Lecture 26: Sexual function and Dysfunction

Question 1

Sexual Response Cycle

Answer 1

• Masters and Johnson 1966 –> observation and recordings of sex –> low levels of volunteers –> High proportion of prostitutes used for studies
  1. Excitement (Arousal phase
  2. Plateau
  3. Orgasm
  4. Resolution
  5. Refractory period
  Overall: groundbreaking research. tested and added too over the years

Question 2

Descriptions for the phases of Sexual Response Cycle

Answer 2

1. Excitement (arousal phase): caused by any reflexogenix or psychogenic stimulation
2. Plateau: arousal reversible –> inevitable orgasm
3. Orgasm
4. Resolution: Involuntary period of tension loss (slower in woman than men)
5. Refractory period
   - Increased HR, Change in BP, sweating, degree of dilitation

Question 3

Sexual response cycle table

Question 4

Kaplan 1979

Answer 4

Kaplan: feminist –> all about X and the Lack there of
3 phase model
1. Desire
2. Arousal
3. Orgasm
- forms basis of DSM IV classification of female sexual Dysfunction
Note: Linear models arent reality for many woman

Question 5

Why are linear models not reality for the majority of woman?

Answer 5

1. disconnection b/w desire and orgasm
2. assumption: vasocongestion measures arousal
3. assumption: Orgasm reflects satisfaction (synonymous)

Question 6

Basson’s mode

Answer 6

Tries to separate desire and arousal –> bigger contention/problem for female sexuality (more than male sexuality)
Allows for consideration: Marital relationship –> husband more eager to have sex than female –> lack of female desire –> but becomes secondarily aroused during act

Question 7

Categories of Sexual Problem Impairments

Answer 7

1. Physiological impairment (sexual dysfunction)
2. Non-Physiological impairment (human relations/difficulties in, consequences of, ways in which people conduct themselves sexually
   a) Psychological
   i) IntERsychic (Within the 2x people of the relationship/communication)
   ii) IntRAsychic (beliefs, meanings, conflicts, guilt, shame, information deficiet/distortion, past sexual trauma, depression, anxiety, aversions, phobias
   b) Social
   i) situational (environmental)
   Note: most common when have newborns/young children

Question 8

PLISSIT model in regards to primary care of sexual dysfunction

Answer 8

• Annon and Robinson 1978
• Model for Sexual counselling –> interventions for common sexual dysfunctions of 4x levels of intensity
  P: ERMISSION to talk about sexual matters, fantasize, enjoy sexuality
  LI: Limited Information (response to patient’s discussion)
  SS: Specific Suggestions (e.g. retroverted uterus –> have sex ontop)
  IT: Intensive Therapy

Question 9

What is the most common female sexual complaint

Answer 9

Lack of desire

Medication: Flibanserin (Girosa)

Question 10

3x Main reasons for Female Sexual dysfunction

Answer 10

1. disorder of sexual Interest or Arousal
2. disorder of orgasm
3. disorder of genito-pelvic pain/penatration
   - dysparenuria
   - vaginismus

Question 11

What are the requirements for a complain of sexual dysfunction by both males and females

Answer 11

1. atleast 6 months
2. atleast 75-100% of time
3. results in atleast significant distress

Question 12

What are the potentail variations in sexual dysfunctions for both males and female?

Answer 12

1. Lifelong or acquire
2. Generalised vs situational
3. Severity: mild, moderate, severe

Question 13

Associated features of sexual dysfunction for both males and females

Answer 13

Factors:

1. partner
2. relationship
3. individual vulnerability factors/ psychiatric co-morbidity / stressors
4. cultural or religious
5. medical factors

Question 14

Description of Associated features of sexual dysfunction for both males and females

Answer 14

Factors:

1. partner: partner sexual problem, partner health status
2. relationship: poor communication, discrepancies in desire for sexual activity
3. individual body factors: poor body image, history of sexual or emotional abuse, Psychiatric comorbidity: depression or anxiety. Stressors: job loss, bereavement
4. Cultural or religious: inhibitions related to prohibitions against sexual activity or pleasure. attitudes towards sexuality
5. Medical: factors relevant to prognosis, course or treatment

Question 15

Treatment of Female Sexual Dysfunction

Answer 15

1. Is there really a problem: If so Whose problem (which partner) and Check associate features of partner (past sexual abuse/domestic violence)
2. Education:
3. Counselling:
   a) Patient Couple
   b) Sensate focus (ban sex, RE-ESTABLISH INTIMACY by starting at foundation)
   c) manage medical problem
   - “menopause” –> sexual function issues:
   i) consider hormone replacement therapy –> topic oestrogen –> adds robustness to vaginal mucosa –> increased lubrication and hence decreased pain during sex
   ii) physiotherapy –> added strength to pelvic floor muscles

