Sexual Medicine Flashcards
1. Screening and assessing male sexual dysfunction
Sexual motivation cycle
- Conscious sexual desire as measured by sexual thoughts, sexual fantasies and conscious urge to be sexual either alone or with a partner
- Person seek out sexual stimuli
OR - from sexually neutral
- Sensual stimulation
- Triggered arousal or desire
When/in whom is conscious sexual desire more common
- early on in relationships
- in men more than women
ANS involvement in sexual arousal
- changes in ANS involve genital congestion,respiration, body temperature, muscle tone, blood pressure and heart rate are reflexly uncousciously activated
- at same time consciou and unconsciou evalution of stimuli (slower process which may or may not lead to subjective arousal)
Genital vasocongestion in women
- increase in genital vasocongestion is rapid response (occurs in seconds)
- happens even if not subjectively aroused/excited
- i.e. stimulus just has to be registered as sexual (not erotic)
Penile congestion and erection in men
- unlike women this occurs more slowly
- occurs with subjective excitement
Once subjective excitement is attained in men/women what happens (in the brain) - how the end effect of this differs in men and women
That state is evaluated both cognitively and emotionally
- if thoughts are negative: subjective arousal will lessen if emotions are negative subjective arousal will lessen
- especially in men there is a strong correlation between subjective arousal and genital swelling/erection
- in women there is a highly variable correlation between subjective sexual arousal and measured increase in vaginal vascongestion
Experiment showing subjective sexual arousal was not necessary for vaginal vasocongestion in women
- watch erotic videos
- the majority of women who complained of lack of arousal reportining no excitment in their minds and no awareness of any genital response actually had increase in vainal cnogestion comparable to control women (finding the videos sexually exciting)
Situations in which physiological response produced involuntarily and not matching subjective response
- genital responding in situations of rape/assault
- women with subjective arousal disorder - lubrication without subjective arousal/excitment
- damage to nerves subserving penile ereticle mechanism –> subjectively sexually excited but no swelling/erection
- autonomic nerves to vulva/clitoris cut –> no clitoral swelling/lubrication when subjectively aroused
Subdivisions of male genitalia
1) internal genitalia (prostate, ejaculatory ducts, seminal vesicles, vas deferens, epididymis, testicles)
2) external genitalia (mons pubis, penis, penil bulb, perineum, scrotum)
Structures that engorge with blood in response to sexual arousal in men and women
- penis
- clitoris
- both tissues contain vascular spaces (sinusoids) lined by endothelium and surrounded by smooth muscle + connective tissue –> form meshwork = trabeculae which is integral to expansion/contraction of sinusoids
Corpora cavernosa
Two parallel erectile tubes
form the major component of the body/shaft of the penis
- each starts as a crus (blunt pointed process in front f tuberosity of ischium)
- just beforie the tubes meet they enlarge slightly (bulb of penis)
- beyond this point undergo constriction and merge into corpus cavernosum proper and join the felow corpus
Tunica albuginea
- strong fibrous envelope that surrounds both corpora cavernosa
- made of superficial and deep fibres
Layers of tunica albuginea
- bilayered
- inner layer = circularly oriented bundles that support and contain cavernous tissue
- outer layer oriented longitudinally extending from the glans penis to the proximal crura and inserting to inferior pubic rami
- between two layers = emissary veins that dain the penis (occluded easily by tunicaly layers during erection -compress veins during erection)
Septum
- thick and complete behind
- but imperfect in front - (arrange in vertical bands like teeth of a comb = septum pectiniforme)
- permeable = alows medication to flow from one corpus to other
Corpus spongiosum
- running underneath corpora cavernosal tissue
- terminates in glans penis
- and heading into body expands to form urethral bulb (palpable between penile shaft and anal opening)
Three “regions” of the penis
