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Flashcards in Sexual Med Deck (73)
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what are the 5 main stages/phases of sex/sexual arousal?



what sexual problems can affect the drive phase of sex?

sexual aversion
sexual addiction


what sexual problems can affect the desire/libido phase of sex?

hypoactive sexual desire disorder (HSDD)


what sexual problems can affect the excitation phase of sex?

female sexual interest/arousal disorder
erectile dysfunction


what sexual problems can affect the orgasm phase of sex?

orgasmic disorder
ejaculatory problems e.g. delayed, rapid, retrograde


what are the sexual pain disorders?

dyspareunia (superficial or deep)


what blood tests might be done as part of assessing sexual problems? what kind of problem would prompt you to do each one?

- fasting glucose, lipid ratio = diabetes, CVD - useful to rule in most sexual problems
- testosterone, SHBG, albumin = desire disorders, arousal disorders, orgasmic disorders, pain disorders
- prolactin = desire disorders, ED
- TSH = desire disorders, rapid ejaculation
- oestrogen = female sexual arousal disorder, orgasmic disorder
- FBC = desire disorders, orgasmic disorders


what is hypoactive sexual desire disorder?

lack/loss of sexual desire - not secondary to other difficulties (E.g. dyspareunia, ED).
doesn't preclude enjoyment or arousal, but make initiation of sexual activity less likely.


give some physical causes of HSDD

chronic medical conditions:
- obesity
- DM
- anaemia
hormonal (men):
- androgen deficiency
- hypogonadism (various causes)
- hyperprolactinaemia
hormonal (women):
- androgen deficiency
- hypothyroidism
- hyperprolactinaemia
- post pregnancy
- Addison's


give some iatrogenic causes of HSDD in men/women

- prescribe medication e.g. antidepressants, finasteride
- post surgical e.g. orchidectomy

- medication e.g. oral contraceptive, oral HRT, tamoxifen (all bind with testosterone); antidepressants and antipsychotics; beta blockers
- post surgery e.g. bilateral oopherectomy


give some psychological causes of HSDD

- psych conditions e.g. depression, anxiety, substance misuse
- psychological experiences e.g. environmental, life events (work stress), prev trauma/abuse
- body image disorder
- couple's script problems
- erotic dissatistfaction
- couple relationship problems


list some psychosexual treatment modalities

- integrative = combines psychosexual options and physical treatments
- cognitive = e.g. addresses unhelpful thinking styles
- behavioural = e.g. Sensate Focus or Self Growth Programme
- CBT = combines the two
- Psychodynamic = e.g. for past events, attachments, partner choice etc
- Systemic e.g. individual, couple, family dynamics


explain role of testosterone replacement in treating HSDD

- do repeat testosterone tests
- replacement can be given via injection, transdermal patches/gel, buccal, SC implants
- HCG can be used as an alternative to testosterone


describe the use of individual psychosexual therapy for HSDD

- sexual education
- encourages vocalising and accepting difficult feelings
- normalising and permission giving
- finds new solutions for old problems
- surmount barriers to psychological intimacy
- expand communication
- lessen performance anxiety
- transforms destructive attitudes that interfere with intimacy
- support


what is the "Sexual Growth Programme"?

an individual behavioural intervention used in treatment of HSDD.
- allows pt to be aware of their own sexual needs through self exploration of physiological responses
- work w/ therapist to understand and overcome negative beliefs and unhelpful thinking patterns


define erectile disorder (ED)

"difficulty in developing or maintaining an erection suitable for satisfactory intercourse"

can be in obtaining or maintaining erection, or decrease in rigidity


list some physical causes of ED

- chronic medical conditions e.g. CVD, DM, neuro disease
- hormonal - androgen deficiency, high prolactin
- iatrogenic - post prostate surgery, drugs (antiHTNs, antidepressants esp SSRIs)
- age related changes
- ineffective sexual stimuli
- pain
- veno-occlusive disorder


list some psychological causes of ED

- psych conditions e.g. depression, substance misuse
- performance anxiety, life events, negative prev experiences
- couple's script problems
- relationship problems, issues from prev relationship
- educational matters
- cultural and religious matters


list some medical treatment options for ED

oral - sildenafil (viagra), avanafil (spedra), tadalafil (cialis), vardenafil (levitra)

injectable - alprostadil (intra cavernosal injection, ICI)

intraurethral - aprostadil MUSE pellet (medical urethral system for erection), alprostradil cream (vitaros)


what patient education advice would you give to someone started on medical treatments for ED?

