B8.069 Big Case: Sexual Dysfunction Flashcards
(105 cards)
1
Q
5 Ps of sexual dysfunction
A
partners (# and gender) practices (high risk) protection past history of STIs prevention of pregnancy
2
Q
sexuality
A
complex interplay of multiple facets, including anatomical, physiological, psychological, developmental, cultural, and relational factors
3
Q
sexual identity
A
- gender identity
- orientation
- intention
4
Q
sexual function
A
- desire
- arousal
- orgasm
- emotional satisfaction
5
Q
genital tubercle
A
male- glans penis
female- glans clitoris
6
Q
urogenital groove
A
male- urethral opening
female- vaginal + urethral opening
7
Q
urogenital folds
A
male- urethra
female- labia minora
8
Q
lateral tubercle
A
male- penile shaft
female- clitoral shaft
9
Q
genital swelling
A
male- scrotum
female- labia majora
10
Q
importance of the glans
A
greatest concentration of sensory nerves
contiguous with corpus spongiosum
11
Q
corpus spongiosum
A
houses the urethra
12
Q
corpus cavernosum
A
erectile bodies
- crus: split of the corpora over the urethra
- tunica albuginea: fibrous wrapping of the corpora cavernosa
13
Q
describe the tunica albuginea
A
strong, fibrous tissue
2 layers
traps blood during erection
14
Q
what is unique about the anterior scrotal artery compared with the rest of the male vascular anatomy
A
comes off of the femoral artery
rest of arteries arise from internal pudendal
has implications in testicular cancer spread (inguinal nodes)
15
Q
mechanisms of pelvic artery damage that can impact sexual function due to downstream effects
A
pelvic fracture
pelvic radiation
16
Q
dorsal penile artery
A
glans filling during erection
17
Q
cavernosal artery
A
corporal filling during erection
18
Q
bulbar/urethral artery
A
corpus spongiosum filling during erection
19
Q
sympathetic pathway of the penis
A
SHOOT
T10-12 fibers innervate the penis
white rami > sympathetic ganglia > inferior mesenteric and superior hypogastric plexus > hypogastric nerves > pelvic (inferior hypogastric) plexus
20
Q
distal fibers of the penile sympathetic pathways
A
form prostatic plexus and cavernous nerves
- responsible for detumescence
- plays a role in emission/ejaculation
21
Q
parasympathetic pathway of the penis
A
POINT
S2,3,4 intermediolateral cells
pelvic nerve > pelvic (inferior hypogastric) plexus, joined by sympathetic fibers > prostatic plexus and cavernous nerves
22
Q
function of parasympathetic pathway of the penis
A
responsible for erections
plays a role in secretion of seminal fluids
23
Q
afferent sensory nerves of the penis
A
innervate skin of glans, penile skin, urethra
dorsal nerve of the penis
-sensory branch of the internal pudendal nerve
24
Q
efferent motor nerves of the penis
A
Onuf’s nucleus of S2,3,4
- motor branch of the internal pudendal nerve
- ischiocavernosus muscles (rigid erection phase)
- bulbospongiosus muscle = rhythmic contraction in ejaculation
25
components of central control of sexual function
cerebral cortex- how we perceive sex
limbic system- how we feel about sex
hypothalamus- stimulation results in arousal
26
components of the limbic system involved in sexual function
amygdala: larger in men
| - visual stimuli men >>> women
27
components of the hypothalamus involved in sexual function
```
medial preoptic area (MPOA)
-sexual stimuli are summated
>dopamine facilitates sexual behavior
>triggers autonomic pathway for erection
-gonadotropin RH cell bodies
```
28
phases of the male sexual response
```
excitement (arousal)
plateau
orgasm
resolution
-contains refractory period
```
29
excitement phase in men
partial erection
elevation of scrotum
vasocongestion of the skin (sex flush)
30
plateau phase in men
increased HR, increased circulation, increased respiration
perspiration
secretions by Cowper's gland
bladder neck contracts
31
orgasm phase in men
cyclic muscle contraction of pelvic musculature
euphoria
ejaculation
32
resolution phase in men
decreased tumescence to 50% of erect state