Question 16

4x main reasons for Male Sexual Dysfunction

Answer 16

1. Hypoactive sexual disorder (decreased libido)
2. Erectile
3. Ejaculation: Delayed (retarted) or Premature (rapid)
   Note: biased research as most researchers are men –> know more about male sexual dysfunction

Question 17

Cuases of Hypoactive sexual disorder/Low libido in men

Answer 17

1. Psycholocial
   a) fatigue
   b) situational
   c) depression –> treament drugs further worsen sexual dysfunction
2. Physical
   a) hypothyroidism
   b) hypogonadism
   c) PADAM (Partial Androgen deficiency in Aging Males)
3. Other: Medicaiton (e.g. antidepressants)

Question 18

PADAM

Answer 18

Partial Androgen Deficiency in Aging Males
–> extreme hypogonadism disproportionate to rate of male aging
Treatment: Testosterone supplementation

Question 19

What are the nerve pathways to penile erections?

Answer 19

Visual, imaginative, auditory, emotional or olfactory sex stimuli to brain –> No release –> increase in cGMP in penile areas –> increased smooth muscle/erectile tissue relaxation –> increased blood flow into corpora cavernosum (arterial expansion)–> compression of veins distended lacunae and cavernous sinuses –> erection –> PDE-5 enzyme breaks down cGMP –> acoids thrombosis + decreases erection
Note: disruption on any level can cause problems
Pelvic level: Contains reflex arch (tactile response cremasteric reflex) –> allows men with spinal cord injuries still being able to get erect –> reflex arch at pelvic level is a tactile response in nerve pathway

Question 20

What is a special loop hole in the Nerve pathway to penile erection?

Answer 20

Reflex arch at pelvic level (tactile response cremasteric reflex)
Clinically: means men with spina cord injuries are still able to get erect (tactile response nerve pathway)

Question 21

What sort of instrument is the penis

Answer 21

Penis isnt a muscle

Hydrolic instrument

Question 22

Components of Penis Flaccid –> Erect

Answer 22

1. Circumflex vein
2. Cavernous sinuses
3. tunic albuginea
4. Helicine arteries
5. Cavernous arteries

Question 23

Erectile Difficulties requirements

Answer 23

Persisitent inability, for alteast 3 months, to obtain and maintain sufficient and satisfactory sexual performance
Note: DSM-5: 6 months

Question 24

Relating features to erectile difficulties

Answer 24

1. Prevalance increases with age (paralleled to increased rate of organic illnesses with age)
2. Organic vs Psychogenic
   - incident w. failure to become erect –> psychological reaction –> perpetuates erectile loss
3. Chronic illnesses (decreased libido/interest), surgery (interruption of fine vessels), trauma (spinal or pelvic)
4. Midifiable risk factors

Question 25

Chronic Illnesses causing Erectile Dysfunction

Answer 25

1. Systemic (atheroscleorisis, dibatere, CVD, renal/heaptic failure) 2. Neurogenic (alzhiemers, multiple sclerosis) 3. Penille disorder (Peyrones) /Psychiatric (depression + performance anxiety) /Endocrine (hyper/hypothyoidism, hypogonadism, hyperprolativemia) Note: Peyrones disease --> Trauma/clot/inflammation --> fibrosis to Tunica --> distortion of erect penis --> hard to achieve

Question 26

Surgery and Trauma as causes of Erectile Dysfunction

Answer 26

1. Neurological (spinal cord) 2. Pelvic (injury, surgery, irradiation of pelvic region) 3. Urological (prostatectomy) --> disruption of fine nerves supplying penis --> risk of impotence with prostatic surgery

Question 27

Prevalence of Erectile Dysfunction

Answer 27

1. No impotence: 48% 2. Minimal: 17% 3. Moderate: 25% 4. Complete impotence: 10% Note: changes would have occurred by now, as this study occurred in 1987-69 Additionally: biased results as involved relatively older test patients (40-70 years) Overall: 52% of men experience some degree of erectile dysfunction

Question 28

Associated of Prevalance of Erectile Dysfunction with age

Answer 28

Overall: Increased probability of ED with age 1. 40 years --> 39% risk of ED 2. 50 years --> 48% risk of ED 3. 60 years --> 57% risk of ED 4. 70 years --> 76% risk of ED

Question 29

Modifiable risk factors which can decrease risk of Erectile dysfunction

Answer 29

1. Alcohol 2. cigarette 3. Drugs (antihypersensitives, anti depressants, hormones, tranquilizers, miscellaneous (NSAIDS, H2RA, cocaine, heroine)

