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Sexual Health + Obs & Gynae > Sexual dysfunction > Flashcards

Sexual dysfunction Flashcards

1
Q

What is erectile dysfunction?

A

Persistent inability to attain and/or maintain an erection sufficient to permit satisfactory sexual performance.

It is a symptom, not a disease.

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2
Q

How are causes for erectile dysfunction categorised? Give examples for each category.

A

Organic
- vascular (cardiovascular, hypertension, hyperlipidaemia, peripheral arterial disease, diabetes mellitus, smoking, and obesity) -most common

  • neuronal (multiple sclerosis, Parkinson’s disease, stroke, and spinal cord or central nervous system disease, diabetes mellitus, chronic kidney or liver disease, and pelvic or urological surgery)
  • hormonal (hypogonadism, and hyperprolactinaemia)

Psychogenic
- lack of arousability
- disorders of sexual intimacy
- stress
- anxiety/depression

Drugs/medications
- antihypertensives
- diuretics, antidepressants
- hormonal treatments
- recreational drugs

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3
Q

How does erectile dysfunction present based on the category of causes?

A

Organic:
- Gradual onset
- Normal libido
- Presence of risk factors

Psychogenic
- sudden onset
- decreased libido
- normal self-stimulated erections
- recent major life events/problems
- changes in relationship

Medical and drug history

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4
Q

How is erectile dysfunction diagnosed?

A

Physical examination
- external genitalia

Laboratory testing
- HbA1c or fasting blood glucose (check for diabetes)
- lipid profile (CVD cause)
- morning total serum testosterone (normally serum testosterone levels are high in the morning, so if it is low that means their testosterone is always low)
- measure free testosterone (if morning total serum testosterone is low/borderline)
- repeat free testosterone with FSH, LH, prolactin (if the first free testosterone level is low/borderline)

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5
Q

How to manage a pt with erectile dysfunction?

A

Refer to urology:
- young pt with erectile dysfunction or if abnormality of penis/testicles on exam

Refer to endocrinology:
- abnormal serum testosterone, FSH, LH, or prolactin

Refer to cardiology:
- severe/unstable CVD that would make sexual activity unsafe or contraindicates PDE-5 inhibitor use (e.g. uncontrolled HTN, unstable angina, recent MI)

Refer to mental health services:
- psychogenic causes

For all pts, manage any reversible/modifiable risk factors:
- e.g. drug related factors. diabetes, HTN, etc.

Regardless of the cause for erectile dysfunction, prescribe PDE-5 inhibitor (e.g. Sildenafil, tadalafil (once daily), vardenafil, avanafil).
- contraindicated for high CV risk.

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6
Q

What is premature ejaculation?

A

This is when ejaculation occurs sooner than desired, which causes distress to either one or both partners.

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7
Q

What are the potential causes for premature ejaculation?

A

Prostatitis
Thyroid disease
Psychological distress

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8
Q

How do you manage a pt with premature ejaculation?

A

Psychosexual counselling

Topical anaesthetic

Dapoxetine
- shorting acting SSRI →this is prescribed because one of the side effect is delayed orgasm
- taken 1-3 hours prior to sexual activity

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9
Q

What is decreased libido?

A

Low sex drive causing distress

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10
Q

What are the causes of decreased libido?

A

Low testosterone
Hypothyroidism
Anxiety/depression
SSRI/SNRIs
Recreational drugs (e.g. heroin, cocaine, marijuna)

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11
Q

What is anorgasmia?

A

Persistent or recurrent delayed, infrequent or absent orgasms.

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12
Q

What causes anorgasmia?

A

Neurological disorders (e.g. Parkinson’s disease)
Previous gynaecological surgeries (e.g. scarring)
Medications (e.g. SSRIs, diuretics)
Alcohol
Smoking
Psychological and relational problems

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13
Q

How do you manage a pt with anorgasmia?

A

Treat underlying cause.

Psychosexual counselling

Oestrogen therapy
- local (suppository or cream) or systemic
- given if pt is postmenopausal and as a result experiences painful sex, so this medication will alleviate that pain and improve the ability to orgasm)

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14
Q

What is vaginismus?

A

Vaginismus is when the vagina suddenly tightens up when you try to insert something into it, causing pain during vaginal penetration (e.g. sexual intercourse, gynaecological exam, tampon insertion)

Involuntary contraction of the vaginal musculature.

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15
Q

What causes vaginismus?

A

Psychological factors:
- previous sexual trauma or adverse sexual experiences
- previous traumatic genital examination

Vestibulodynia:
- tender area at entrance of vagina due to postmenopausal oestrogen deficiency, previous genital surgery, or skin disorder.

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16
Q

How does vaginismus present?

A

Dyspareunia (painful sex)
Lack of interest in sex (due to pain)
Inability to be aroused
Vaginal dryness and lack of lubrication
Inability to use tampons
Anorgasmia
Hx of traumatic examination or sexual experiences

+/- urogenital anomalies, scarring, lichenification (thickening of the skin), inflammation

17
Q

How to manage a pt with vaginismus?

A

Vaginal trainers
- tampon-shaped objects in different sizes to help you gradually get used to having something put into your vagina.

Psychosexual and couple therapy
- a type of talking therapy that aims to help you understand and change your feelings about your body and sex.

