Sexual Medicine Flashcards by Harriet Haughney

What are the two main features of hypoactive sexual desire disorder (HSDD)?

Lack or loss of sexual desire CAUSING distress - primary prob. Doesn’t mean can’t have sexual enjoyment or arousal, but makes initiation of sexual activity less likely.

Persistently/recurrently deficient (or absent) sexual/erotic thoughts or fantasies desire for sexual activity.

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Aetiology of hypoactive sexual desire disorder (HSDD)

Chronic diseases e.g. obesity, CVD, DM, anaemia
Hormonal disorders (androgen defic., hypogonadism, hyperprolactinaemia, hypothyroidism, post-preg, Addison’s disease)
Iatrogenic: prescribed meds (SSRIs, finasteride (for BPH), oral contraceptive, HRT, tamoxifen (all of these bind with testosterone), surgery)
Psych (depression, anxiety, substance misuse, prev trauma, relationship probs

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HSDD treatment options

Psychosexual therapy - CBT, psychodynamic, cognitive, integrative, behavioural
Medication - testosterone replacement (Flibanserin if pre menopausal women)

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Define erectile dysfunction

Difficulty in developing or maintaining an erection suitable for satisfactory intercourse

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Aetiology of erectile dysfunction

Physiological:

Chron med conds (CVD, DM, neurological disease)
Hormonal disorders
e. g. androgen defic., high prolactin
Iatrogenic e.g. post prostate surgery, SSRIs, HTN
Age related
Ineffective sexual stimuli
Pain
Veno-occlusive disorder

Psychological:

Psych conds e.g. depression, substance misuse
Couples script problems
Relationship problems or issues from previous relationship
Educational matters
Cultural and Religious matters

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Medication for erectile dysfunction

1st line - phosphodiesterase inhibitors e.g. sildenafil (viagra). S/E: headaches and flushing
2nd line: alprostadil (injectable or intraurethral via MUSE - medical urethral system for erection)

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Non-medical treatment for ED

Vacuum device
Penile/scrotal rings
New stimulating routines e.g. enhancing lubricants, vibrators
Kegel exercises
Psychological treatment (CBT, integrative, psychodynamic, systemic)

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Define female sexual interest/arousal disorder (FSAD)

Failure of genital response - main problem is vaginal dryness or failure of lubrication.
Reduced sexual interest/arousal:
Absent/reduced interest in sexual activity
Absent/reduced sexual/erotic thoughts or fantasies
Absent/reduced sexual pleasure
Absent/reduced sexual arousal in response to sexual stimuli

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Aetiology of FSAD

-Chron med conds e.g. CVD, DM, neurological disease, connective tissue disease
-Hormonal disorders - oestrogen deficiency, e.g. post menopause
-Iatrogenic - SSRIs
-Lactation
-Vaginal dryness is a common presenting problem and can also be caused by local irritants and douching
Psychological - depression, eating disorders, relationship probs

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General causes of sexual disorders

Chronic medical conditions (CVD/T2DM/Obesity)
Hormonal
Iatrogenic
Psychiatric

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General investigations for sexual disorders

Full sexual history
Exam
Blood tests: Fasting glucose/lipid ratio, testosterone, SHBG,p prolactin, TSH, oestrogen, FBC, GnRH

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General psychological treatments for sexual disorders

Integrative - combination of psychosexual options and physical treatments
CBT - sensate focus or self growth programme
Psychodynamic - past events, attachments, partner choice
Systemic - interactions and roles in a relationship

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Treatment for FSAD

Behavioural: sensate focus, eros therapy device, lubricants

Psychosexual couples therapy

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Define rapid ejaculation

Inability to control ejaculation sufficiently for BOTH partners to enjoy sexual interaction
Ejaculation occurring within 1 minute

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Aetiology of rapid ejaculation

Genetic susceptibility
Hyperthyroidism
Penile hypersensitivity
Psychological (performance anxiety, lack of experience, issues, early experience)

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Treatment of rapid ejaculation

1st line - SSRIs : dapoxetine (increased risk of suicide), STUD 100 spray (topical anaesthetic)
Psychosexual therapy
Behavioural (stop start technique, Kegel exercises)

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What is female orgasmic disorder

Orgasm does either not occur or is markedly delayed

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Causes of female orgasmic disorder

Chronic disease (DM, CVD, anaemia, obesity)
Hormonal (androgen deficiency, hyperprolactinaemia, hypothyroid)
Pelvic floor weakness, damage
Ageing
SSRIs
Psychological (abuse, relationship problems)

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Treatment of female orgasmic disorder

Topical oestrogens

Behavioural interventions - guided masturbation, vibrators

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What is vaginismus?

Spasm of the pelvic floor muscles that surround vaginal opening.
Make penile entry painful or impossible

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Causes of vaginismus

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Thrush, FGM, congenital abnormality

Psychological: previous trauma/abuse, fear/dislike partner or pregnancy

Treatment of vaginismus

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Psychosexual

Behavioural: self-exploration, vaginal dilators, graded penetration therapy

Define dyspareunia.