- a root (tri-radiate - median urethral bulb + diverging crura, each crus covered by ishiocavernosus and bulb by bulbocavernosus muscle, attaches to fascia and pubic rami)
- body extends from root to the ends of copora cavernosal bodies
- glans extremity = glans penis (expanded anterior end of corpus spongiosum)
Scrotum
- pouch like structure behind the penis
- holds and protects the testes + contains numerous nerves/blood vessels
Function of cremaster muscle
-low temp –> contracts and pulls scrotum closer to the body (wrinkled apperance of scrotum)
Connection scrotum with abdomen/pelvic cavity
Via inguinal canal
Route taken by sperm
1) produced in testes
2) pass through epididymis, vas deferens, seminal vesicles, ejaculatory duct and urethra
3) expelled through ejaculation
Epididymis
Tightly coiled tubes cupped against each testicle
-for maturation and storage of sperm
Vas deferens
Structure that sperm propelled up through during ejaculation
17 inches long (approx)
Seminal vesicles
-produce fructose to nourish sperm cells and aid in their motility
Prostate gland
-produces prostatic fluid which mixes with fluid + sperm arriving from seminal vesicles
Bulborethral glands (cowper’s gland)
Two small glands located on the sides of the urethra just below the prostate gland
Produce a clear slippery fluid that empties directly into the urethra
(nourishes the spermatozoa)
What nervous systems are responsible for arousal in men
1) sacral parasympathetic (pelvic nerve)
2) thoracolumbar sympathetic (hypogastric and lumbar sympathetic chain)
3) somatic (pudendal) nervous system
MOA by which genital structures in both men and women respond to arousal
- response to arousal = increased vascongestion and neuromuscular tension and become engorged with blood (tumescent)
- via smooth muscle relaxation in the erectile bodies
What is the primary neurotransmitter responsible for smooth muscle relaxation and relaxation of helicine arteries in the penis
Nitric oxide
Where is NO generated
- neuronal NO - majori singificance in sexual response
- also generated from endothelium
MOA of NO
1) NO activates guanylyl cyclase - produces cGMP
2) NO stimulates Na pump activity to induce hyperpolarization with subsequent closure of voltage sensitive Ca2+ channels and sequestration of Calcium by intraceullarorganelles = decreases intracellualr Ca2+ causes SMC relaxation
Effect smooth muscle relaxation in the penis
1) Dilation of cavernosal and helicine arteries
2) 5-10x increase in blood flow to penis
3) Expansion of corporal snusoids = volume of blood in corporal increases
4) Subtunical venular plexuses are compressed between the tunica albuginea and peripheral sinusoids = reduced venous drainage
5) Intracavernosal pressure rises to mean blood pressure to achieve full errect state
Diagnosis erectile disorder
- min one of 3 following symptoms
a) marked difficulty in obtaining an erection during sexual activity
b) marked difficulty in maintain an erection until the completion of sexual activity
c) marked decrease in erectile rigidity that interferes with sexual activity
Male orgasmic disorder diagnosis
Male Orgasmic Disorder: (Delayed Ejaculation)
At least one of the two following symptoms must have been present for a minimum duration of approximately 6 months and be experienced on all or almost all (approximately 75%) occasions of partnered sexual activity and without the man desiring the delay:
1. Marked delay in ejaculation
2. Marked infrequency or absence of ejaculation
Early ejaculation diagnosis
The following symptom must have been present for a minimum duration of approximately 6 months and be experienced on all or almost all (approximately 75%) occasions of sexual activity: Persistent or recurrent pattern of ejaculation occurring within approximately one minute of vaginal penetration and before the person wishes it. Although the diagnosis may be applied to individuals engaged in non-vaginal sexual activities, no precise duration criteria are specified.
Male hypoactive sexual desire disorder
Persistent or recurrently deficient (or absent) sexual fantasies and desire for sexual activity for a minimum duration of approximately 6 months. The judgment of deficiency is made by the clinician taking into account factors that affect sexual functioning such as age and context of the person’s life.
