Sexual problems

Question 1

Define Male Hypoactive Sexual Desire Disorder

Answer 1

Lack/loss of sexual desire
(doesnt mean loss of enjoyment - just less likely to happen)
Lack of thoughts/interest about sex

not secondary to any other causes

Question 2

Causes of Male Hypoactive Sexual Desire Disorder

Answer 2

Medical - CVD, DM, obesity, anaemia
Hormonal - \/ Androgen, hypogonadism, ^prolactin, hypothyroidism (F - post-pregnancy, addisons)
Iatrogenic - SSRIs, finasteride, orchidectomy (F-COCP, HRT)
Psychiatric - depression, anxiety, past experiences (abuse), body image disorders, erotic dissatisfaction etc

Question 3

Treatment options for Male Hypoactive Sexual Desire Disorder

Answer 3

Psychosexual treatment (gel to start, IM after)
Testosterone replacement if low

Question 4

Psychosexual treaments -Cognitive - what is it?

Answer 4

Addressing unhelpful thinking styles

Question 5

Psychosexual treaments -behavioural - what is it?

Answer 5

ie Self growth - learning own needs/responses
understand and overcome unhelpful thinking patterns

sensate focus - making couple focus on the senses and intimacy rather than the sex - so no sex allowed - couple touch each other to get more comfortable with no pressure of sex

Question 6

Psychosexual treaments -CBT- what is it?

Answer 6

combination of cognitive and behavioural therapies

Addressing unhelpful thinking styles

ie Self growth - learning own needs/responses
understand and overcome unhelpful thinking patterns

Question 7

Psychosexual treaments - psychodynamic - what is it?

Answer 7

talking about how past events affect present

past events, abuse, partner choices transference etc

Question 8

Psychosexual treaments - systemic - what is it?

Answer 8

individual - sexual education, encourage vocalisation of feelings, lessen performance anxiety etc

couple, family other types

Question 9

Low testosterone symptoms

Answer 9

Low mood
irritable
aches, pains
reduced cognition
sexual problems

so IM testosterone can sort these out and make people feel much better

Question 10

Define erectile disorder

Answer 10

= erectile dysfunction

struggle to get or maintain an erectile long enough for sex decrease in rigidity

Question 11

Causes of erectile disorder

Answer 11

psychological

Biological
medical - CVD, DM, neurological sensation loss
hormones - low androgens, high prolactin
iatrogenic - SSRIs, antihypertensives, prostate surgery
Aging, pain
veno-occlusive disorder (penile veins don constrict properly)

porn (8month clear out)
depression, substance misuse
performance anxiety

Question 12

Treatment for erectile disorder

Answer 12

1st line sildenafil (viagra) PO
(others - avanafil, tadalafil, vardenafil all PO)

ICI (intracavernous injection) -alprostadil

also can use vaccum device + penile ring

Question 13

sildenafil - important patient information

Answer 13

need sexual stimulation to work still
work best on empty stomach
wait 45-60 mins before starting
efficacy improves with each dose up to 8th

Question 14

define Female Sexual Interest/Arousal Disorder

Answer 14

failure of genital response
- vaginal dryness common presenting complaint

lack of/reduced sexual interest, thoughts, enjoyment etc

Question 15

causes of Female Sexual Interest/Arousal Disorder

Answer 15

#biological
medical - CVD, DM, neuro
hormones - v-oestrogen, (menopause, thyroid)
SSRIs
breastfeeding
vaginal dryness

#psychological 
depression, anxiety, binge eating, Hx abuse, v intimacy

Question 16

define female orgasmic disorder

Answer 16

orgasm doesnt occur or is markedly delayed

not as intense etc

Question 17

causes of female orgasmic disorder

Answer 17

biological
medical- CVD, DM, neurological disorder
hormones- v oestrogen/androgens (post menopause/hypothyroidism)
pelvic floor weakness 
age
SSRIs

psychological
depression, substance misuse
abuse, relationship problems, environment, stress

Question 18

Menopause effects on sexual function

Answer 18

vaginal/pelvic pain
vaginal atrophy
dryness
change in mood, self image, cognition, desire 
night sweats, sleeplessness

Question 19

SSRIs for depression can affect sexual function. What drug is good for avoiding these side effects?

