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1 - Psychiatry AE > Sexual medicine > Flashcards

Sexual medicine Flashcards

1
Q

What are some disorders of sexual drive?

A

Sexual aversion

Sexual addiction

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2
Q

What are some disorders of sexual desire?

A

Hypoactive sexual desire disorder (HSDD)

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3
Q

What are some disorders of sexual excitation?

A

Female sexual interest/arousal disorder,
Erectile disorder,
Paraphilias

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4
Q

What are some disorders of sexual orgasm?

A

Orgasmic disorder,

Ejaculatory problems e.g. delayed, rapid retrograde

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5
Q

What are some disorders of sexual pain?

A

Dyspareunia,
Vaginismus,
Vulvodynia.

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6
Q

What blood tests would you do for which sexual problems?

A

Fasting Glucose/Lipid ratio - diabetes/CVD, useful to rule out for most sexual problems
Testosterone, SHBG (sex hormones), 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

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7
Q

What psychological treatment would you use for predisposing, precipitating and maintaining causes?

A

Predisposing - psychodynamic
Precipitating - CBT
Maintaining - systemic

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8
Q

What are some maintaining causes of sexual disorders?

A

Relationship issues and avoiding intimacy

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9
Q

What is male hypoactive sexual desire disorder?

A

Loss of sexual desire is the principal problem and is not secondary to other sexual difficulties, such as erectile failure or dyspareunia. Lack of sexual desire does not preclude sexual enjoyment or arousal, but makes the initiation of sexual activity less likely.

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10
Q

What are some causes of male hypoactive sexual desire disorder?

A

Chronic medical conditions - Obesity, CVD, diabetes mellitus, anaemia
Hormonal disorder - Androgen deficiency, hypogonadism from various aetiologies, hyperprolactinameia
Iatrogenic - anti-depressants orchidectomy
Psychological - psychiatric conditions, e.g. depression, anxiety, substance misuse, body image disorder, couples script problems, eWrotic dissatisfaction
Couple relationship problems
Psychological experiences, e.g. environmental, life events (including work stressors), previous trauma or abuse

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11
Q

What are some causes of female hypoactive sexual desire disorder?

A

Hormonal disorder - androgen deficiency, hypothyroidism, hyperprolactinaemia, post pregnancy, addison’s disease
Iatrogenic - oral contraceptive, oral HRT, tamoxifen (all bind with testosterone), anti-depressants & anti-psychotics, b-blockers.
Chronic medical conditions and psychological issues same as men

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12
Q

What are the psychosexual treatment options?

A

Integrative (combination of psychosexual options and physical treatments)
Cognitive (e.g. Address unhelpful thinking styles)
Behavioural (e.g. Sensate Focus or Self Growth Programme)
CBT (Combination of Cognitive and Behavioural)
Psychodynamic (e.g. Past events, attachments, partner choice, unconscious motivations, transference)
Systemic (e.g. Individual, couple, family dynamics)

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13
Q

What are the testosterone replacement options?

A 
Repeat tests - fasted sample
Injection
Transdermal patches or gel
Buccal
Subcutaneous implants - alternative to Testosterone, Human Chorionic Gonadotrophin
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14
Q

What is incorporated in individual psychosexual therapy?

A

Sexual education
Encourage vocalisation and acceptance of difficult feelings regarding onerous life circumstances
Normalising and permission giving
Find new solutions for old problems (timetabling)
Surmount barriers to psychological intimacy (work on confidence gain)
Expand communication
Lessen performance anxiety
Transform destructive attitudes that interfere with intimacy
Support

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15
Q

How does personal sexual growth programme work?

A

Enables patient to become aware of their own sexual needs through self exploration of their physiological responses
Work with the therapist to understand and overcome negative beliefs and unhelpful thinking patterns in relation to sexual behaviour

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16
Q

What is erectile disorder?

A

Difficulty in developing or maintaining an erection suitable for satisfactory intercourse

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17
Q

What are the physiological causes of erectile disorder?

A

Chronic medical conditions - CVD, diabetes mellitus, neurological disease
Hormonal disorders - androgen deficiency, high prolactin
Iatrogenic - post prostate surgery, prescribed medications (antihypertensive, antidepressants especially SSRIs)
Age related changes
Ineffective sexual stimuli
Pain
Veno-occlusive disorder

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18
Q

What are the psychological causes of erectile disorder?

A

Psychiatric conditions e.g. depression, substance misuse
Performance anxiety, life events and negative previous experiences, unhelpful use of pornography
Couples script problems
Relationship problems or issues from previous relationship
Educational matters
Cultural and Religious matters

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19
Q

What is the medical treatment for ED?

