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MFSRH Part 2 (2023) > Sexual Wellbeing > Flashcards

Sexual Wellbeing Flashcards

1
Q

What is the innervation to the vagina?

A

Anterior 1/3
- Ilioinguinal and genitofemoral nerve (L1)
Posterior 2/3
- Medial: posterior femoral cutaneous nerve (S2)
- Lateral: pudendal nerve (S3)

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2
Q

What is the Masters and Johnson / Kaplan sexual response cycle?

A

Desire - Excitement - Plateau - Orgasm - Resolution

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3
Q

Describe the physiology of a female orgasm

A
  • 70-80% clitoral stimulation (glans clitoris has similar sensory nerve density as glans penis)
  • Distal vaginal roof + periurethral areas of anterior vaginal wall
  • Autonomic nervous system
  • Physical effects, psychosocial contribution greater than in males, oxytocin/prolactin released
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4
Q

What is the DSM Framework to Sexual dysfunction/function?

A
  1. Desire Disorders
    - Male hypoactive sexual desire disorder
    - Female sexual interest / arousal disorder
  2. Arousal Disorders
    - Female sexual interest / arousal disorder
    - Male erectile disorder
    - Persistent genital arousal disorder
  3. Orgasmic disorders
    - Female orgasmic disorder
    - Delayed ejaculation
    - Premature ejaculation
  4. Pain disorders
    - Genito-pelvic pain / penetration disorder
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5
Q

As part of the biopsychosocial model for sexual dysfunction, what are some biological factors that play a part?

A
  • Menopause
  • Pelvic surgery
  • Low testosterone
  • Vulval dermatoses
  • STIs
  • Endocrine disease
  • Non-STI such as candidiasis
  • Iatrogenic such as chemo / drug history
  • Chronic medical conditions (DM, CVD, renal failure, cancer, HIV)
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6
Q

As part of the biopsychosocial model for sexual dysfunction, what are some of the psychological factors that play a part?

A
  • Depression
  • Anxiety
  • Infertility
  • Psychosis
  • Substance and alcohol misuse
  • Living with HIV
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7
Q

As part of the biopsychosocial model for sexual dysfunction, what are some of the social factors that play a part?

A
  • Poverty
  • Negative cultural attitudes towards sex
  • Unemployment
  • Domestic violence
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8
Q

Name some common medications that can cause / contribute to sexual dysfunction

A
  • Antihypertensives
  • Antidepressants
  • Antiepileptics
  • Diuretics
  • Antipsychotics
  • Chemo
  • Statins
  • Opioids
  • Parkinsons meds
  • Sedatives
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9
Q

What are the 6 diagnostic criteria to be diagnosed with hyposexual desire disorder? (lack of desire must cause clear distress and interpersonal difficulty)

A
  1. Absent / reduced interest in sexual activity
  2. Absent / reduced sexual / erotic thoughts or fantasies
  3. No / reduced initiation of sexual activity and typically unresponsive to partner’s attempts to initiate
  4. Absent / reduced sexual excitement / pleasure during sexual activity on almost all (approx 75-100% of) sexual encounters
  5. Absent / reduced sexual interest in response to any internal or external sexual / erotic cues (e.g. written, verbal, visual)
  6. Absent / reduced genital or non-genital sensations during sexual activity on almost all (approx 75-100% of) sexual encounters
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10
Q

Name 7 associated factors that could contribute to hyposexual desire disorder

A
  1. Partner factors (e.g. partner’s sexual problems, health status)
  2. Relationship factors (e.g. poor communication, discrepancies in desire for sex)
  3. Individual vulnerability factors (e.g. poor body image, history of abuse)
  4. Psychiatric comorbidity (e.g. depression, anxiety)
  5. Stressors (e.g. job loss)
  6. Cultural/religious factors (e.g. attitudes towards sexuality)
  7. Medical factors
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11
Q

