Sexual Health

Question 1

What is gender dysphoria and how is it assessed?

Answer 1

Disorder of gender identity - desire to live as opposite sex.
Hx of 2 years transsexual identity with full psych hx - gender development, sexual hx

Question 2

Rx for gender dysphoria?

Answer 2

Referral to gender clinic, real life testing for 1 year
Hormone therapy (synthetic oestrogen, testosterone)
Gender reassignment surgery eg penectomy, vaginoplasty, hysterectomy

Question 3

Investigations for sexual disorder?

Answer 3

Full sexual hx, examination
Blood tests: fasting glucose, lipids, testosterone, SHBG (sex hormone binding globulin), prolactin, TSH, Oestrogren, FBC, GnRH

Question 4

Psychological treatments for sexual disorders?

Answer 4

CBT, psychodynamic (past events, attachments, partner choice), systemic (interactions and roles in relationship), Integrative (combination)

Question 5

What is hypoactive sexual desire and what causes it?

Answer 5

Lack of/loss of sexual desire causing destress - doesn’t preclude enjoyment

Cause: chronic disease (DM, CVD, anaemia, obesity), hormonal (androgen deficiency, hypothyroid), iatrogenic (SSRI, OCP, surgery), psychiatric (depression, anxiety)

Question 6

Rx for hypoactive sexual desire disorder?

Answer 6

Psychosexual - CBT, psychodynamic, integrative).

Medication - testosterone = M, Flibanserin = F

Question 7

What is erectile dysfunction and what causes it?

Answer 7

Difficulty in developing/maintaining an erection suitable for sexual intercourse. With adequate stimulation.
Cause: chronic medical condition (CVD, DM, Neuro, BPH), hormonal deficiency - testosterone, high prolactin - prolactinoma, Iatrogenic (prostate sx, SSRI, opiates) psychiatric (depression, stress, anxiety)
Peyronie’s disease
Partner: relationship issues, conflict, if they have a sexual problem - man doesn’t want to hurt partner w/vaginismus

Question 8

ED investigations and Rx?

Answer 8

Ix: history, bloods: HbA1c, lipids, testosterone + SHBG + albumin, FSH, LH, prolactin, PSA

1st line…
-Phosphodiesterase inhibitors e.g. Sildenafil (viagra)
-S/E=Headaches and flushing
-C/I= Hypotension
Then try w/one of others = tadalafil/avanofil

2nd line…
-Alprostadil (intracavernosal injectable or intraurethral via MUSE)

NON MEDICAL
Vacuum device
Penile/scrotal rings
Kegel exercises
Psychological - personal sexual growth work

Question 9

What is Female Sexual arousal disorder?

Answer 9

Failure of genital response (vaginal dryness, reduced sexual interest, reduced response to stimuli)

Question 10

Causes of female sexual arousal disorder?

Answer 10

Disease (DM, CVD, neuro)
Hormonal - oestrogen deficiency - menopause
Iatrogenic - SSRI
Psychological

Question 11

Rx for female sexual arousal disorder?

Answer 11

Behavioural: sensate focus, Eros therapy device, lubricants

Psychosexual couples therapy

Question 12

What is rapid ejaculation and what causes it?

Answer 12

Inability to control ejaculation sufficiently for both partners to enjoy sexual interaction - under 1 min
Hyperthyroidism, penile hypersensitivity, psychological - performance anxiety, lack of experience

Question 13

Rx for rapid ejaculation?

Answer 13

1st line - SSRI - dapoxetine (increased risk of suicide), STUD 100 spray (topical anaesthetic), psychosexual therapy, behavioural - start/stop

Question 14

What is female orgasmic disorder w/ cause and rx?

Answer 14

orgasm delayed or does not come.
Cause: Chronic disease - DM, CVD, obesity, androgen deficiency, pelvic floor weakness, SSRI, psychological
Rx: topical oestrogens, guided masturbation, vibrators

Question 15

What is vaginismus and what is cause?