A 
Oral
Sildenafil (Viagra)
Avanafil (Spedra)
Tadalafil (Cialis)
Vardenafil (Levitra)

Injectable
Alprostadil (Intra Cavernosal Injection ICI)

Intraurethral
Alprostadil MUSE (medical urethral system for erection) pellet
Alprostadil Cream (Vitaros)
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20
Q

What are the behavioural advice you can give to patients?

A

Patient education:
They need sexual stimulation to work!
They work best when taken on an empty stomach
They need to wait 45-60 minutes before sexual activity (less with avanafil approx 20-30 minutes)
Efficacy improves from the first dose to the eighth

Unacceptable ratio of benefit to side effect
Fear of serious adverse events
Lack of partner support
Difficulty incorporating into sexual script

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21
Q

What are the non-medical treatments for ED?

A

Vacuum device
Penile/scrotal rings
New stimulating routines e.g. enhancing lubricants, vibrators
Kegel excercises

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22
Q

What are the NHS conditions for physiological treatments?

A

Sildenafil can be prescribed on the NHS universally
OR
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)

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23
Q

What is female sexual interest/arousal disorder?

A

Failure of genital response

The principle problem is vaginal dryness or failure of lubrication.

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24
Q

What are the physiological causes of female sexual interest/arousal disorder?

A

Chronic medical conditions - CVD, diabetes mellitus, neurological disease, connective tissue disease,
Hormonal disorders - estrogen deficiency, e.g. post menopause, thyroid disorders
Iatrogenic - prescribed medications e.g. antidepressants
Lactation - breastfeeding women can suffer
Vaginal dryness is a common presenting problem and can also be caused by local irritants and douching

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25
Q

What are the psychological causes of female interest/arousal disorder?

A

Psychiatric conditions - depression, anxiety, binge eating disorders, excessive dieting
Previous abuse
Couple script problems - not enough foreplay
Decreased intimacy
Couples relationship problems

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26
Q

What are the hierarchy of interventions in couples psychosexual therapy?

A 
Timetabling
Communication
Negotiation/contracting
Addressing intimacy
Being sexual
Adjusting to difficulties
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27
Q

What are the behavioural interventions for female interest/arousal disorders?

A

Sensate Focus

New sexual routines, lubricant, vibrators, vielle

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28
Q

What is sensate focus?

A

A staged programme of exercises to enable the couple to identify own and others sexual likes/dislikes and explore new techniques etc.
Work with therapist to understand and overcome negative beliefs and unhelpful thinking patterns in relation to sexual behaviour

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29
Q

What is female orgasmic disorder?

A

Orgasm either does not occur or is markedly delayed

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30
Q

What are the physiological causes of female orgasmic disorder?

A

Chronic medical conditions -CVD, Diabetes Mellitus, neurological disorder, renal/liver problems
Hormonal disorders - oestrogen and/or androgen insufficiency (e.g. post menopause), hypothyroidism
Pelvic floor weakness or damage
Ageing
Prescribed medication especially SSRIs, specifically citolapram

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31
Q

What are the psychological causes of female orgasmic disorder?

A 
Psychiatric conditions - depression, anxiety, substance misuse
Previous abuse
Couple script problems
Couple relationship problems
Cultural and religious issues
Lack of understanding
Environmental factors
Stress
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32
Q

How can the menopause affect sexual function?

A

Vaginal or pelvic pain
Vaginal Atrophy
Dryness
Change in self image, mood, memory, cognition
Changes in desire
Relationship, psychosocial and health factors play their part
Physical discomfort – sleeplessness, night sweats

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33
Q

What is rapid ejaculation?

A

The inability to control ejaculation sufficiently for both partners to enjoy sexual interaction

34
Q

What are the physiological causes of rapid ejaculation?

A 
Genetic susceptibility (Neuroreceptor sensitivity)
Penile hypersensitivity
Hyperthyroidism
Prostatitis
Co-morbid sexual problems e.g. ED
Sympathomimetic medication
35
Q

What are the psychological causes of rapid ejaculation?

A 
Anxiety states
Early learned experiences
Lack of experience/infrequent sexual activity
Psychosocial and environmental factors
Relationship issues
Partner issues eg pain
36
Q

What are the treatment options for rapid ejaculation?

A

Physical examination
Topical local anaesthetic (e.g. stud 100 spray)
Medication - Dapoxetine
Couple psychosexual therapy - education, permission giving, normalising - manage partner expectations
Behavioural Interventions:
- Stop/start technique & Sensate Focus
- Practice ‘point of inevitability’
- Kegel exercises

37
Q

What is delayed ejaculation?

A

On almost or all occasions (75-100%) either generalised or situational, without the individual desiring delay:
Marked delay in ejaculation
Marked infrequency or absence of ejaculation
May be lifelong or acquired, mild, moderate or severe.

38
Q

What are the physiological causes of delayed ejaculation?