Name some organic causes of hyposexual desire disorder

A
  • Menopause
  • Depression
  • Post childbirth
  • Severe chronic medical condition
  • Acquired i.e. after bilateral oophorectomy, chemotherapy, irradiation
  • Medications (SSRIs/SNRIs, TCAs, CHC, beta blockers, hormones given for estrogen receptive breast cancer)
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12
Q

Describe the PLISSIT model in conducting a sexual dysfunction consultation

A

P- Permission to speak (patient to voice concerns you to listen to them)
LI - Limited Information (which might help like sexual anatomy and physiology)
SS - Specific Suggestions
IT - Intensive Therapy (such as sensate focus)

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13
Q

How can phosphodiesterase type 5 inhibitors be used for hyposexual desire disorder?

A
  • Sildenafil (viagra)
  • Not licensed for use in women but sometimes has good results
  • Can help reverse the SSRI-induced low desire and arousal
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14
Q

How can testosterone gel or implants be used for hyposexual desire disorder?

A
  • Some efficacy in increasing desire and arousal over short term and appears safe
  • Usually optimise estrogen first
  • Important to avoid increased androgen: estrogen ratio
  • No licensed in UK
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15
Q

What other hormone treatments can be used for hyposexual desire disorder?

A
  • Local genital estrogen therapy (useful where systemic HRT contraindicated, can help to treat poor genital response in peri- and post- menopause)
  • Tibolone HRT can enhance sexual desire
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16
Q

Name some causes of anorgasmia

A
  • Low libido / unwanted sex / sex not enjoyable
  • Neurological (MS, epilepsy, AEDs)
  • Endocrine / hypopituitarism (hypogonadism, DM, hypothyroid, Addisons, Cushings, Sheehans)
  • Malignancy (pelvic irradiation)
  • Dermatological (any vulvovaginitis, vulval skin conditions)
  • Medications
  • Psychosocial (home, work, relationships)
  • Psychosexual (CSA, SA, sexuality, TOP, childbirth, motherhood)
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17
Q

Name some anogenital causes of female genito-pelvic pain (i.e. vaginismus, dyspareunia)

A
  • Acute STIs
  • Candida
  • PID
  • Prostatitis
  • Anal fissures or haemorrhoids
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18
Q

Name some gynaecological/urological causes of female genito-pelvic pain (i.e. vaginismus, dyspareunia)

A
  • FGM
  • Endometriosis
  • Anatomical abnormality (e.g. vaginal septum or imperforate hymen)
  • Postpartum scar tissue
  • Menopausal GSM
  • UTI
  • Interstitial cystitis
  • Hernia
  • Pelvic cancer
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19
Q

Name some psychosexual causes of female genito-pelvic pain (i.e. vaginismus, dyspareunia)

A
  • Previous sexual trauma
  • Anxiety about sex
  • Fear of pregnancy
  • Previous difficult childbirth
  • Previous STIs
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20
Q

Name some physical causes of vaginismus

A
  • Vaginal scarring / stenosis / shortening after childbirth / surgery
  • FGM
  • Skin and mucosal conditions (LS, LP)
  • Menopause
  • Rarely, rigid hymen, vaginal septum, shortened vaginas
21
Q

Describe the non-medical concept of managing vaginismus

A

Overcome the cycle of pain anticipation and vaginal spasm
- Psychosexual treatment
- Pelvic floor exercises
- Graduated vaginal dilators at home

22
Q

Name some medical treatments for vaginismus

A
  • Can treat vulvodynia / vestibulodynia with topical lidocaine, amitriptyline, gabapentin
  • Can treat menopausal symptoms with HRT / vaginal moisturisers / lubricants
23
Q

How do you counsel a patient on vaginal dilators?