- need sexual stimulation to work
- work best taken on empty stomach
- need to wait 45-60 mins before sexual activity (only 20-30mins on avanafil)
- efficacy improves from first dose to eighth

watch for unacceptable ratio of benefits to side effects.
need partner support
may have difficulty incorporating into sexual script


what are some non-medical treatment options for ED?

- vacuum device
- penile/scrotal rings
- new stimulating routines e.g. enhancing lubes, vibrators
- Kegel exercises


what are the criteria for prescribing medical treatments for ED on the NHS?

can prescribe sildenafil universally, but for others:
i. Have diabetes, multiple sclerosis, Parkinson’s disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida or spinal cord injury.
ii. Are receiving dialysis for renal failure.
iii. Have had radical pelvis surgery, prostatectomy (including transurethral resection of the prostate), or kidney transplant.
iv. Were receiving Caverject, Erecnos, MUSE, Viagra or Viridal for erectile dysfunction at NHS expense on/before 14 September 1998.
v. Are suffering severe distress as a result of impotence (prescribed in specialist centres only)

- psychological treatments - individual sexual and/or couple therapy - expensive!


what is female sexual arousal disorder?

lack of/reduced/failure of genital response - principle issues is vaginal dryness or failure of lubrication

DSM also included reduced interest in sex, reduced erotic thoughts/fantasies etc


give some physical causes of female sexual arousal disorder

- chronic medical conditions - CVD, DM, neuro disease, connective tissue disease
- hormonal disorders - oestrogen deficiency (e.g. post menopause), thyroid disorders
- iatrogenic - prescribed meds (e.g. antidepressants)
- lactation

vaginal dryness is often presenting problem - can be caused by local irritants and douching


list some psychological causes of female sexual arousal disorder

- psych conditions e.g. depression, anxiety, binge eating disorders, excessive dieting
- prev abuse
- couple script problems
- decreased intimacy
- couple's relationship problems


what is the role of couple psychosexual therapy for treating female sexual arousal disorder?

elements are similar to those used in individual options

hierarchy of interventions:
- timetabling
- communication
- negotiation/contracting
- addressing intimacy
- being sexual
- adjusting to difficulties


describe behavioural interventions that might be used for female sexual arousal disorder

Sensate Focus:
- staged programme of exercises - helps couple identify their own likes/dislikes, explore new techniques
- work w/ therapist to understand and overcome negative beliefs/thinking patterns

New sexual routines, lubricant, vibrators, vielle (device worn on fingers)

Eros therapy device:


what is the Eros therapy device?

- small handheld device used at home
- proven treatment for arousal and orgasmic disorders
- greater clitoral/genital engorgement
- increase vaginal lubrication
- enhanced ability to achieve orgasm
- improved sexual satisfaction


describe a "level 1" couple presenting to sexual medicine clinic

the ideal couple!
high quality relationship, continuing to be affectionate, maintaining non-coital play.
realistic expectations re treatment.
value return of satisfying sex life.

treatment - will usually only require medical intervention and succinct advice.
must follow up though!


describe a "level 2" couple presenting to sexual medicine clinic

- been sexually abstinent for extended time
- expressions of affection dwindled
- one or both are depressed
- moderate levels of performance anxiety
- treatment expectations unrealistic
- uncertain how to restart lovemaking

treatment -
coaching - direct advice on how to communicate, suggestions for performance anxiety
sex/psycho -therapy - brief targeted intervention to overcome resistance to using treatment