A

Congenital disorders
Trauma or surgery
Age
Infectious disorders
Neurological idsorders eg DM, spinal cord injury, alcohol neuropathy
Depression
Medication induced eg SSRI, phenothiazines, thiazides, some alpha blockers
Low testosterone levels
* Important to exclude retrograde ejaculation *

39
Q

What is retrograde ejaculation?

A

Sensation of ejaculation, but ejaculating into bladder rather than out of the penis.
Different to delayed or inhibited ejaculation

40
Q

What are the psychological causes of delayed ejaculation?

A

Insufficient stimulation/poor sexual arousal
Masturbation technique
Individual vulnerability factors eg poor body image, history of sexual or emotional abuse.
Outgrowth of psychic conflict eg fear, hostility
Relationship factors eg poor communication, desire discrepancies
Partner issues eg ill health, sexual problems
Disguised desire disorder
Secondary to other sexual problems eg pain disorder

41
Q

What are the investigations for delayed ejaculation?

A

Physical examination – testes, epididymis, vasa, prostate
Blood tests – FBC, Glucose, Testosterone, B12, Folate, PSA
Urine sample for presence of spermatozoa and fructose (if retrograde ejaculation suspected)

42
Q

How would you treat delayed ejaculation?

A 
PSGP (Personal Sexual Growth Programme)
Individual therapy
Couples therapy
Kegel exercises
Use of vibration/superstimulation
43
Q

What is vaginismus?

A

Spasm of the pelvic floor muscles that surround the vagina, causing occlusion of the vaginal opening. Penile entry is either impossible or painful.

44
Q

What are the physiological causes of vaginismus?

A

Medical conditions where the vulva is sore to touch (e.g. thrush)
Other pain conditions or where pain is anticipated
Female Genital Mutilation
Congenital abnormality

45
Q

What are the psychological causes of vaginismus?

A

Misinformation and mistaken beliefs - vagina too small, no opening, first intercourse will be painful
Religious or cultural issues
Fear of pregnancy
Previous sexual abuse/trauma, or unpleasant first sexual experience or gynaecological examination
Fear or dislike of partner
Relationship dissatisfaction
Situational

46
Q

What is dyspareunia?

A

Dyspareunia (or pain during intercourse) occurs in both women and men. It can often be attributed to local pathology and should then be properly categorised under the pathological condition. This category is to be used only if there is no primary nonorganic sexual dysfunction (e.g. Vaginismus or vaginal dryness)

47
Q

What are the physiological causes of dyspareunia?

A

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

48
Q

What are the psychological causes of dyspareunia?

A

Previous experience of pain
Previous sexual abuse
Poor sexual education
Poor understanding of anatomy and physiology
Insufficient relaxation
Painful or unpleasant Gynaecological examination

49
Q

What are the relationship causes of dyspareunia?

A

Poor technique of partner
Speed / timing of partner
Fear of intimacy
Anger / resentment towards partner

50
Q

How do you treat dyspareunia?

A

Examination by specialist doctor or nurse
Repeat bloods, testosterone replacement
Couple Therapy
Personal Sexual Growth program (both)
Sensate focus to (re)start and (re)learn sexual contact with the addition of pain and how it can be managed in a sexual context

51
Q

What are the main relationship issues?

A 
Communication issues
Timetabling
Conflict
Difficulties with compromise
Power issues
Trust issues
Sexual problems
52
Q

Which extra things need to be addressed in sexual medicine and psychosexual therapy?

A

The relationship between sexual and relationship problems
Our professional and personal values and beliefs
Issues of diversity
Changes in relationships brought about by the internet and technology
Awareness of relationship therapy and what it can help with.

53
Q

What are the effects of our professional values and beliefs?

A

Ideas about appropriate treatment
Environment of costings and scarce resources
Deserving and undeserving categories
Ideas about what is ok and not ok in sex
Beliefs about how couple relationship should operate
General ethical and moral positions

54
Q

How can we alter or manage our professional values and beliefs?

A

We need to recognise that there are issues for us as well and not just for patients
We need to be able to deal with the interface between our values and beliefs and those of patients
We need to be able to monitor the ways in which we communicate to patients our personal values and expectations

55
Q

How do you address patients values and beliefs?

A

Assess the degree to which patients are being pressurised about what is normal or what constitutes a problem
Be aware of ideas and beliefs that may impact on advice or treatment

56
Q

What does working with diversity involve?

A

Being aware of the diversity issues in the geographical and clinical areas in which we work
Taking account of the variety and complexity of the couple arrangements in contemporary society compared with the past
Seeing couples in the context of wider family values and culture and the variable importance of these
Taking account of ethnicity and culture
Addressing the effects of illness on relationships

57
Q

What does taking account of ethnicity and culture involve?