A
  • Little and often is best
  • Start at 1 minute (building up to 5-10 mins) 5-6 days a week
  • Each step can take weeks, if you go too fast risk more muscle spasms / pain
  • Wash the dilators with hot soapy water first
  • Assemble the dilator
  • Lubricate the tip of the dilator and vaginal opening
  • Find a comfortable relaxing position (e.g. lying on back with knees bent)
  • Insert the dilator into the vagina as far as is comfortable
  • Rotate the dilator in a circular motion for 5 minutes
  • As you remove the dilator, move it side to side
  • Clean the dilator with warm, soapy water and dry
24
Q

Name from specific disorders that can cause vulvar pain

A
  • Infectious (candidiasis, herpes, TV)
  • Inflammatory (LP, LS, atrophic vaginitis, immunobullous disorder)
  • Neoplastic (Paget’s, SCC)
  • Neurologic (herpes neuralgia, spinal nerve compression)
25
Q

How do you examine vulvodynia?

A
  • Inspection
  • Q tip test
  • Bulbocavernosus reflex / anal wink test (peripheral neuropathy)
  • VE (?atrophy ?erosions ?vaginismus)
26
Q

What investigations can you do for vulvodynia?

A
  • STI screen
  • Colposcopy / vulvoscopy
  • Vulval bx
  • MRI
27
Q

What are the endpoints of treatment for vulvodynia?

A
  • Reducing triggers of irritation
  • Blocking peripheral nociceptors
  • Central inhibition
  • Tackling pelvic floor dysfunction
  • Addressing psychosexual dysfunction
28
Q

What are 7 possible steps for vulvodynia treatment? (not necessarily in order)

A
  1. Vulval care
  2. Topical local anaesthetics (provoked vulvodynia)
  3. TCAs or amitriptylinee / notriptyline (unprovoked vulvodynia) - 2nd line gabapentin
  4. Modified vestibulectomy (refractory localised provoked)
  5. Psychosexual therapy
  6. Pelvic floor techniques and desensitisation of pelvic floor muscles
  7. Alternative therapies
29
Q

What are some risk factors for erectile dysfunction?

A

Similar to those for cardiovascular disease (is an accurate predictor for CVD)
- Older age
- Sedentary lifestyle
- Obesity
- Dyslipidaemia
- Metabolic syndrome
- Diabetes
- Smoking

30
Q

What examination can you do for erectile dysfunction?

A
  • HR + BP
  • BMI
  • PR if genitourinary or protracted secondary ejaculatory symptoms
  • Genital exam
31
Q

What investigations can be done for erectile dysfunction?

A
  • Lipids
  • Glucose / HbA1C
  • Serum free testosterone (fasting, before 11am)
  • Hormones (SHBG, LH, SFH, prolactin)
  • PSA if planning testosterone replacement
  • TFTs
32
Q

What are first-line interventions for erectile dysfunction?

A
  • Lifestyle and risk factor modification
  • PDE5i or vacuum erection device
  • Intercavernous injection therapy or intraurethral alprostadil or alprostadil cream or low intensity extracorporeal shock wave therapy
  • Penile prosthesis
33
Q

How do PDE5 inhibitors work for erectile dysfunction?

A

Increase blood flow to the penis
Need the initial desire
25-50% of men fail to respond within 12 months

34
Q

What are some side effects to PDE5 inhibitors?

A
  • Headache
  • Flushing
  • Heartburn
  • Dizziness
  • Visual disturbance
35
Q

What are some contraindications to PDE5 inhibitors?

A
  • Use of nitrates
  • Loss of vision in one eye due to non-arteritic anterior ischaemic optic neuropathy (NAION) - loss of blood flow to the optic nerve
  • Severe renal/hepatic impairment
  • Hypotension
  • Poppers (extreme hypotension - cardiovascular crisis = death)
36
Q

Name some PDE5 inhibitors

A
  • Sildenafil (viagra)
  • Vardenafil
  • Tadalafil
  • Avanafil
37
Q

What are the advantages and disadvantages of PDE5 inhibitors?

