

A
  1. Prevalance increases with age (paralleled to increased rate of organic illnesses with age)
  2. Organic vs Psychogenic
    - incident w. failure to become erect –> psychological reaction –> perpetuates erectile loss
  3. Chronic illnesses (decreased libido/interest), surgery (interruption of fine vessels), trauma (spinal or pelvic)
  4. Midifiable risk factors
25
Q

Chronic Illnesses causing Erectile Dysfunction

A
  1. Systemic (atheroscleorisis, dibatere, CVD, renal/heaptic failure)
  2. Neurogenic (alzhiemers, multiple sclerosis)
  3. Penille disorder (Peyrones) /Psychiatric (depression + performance anxiety) /Endocrine (hyper/hypothyoidism, hypogonadism, hyperprolativemia)
    Note: Peyrones disease –> Trauma/clot/inflammation –> fibrosis to Tunica –> distortion of erect penis –> hard to achieve
26
Q

Surgery and Trauma as causes of Erectile Dysfunction

A
  1. Neurological (spinal cord)
  2. Pelvic (injury, surgery, irradiation of pelvic region)
  3. Urological (prostatectomy) –> disruption of fine nerves supplying penis –> risk of impotence with prostatic surgery
27
Q

Prevalence of Erectile Dysfunction

A
  1. No impotence: 48%
  2. Minimal: 17%
  3. Moderate: 25%
  4. Complete impotence: 10%
    Note: changes would have occurred by now, as this study occurred in 1987-69
    Additionally: biased results as involved relatively older test patients (40-70 years)
    Overall: 52% of men experience some degree of erectile dysfunction
28
Q

Associated of Prevalance of Erectile Dysfunction with age

A

Overall: Increased probability of ED with age

  1. 40 years –> 39% risk of ED
  2. 50 years –> 48% risk of ED
  3. 60 years –> 57% risk of ED
  4. 70 years –> 76% risk of ED
29
Q

Modifiable risk factors which can decrease risk of Erectile dysfunction

A
  1. Alcohol
  2. cigarette
  3. Drugs (antihypersensitives, anti depressants, hormones, tranquilizers, miscellaneous (NSAIDS, H2RA, cocaine, heroine)
30
Q

Etiology behind Erectile Dysfunction

A
  1. Organic (vasculogenis, neurological, hormonal or cavernosal abnormalities/lesions)
  2. Psychogenic (central inhibition of erectile mechanism w/o physical insult) –> typically secondary to original ED occurrence –> continued stress of reoccurrence –> Physchogenic problems
31
Q

What is the common occurance order b/w Organic or Psychogenic problems in relation to Erectile Dysfunction

A

Psychogenic problems are often Secondary to the actual ED effect –> due to continued worrying of reoccurrence –> psychogenic problems

32
Q

Sexual Performance Anxiety Circle

A
  1. Loss of confidence –> 2. Lack of interest –> 3. Treatment Feedback Loop –> 4. Performance Anxiety
    - mindfulness based approaches as a component of treatment
    - pro erectile drugs can be like training wheels –> brief dose to get confidence back
33
Q

PDE5 inhibitors

A
  1. Sildenafil (viagra) : generics now cheaper
  2. Tadalafil (cialis): not yet off patent
    - longer duration of action
    - option of low dose (5mg) daily –> maintains oxygenation –> improves endothelial smooth muscle health
  3. Vardenafil (levitra): shorter duration of action –> dont feel terrible for long
34
Q

Male Erectile Dysfunction Treatment approaches

A
  1. PDE5 inhibitors
  2. Alprosatdil (Caverject) (inject into cavernosa)
  3. Bimix (papaverine and phentolamine) –> Note: Papaverine often creates problems –> need to reverse with another drug
  4. Trimix (prostaglandin PGE1, papaverine and phentolamine)
  5. ED shock wave therapy
  6. Vacuum device
  7. Surgery
35
Q

Rapid Premature Ejaculation

A 
ejaculation occurs before the individual wants to 
Traditional theories:
1. Furtive early masturbation
2. the "too exciting vagina"
3. Genital hypersensitivity
4. Lack of alarm signal
36
Q

Traditional therapeutic responses to premature ejaculation

A
  1. Sensate focus with “squeeze” technique –> blunt blow to glans penis
  2. “Stop-Start” technique
  3. Local anaesthetic spray (benzocaine)
37
Q

Neurobiological approach to Ejaculatory disorders

A

SSRI (Selective serotonin reuptake inhibitors)
- decreased serotonin neurotransmission –> hypofunction of 5HT2c receptor –> Familial aspects
- is premature ejaculation a natural selective advantage in nature?
Pharmacotherapy:
- SSRI daily
or: Clomipramine daily/ 12 hours before sex
- Dapoxetine (Priligy): –> related to SSRIs –> really helpful with temporal ejaculation problem –> but is rapidly metabolised therefore dont help treat depression
30mg or 60mg -> smaller dose is in and out of body faster –> less concern with suicidality risk of SSRIs over time

38
Q

Delayed Retarded Ejaculation

A

No consensus operational definition
Generalised or situational
Lifelong DE rel Uncommon (1.5/1000, 3-4%)
Classically attributed to psychological issues: fear, anxiety, hostility, and relationship difficulties
Contemporary: Waldinger’s Ejaculation Distribution therapy (EDT) –> Bell curve normal distribution within men (natural variation, most normal, some premature some delayed)

39
Q

Available options of Erectile Dysfunction treatment

A
  1. Non-invasive
    - elimination of modifiable risk factors
    - couselling and/or psychological therapy
    - medication
    - vaccum constriction devices (decreased efficancy. neurological)
  2. Invasive
    - Transurethral drug application (hardly used anymore)
    - intracavernous injection therapy
    - prosthesis implantation
    - venous/arterial surgery (Steel)
40
Q

Route’s and sites of ED Drug treatment

A
  1. brain
    a) apomorphine (dopamine agonist, sublingual delivery)
    b) sidinaphil (phosphodiesterase inhibitor, oral delivery)
    c) phenolalamine (aplha-adrenergic blocker, oral delivery)
  2. Groin area
    a) Prostaglandin (vasodilator. 3x delivery areas)
    - injeciton (intracavernous)
    - suppository (intraurethral)
    - transcutaneous ointment –> neuromuscular junction’s corpora cavernosa smooth muscle cells –> vasodilation
41
Q

Which is more complex out of ED and ED

A

Ejaculatory dysfunction disorders are more complex

42
Q

Psychological and Acquired ED

A
  1. Hypofunction of 5-HT1A receptors
    - and/or possibly hyperfunction of 5-HT2c
    - treatment research: h-HT receptor agonists
  2. Acquired DE
    - psychological
    - disease states (neurological conditions) (diabetes mellitus)
    - medication: SSRIs , Tricyclic antidepressants, antipsychotics and others

Sita GenitoUrinary System (28 decks)

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