A

Not making assumptions around couple arrangements and sexual practices
Knowing about and taking account of issues around couple arrangements and sexual practices in consultations
Addressing religion where relevant
It is important to find out from patients about their beliefs

58
Q

How does religion effect sexual medicine?

A

Religious patients fear their belief system will be seen as at best unusual and at worst unhealthy
Personal discomfort with discussing religious topics is the sole predictor of clinical religious behaviour
Patients would welcome a discussion about religious beliefs and their relationship to health matters

59
Q

What are Petok’s four principles?

A

Ask about religious beliefs during the initial visit
Ask about religious teachings regarding sexual behaviour
When in doubt, consult with a religious expert
Help couples set reasonable expectations consistent with their beliefs

60
Q

What are the main factors in the impact of chronic illnesses on relationships?

A

Life-threatening illness can lead to withdrawal
Tiredness, low mood, anxiety
Disturbance of body image
Disturbance of roles and life narratives
Limitations on mobility and social contact
Disturbance of mental functioning
Postponement of relationship breakdown

61
Q

What are the general principles of couples therapy?

A

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

62
Q

What are the four main couple therapy approaches?

A

Cognitive-Behavioural
Psychodynamic
Systemic
Integrative

63
Q

What does cognitive behavioural couples therapy involve?

A

Focusses on dysfunctional patterns of belief and behaviour in the here-and-now

64
Q

What does psychodynamic couples therapy involve?

A

Focuses on the relationship between current problems and earlier patterns of response and behaviour from earlier life and takes into account unconscious processes

65
Q

What does systemic couples therapy involve?

A

Focuses on process and context rather than and content to bring about change which is not necessarily based on understanding and intent

66
Q

What does integrative couples therapy involve?

A

Uses understanding and interventions from more than one approach
Can appear to offer the best of possible worlds but has risks and limitations

67
Q

What are the rational for psychosexual therapy referral?

A
  1. Maximize a person’s overall psychological well-being, quality of life and self-fulfilment.
  2. Explore sexual and/or relationship concerns and find ways to address dysfunctions, symptoms or difficulties.
  3. Achieve long term comfort in their sexual and relationship identity and expression.
  4. Clarifying and exploring sexual and/or relationship concerns.
  5. Address co-existing mental and/or physical health concerns identified during assessment, where this is impacting on sexual and relationship functioning, and in collaboration with other health service providers
  6. Facilitate development of an individualized plan with specific goals and timelines relating to sex and relationship satisfaction.
  7. Provide a space for patients to express themselves and find a way to overcome fears.
  8. Provide stability and satisfaction with their sense of sexual identity.
68
Q

What is gender identity?

A

Intrinsic sense of being “male‟/‟female‟/‟alternative‟

69
Q

What is gender role/expression?

A

Personality, appearance and behaviour (cultural & historical context)

70
Q

What are primary sexual characteristics?

A

Present before, during and after puberty.
MALE : penis, scrotum and testes
FEMALE: Vagina and other internal genitalia, vulva and other internal genitalia, ovaries

71
Q

What are secondary sexual characteristics?

A

Present during and after puberty.
MALE: enlargement of genitalia, lowering of voice pitch, redistribution of muscle tissue and fat, pubic, facial, body and armpit hair
FEMALE: enlargement of genitalia, development of breast, pubic and armpit hair

72
Q

What is transgender?

A

Diverse gender variance, including transsexual/genderqueer/agender

73
Q

What is gender dysphoria?

A

Distress due to incongruence between gender identity and sex assigned at birth

74
Q

What is transsexual?

A

Individuals who seek to change or have changed their primary &/or secondary sex characteristics

75
Q

What is transmale?

A

Female at birth changing or changed to male role/body

76
Q

What is transfemale?

A

Male at birth changing or changed to female role/body

77
Q

What is sexual orientation?

A

Sex of person/s to whom sexual fantasies, arousal and activities directed

78
Q

Does every embryo grow up to be male or female?

A

Female

79
Q

When do the external genitalia and gonads develop?

A

8 weeks

80
Q

What are the consequences that transphobia could lead to ?

A

Vulnerable to lack of family & social acceptance & support, discrimination at work, access to services, higher risk of anxiety, low mood, self harm and substance misuse, higher levels of suicide attempt

81
Q

How can you manage transmale?

A 
Assessment & diagnosis
Social transition +/- psychotherapy/OT • Fertility options
Androgens +/- GNrH analogue
Voice & communication
Male chest reconstruction
Hysterectomy & b/l oophorectomy
Phalloplasty/metoidoplasty
82
Q

How can you manage transfemale?

A 
Assessment & diagnosis
Social transition +/- psychotherapy/OT • Fertility options
Oestrogens +/- antiandrogens
Voice & communication
Facial hair removal
Vaginoplasty
Augmentation mammoplasty
Facial feminisation surgery

1 - Psychiatry AE (6 decks)

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