refractory period where another erection can't be achieved (increases with age)
return to flaccid state
33
types of erections
psychogenic
reflexogenic
nocturnal
34
psychogenic erections
controlled by cerebral cortex
stimuli: sight, smell, hearing, and fantasy
thoracolumbar erection center (T10-L2)
35
reflexogenic erections
reflex pathway through direct genital stimulation
| sacral erection center (S2-4)
36
nocturnal erections
REM sleep dreaming
-reduction of sympathetic activity
-increased parasympathetic activity
useful to determine psychogenic ED vs. physiological ED (if person still gets morning erections, machinery is working ok)
37
hemodynamics of flaccid penis
sympathetic input: smooth muscle in cavernosal tissue is contracted
reduced arterial blood blow
blood flow to penis is minimal (must keep tissue alive)
flaccid penis length variable
-not predictive of overall erectile length
-influenced by temperature and emotion
38
hemodynamics of erection
1. cavernous nerve stimulation results in relaxation of smooth muscle
2. arteriole dilation increased blood flow into sinusoids
3. increased sinusoidal pressure causes venous compression and decreases venous outflow
4. subtunical venous plexus compressed against tunica albuginea
5. stretched tunica further compresses emissary veins
6. ischiocavernous muscles contract to increase penile pressure (creates rigid erection phase)
39
what is the importance of the nitric oxide pathway?
causes cavernous smooth muscle relaxation = erection
40
release of NO in cavernous smooth muscle
parasympathetic cavernosal nerves allow for:
- direct NO release
- release of ACh, which stimulates endothelial cells to release more NO
41
steps of the NO pathway
1. NO > cGMP production
2. protein kinase G activated
3. K+ channels open, Ca2+ channels close
4. decreased intracellular Ca2+ levels
5. smooth muscle relaxation
42
mechanisms of PDE5 inhibitors
cGMP is degraded by PDE5 which eventually restores cell increased muscle tone
when PDE5 is INHIBITED
-decreased cGMP breakdown
-continues state of smooth muscle relaxation
43
unique characteristics of sildenafil
viagra
| blue visual hue due to cross reactivity with PDE6 in retina
44
unique characteristics of tadalafil (cialis)
longest half life (17.5 hrs)
"weekend pill"
muscle leg/back aches in 9%
45
avanafil (stendra)
fastest onset of 15 min
| can take with alcohol
46
general side effects of PDE5 inhibitors
mostly vasodilation
- headache (16%)
- flushing (10%)
- heart burn
- visual effects (3%); generally transient and mild to moderate
- sinus pressure
47
contraindications for PDE5 inhibitors
a blockers
nitrates
will cause a drop in BP when combined
48
injectable ED meds
papaverine: general PDE inhibitor
-increased cGMP and cAMP
prostaglandin PGE1
-increases cAMP
49
what is priapism
erection lasting more than 4 hours
blood becomes trapped in the penis
-lack of circulation causes ischemic damage of the cavernosal issue
50
priapism from ED drugs
rare with PDE5 inhibitors
| more common with injectables
51
treatment of priapism
irrigation of corpora with normal saline
injection of sympathomimetics (phenylephrine)
-a adrenergic agonist
52
main physical causes of ED
1. vascular
2. diabetes
3. meds
4. pelvic surgery, radiation, or trauma
5. neurologic causes
6. endocrine problems
53
relationship between ED and CAD
men with ED have higher prevalence of CAD risk factors than men without ED
54
phases of erection
0. flaccid
1. latent (filling) phase
2. tumescent phase
3. full erection phase
4. rigid erection phase
5. detumescence
55
flaccid phase
cavernosal smooth muscle contracted
sinusoids empty
minimal arterial flow
56
latent (filling) phase
increased pudendal artery flow, penile elongation
57
tumescent phase
rising intracavernosal pressure; erection forming
58
full erection phase
increased cavernosal pressure (100 mmHg) causes penis to become full erect
59
rigid erection phase