Question 30

Etiology behind Erectile Dysfunction

Answer 30

1. Organic (vasculogenis, neurological, hormonal or cavernosal abnormalities/lesions) 2. Psychogenic (central inhibition of erectile mechanism w/o physical insult) --> typically secondary to original ED occurrence --> continued stress of reoccurrence --> Physchogenic problems

Question 31

What is the common occurance order b/w Organic or Psychogenic problems in relation to Erectile Dysfunction

Answer 31

Psychogenic problems are often Secondary to the actual ED effect --> due to continued worrying of reoccurrence --> psychogenic problems

Question 32

Sexual Performance Anxiety Circle

Answer 32

1. Loss of confidence --> 2. Lack of interest --> 3. Treatment Feedback Loop --> 4. Performance Anxiety - mindfulness based approaches as a component of treatment - pro erectile drugs can be like training wheels --> brief dose to get confidence back

Question 33

PDE5 inhibitors

Answer 33

1. Sildenafil (viagra) : generics now cheaper 2. Tadalafil (cialis): not yet off patent - longer duration of action - option of low dose (5mg) daily --> maintains oxygenation --> improves endothelial smooth muscle health 3. Vardenafil (levitra): shorter duration of action --> dont feel terrible for long

Question 34

Male Erectile Dysfunction Treatment approaches

Answer 34

1. PDE5 inhibitors 2. Alprosatdil (Caverject) (inject into cavernosa) 3. Bimix (papaverine and phentolamine) --> Note: Papaverine often creates problems --> need to reverse with another drug 4. Trimix (prostaglandin PGE1, papaverine and phentolamine) 5. ED shock wave therapy 6. Vacuum device 7. Surgery

Question 35

Rapid Premature Ejaculation

Answer 35

``` ejaculation occurs before the individual wants to Traditional theories: 1. Furtive early masturbation 2. the "too exciting vagina" 3. Genital hypersensitivity 4. Lack of alarm signal ```

Question 36

Traditional therapeutic responses to premature ejaculation

Answer 36

1. Sensate focus with "squeeze" technique --> blunt blow to glans penis 2. "Stop-Start" technique 3. Local anaesthetic spray (benzocaine)

Question 37

Neurobiological approach to Ejaculatory disorders

Answer 37

SSRI (Selective serotonin reuptake inhibitors) - decreased serotonin neurotransmission --> hypofunction of 5HT2c receptor --> Familial aspects - is premature ejaculation a natural selective advantage in nature? Pharmacotherapy: - SSRI daily or: Clomipramine daily/ 12 hours before sex - Dapoxetine (Priligy): --> related to SSRIs --> really helpful with temporal ejaculation problem --> but is rapidly metabolised therefore dont help treat depression 30mg or 60mg -> smaller dose is in and out of body faster --> less concern with suicidality risk of SSRIs over time

Question 38

Delayed Retarded Ejaculation

Answer 38

No consensus operational definition Generalised or situational Lifelong DE rel Uncommon (1.5/1000, 3-4%) Classically attributed to psychological issues: fear, anxiety, hostility, and relationship difficulties Contemporary: Waldinger's Ejaculation Distribution therapy (EDT) --> Bell curve normal distribution within men (natural variation, most normal, some premature some delayed)

Question 39

Available options of Erectile Dysfunction treatment

Answer 39

1. Non-invasive - elimination of modifiable risk factors - couselling and/or psychological therapy - medication - vaccum constriction devices (decreased efficancy. neurological) 2. Invasive - Transurethral drug application (hardly used anymore) - intracavernous injection therapy - prosthesis implantation - venous/arterial surgery (Steel)

Question 40

Route's and sites of ED Drug treatment

Answer 40

1. brain a) apomorphine (dopamine agonist, sublingual delivery) b) sidinaphil (phosphodiesterase inhibitor, oral delivery) c) phenolalamine (aplha-adrenergic blocker, oral delivery) 2. Groin area a) Prostaglandin (vasodilator. 3x delivery areas) - injeciton (intracavernous) - suppository (intraurethral) - transcutaneous ointment --> neuromuscular junction's corpora cavernosa smooth muscle cells --> vasodilation

Question 41

Which is more complex out of ED and ED

Answer 41

Ejaculatory dysfunction disorders are more complex

Question 42

Psychological and Acquired ED

Answer 42

1. Hypofunction of 5-HT1A receptors - and/or possibly hyperfunction of 5-HT2c - treatment research: h-HT receptor agonists 2. Acquired DE - psychological - disease states (neurological conditions) (diabetes mellitus) - medication: SSRIs , Tricyclic antidepressants, antipsychotics and others