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Pain during intercourse. Often due to local pathology

ONLY used if no primary non-organic sexual dysfunction.

Causes of dyspareunia

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Female:
Superficial: STIs, episiotomies, vaginal atrophy
Deep: PID, endometriosis

Male:
STIs, urethral stricturesm, varicocoeles
Psychological
Relationship causes (poor technique of partner)

Treatment of dyspareunia

Lubricants Couples therapy Behavioural therapy Poss refer to gynae

Presentation of candida albicans (thrush)

``` Cottage cheese discharge - thick, creamy, odourless Itching Soreness Redness Dyspareunia Dysuria ```

Risk factors for candida albicans (thrush)

Pregnancy, DM, Abx, chemo, HIV, vaginal dryness

Investigations for candida albicans (thrush)

Clinical diagnosis, MC+S - show Mycelia spores

What is candidiasis?

Common yeast infection, NOT STI Caused by candida albicans - frequently present in normal vagina but kept under control by other bacteria, so only symptomatic when immunosuppressed.

Treatment for candidiasis

General advice: Vulval moisturiser as soap substitute Avoid tight fitting synthetic clothing Avoid local irritants like perfumed products Pharm: Antifungals - Topical clotrimazole cream stat, clotrimazole pessary if more severe, oral fluconazole (avoid in preg and breastfeeding) No rx needed for male partner

What is bacterial vaginosis?

Commonest cause of abnormal vaginal discharge. Normal balance of organisms in the vagina disrupted (e.g. due to vaginal douching) - anaerobes like gardnerella vaginalis take over

Presentation of bacterial vaginosis?

50% symptomatic - white, fishy smelling discharge No soreness/itchiness Thin white discharge coating vaginal wall

Investigations and diagnosis for BV?

Diagnosis by Amsel's criteria (need 3 out of 4): thin, white discharge, CLUE cells, whiff test +ve, pH>4.5 Also Gram stained vaginal smear - look for gardnerella/lactobacillus

Risk factors for BV?

sexually active, IUCD, new partner

Management of BV?

Metronidazole single dose Treat pregnant women same way No screening or treatment needed for male partners

What is trichomonas vaginalis?

STI - caused by T. Vaginalis (flagellated protazoan)

Presentation of TV?

``` 50% asymptomatic. Frothy, offensive smelling, yellow/green discharge Strawberry cervix Dyspareunia Dysuria Itchiness/soreness ```

Ix for TV?

Vaginal swab for immediate microscopy (w/in 10 mins so trichomonas still motile) First void urine for NAAT (nucleic acid amplification testing)

Management for TV?

Metronidazole 2g stat Treat pregnant women the same (some prefer delay of rx until 2nd trimester) - affects taste of breast milk, so use low dose. NEEDS ABSTINENCE for at least 1 week post stat dose of metronid. Treat sexual partner(s)

What is chlamydia?

Most common curable STI in UK. Highest prev in 15-24 yo, high freq. of transmission. Caused by chlamydia trachomatis If untreated, can resolve (50%) but can also --> PID, infertility

Diagnosis of chlamydia?

Vulvovaginal swab and first-catch urine then NAAT

Risk factors for chlamydia?

Previous STI, multiple partners

Presentation of chlamydia?

Majority asyptomatic. Discharge, dysuria, IMB & PCB, deep dyspareunia, lower abo pain. Signs: cervicitis, cervical motion tenderness, pelvic tenderness.

Complications of chlamydia?

PID, Reiters (conjunctivitis, urethritis, reactive arthritis - can't see, can't pee, can't climb a tree), infertility

Management of chlamydia?

Pharm: Azithromycin 1g oral stat OR doxycycline 100mg BD for 7 days (not in preg) ABSTINENCE UNTIL 1 week after stat dose. Advise safe sex and contraception CONTACT TRACING - advise partners to do full STI screen (HIV inclusive)

What is gonorrhoea?

STI - caused by gram -ve diplococcus Neisseria Gonorrhoea. Infection site: endocervix, rectum, pharynx, urethra, conjunctiva. Risk factors: previous STI, multiple partners.

Presentation of gonorrhoea?

90% men & 50% women asymptomatic. | Discharge, dysuria

Investigations for gonorrhoea?

NAAT, microscopy (gram neg diplococci within polymorphnucear leukocytes), culture.

Management for gonorrhoea?

Pharm: azithromycin 1g oral stat (covering for chlamydia) AND ceftriaxone 500mg IM stat ABSTINENCE until 1 week after stat dose CONTACT TRACING Advise safe sex and contraception

Causes and risk factors of genital warts?

HPV 6 & 11 (now vaccinated against) - don't usually cause cervical cancer. Risk factors: smoking, multiple partners, early age intercourse

Presentation of genital warts?

Growths/lesions, multiple/solitary, painless, itch, dyspareunia

Diagnosis and treatment of genital warts?

Dx: STI screen Rx: cryotherapy, podophyllotoxin cream

Sexual Medicine Flashcards

(52 cards)