Lecture 26: Sexual function and Dysfunction Flashcards
Sexual Response Cycle
- 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
Descriptions for the phases of Sexual Response Cycle
- Excitement (arousal phase): caused by any reflexogenix or psychogenic stimulation
- Plateau: arousal reversible –> inevitable orgasm
- Orgasm
- Resolution: Involuntary period of tension loss (slower in woman than men)
- Refractory period
- Increased HR, Change in BP, sweating, degree of dilitation
Sexual response cycle table
Kaplan 1979
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
Why are linear models not reality for the majority of woman?
- disconnection b/w desire and orgasm
- assumption: vasocongestion measures arousal
- assumption: Orgasm reflects satisfaction (synonymous)
Basson’s mode
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
Categories of Sexual Problem Impairments
- Physiological impairment (sexual dysfunction)
- 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
PLISSIT model in regards to primary care of sexual dysfunction
- 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
What is the most common female sexual complaint
Lack of desire
Medication: Flibanserin (Girosa)
3x Main reasons for Female Sexual dysfunction
- disorder of sexual Interest or Arousal
- disorder of orgasm
- disorder of genito-pelvic pain/penatration
- dysparenuria
- vaginismus
What are the requirements for a complain of sexual dysfunction by both males and females
- atleast 6 months
- atleast 75-100% of time
- results in atleast significant distress
What are the potentail variations in sexual dysfunctions for both males and female?
- Lifelong or acquire
- Generalised vs situational
- Severity: mild, moderate, severe
Associated features of sexual dysfunction for both males and females
Factors:
- partner
- relationship
- individual vulnerability factors/ psychiatric co-morbidity / stressors
- cultural or religious
- medical factors
Description of Associated features of sexual dysfunction for both males and females
Factors:
- partner: partner sexual problem, partner health status
- relationship: poor communication, discrepancies in desire for sexual activity
- individual body factors: poor body image, history of sexual or emotional abuse, Psychiatric comorbidity: depression or anxiety. Stressors: job loss, bereavement
- Cultural or religious: inhibitions related to prohibitions against sexual activity or pleasure. attitudes towards sexuality
- Medical: factors relevant to prognosis, course or treatment
Treatment of Female Sexual Dysfunction
- Is there really a problem: If so Whose problem (which partner) and Check associate features of partner (past sexual abuse/domestic violence)
- Education:
- 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
4x main reasons for Male Sexual Dysfunction
- Hypoactive sexual disorder (decreased libido)
- Erectile
- Ejaculation: Delayed (retarted) or Premature (rapid)
Note: biased research as most researchers are men –> know more about male sexual dysfunction
Cuases of Hypoactive sexual disorder/Low libido in men
- Psycholocial
a) fatigue
b) situational
c) depression –> treament drugs further worsen sexual dysfunction - Physical
a) hypothyroidism
b) hypogonadism
c) PADAM (Partial Androgen deficiency in Aging Males) - Other: Medicaiton (e.g. antidepressants)
PADAM
Partial Androgen Deficiency in Aging Males
–> extreme hypogonadism disproportionate to rate of male aging
Treatment: Testosterone supplementation
What are the nerve pathways to penile erections?
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
What is a special loop hole in the Nerve pathway to penile erection?
