Sexual Problems

Question 1

Definition of a psychosexual problem

Answer 1

‘When thoughts, feelings or physiological response affects a person’s ability to enjoy sexual activity alone or with a partner’

Question 2

Causes of psychosexual problems

Answer 2

Individual–> thoughts, feelings, physiology
Relational–> fear of informing partner, partner infidelity, blame or conflict
Societal–> actual or perceived stigma, isolation

Question 3

Common Male sexual problem

Answer 3

Premature ejaculation
Erectile problems
Loss of sexual desire
Retarded ejaculation

Question 4

Common Female sexual problem

Answer 4

Loss of sexual desire
Dyspareunia
Vaginismus
Orgasmic dysfunction

Question 5

Types of sexual practices and disorders which can influence psychosexual health

Answer 5

Gender dysphoria
Paraphilic Disorders–> Voyeuristic/exhibitionist, Frotteuristic, Masochism/sadism, pedophilia, fetishistic disorders, tranvestic disorders

Question 6

Incidence of psychosexual disorders

Answer 6

Men–>PE 3%, LSD 2%, ED 1%

Women–>LSD 10%, Orgasmic problems 4%, Dyspareunia 3%

Question 7

Where do people seek help for psychosexual problems

Answer 7

Men –> GP 65%, GUM 10%, other 25%

Women–> GP 75%, GUM 5%, other 20%

Question 8

When assessing a psychosexual problem

Answer 8

Problem itself:When did it start? all situations?
Psychogenic factors:How do you feel? Partner response? Any related problems (arousal, libido, pain,orgasm)?
Any significant physical PMHx?

Question 9

Premature Ejaculation

Answer 9

Intravaginal ejaculatory latency time (IELT) of less than 1 minute
Can be lifelong or secondary

Question 10

Causes of lifelong PE

Answer 10

psychogenic–> lack of learned control (most common), lack of sensory awareness
Organic –> inherited, 5HT receptor dysfunction

Question 11

Causes of secondary PE

Answer 11

Psychogenic–> Anxiety/stress. Relational–> pressure, anger. Social–> pressure of perceived norms. Organic–>Prostatitis/BPH, hyperthyroid, neurological problems, medication (antidepressants, antihypertensives)

Question 12

Management of PE

Answer 12

Information–> very common problem, 90% of men have IELT of 3. Masturbation with focusing
Pelvic floor exercises. Self help books are available
Medication (Antidepressants,PDE5 inhibitors or LA)

Question 13

Assessing Erectile dysfunction (ED)

Answer 13

Strength of Erections–> 0-10, spontaneous/ masturbation/SI, is it the same with all partners?
Psychogenic–> >50yo, gradual onset,in all situations, PMHx and relevant medications

Question 14

Treatments for ED

Answer 14

Physical check up–> BP, BMI/abdo girth, genitals, bloods, hormone levels
Medication–> Oral PDE inhibitors, trans-urethral or Intra-cavernosal prostaglandins,
Vacuum pumps or constriction ring
surgery or lifestyle changes

Question 15

Oral PDE Inhibitors for ED

Answer 15

Sildenafil (viagra), Tadalafil (cialis) & Vardenafil (levitra) –> require arousal
60-90% effective compared to 20-50% placebo
Can cause headaches, flushing and reflux
Should not be used with nitrates or after a MI
onset 30-60mins and last for 12-48 hours

Question 16

Intra-cavernosal prostaglandins

Answer 16

Alprostadil (Caverject or Viridal) work by peripheral S muscle relaxation
>75% efficacy compared to <10% placebo
can cause pain (17%), fibrosis (2%), priapism (1%) or haematoma (1.5%)
Dose titrated to response and onset in 5-10mins

Question 17

Contra-indications for intra-cavernosal prostaglandins

Answer 17

Sickle cell, multiple myeloma, leukaemia, anatomical deformities.

Question 18

Prescribing guidelines for ED

Answer 18

First line is to improve lifestyle and general health
Then try a PDE5 inhibitor
Can only get NHS treatment if there is a significant medical or surgical background or ‘severe distress’

Question 19

Female Sexual Dysfunction

Answer 19

A general term encompassing:
–>Desire disorder
–>Arousal disorder (subject arousal vs genital arousal disorders)
–>Orgasmic disorder
Less often related to physiology and more linked to relationship quality

Question 20

Medical Factors in the Aetiology of FSD

Answer 20

Endocrine–> hypothyroid, hyperprolactinaemia, oestrogen/testosterone deficiency
Neurological–>IDDM, MS
Vascular–>IHD, HTN
Psychiatric–>psychosis or depression
Systemic–> HIV, renal failure
Medication–> anticonvulsants, opiates, lithium, antipsychotics,benzos, antidepressants

Question 21

Management of FSD

Answer 21

Rule out organic causes
Distinguish between subjective and genital arousal disorders–> for genital arousal disorder HRT, lubrication, PDE5 and increased stimulation
For desire, orgasmic and subjective arousal disorders–> refer for psychosexual help

Question 22

Dyspreunia

Answer 22

A persistent or recurrent genital pain associated with sexual intercourse–> can be superficial or deep
Many organic causes–> need to pinpoint the source of pain, inadequate arousal is the major cause

Question 23

Causes of Superficial Dyspareunia

Answer 23

Structural–>stricture of hymen or vagina, vulval cancer
Endocrine–>diabetic, menopausal atrophy
Infection–>thrush, trichomonas, herpes
Inflammatory–>lichen sclerosus, allergies, ezcema
Surgical–> post-episiotomy, FGM, anterior/posterior repairs

Question 24

Causes of deep dyspareunia

Answer 24

Structural –>stricture of vagina or fibroids
Infection–> PID
Inflammatory–>endometriosis or IBD
Neoplastic–> cancer of cervix, uterus or ovary
Surgical–> post-hysterectomy

Question 25

Vaginismus

Answer 25

Persistant or recurrent difficulty in allowing desired vaginal entry by any object. often associated with phobic avoidance. Involves involuntary pelvic muscle contraction and anticipation/fear/experience of pain
–> Leads to superficial dyspareunia or non-consumation

Question 26

Causes of Vaginismus

Answer 26

Psychological–> fear of pain/pregnancy/adulthood, guilt or past bad experiences
Relationship–> masking partner dysfunction
Social/cultural–> FGM
Medical–> Anything which can cause dyspareunia can cause protective vaginismic reflexes

Question 27

Management of Vaginismus

Answer 27

Stop the pain–> break the cycle
Pelvic floor exercises–> control the spasm
Self-exploration–> desensitizes the spasm