further increases in pressure (several hundred mmHg) + ischiocavernosal muscle contraction
60
detumescence phase
following ejaculation, sympathetic discharge resumes
smooth muscle contraction and vasocontriction
reduced arterial flow
blood is expelled from sinusoidal spaces
61
emission
secretion of seminal components by seminal vesicles, prostate, ampulla
-stimulated by parasympathetics
62
expulsion
forceful propulsion of semen out the urethra
- bladder neck contracts to prevent retrograde flow (sympathetic)
- contraction of bulbospongiosus (pudendal motor neurons, S2-4)
63
orgasm
cerebral processing of pudendal nerve sensory stimuli
64
dopamine and ejaculation
promotes
65
serotonin and ejaculation
inhibits
66
ejaculation disorders
premature ejaculation
anejaculation
retrograde ejaculation
67
premature ejaculation
ejaculation occurs sooner than desires by him or partner
- low serotonin plays a role (can use SSRI)
- behavior modification
- numbing cream or spray
68
anejaculation
failure of ejaculation
- spinal cord injury, diabetes
- surgical resection
69
retrograde ejaculation
ejaculation into the bladder
- prostate surgery and BPH treatments
- a blockers- relax bladder neck
70
meds that can cause male sexual dysfunction
anti psychotics (increased prolactin, decreased dopamine)
B blockers
anti depressants (SSRIs)
narcotics (suppress GnRH, decrease T)
71
effects of aging on male sexual function
increased refractory period, decreased recurrent sex
increased rates of ED
decreased GnRH > decreased T > less libido
72
internal pudendal vessels of the female
supply the distal 1/3 of the vagina
73
vulvar vascular anatomy
```
from bottom to top:
inferior rectal artery
internal pudendal artery gives off:
1. perineal artery
2. artery to the vestibular bulb
3. deep artery of the clitoris
```
74
neuroanatomy of female pelvis
pudendal nerve supplies clitoris and erectile bodies
| S2-4 somatic nerve
75
indications for pudendal nerve blocks
2nd stage of labor
episiotomy repair
minor surgery of lower vagina and perineum
76
function of pudendal nerve blocks
reduces sensation in the genitalia, urethra, anus, and perineum
largely replaced in modern era by spinal anesthesia
77
technique for pudendal block
1. lithotomy position
2. palpate ischial spine transvaginally
3. needle guide used to prevent over injection; place at tip of ischial spine
4. 3 injections
- mucosal wheel
- advance 1 cm into sacrospinous ligament (target 1cm medial and 1 cm posterior to ischial spine)
- advance 1 cm past sacrospinous ligament
78
function of ischiocavernosus in females
increases pressure in the clitoris
79
variations in the female sexual response
doesnt have a refractory period, but only about 20% can get multiple orgasms
3 main outcomes:
1. multiple orgasms > resolution
2. stays at plateau and never reaches orgasm > resolution
3. reaches orgasm and has resolution right after
80
components of the female sexual response
willingness to become aroused
sensation of desire
vascular and neuro structures are analogous to erectile tissue in the male
81
excitement phase in women
central arousal due to stimuli
increased HR, breathing, BP
sex flush (more common in women)
engorgement of venous plexus of lower vagina
-erectile bulbs of the vestibule swell
-labia expands
clitoris enlarges
-NO mediated pathway
uterus elevates and vaginal lubrication begins
-transudative process, not glandular secretions
82
plateau phase in women
breast enlargement continues
clitoris elevates, retracting under the hood
tenting of uterus to allow sperm entry
more increase in HR, breathing, and BP
83
orgasmic phase in women
```
release of sexual tension
peak HR, breathing, BP
5-10 rhythmic contractions of vaginal, uterine, anal, and abdominal musculature
-2 to 4 seconds after orgasm
-0.8 second interval
```
84
resolution phase in women
```
sex flush resolves
vitals return to normal
breasts and vulva return to normal size
no refractory period
-multiple orgasms can occur in some women