Topical liodcaine

HRT in post-hysterectomy and perimenopausal females

Pelvic floor exercises
- squeezing and releasing exercise to gain control of the vaginal muscles

17
Q

What is atrophic vaginitis?

A

Atrophy of the vulvovaginal area that causes dryness and inflammation, which is due to decrease in oestrogen levels in peri and post menopause.

Atrophy = decrease in size or wasting away part of a tissue.

18
Q

How does atrophic vaginitis present?

A

Dyspareunia
Light bleeding after sexual intercourse
Vaginal dryness, burning
Vaginal discharge
Pruritus vulvae
Dysuria
Urinary urgency
Polyuria
Urinary incontinence
Recurrent UTIs

19
Q

How is atrophic vaginitis diagnosed?

A

Pelvic examination
Urinalysis

20
Q

How is atrophic vaginitis managed?

A

Vaginal moisturisers
- help relieve dryness

Water-based lubricants (K-Y jelly)
- apply prior to sexual activity to reduce discomfort

Topical oestrogen
- indicated for menopausal atrophic vaginitis
- short-term use only due to risk of endometrial hyperplasia and carcinoma

21
Q

What is infertility?

A

Infertility is the period of time people have been trying to conceive without success, after which formal investigation is justified and possible treatment implemented.

In other words, failure to conceive after frequent unprotected sexual intercourse for at least one year.

22
Q

What are the causes of infertility?

A

Oligozoospermia (low levels of sperm)
Asthenozoospermia (reduced sperm motility)
Teratozoospermia (high amount of abnormal shaped sperm)

Ovulatory disorders (e.g. PCOS, premature menopause, premature ovarian insufficiency)

Tubal damage (due to pelvic inflammatory disorder)

Uterine or peritoneal disorders (e.g. fibroids)

Idiopathic

23
Q

What to ask/look for in female infertility assessment hx taking and examination?

A

Full medical, sexual and social hx.

Length of time trying to conceive and sexual intercourse frequency

Hx and symptoms that indicate ovulatory problems:
- menstrual cycle details, menorrhagia, oligomenorrhea, amenorrhoea
- galactorrhoea, hirsutism
- systemic disease (e.g. thyroid dysfunction, DM, IBD)
- excessive exercise, weight loss or psychological distress

Hx and symptoms that indicate tubal, uterine or cervical factors:
- symptoms of PID, endometriosis
- Hx of STIs or PID
- previous pelvic, genitourinary surgeries
- Intermenstrual or postcoital bleeding

Lifestyle factors:
- smoking
- excessive alcohol consumption

Physical examination:
- BMI
- hirsutism
- acne
- pelvic exam

24
Q

What are primary and secondary care female infertility assessment?

A

Primary care initial assessment:
- serum mid-luteal phase progesterone (confirms ovulation)
- chlamydia testing (checks for signs of PID)
- serum FSH and LH (if anovulation or oligo-ovulation)
- TFTs
- serum prolactin

Secondary care assessment:
- hysterosalpingography (looks at uterus, fallopian tubes) or ultrasonography

25
Q

What to ask/look for in male infertility assessment hx taking and examination?

A

Full medical, sexual and social hx.

Length of time trying to conceive and sexual intercourse frequency

Hx and symptoms that indicate spermatogenic failure or obstructive azoospermia:
- Hx of mumps, STIs, or testicular trauma/torsion
- Previous urogenital abnormality & treatment (e.g. undescended testis)
- Systemic diseases (e.g. cardiac failure, CKD, DM, liver cirrhosis)

Ejaculatory or erectile dysfunction

Lifestyle factors (e.g. smoking, excessive alcohol intake, anabolic steroids, occupational situations that may cause testicular hyperthermia)

Physical examination
- Penile structural abnormalities (e.g. hypospadias)
- Scrotal examination (varicocele, hernia, undescended testes)
- Signs of hypogonadism (small testes, gynaecomastia, decrease in body hair)

26
Q

What are primary and secondary care male infertility assessment/IVx?

A

Primary care initial assessment/IVx:
- semen analysis (are they moving correctly, do they look normal?)
- chlamydia testing (checks for signs of PID)

Secondary care assessment/IVx:
- imaging of urogenital tract
- testicular biopsy
- endocrine tests

27
Q

How is infertility managed?

A

General advice
- regular sexual intercourse 2-3 days
- take folic acid
- smoking cessation
- healthy body wt

Initiate infertility assessment if not conceived after 1 year of regular unprotected sexual intercourse.

Refer to secondary care if normal hx, exam, and initial IVx.

Fertility tx:
- medicine (e.g. clomifene -induce ovulation)
- surgery
- assisted conception (e.g. intrauterine insemination [IUI], in vitro fertilisation (IVF), embryo donation)

28
Q

What is female genital mutilation (FGM)?

A

A procedure where the female genitals are deliberately cut, injured or changed, but there’s no medical reason for this to be done.

29
Q

What are the types of FGM?

A

Four types:
Type 1: clitoris removed
Type 2: clitoris and labia menorah and majora removed
Type 3: vaginal opening is stitched up
Type 4: any kind of trauma to the vaginal opening

30
Q

What would you do if a young pt (<18 years) tells you they have been a victim of FGM or you see evidence of FGM on exam?

A

Mandatory reporting to police (call 101)

31
Q

When should you consider referral to local safeguarding team?

A

Suspect FGM
Suspect a pt is at risk of FGM

Sexual Health + Obs & Gynae (5 decks)

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