Answer 19

mirtazapine

Question 20

define Rapid ejaculation

Answer 20

= premature ejaculation

ejaculation occurring too soon for both partners to enjoy their sex

Question 21

causes of rapid ejaculation

Answer 21

genetic - penile hypersensitivity
hyperthyroidism
prostatitis
drugs

anxiety, early learned experiences
lack of experience, psychosexual/environmental factors
relationship issues

Question 22

treatments for rapid ejaculation

Answer 22

topical anaesthetic 
dapoxetine 
couple psychosexual therapy 
behavioural therapy - sensate focus
practice start stop, point of inevitability

Question 23

define delayed ejaculation

Answer 23

marked delay or absence in ejaculation - without desiring it

Question 24

causes of delayed ejaculation

Answer 24

psychological

#biological
congenital, trauma, age, infection
neurological causes - DM, myelopathy, alcohol neuropathy
depression, SSRIs, etc 
low testosterone 

IMPORTANT - need to exclude retrograde ejaculation [ejaculate going into bladder] (white/cloudy urine after sex/urinalysis for fructose/sperm)

technique/not aroused
v body image, Hx abuse, fear, relationship problems

Question 25

management of delayed ejaculation

Answer 25

physical examination (testes, prostate etc)
FBC, HbA1C, testosterone, B12, folate, PSA
urinalysis for fructose/sperm

individual/couple therapy
kegal exercises
vibration/superstimulation

Question 26

What is vaginismus

Answer 26

spasm of the pelvic floor muscles surrounding the vagina which occludes the vaginal opening and makes penetration difficult or impossible

often a response to pain

Question 27

causes of vaginismus

Answer 27

things that cause pain - thrush, FGM etc

mistaken beliefs, fear of pregnancy, previous trauma, fear/dislike of partner/relationship

Question 28

treatment for vaginismus

Answer 28

individual psychosexual therapy
CBT - for phobic reaction to sex

kegel exercises, vaginal trainers, breathing control/relaxation

Question 29

what is dyspareunia

Answer 29

pain during intercourse - no primary cause

Question 30

causes of dyspareunia

Answer 30

manipulation - infection, injury, hypersensitivity

introitus (pain on entry) - herpes, vaginal atrophy, dryness

mid-deep pain - endometriosis, congenital short vagina, surgical adhesions, constipation

pysch
previous experience of pain, abuse, stress, poor technique, fear of intimacy

Question 31

management of dyspareunia

Answer 31

rule out any treatable cause (creams for dryness etc)
couple therapy
personal sexual growth program (PSGP)
sensate focus

Question 32

couple therapy - cognitive behavioural therapy

Answer 32

focus on dysfunctional beliefs and behaviours in the present

Question 33

psychodynamic couple therapy

Answer 33

focuses on early responses in life to things now affects present situation

Question 34

places to refer people with sexual problems

Answer 34

Relate - help with any relationship problems
Porterbrook - problems with sexual relationships
COSRT- college of sexual and relationship therapists
SAA - sex addicts anonymous

Question 35

lichen sclerosus

Answer 35

Lichen sclerosus (LS) is a chronic inflammatory dermatosis which usually affects the skin of the anogenital region in women, and the glans penis and foreskin in men

white thickened patches
itchy in women - not in men

can make sex etc painful

topical steroids help

Question 36

what is vulvodynia

Answer 36

unexplained vulval pain

Question 37

azoospermia

Answer 37

low sperm count

Question 38

hypospadias

Answer 38

opening of penis on underside of penis not at the end

Question 39

Peyronie’s disease

Answer 39

curved penis - after fracture of penis

fibrotic bands/plaques make it curved