Answer 15

Spasm of pevic floor muscles surrounding vaginal opening making penile entry impossible/painful.
Cause: thrush, FGM, congenital, psychological - tramuam/fear

Question 16

Rx for vaginismus?

Answer 16

Psychosexual, self exploration, vaginal dilators and graded penetration therapy

Question 17

What is dyspareunia and what causes?

Answer 17

Pain during intercourse - only when no non-organic dysfunction
Cause: local pathology:
female: deep: PID, entometriosis, gynae (fibroids/cyst), surgery (episiotomy), trauma, radiotherapy
Superficial - lichen sclerosis, STI, episiotomies, vaginal atrophy, anaemia, recurrent UTIs

male - STI, urethral strictures, varicoceles, psychological

Partner issues - check sexual practices
Psych: avoidance, can’t relax, stress, relationship - is she aroused enough/giving enough time.too much time e.g. prolonged ejaculation, body dysmorphia

Question 18

Ix and Rx for dyspareunia

Answer 18

Ix: Physical exam - bimanual/speculum; bloods: FBC (infection/ANAEMIA), glucose, hormones: oestrogen, testosterone (if symptomatic), FSH, LH, prolactin

Rx: Lubricants, couples therapy/behaviour therapy, kegals exercises

Question 19

Risk factors and presentation of candida albicans?

Answer 19

Pregnancy, DM, antibiotics.

Pres: cottage cheese discharge, itching, sorenes

Question 20

Ix and Rx for candida albicans?

Answer 20

Ix: clinical, MC&S - mycelia spores
Rx: clotrimazole cream / PO fluconazole

Question 21

RF, pres, Ix and Rx of bacterial vaginosis?

Answer 21

RF: Sexual active, IUD, new partner
Pres: 50% symptomatic - white, fishy smelling discharge
Ix: vaginal swab - pH >4.5, clue cells
Rx: metronidazole

Question 22

Cause, RF, pres of gonorrhoea?

Answer 22

Neisseria gonorrhoea - Gram -ve diplococcus
RF: previous STI, multiple partners
Pre: 90% M and 50% F asymptomatic - white/yellow/green discharge

Question 23

Ix and Rx for gonnorhoea?

Answer 23

Ix: NAAT (nucleic acid amplification test)
Rx: IM ceftriaxone and PO azithromycin (cover chlamydia)

Question 24

Cause, RF, Pres, Ix and Rx for chlamydia?

Answer 24

Chlamydia trochomatis, gram -ve
RF: previous STI, multiple partner, PID, Reiters
Pres: 70% F and 50% M asymptomatic - milky white/yellow discharge, dysuria, intermenstrual bleeding
Ix: NAAT, swabs
Rx: PO azithromycin

Question 25

Cause, pres, Ix, Rx for Trichomonas vaginalis

Answer 25

Flagellated protozoan - T. vaginalis
Pres: 50% asymptomatic - frothy offensive smelling yellow/green discharge, strawberry cervix, dysuria, itchy and sore
Ix: NAAT, swabs
Rx: metronidazole

Question 26

Cause, RF, Pres, Dx, Rx for genital warts?

Answer 26

Cause: HPV
RF: smoking, multiple partners, early age intercourse
Pres: Growth/lesion, itch, dyspareunia
Dx: STI screen
Rx: Cryotherapy, podophyllotoxin cream

Question 27

Male 40+ presents w/ a hard lump in the shaft of the penis and complain’s there is a curve in the penis when erect. Diagnosis and treatment? What is the pt at risk of?

Answer 27

Peyronie’s disease - fibrous plaque in the tunica albicans. Can occur in trauma to the penis.

Treatment: non surgical NICE = extracorporeal shockwave therapy (aimed at the plaque) but not enough evidence

surgical: removal of plaque,
implantation of instrument to straighten penis,
removing area opposite plaque to cancel out bend -> results in shortening of penis

R/o ED