Sexual Wellbeing Flashcards
What is the innervation to the vagina?
Anterior 1/3
- Ilioinguinal and genitofemoral nerve (L1)
Posterior 2/3
- Medial: posterior femoral cutaneous nerve (S2)
- Lateral: pudendal nerve (S3)
What is the Masters and Johnson / Kaplan sexual response cycle?
Desire - Excitement - Plateau - Orgasm - Resolution
Describe the physiology of a female orgasm
- 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
What is the DSM Framework to Sexual dysfunction/function?
- Desire Disorders
- Male hypoactive sexual desire disorder
- Female sexual interest / arousal disorder - Arousal Disorders
- Female sexual interest / arousal disorder
- Male erectile disorder
- Persistent genital arousal disorder - Orgasmic disorders
- Female orgasmic disorder
- Delayed ejaculation
- Premature ejaculation - Pain disorders
- Genito-pelvic pain / penetration disorder
As part of the biopsychosocial model for sexual dysfunction, what are some biological factors that play a part?
- 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)
As part of the biopsychosocial model for sexual dysfunction, what are some of the psychological factors that play a part?
- Depression
- Anxiety
- Infertility
- Psychosis
- Substance and alcohol misuse
- Living with HIV
As part of the biopsychosocial model for sexual dysfunction, what are some of the social factors that play a part?
- Poverty
- Negative cultural attitudes towards sex
- Unemployment
- Domestic violence
Name some common medications that can cause / contribute to sexual dysfunction
- Antihypertensives
- Antidepressants
- Antiepileptics
- Diuretics
- Antipsychotics
- Chemo
- Statins
- Opioids
- Parkinsons meds
- Sedatives
What are the 6 diagnostic criteria to be diagnosed with hyposexual desire disorder? (lack of desire must cause clear distress and interpersonal difficulty)
- Absent / reduced interest in sexual activity
- Absent / reduced sexual / erotic thoughts or fantasies
- No / reduced initiation of sexual activity and typically unresponsive to partner’s attempts to initiate
- Absent / reduced sexual excitement / pleasure during sexual activity on almost all (approx 75-100% of) sexual encounters
- Absent / reduced sexual interest in response to any internal or external sexual / erotic cues (e.g. written, verbal, visual)
- Absent / reduced genital or non-genital sensations during sexual activity on almost all (approx 75-100% of) sexual encounters
Name 7 associated factors that could contribute to hyposexual desire disorder
- Partner factors (e.g. partner’s sexual problems, health status)
- Relationship factors (e.g. poor communication, discrepancies in desire for sex)
- Individual vulnerability factors (e.g. poor body image, history of abuse)
- Psychiatric comorbidity (e.g. depression, anxiety)
- Stressors (e.g. job loss)
- Cultural/religious factors (e.g. attitudes towards sexuality)
- Medical factors
Name some organic causes of hyposexual desire disorder
- 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)
Describe the PLISSIT model in conducting a sexual dysfunction consultation
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)
How can phosphodiesterase type 5 inhibitors be used for hyposexual desire disorder?
- Sildenafil (viagra)
- Not licensed for use in women but sometimes has good results
- Can help reverse the SSRI-induced low desire and arousal
How can testosterone gel or implants be used for hyposexual desire disorder?
- 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
What other hormone treatments can be used for hyposexual desire disorder?
- 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
Name some causes of anorgasmia
- 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)
Name some anogenital causes of female genito-pelvic pain (i.e. vaginismus, dyspareunia)
- Acute STIs
- Candida
- PID
- Prostatitis
- Anal fissures or haemorrhoids
Name some gynaecological/urological causes of female genito-pelvic pain (i.e. vaginismus, dyspareunia)
- FGM
- Endometriosis
- Anatomical abnormality (e.g. vaginal septum or imperforate hymen)
- Postpartum scar tissue
- Menopausal GSM
- UTI
- Interstitial cystitis
- Hernia
- Pelvic cancer
Name some psychosexual causes of female genito-pelvic pain (i.e. vaginismus, dyspareunia)
- Previous sexual trauma
- Anxiety about sex
- Fear of pregnancy
- Previous difficult childbirth
- Previous STIs
Name some physical causes of vaginismus
- Vaginal scarring / stenosis / shortening after childbirth / surgery
- FGM
- Skin and mucosal conditions (LS, LP)
- Menopause
- Rarely, rigid hymen, vaginal septum, shortened vaginas
Describe the non-medical concept of managing vaginismus
Overcome the cycle of pain anticipation and vaginal spasm
- Psychosexual treatment
- Pelvic floor exercises
- Graduated vaginal dilators at home
Name some medical treatments for vaginismus
- Can treat vulvodynia / vestibulodynia with topical lidocaine, amitriptyline, gabapentin
- Can treat menopausal symptoms with HRT / vaginal moisturisers / lubricants
How do you counsel a patient on vaginal dilators?