A

Advantages
- Oral route
- Safe
- Long-term efficacy
- Effective irrespective of age

Disadvantages
- Reduced efficacy in certain situations (e.g. DM)
- Lack of spontaneity
- Interactions with food (fatty foods may reduce efficacay of sildenafil and vardenafil)
- Contraindicated with nitrates
- Does not address underlying reason for ED

38
Q

How do vacuum devices work for erectile dysfunction?

A
  • Exert negative pressure on penis which increases corporeal blood flow
  • Constriction ring placed around base of penis to prevent collapse of erection due to venous drainage
  • Remove ring within 30 mins to avoid skin necrosis
39
Q

What are the advantages and disadvantages of vacuum devices for erectile dysfunction?

A

Advantages
- On demand use
- No systemic side effects
- Low cost
- No drug interactions
- Can be used early post op for penile rehab
- Does not require arousal

Disadvantages
- Cumbersome
- Minor side effects (pain, numbness, bruising, lack of ejaculation)
- Cold erect penis
- Cannot be used in those with bleeding disorders or anticoagulant therapy

40
Q

What is alprostadil?

A
  • Prostaglandin analogue which acts locally on the penile spongy tissue to produce an erection
  • Self administered
  • Can be given intraurethrally
  • Can be given intracaverenosally via injections (Risk of priapism)
41
Q

What conditions may predispose to priapism?

A
  • Sickle cell anaemia (or trait)
  • Thombocythaemia
  • Polycythaemia
  • Multiple myeloma
  • Leukaemia
  • Hyper-viscosity syndrome
  • Venous thrombosis
  • Intracavernosal injections
42
Q

What are the two types of penile prosthesis?

A
  1. Malleable
    - Two semi-rigid rods inserted into corpora to produce a permanent, semi-hard erection. Difficult to conceal or uncomfortable when not in a sexual setting
  2. Inflatable
    - 2 rods inserted and connected to a fluid-filled chamber which can be externally pumped and deflated
43
Q

What are the advantages and disadvantages of penile prosthesis?

A

Advantages
- Permanent
- Useful in patients with Peyronie’s
- Option when all other treatments have failed

Disadvantages
- High, initial cost
- Mechanical problems
- Postop complications
- Prevents further use of other treatments

44
Q

Define premature ejaculation

A
  • Ejaculation which nearly always occurs prior to or within 1 minute of penetration
  • Inability to delay ejaculation on all or nearly all vaginal penetrations
  • Negative personal consequences, i.e. distress, frustration or avoidance of sexual intimacy
45
Q

What are some behavioural techniques for premature ejaculation?

A
  • The squeeze technique and the stop start technique
  • Half sexual activity just before point of inevitable ejaculation and allow arousal to diminish slightly
  • Over time, ejaculatory control is learned
46
Q

What are some topical therapies for premature ejaculation?

A
  • EMLA cream (not evidence-based)
  • Apply to tip of penis and use condom
  • Loss of sensation may make it difficult to maintain arousal and erection
47
Q

What are some medical therapies for premature ejaculation?

A
  • Dapoxetine (SSRI licensed in PE)
  • PDE5-i (where significant contribution from ED too)
  • Alpha-1 adrenoceptor antagonists

Don’t forget psychosexual therapies

48
Q

Describe dapoxetine for premature ejaculation

A
  • Short-acting SSRI, PRN, 1-3h before sex
  • Prescribe for acquired PE over past 6 months causing severe distress
  • May increase intravaginal ejaculation latency time by 3-4x
  • Side effects less common with short acting SSRI
49
Q

What causes delayed ejaculation?

A
  • Psychological
  • Diabetic autonomic neuropathy
  • MS
  • Spinal cord injury
  • Hypogonadism
  • Hypothyroidism
  • Medication such as SSRI or alpha-blockers
  • Penile pain

MFSRH Part 2 (2023) (22 decks)

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