Sexual Med Flashcards
what are the 5 main stages/phases of sex/sexual arousal?
drive desire/libido excitation orgasm resolution
what sexual problems can affect the drive phase of sex?
sexual aversion
sexual addiction
what sexual problems can affect the desire/libido phase of sex?
hypoactive sexual desire disorder (HSDD)
what sexual problems can affect the excitation phase of sex?
female sexual interest/arousal disorder
erectile dysfunction
paraphilias
what sexual problems can affect the orgasm phase of sex?
orgasmic disorder
ejaculatory problems e.g. delayed, rapid, retrograde
what are the sexual pain disorders?
dyspareunia (superficial or deep)
vaginismus
vulvodynia
what blood tests might be done as part of assessing sexual problems? what kind of problem would prompt you to do each one?
- fasting glucose, lipid ratio = diabetes, CVD - useful to rule in most sexual problems
- testosterone, SHBG, albumin = desire disorders, arousal disorders, orgasmic disorders, pain disorders
- prolactin = desire disorders, ED
- TSH = desire disorders, rapid ejaculation
- oestrogen = female sexual arousal disorder, orgasmic disorder
- FBC = desire disorders, orgasmic disorders
what is hypoactive sexual desire disorder?
lack/loss of sexual desire - not secondary to other difficulties (E.g. dyspareunia, ED).
doesn’t preclude enjoyment or arousal, but make initiation of sexual activity less likely.
give some physical causes of HSDD
chronic medical conditions: - obesity - CVD - DM - anaemia hormonal (men): - androgen deficiency - hypogonadism (various causes) - hyperprolactinaemia hormonal (women): - androgen deficiency - hypothyroidism - hyperprolactinaemia - post pregnancy - Addison's
give some iatrogenic causes of HSDD in men/women
men:
- prescribe medication e.g. antidepressants, finasteride
- post surgical e.g. orchidectomy
women:
- medication e.g. oral contraceptive, oral HRT, tamoxifen (all bind with testosterone); antidepressants and antipsychotics; beta blockers
- post surgery e.g. bilateral oopherectomy
give some psychological causes of HSDD
- psych conditions e.g. depression, anxiety, substance misuse
- psychological experiences e.g. environmental, life events (work stress), prev trauma/abuse
- body image disorder
- couple’s script problems
- erotic dissatistfaction
- couple relationship problems
list some psychosexual treatment modalities
- integrative = combines psychosexual options and physical treatments
- cognitive = e.g. addresses unhelpful thinking styles
- behavioural = e.g. Sensate Focus or Self Growth Programme
- CBT = combines the two
- Psychodynamic = e.g. for past events, attachments, partner choice etc
- Systemic e.g. individual, couple, family dynamics
explain role of testosterone replacement in treating HSDD
- do repeat testosterone tests
- replacement can be given via injection, transdermal patches/gel, buccal, SC implants
- HCG can be used as an alternative to testosterone
describe the use of individual psychosexual therapy for HSDD
- sexual education
- encourages vocalising and accepting difficult feelings
- normalising and permission giving
- finds new solutions for old problems
- surmount barriers to psychological intimacy
- expand communication
- lessen performance anxiety
- transforms destructive attitudes that interfere with intimacy
- support
what is the “Sexual Growth Programme”?
an individual behavioural intervention used in treatment of HSDD.
- allows pt to be aware of their own sexual needs through self exploration of physiological responses
- work w/ therapist to understand and overcome negative beliefs and unhelpful thinking patterns
define erectile disorder (ED)
“difficulty in developing or maintaining an erection suitable for satisfactory intercourse”
can be in obtaining or maintaining erection, or decrease in rigidity
list some physical causes of ED
- chronic medical conditions e.g. CVD, DM, neuro disease
- hormonal - androgen deficiency, high prolactin
- iatrogenic - post prostate surgery, drugs (antiHTNs, antidepressants esp SSRIs)
- age related changes
- ineffective sexual stimuli
- pain
- veno-occlusive disorder
list some psychological causes of ED
- psych conditions e.g. depression, substance misuse
- performance anxiety, life events, negative prev experiences
- couple’s script problems
- relationship problems, issues from prev relationship
- educational matters
- cultural and religious matters
list some medical treatment options for ED
oral - sildenafil (viagra), avanafil (spedra), tadalafil (cialis), vardenafil (levitra)
injectable - alprostadil (intra cavernosal injection, ICI)
intraurethral - aprostadil MUSE pellet (medical urethral system for erection), alprostradil cream (vitaros)
what patient education advice would you give to someone started on medical treatments for ED?