```
85
definition of female sexual dysfunction
failure of 1 or more phases of sexual response
-generally must include distress
up to 32% of women in a year
86
subtypes of female sexual dysfunction
- primary (lifelong) vs secondary (acquired)
- generalized vs situational
- origin: organic, psychogenic, mixed, unknown
87
classes of female sexual dysfunction
```
sexual desire disorders
-hypoactive sexual desire disorder
-sexual aversion disorder
sexual arousal disorder
orgasmic disorder
sexual pain disorders
-dyspareunia
-vagismus
```
88
hypoactive sexual desire disorder (HSDD)
persistent or deficient sexual fantasies or desire for sexual activity
often psychosocial
-depression
-lack of time
-emotional stressors
-life changes
*rule out difference in partner's sexual appetite
89
treatment of HSDD
psychotherapy, sex therapy often helpful
rule out substance induced sexual dysfunction (anti-psychotics, B blockers, anti depressants, opioids)
rule out sexual disorders due to medical condition
90
medical conditions than can cause sexual disorders
```
hypothyroidism
CAD > fear of triggering an MI
renal failure (high prolactin)
incontinence
neuro disease > direct damage to areas responsible for processing stimuli
menopause
```
91
sexual aversion disorder (SAD)
```
rare
severe aversion to genital contact
must have associated pscyhophysiological diagnosis
-anxiety
-often associated with trauma
personal aversion (poor self worth)
```
92
treatment of SAD
counseling
| antidepressants
93
general treatment strategies in desire disorders
counseling / reduction of stressors
T therapy controversial in women
-increased fantasy, desire, and satisfaction with sex
-risk of virilization
estrogen supplementation in postmenopausal women
-increased genital sensitivity, increased libido, decreased dryness
amphetamines
-increased D2 secretion, increased desire
buproprion
-NE and D2 reuptake inhibitor
-increased dopamine
94
what is Filbanserin
only FDA approved med for HSDD
-multifunctional serotonin agonist and antagonist
-approved in premenopausal, unlabeled in postmenopausal
increases # of sexual satisfying events per month
avoid alcohol
95
sexual arousal disorder
inability to maintain sufficient sexual excitement to complete sexual activity
96
causes of sexual arousal disorder
- depression, low self esteem, stress, anxiety
- medication, low E
- postmenopausal atrophic vaginitis
- skin disorder of the genital skin
97
treatment of sexual arousal disorder
```
psychogenic causes
-cognitive behavioral therapy
-improving relationship stressors
-stopping SSRI, SNRI
vaginal atrophy
-topical estrogen
sildenafil
-conflicting results
```
98
orgasmic disorder
persistent delay or absence attaining orgasm with sufficient stimulation and arousal
primary: associated with trauma or abuse
secondary: associated with HSDD, pelvic surgery, drugs
99
treatment of orgasmic disorder
cognitive behavior therapy
-benefit in symptom severity and sexual satisfaction
no pharm treatments
100
dyspareunia
recurrent genital pain associated with intercourse
101
vaginismus
recurrent involuntary spasm of musculature in distal 1/3 of vagina that prevents vaginal penetration
psychogenic - anticipation of pain associated with sex
rule out medical causes
102
onset sexual pain disorders
lifelong: congenital or psychological etiology
| new onset: MSK, pelvic, genital, dermatological
103
causes of superficial sexual pain
```
vulvovaginal atrophy
injury/trauma
inflammation or infection
vestibulodynia/vulvar vestibulitis
vulvar skin disease (lichen sclerosis)
```
104
deep sexual pain disorders
```
endometriosis
interstitial cystitis
uterine fibroids
vaginal prolapse
adnexal pathology (ovarian cyst or neoplasm)
myofascial pain
```
105
relationship between female sexual function and menopause
```
no clear evidence
less easily aroused and less genital sensitivity
decreased blood flow to vagina
-reduced lubrication
atrophy and stenosis of vaginal canal
```