- 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
Name from specific disorders that can cause vulvar pain
- Infectious (candidiasis, herpes, TV)
- Inflammatory (LP, LS, atrophic vaginitis, immunobullous disorder)
- Neoplastic (Paget’s, SCC)
- Neurologic (herpes neuralgia, spinal nerve compression)
How do you examine vulvodynia?
- Inspection
- Q tip test
- Bulbocavernosus reflex / anal wink test (peripheral neuropathy)
- VE (?atrophy ?erosions ?vaginismus)
What investigations can you do for vulvodynia?
- STI screen
- Colposcopy / vulvoscopy
- Vulval bx
- MRI
What are the endpoints of treatment for vulvodynia?
- Reducing triggers of irritation
- Blocking peripheral nociceptors
- Central inhibition
- Tackling pelvic floor dysfunction
- Addressing psychosexual dysfunction
What are 7 possible steps for vulvodynia treatment? (not necessarily in order)
- Vulval care
- Topical local anaesthetics (provoked vulvodynia)
- TCAs or amitriptylinee / notriptyline (unprovoked vulvodynia) - 2nd line gabapentin
- Modified vestibulectomy (refractory localised provoked)
- Psychosexual therapy
- Pelvic floor techniques and desensitisation of pelvic floor muscles
- Alternative therapies
What are some risk factors for erectile dysfunction?
Similar to those for cardiovascular disease (is an accurate predictor for CVD)
- Older age
- Sedentary lifestyle
- Obesity
- Dyslipidaemia
- Metabolic syndrome
- Diabetes
- Smoking
What examination can you do for erectile dysfunction?
- HR + BP
- BMI
- PR if genitourinary or protracted secondary ejaculatory symptoms
- Genital exam
What investigations can be done for erectile dysfunction?
- Lipids
- Glucose / HbA1C
- Serum free testosterone (fasting, before 11am)
- Hormones (SHBG, LH, SFH, prolactin)
- PSA if planning testosterone replacement
- TFTs
What are first-line interventions for erectile dysfunction?
- 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
How do PDE5 inhibitors work for erectile dysfunction?
Increase blood flow to the penis
Need the initial desire
25-50% of men fail to respond within 12 months
What are some side effects to PDE5 inhibitors?
- Headache
- Flushing
- Heartburn
- Dizziness
- Visual disturbance
What are some contraindications to PDE5 inhibitors?
- 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)
Name some PDE5 inhibitors
- Sildenafil (viagra)
- Vardenafil
- Tadalafil
- Avanafil
What are the advantages and disadvantages of PDE5 inhibitors?
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
How do vacuum devices work for erectile dysfunction?
- 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
What are the advantages and disadvantages of vacuum devices for erectile dysfunction?
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
What is alprostadil?
- 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)
What conditions may predispose to priapism?
- Sickle cell anaemia (or trait)
- Thombocythaemia
- Polycythaemia
- Multiple myeloma
- Leukaemia
- Hyper-viscosity syndrome
- Venous thrombosis
- Intracavernosal injections
What are the two types of penile prosthesis?
- 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 - Inflatable
- 2 rods inserted and connected to a fluid-filled chamber which can be externally pumped and deflated
What are the advantages and disadvantages of penile prosthesis?
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
Define premature ejaculation
- 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
What are some behavioural techniques for premature ejaculation?
- 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
What are some topical therapies for premature ejaculation?
- 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
What are some medical therapies for premature ejaculation?
- Dapoxetine (SSRI licensed in PE)
- PDE5-i (where significant contribution from ED too)
- Alpha-1 adrenoceptor antagonists
Don’t forget psychosexual therapies
Describe dapoxetine for premature ejaculation
- 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
What causes delayed ejaculation?
- Psychological
- Diabetic autonomic neuropathy
- MS
- Spinal cord injury
- Hypogonadism
- Hypothyroidism
- Medication such as SSRI or alpha-blockers
- Penile pain