- need sexual stimulation to work
- work best taken on empty stomach
- need to wait 45-60 mins before sexual activity (only 20-30mins on avanafil)
- efficacy improves from first dose to eighth
watch for unacceptable ratio of benefits to side effects.
need partner support
may have difficulty incorporating into sexual script
what are some non-medical treatment options for ED?
- vacuum device
- penile/scrotal rings
- new stimulating routines e.g. enhancing lubes, vibrators
- Kegel exercises
what are the criteria for prescribing medical treatments for ED on the NHS?
can prescribe sildenafil universally, but for others:
i. Have diabetes, multiple sclerosis, Parkinson’s disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida or spinal cord injury.
ii. Are receiving dialysis for renal failure.
iii. Have had radical pelvis surgery, prostatectomy (including transurethral resection of the prostate), or kidney transplant.
iv. Were receiving Caverject, Erecnos, MUSE, Viagra or Viridal for erectile dysfunction at NHS expense on/before 14 September 1998.
v. Are suffering severe distress as a result of impotence (prescribed in specialist centres only)
- psychological treatments - individual sexual and/or couple therapy - expensive!
what is female sexual arousal disorder?
lack of/reduced/failure of genital response - principle issues is vaginal dryness or failure of lubrication
DSM also included reduced interest in sex, reduced erotic thoughts/fantasies etc
give some physical causes of female sexual arousal disorder
- chronic medical conditions - CVD, DM, neuro disease, connective tissue disease
- hormonal disorders - oestrogen deficiency (e.g. post menopause), thyroid disorders
- iatrogenic - prescribed meds (e.g. antidepressants)
- lactation
vaginal dryness is often presenting problem - can be caused by local irritants and douching
list some psychological causes of female sexual arousal disorder
- psych conditions e.g. depression, anxiety, binge eating disorders, excessive dieting
- prev abuse
- couple script problems
- decreased intimacy
- couple’s relationship problems
what is the role of couple psychosexual therapy for treating female sexual arousal disorder?
elements are similar to those used in individual options
hierarchy of interventions:
- timetabling
- communication
- negotiation/contracting
- addressing intimacy
- being sexual
- adjusting to difficulties
describe behavioural interventions that might be used for female sexual arousal disorder
Sensate Focus:
- staged programme of exercises - helps couple identify their own likes/dislikes, explore new techniques
- work w/ therapist to understand and overcome negative beliefs/thinking patterns
New sexual routines, lubricant, vibrators, vielle (device worn on fingers)
Eros therapy device:
what is the Eros therapy device?
- small handheld device used at home
- proven treatment for arousal and orgasmic disorders
- greater clitoral/genital engorgement
- increase vaginal lubrication
- enhanced ability to achieve orgasm
- improved sexual satisfaction
describe a “level 1” couple presenting to sexual medicine clinic
the ideal couple!
high quality relationship, continuing to be affectionate, maintaining non-coital play.
realistic expectations re treatment.
value return of satisfying sex life.
treatment - will usually only require medical intervention and succinct advice.
must follow up though!
describe a “level 2” couple presenting to sexual medicine clinic
- been sexually abstinent for extended time
- expressions of affection dwindled
- one or both are depressed
- moderate levels of performance anxiety
- treatment expectations unrealistic
- uncertain how to restart lovemaking
treatment -
coaching - direct advice on how to communicate, suggestions for performance anxiety
sex/psycho -therapy - brief targeted intervention to overcome resistance to using treatment
what is female orgasmic disorder?
orgasm doesn’t occur or is markedly delayed
list some physical causes of female orgasmic disorder
- chronic medical conditions - CVD, DM, neuro disorder, renal/liver probs
- hormonal - oestrogen and/or androgen insufficiency e.g. post menopause, hypothyroidism
- pelvic floor weakness or damage
- ageing
- prescribed meds esp. SSRIs
list some psychological causes of female orgasmic disorder
- psych conditions (depression, anxiety, substance misuse)
- prev abuse
- couple script problems
- couple relationship problems
- cultural and religious issues
- lack of understanding
- environmental factors
- stress
give some treatment options for female orgasmic disorder
- do they need testosterone replacement? topical oestrogen?
- individual psychotherapy w/ sex therapy focus - promoting changes and attitudes in sexually relevant thoughts
- treat underlying depression
- behavioural - education, personal sexual growth programme, guided masturbation, lubricants and vibrators, kegel exercises
list some ways the menopause can affect sexual function
- vaginal or pelvic pain
- vaginal atrophy
- dryness
- changes in self image, mood, memory, cognition
- changes in desire
- relationship, psychosocial, health factors
- physical discomfort - sleeplessness, night sweats
what is rapid ejaculation?
