Sexual Dysfunction

Question 1

What is primary vulvodynia?

Answer 1

Chronic vulval pain of more than 3 months dating from 1st sexual experience or tampon use

Question 2

What is secondary vulvodynia?

Answer 2

Chronic vulval pain of more than 3 months developing after previous pain free sexual intercourse

Question 3

Associations with vulvodynia

Answer 3

Change in sexual partner
Thrush
STI
Depression / anxiety

Question 4

Causes of dysparunia

Answer 4

Vulvovaginitis (esp thichomoniasis and candida)
Vaginal cysts
Infected bartholins gland
Post menopause
Congenitally small ostium / thick hymen 
Deep retroverted uterus 
Chronic pelvic infection
Endometriosis
Adenomyosis
Pelvic tumours
Ectopic pregnancy

Question 5

What is premenstrual syndrome

Answer 5

Physical and/or psychological symptoms
affecting some women up to 10 days prior to menstruation.
Acne, breast tenderness, bloating, fatigue, nervousness, irritability, emotional disturbance, headache, mood changes.
Usually resolves with or after menstruation

Question 6

what conditions are often associated with vulvodynia

Answer 6

anxiety
depression
somatisation
hyperchondriasis

Question 7

management options for vulvodynia

Answer 7

pelvic floor excercises
external / internal soft tissue self massage with organic lubricants
trigger point pressure
biofeedback
vaginal trainers
accupuncture
lidocaine gel / capsicum cream
amitryptilline / gabapentin / pregabalin

Question 8

what is hypoactive sexual desire disorder?

Answer 8

loss of Iibido
decline in sexual desire
causing distress and interpersonal difficulties

Question 9

causes of hypoactive sexual desire disorder?

Answer 9

psychosexual cause
physical causes 
- depression 
- menopause
- TCAs
- SSRIs
- chemotherapy
- radiotherapy
- oophorectomy

Question 10

What is tokophobia

Answer 10

fear of pregnancy and childbirth

more common in primigravid women
anecdotally is increasing

Question 11

causes of tokophobia

Answer 11

primary tokophobia = in nullips / primips

• adolescence - avoid pregnancy at all costs
• cultural attitudes
• family attitudes
• media
• childhood or adulthood abuse

secondly tokophobia - occurs after previous birth

• previous traumatic birth
• previous instrumental delivery
• spontaneous birth
• previous termination
• previous still birth

Question 12

factors to explore in women with tokophobia

Answer 12

triggering factors
causes of concern
- fear of pain
- loss of control
- fear of harm to them
- fear of harm to the baby
- lack of support
- concern birth will stretch vagina
- concern anatomy is not normal

Question 13

What does LOFTI stand for in a psycho-sexual consultation

Answer 13

Listening
Observing
Feelings
Thinking
Interpreting

Question 14

examples of defence mechanisms in psychosexual patients

Answer 14

regression 
dissociation 
introjection 
sublimation
denial
avoidance

Question 15

what is vaginismus

Answer 15

involuntary spasm of the pubococcygeus muscle and associated muscles
causing painful and difficult vaginal penetration

can be primary or secondary

Question 16

What may erectile dysfunction be an early marker for?

Answer 16

coronary artery disease (CAD) and generalized arteriopathy

Question 17

first-line medical treatment for erectile dysfunction

Answer 17

Phosphodiesterase inhibitors type 5

• sildenafil (Viagra)
• tadalafil (Cialis)
• Avanafil (Spedra)
• vardenafil (Levitra)

Question 18

factors potentially contributing to delayed ejaculation in men with HIV

Answer 18

medications (especially antidepressants)
penile sensation loss due to neuropathy (incl drug- induced)
endocrinopathies
psychological

Question 19

factors potentially contributing to female sexual dysfunction in women with HIV

Answer 19

Fear of onward transmission 
difficulties negotiating condom use 
menopause
low CD4 count
low mood 
poor body image 
neuropathy (HIV or drug- induced)
endocrine disturbances
atherosclerosis

Question 20

Aetiology of Localised provoked vulvodynia (vestibulodynia)

Answer 20

Likely multifactorial

History of vulvovaginal candidiasis, usually recurrent - is commonly reported

Question 21

Symptoms of localised provoked vulvodynia

Answer 21

Vulval pain – frequently at the introitus at penetration during sex or on insertion of tampons
Usually a long history

Question 22

Signs of localised provoked vulvodynia

Answer 22

Focal tenderness

elicited by gentle application of a cotton wool tip bud at the introitus or around the clitoris

Question 23

Complications of localised provoked vulvodynia

Answer 23

Sexual dysfunction and psychological morbidity

Question 24

Diagnosis of localised provoked vulvodynia

Answer 24

Clinical diagnosis

history and examination

Question 25

Further investigation of localised provoked vulvodynia

Answer 25

Exclusion other treatable causes | Biopsy only if there is any suspicion of an underlying dermatosis

Question 26

Treatment of localised provoked vulvodynia

Answer 26

``` Avoid irritating factors Use emollient soap substitute. Topical local anaesthetics - e.g. 5% lidocaine ointment / 2% lidocaine gel - use with caution - may cause irritation Pelvic floor muscle biofeedback Vaginal transcutaneous electrical nerve stimulation Vaginal trainers CBT Psychosexual counselling. ``` Pain modifiers – amitriptyline / TCAs, gabapentin, pregabalin. Surgery – modified vestibulectomy - considered if other measures unsuccessful. Patients who responded to topical lidocaine prior to sex have a better outcome

Question 27

Follow-up for patients with localised provoked vulvodynia

Answer 27

As clinically required | Long-term follow-up and psychological support may be needed

Question 28

Aetiology of Unprovoked vulvodynia

Answer 28

Aetiology unknown | Condition best managed as a chronic pain syndrome

Question 29

Symptoms of unprovoked vulvodynia

Answer 29

``` Pain Longstanding Unexplained May be associated with urinary symptoms Can be associated with irritable bowel syndrome and fibromyalgia ```

Question 30

Signs of unprovoked vulvodynia

Answer 30

vulva appears normal

Question 31

Complications of unprovoked vulvodynia

Answer 31

Sexual dysfunction | Psychological morbidity.

Question 32

Diagnosis of unprovoked vulvodynia

Answer 32

Clinical diagnosis Made on history and examination Once excluded other causes

Question 33

Further investigations for suspected unprovoked vulvodynia

Answer 33

Exclude other treatable causes | Biopsy ONLY if any suspicion of alternative diagnosis

Question 34

Treatment of unprovoked vulvodynia

Answer 34

Use of emollient soap substitute Pain modifiers – TCAs (amitriptyline) frequently 1st line; gabapentin or pregabalin Topical local anaesthetic - e.g. 5% lidocaine ointment / 2% lidocaine gel CBT Psychotherapy Acupuncture Physiotherapy -if evidence of a weak pelvic floor Referral to a pain clinic

Question 35

Follow up of patients with unprovoked vulvodynia

Answer 35

As clinically required

Question 36

recommended dose of amitryptiline for unprovoked vulvodynia

Answer 36

Start at 10mg ON | increase by small increments up to 100mg daily according to the patient’s response

Question 37

what is Dyspareunia

Answer 37

Pain on sexual intercourse

Question 38

what is anorgasmia

Answer 38

female failure to reach orgasm | and finds this a problem