sex function and dysfunction Flashcards
sexual response cycle
desire > excitement > plateau > orgasm > resolution
desire phase
innate- similar to appetite. Can be augmented or inhibted by learned responses and experiences. Different than attraction. Partially under influence of estrogen and testosterone
describe elements of attraction
Modifiable elements – age, body habitus, personality/maturity. Constant elements – gender, “type”
causes of desire disorders
performance anxiety or aversion
Arousa/ excitement phase
Increased pulse/ 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
What causes an erection
increased penile blood flow resulting from the relaxation of penile arteries and corpus cavernosal smooth muscle. mediated by the release of nitric oxide (NO) from nerve terminals and endothelial cells, which stimulates the synthesis of cyclic GMP in smooth muscle cells. Cyclic GMP causes smooth muscle relaxation and increased blood flow into the corpus cavernosum
orgasm phase
series of rhythmic contractions of the perineal muscles occurring every 0.8 seconds. In the male it is accompanied by 3 to 7 ejaculatory spurts of seminal fluid. In the female it is accompanied by elevation of the “orgasmic platform” - posterior vaginal wall. In both sexes there are involuntary contractions of skeletal muscles and EEG changes.
resolution phase- males
In males, orgasm is followed by an obligatory resolution phase in which physiologic changes return to baseline and further stimulation cannot produce excitement. The length of the resolution phase varies with age, ranging from less than 5 minutes in adolescents to 24 hours or longer in elderly men
resolution phase- females
In females resolution is not always obligatory—women may return to plateau and have repeated orgasm without resolution to a basal state. Some women do have an obligatory resolution phase
3 questions to ask in ROS for sexual history
Are you in a sexual relationship? How often do you have intercourse? Women -Do you have pain with intercourse?How often do you have orgasm with intercourse? Men – Do you have problems getting or keeping an erection? Do you ejaculate before you want?
Desire phase disorders
Low libido - Hypoactive Sexual Desire Disorder: Usually associated with chronic disease, depression, hypoestrogenic states. Inhibited sexual desire - Sexual Aversion Disorder : Result of pain or other dysfunction. Sexual aversion and HSDD are a continuum
arousal/ excitement phase disorders
Male erectile disorder, Female sexual arousal disorder, Premature ejaculation, Dyspareunia, Vaginismus
criteria for Female Sexual Arousal Disorder
Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement. Causes distress or interpersonal difficulty
components of female aroused state
Labia minora: increased blood flow, engorgement. Clitoris: increased blood flow, engorgement. Vagina: increased length and width, increased blood flow, increased lubrication
Why isnt there a “viagra” for female sex arousal disorder
Disconnect between objective measures of vasocongestion and subjective arousal. Conditioned negative response to arousal. Drug therapy without education/psychotherapy is less likely to be successful
describe dyspareunia
Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female causing distress. May be introital, vaginal or deep and may be reproduced on exam
cycle of dyspareunia
pain with intercourse > inhibited desire/ sexual aversion > failure of excitement > lack of lubrication and expansion
describe vaginismus
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. May make penetration impossible. Causes: pain, religious orthodoxy, severe negative parental attitudes
Plateau phase disorders
female orgasmic disorder, delayed ejaculation/ male orgasmic disorder
Define female/male orgasmic disorder
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm.
sensate focus therapy
12-16 vsits involving behavioral modification, marital therapy. Focus on sensations and emotions and recognize that same stimulus does not give same response
bibliotherapy
Assign readings to patients. Most successful in orgasmic dysfunction
Which drugs can have sex side effects
contraceptives, anti-hypertensives, Anti-epileptics, Psycho-active drugs, Illicit/recreational drugs
contraceptives side effects
OCPs- little evidence. Depo provera- hypoestrogenic state and atrophic vaginitis. Decreased libido in 1.6-15%
Antihypertensives sex side effects
can affect sexual function by acting on the central or peripheral nervous system, the vascular system, or by having hormonal effects. Adrenergic inhibiting drugs, diuretics, vasodilators, monoamine oxidase inhibitors, antiarrhythmics, hypolipidemics, and digitalis may affect the sexual response .
anti epileptic drugs sex side effects
Women who were treated with lamotrigine initially or were switched to lamotrigine had a significantly improved change in sexual functioning . Gabapentin has been reported to induce orgasmic dysfunction . Topiramate has been reported to cause reversible anorgasmia
alpha adrenergic drugs sex side effects
Clonidine and prazosin have been reported to reduce desire in women (wish for partner to approach them) in a small randomized trial. Clonidine has been shown to reduce subjective and physiological arousal in women as measured by a vaginal plethysmograph
Which antidepressants have higher vs lower rates of sexual dysfunction side effects
Higher rates: Duloxetine and paroxetine, sertraline and fluoxetine. Lower: bupropion, moclobemide, nefazodone and reboxetine
list antipsychotics whigh high and low rates of sexual dysfunction
May increase serum prolactin leading to hypogonadotrophic state. High: haloperidol (38.1%) and also with olanzapine (35.3%), quetiapine (18.2%), and risperidone (43.2%). Low: Olanzapine and quetiapine
how does alcohol affect sexual function
acute alcohol intoxication decreases libido, interferes with arousal, leads to failure of erection and ejaculation, and impedes orgasm in women. Chronic alcohol leads to hypogonadotrophic state and loss of sexual function in men and women
how does marijuana affect sexual function
inhibits orgasm, painful sex
PDE5 inhibitors
*Inhibition of phosphodiesterase type 5 (PDE5) enhances erectile function by increasing the amount of cGMP. Sexual stimulation required to initiate release of NO, so no effect in absence of sex stimulation.
List PD5 inhibitors
–Sildenafil, vardenafil,tadalafil
Use of estrogen for sexual dysfunction
*high correlation between serum estradiol levels and sexual function in women. estrogens given by the oral or vaginal route significantly improved symptoms, dyspareunia, and vaginal pH
use of antidepressants for sexual dysfunction
bupropion may have a beneficial effect on desire and orgasm in some women but it is not clear which women, or if the effect is independent of the antidepressant effect.
What Is The Role Of Testosterone In Female Inhibited Sexual Desire
*Transdermal testosterone is more effective than placebo in treatment of hypoactive sexual desire disorder, but the effect is small. It is not FDA approved though
Vaginismus treatment
Use dilators to learn to have something in vagina and confront fears. MUST involve partner