aka premature ejaculation
- inability to control ejaculation sufficiently for both partners to enjoy sexual interaction
DSM = ejaculation within 1 minute of vaginal penetration
give some physical causes of rapid ejaculation
- genetic susceptibility (neuroreceptor sensitivity)
- penile hypersensitivity
- hyperthyroidism
- prostatitis
- co-morbid sexual problems e.g. ED
- sympathomimetic medication
give some psychological causes of rapid ejaculation
- anxiety states
- early learned experiences
- lack of experience/infrequent sexual activity
- psychosocial and environmental factors
- relationship issues
- partner issues e.g. pain
list some treatment options for rapid ejaculation
- do a physical examination to check for abnormalities
- topical local anaesthetic e.g. stud 100 spray
- medication - dapoxetine
- couple psychosexual therapy
- behavioural interventions - Sensate Focus, stop/start technique, ‘point of inevitability’, Kegel exercise
what is delayed ejaculation?
on almost or all occasions, either generalised or situational, there’s a marked delay or marked infrequency/absence of ejaculation
can be lifelong or acquired, mild/moderate/severe
list some physical causes of delayed ejaculation
- congenital disorders
- trauma or surgery
- age
- infectious disorders
- neuro - DM, spinal cord injury, alcohol neuropathy
- depression
- medications - SSRI, phenothiazines, thiazides, some alpha blockers
- low testosterone levels
exclude retrograde ejaculation
list some psychological causes of delayed ejaculation
- insufficient stimulation/poor sexual arousal
- masturbation technique
- individual vulnerability factors e.g. poor body image, hx sexual/emotional abuse
- outgrowth of psychic conflict e.g. fear, hostility
- relationship factors eg. poor communication, desire discrepancies
- partner issues e.g. ill health, sexual problems
- disguised desire disorder
- secondary to other sex problems
what investigations should be ordered for delayed ejaculation?
physical exam - testes, epididymis, vasa, prostate
blood tests - FBC, glucose, testosterone, B12, folate, PSA
urine sample - for presence of spermatozoa/fructose (to check for retrograde ejaculation)
what are the treatment options for delayed ejaculation?
- personal sexual growth programme
- individual therapy
- couple therapy
- Kegel exercises
- use of vibration/superstimulation
what is retrograde ejaculation?
emen travels backwards into the bladder instead of through the urethra
main symptoms incl:
- producing no semen, or only a small amount, during ejaculation
- producing cloudy urine (because of the semen in it) when you first go to the toilet after having sex
still experience sensation of orgasm but no ejaculation. not a risk to physical health but will impact fertility.
what causes retrograde ejaculation?
Normally, sphincter of the bladder contracts before ejaculation forcing the semen to exit via the urethra, the path of least resistance. When the bladder sphincter does not function properly, retrograde ejaculation may occur.
causes:
- problem with autonomic innervation to bladder neck
- post prostate op
- SE of tamsulosin, antidepressants, antihypertensives, antipsychotics, NRIs (atomoxetine)
- diabetes, MS
how do you treat retrograde ejaculation?
depends on cause -
if due to mild nerve damage (diabetes, MS, spinal cord injury) - TCAs (imipramine), antihistamines (chlorphenamine), decongestants (ephederine)
should take these 1-2 hrs before sex - cause bladder neck muscle to tighten up.
treat subfertility with ICSI, or can centrifuge semen out from urine post coitally.
what is vaginismus?
spasm of pelvic floor muscles that surround the vagina, causing occlusion of vaginal opening
penile entry is either impossible or painful
list some physical causes of vaginismus
- medical conditions where vulva is sore to touch e.g. thrush
- other pain conditions or where pain is anticipated
- FGM
- congenital abnormality
list some psychological causes of vaginismus
- misinformation/mistaken beliefs e.g. that vagina is too small, or first intercourse will be painful
- religious or cultural issues
- fear of pregnancy
- prev sexual abuse/trauma, unpleasant first experience or gynae exam
- fear or dislike of partner
- relationship dissatisfaction
- situational
list some treatment options for vaginismus
- individual psychosexual therapy
- integrated CBT - deconstruct and eventually control phobic reaction
- behavioural interventions - breathing control/relaxation, self exploration and examination, personal sexual growth programme, kegel exercises, vaginal trainers
describe a “level 3” patient presenting to sexual medicine clinic
the difficult -
- in addition to prolonged abstinence, lack of affection etc there’s also profound psychological/interpersonal pathology in one or both partners
- barriers too great to surmount with medical intervention alone
- individual/interpersonal terrains not adequately prepared to use medical treatment
- might have history of abuse
treatment - psychotherapy should precede medical treatment, or may be used in combination
what is dyspareunia?
pain during intercourse - can occur in both men and women.
often caused by local pathology so should investigate appropriately.