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)
What sort of instrument is the penis
Penis isnt a muscle
Hydrolic instrument
Components of Penis Flaccid –> Erect
- Circumflex vein
- Cavernous sinuses
- tunic albuginea
- Helicine arteries
- Cavernous arteries
Erectile Difficulties requirements
Persisitent inability, for alteast 3 months, to obtain and maintain sufficient and satisfactory sexual performance
Note: DSM-5: 6 months
Relating features to erectile difficulties
- Prevalance increases with age (paralleled to increased rate of organic illnesses with age)
- Organic vs Psychogenic
- incident w. failure to become erect –> psychological reaction –> perpetuates erectile loss - Chronic illnesses (decreased libido/interest), surgery (interruption of fine vessels), trauma (spinal or pelvic)
- Midifiable risk factors
Chronic Illnesses causing Erectile Dysfunction
- Systemic (atheroscleorisis, dibatere, CVD, renal/heaptic failure)
- Neurogenic (alzhiemers, multiple sclerosis)
- 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
Surgery and Trauma as causes of Erectile Dysfunction
- Neurological (spinal cord)
- Pelvic (injury, surgery, irradiation of pelvic region)
- Urological (prostatectomy) –> disruption of fine nerves supplying penis –> risk of impotence with prostatic surgery
Prevalence of Erectile Dysfunction
- No impotence: 48%
- Minimal: 17%
- Moderate: 25%
- 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
Associated of Prevalance of Erectile Dysfunction with age
Overall: Increased probability of ED with age
- 40 years –> 39% risk of ED
- 50 years –> 48% risk of ED
- 60 years –> 57% risk of ED
- 70 years –> 76% risk of ED
Modifiable risk factors which can decrease risk of Erectile dysfunction
- Alcohol
- cigarette
- Drugs (antihypersensitives, anti depressants, hormones, tranquilizers, miscellaneous (NSAIDS, H2RA, cocaine, heroine)
Etiology behind Erectile Dysfunction
- Organic (vasculogenis, neurological, hormonal or cavernosal abnormalities/lesions)
- Psychogenic (central inhibition of erectile mechanism w/o physical insult) –> typically secondary to original ED occurrence –> continued stress of reoccurrence –> Physchogenic problems
What is the common occurance order b/w Organic or Psychogenic problems in relation to Erectile Dysfunction
Psychogenic problems are often Secondary to the actual ED effect –> due to continued worrying of reoccurrence –> psychogenic problems
Sexual Performance Anxiety Circle
- 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
PDE5 inhibitors
- Sildenafil (viagra) : generics now cheaper
- Tadalafil (cialis): not yet off patent
- longer duration of action
- option of low dose (5mg) daily –> maintains oxygenation –> improves endothelial smooth muscle health - Vardenafil (levitra): shorter duration of action –> dont feel terrible for long
Male Erectile Dysfunction Treatment approaches
- PDE5 inhibitors
- Alprosatdil (Caverject) (inject into cavernosa)
- Bimix (papaverine and phentolamine) –> Note: Papaverine often creates problems –> need to reverse with another drug
- Trimix (prostaglandin PGE1, papaverine and phentolamine)
- ED shock wave therapy
- Vacuum device
- Surgery
Rapid Premature Ejaculation
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
Traditional therapeutic responses to premature ejaculation
- Sensate focus with “squeeze” technique –> blunt blow to glans penis
- “Stop-Start” technique
- Local anaesthetic spray (benzocaine)
Neurobiological approach to Ejaculatory disorders
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
Delayed Retarded Ejaculation
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)
Available options of Erectile Dysfunction treatment
- Non-invasive
- elimination of modifiable risk factors
- couselling and/or psychological therapy
- medication
- vaccum constriction devices (decreased efficancy. neurological) - Invasive
- Transurethral drug application (hardly used anymore)
- intracavernous injection therapy
- prosthesis implantation
- venous/arterial surgery (Steel)
Route’s and sites of ED Drug treatment
- brain
a) apomorphine (dopamine agonist, sublingual delivery)
b) sidinaphil (phosphodiesterase inhibitor, oral delivery)
c) phenolalamine (aplha-adrenergic blocker, oral delivery) - Groin area
a) Prostaglandin (vasodilator. 3x delivery areas)
- injeciton (intracavernous)
- suppository (intraurethral)
- transcutaneous ointment –> neuromuscular junction’s corpora cavernosa smooth muscle cells –> vasodilation
Which is more complex out of ED and ED
Ejaculatory dysfunction disorders are more complex
Psychological and Acquired ED
- Hypofunction of 5-HT1A receptors
- and/or possibly hyperfunction of 5-HT2c
- treatment research: h-HT receptor agonists - Acquired DE
- psychological
- disease states (neurological conditions) (diabetes mellitus)
- medication: SSRIs , Tricyclic antidepressants, antipsychotics and others