list some physical causes of dyspareunia
Manipulation:
- Infection, injury, irritation, lesions, hypersensitivity
Introitus (pain on entry):
- Episiotomy/circumcision
- recurrent infection
- herpes
- allergies
- Bartholin’s cyst
- interstitial cystitis
- urethritis
- vaginal atrophy
- menopause
- post-radiotherapy
- poor lubrication
- insufficient sexual arousal
- effects of a substance (drug/medication)
- penis size
Mid-deep vaginal pain:
- Endometriosis
- congenital shortened vagina
- fixed uterine retroversion
- pelvic tumours
- surgical adhesions
- irritable bowel
- constipation
list some psychological causes of dyspareunia
- prev experiences of pain
- prev sexual abuse
- poor sexual education
- poor understanding of anatomy and physiology of sex
- insufficient relaxation
- painful or unpleasant gynae exam
list some relationship causes of dyspareunia
- poor technique of partner
- speed/timing of partner
- fear of intimacy
- anger/resentment towards partner
list some treatment options for dyspareunia
- physical examination, treat physical causes (e.g. topical oestrogen cream)
- repeat bloods, consider testosterone replacement
- couple therapy
- personal sexual growth programme
- Sensate focus
what are the general principles in couple therapy?
- Create a working alliance with the couple
- Offer insight and understanding into problem and their origins
- Enable feelings to be tolerated and managed
- Facilitate more effective communication
- Change dysfunctional thought patterns
- Help resolve conflict and enable compromise
- Help shift major dysfunctional dynamics eg intimacy and power
what are the four main approaches to couple therapy?
- CBT - focusses on dysfunctional patterns of belief and behaviour in the here-and-now
- psychodynamic - focusses on relationship between current probs and earlier patterns of response/behaviour + unconscious processes
- systemic - focusses on process and context to bring about change, without worrying about understanding/intent
- integrative - combines multiple approaches
what are hypospadias?
congenital abnormality of the penis characterised by:
- a ventral urethral meatus
- a hooded prepuce
- chordee (ventral curvature of the penis) in more severe forms
the urethral meatus may open more proximally in the more severe variants.
what is vulvodynia?
chronic vulval pain occurring without identified cause
pain may be constant, intermittent, occur on touch and can be sharp, burning, stinging in nature.
what is Peyronie’s disease?
condition causing penis to become curved when erect - abnormal formation of scar tissue. can be painful.
what is sexual aversion disorder?
avoidance of sex due to negative feelings (fear, anxiety, repulsion) or lack of enjoyment
actively avoids, vs HSDD where they just lose desire to initiate
list the paraphilias “abnormalities of the object of sexual interest”
paedophilia - to do with children
fetishism - inanimate objects, or parts of body not typically erogenous
transvestic fetishism - involving cross-dressing
zoophilia - aka bestiality - animals
necrophilia - corpses
list the paraphilias “abnomalities of the object of sexual act”
exhibitionism - exposure of genitals to unsuspecting strangers
voyeurism - observing unsuspecting people engaged in sexual activity and/or undressing
sexual sadism - infliction of acts of physical or psychological suffering/humiliation on others
sexual masochism - infliction of these acts on themself
differentiate between ‘assigned sex’, ‘gender identity’ and ‘gender role/expression’
assigned sex = male or female, based on external genitalia
gender identity - intrinsic sense of being male/female/alternative
gender role/expression - personality, appearance and behaviour (within cultural and historical context)
define transgender
diverse gender variance (from the assigned sex), including transsexual, genderqueer, agender
define gender dysphoria
distress due to incongruence between gender identity and sex assigned at birth
define transsexual
individuals who seek to change/have changed their primary and/or secondary sex characteristis
define transmale (FtM) and transfemale (MtF)
transmale = female at birth, changing or changed to male role/body transfemale = male at birth changing or changed to female role/body
briefly outline how sex determination happens (in the embryo)
- external genitalia and gonads develop at around8 weeks
- defeminisation and masculinisation is determined by SRY gene on the Y chromosome - leads to development of testes and production of testosterone and Mullerian inhibiting substance
- sexual differentiation of the brain starts in second half of pregnancy, dictated by testosterone/oestrogen/genes –> gender identity
studies suggest that because these are two quite separate processes, at different intra-uterine periods, they could be influenced independently
outline the management considerations for a transmale individual
- assessment and diagnosis
- social transition ± psychotherapy/OT
- fertility options
- androgens ± GnRH analogue
- voice and communication
- male chest reconstruction
- hysterectomy and bilateral oophorectomy
- phalloplasty/metoidoplasty
outline the management considerations for a transfemale individual
- assessment and diagnosis
- social transition ± psychotherapy/OT
- fertility options
- oestrogens ± antiandrogens
- voice and communication
- facial hair removal
- vaginoplasty
- augmentation mammoplasty
- facial feminisation surgery
