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1 - Psychiatry AE > Sexual medicine > Flashcards

Sexual medicine Flashcards

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1
Q

What are some disorders of sexual drive?

A

Sexual aversion

Sexual addiction

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2
Q

What are some disorders of sexual desire?

A

Hypoactive sexual desire disorder (HSDD)

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3
Q

What are some disorders of sexual excitation?

A

Female sexual interest/arousal disorder,
Erectile disorder,
Paraphilias

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4
Q

What are some disorders of sexual orgasm?

A

Orgasmic disorder,

Ejaculatory problems e.g. delayed, rapid retrograde

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5
Q

What are some disorders of sexual pain?

A

Dyspareunia,
Vaginismus,
Vulvodynia.

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6
Q

What blood tests would you do for which sexual problems?

A

Fasting Glucose/Lipid ratio - diabetes/CVD, useful to rule out for most sexual problems
Testosterone, SHBG (sex hormones), 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

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7
Q

What psychological treatment would you use for predisposing, precipitating and maintaining causes?

A

Predisposing - psychodynamic
Precipitating - CBT
Maintaining - systemic

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8
Q

What are some maintaining causes of sexual disorders?

A

Relationship issues and avoiding intimacy

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9
Q

What is male hypoactive sexual desire disorder?

A

Loss of sexual desire is the principal problem and is not secondary to other sexual difficulties, such as erectile failure or dyspareunia. Lack of sexual desire does not preclude sexual enjoyment or arousal, but makes the initiation of sexual activity less likely.

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10
Q

What are some causes of male hypoactive sexual desire disorder?

A

Chronic medical conditions - Obesity, CVD, diabetes mellitus, anaemia
Hormonal disorder - Androgen deficiency, hypogonadism from various aetiologies, hyperprolactinameia
Iatrogenic - anti-depressants orchidectomy
Psychological - psychiatric conditions, e.g. depression, anxiety, substance misuse, body image disorder, couples script problems, eWrotic dissatisfaction
Couple relationship problems
Psychological experiences, e.g. environmental, life events (including work stressors), previous trauma or abuse

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11
Q

What are some causes of female hypoactive sexual desire disorder?

A

Hormonal disorder - androgen deficiency, hypothyroidism, hyperprolactinaemia, post pregnancy, addison’s disease
Iatrogenic - oral contraceptive, oral HRT, tamoxifen (all bind with testosterone), anti-depressants & anti-psychotics, b-blockers.
Chronic medical conditions and psychological issues same as men

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12
Q

What are the psychosexual treatment options?

A

Integrative (combination of psychosexual options and physical treatments)
Cognitive (e.g. Address unhelpful thinking styles)
Behavioural (e.g. Sensate Focus or Self Growth Programme)
CBT (Combination of Cognitive and Behavioural)
Psychodynamic (e.g. Past events, attachments, partner choice, unconscious motivations, transference)
Systemic (e.g. Individual, couple, family dynamics)

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13
Q

What are the testosterone replacement options?

A 
Repeat tests - fasted sample
Injection
Transdermal patches or gel
Buccal
Subcutaneous implants - alternative to Testosterone, Human Chorionic Gonadotrophin
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14
Q

What is incorporated in individual psychosexual therapy?

A

Sexual education
Encourage vocalisation and acceptance of difficult feelings regarding onerous life circumstances
Normalising and permission giving
Find new solutions for old problems (timetabling)
Surmount barriers to psychological intimacy (work on confidence gain)
Expand communication
Lessen performance anxiety
Transform destructive attitudes that interfere with intimacy
Support

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15
Q

How does personal sexual growth programme work?

A

Enables patient to become aware of their own sexual needs through self exploration of their physiological responses
Work with the therapist to understand and overcome negative beliefs and unhelpful thinking patterns in relation to sexual behaviour

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16
Q

What is erectile disorder?

A

Difficulty in developing or maintaining an erection suitable for satisfactory intercourse

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17
Q

What are the physiological causes of erectile disorder?

A

Chronic medical conditions - CVD, diabetes mellitus, neurological disease
Hormonal disorders - androgen deficiency, high prolactin
Iatrogenic - post prostate surgery, prescribed medications (antihypertensive, antidepressants especially SSRIs)
Age related changes
Ineffective sexual stimuli
Pain
Veno-occlusive disorder

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18
Q

What are the psychological causes of erectile disorder?

A

Psychiatric conditions e.g. depression, substance misuse
Performance anxiety, life events and negative previous experiences, unhelpful use of pornography
Couples script problems
Relationship problems or issues from previous relationship
Educational matters
Cultural and Religious matters

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19
Q

What is the medical treatment for ED?

A 
Oral
Sildenafil (Viagra)
Avanafil (Spedra)
Tadalafil (Cialis)
Vardenafil (Levitra)

Injectable
Alprostadil (Intra Cavernosal Injection ICI)

Intraurethral
Alprostadil MUSE (medical urethral system for erection) pellet
Alprostadil Cream (Vitaros)
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20
Q

What are the behavioural advice you can give to patients?

A

Patient education:
They need sexual stimulation to work!
They work best when taken on an empty stomach
They need to wait 45-60 minutes before sexual activity (less with avanafil approx 20-30 minutes)
Efficacy improves from the first dose to the eighth

Unacceptable ratio of benefit to side effect
Fear of serious adverse events
Lack of partner support
Difficulty incorporating into sexual script

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21
Q

What are the non-medical treatments for ED?

A

Vacuum device
Penile/scrotal rings
New stimulating routines e.g. enhancing lubricants, vibrators
Kegel excercises

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22
Q

What are the NHS conditions for physiological treatments?

A

Sildenafil can be prescribed on the NHS universally
OR
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)

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23
Q

What is female sexual interest/arousal disorder?

A

Failure of genital response

The principle problem is vaginal dryness or failure of lubrication.

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24
Q

What are the physiological causes of female sexual interest/arousal disorder?

A

Chronic medical conditions - CVD, diabetes mellitus, neurological disease, connective tissue disease,
Hormonal disorders - estrogen deficiency, e.g. post menopause, thyroid disorders
Iatrogenic - prescribed medications e.g. antidepressants
Lactation - breastfeeding women can suffer
Vaginal dryness is a common presenting problem and can also be caused by local irritants and douching

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25
What are the psychological causes of female interest/arousal disorder?
Psychiatric conditions - depression, anxiety, binge eating disorders, excessive dieting Previous abuse Couple script problems - not enough foreplay Decreased intimacy Couples relationship problems
26
What are the hierarchy of interventions in couples psychosexual therapy?
``` Timetabling Communication Negotiation/contracting Addressing intimacy Being sexual Adjusting to difficulties ```
27
What are the behavioural interventions for female interest/arousal disorders?
Sensate Focus | New sexual routines, lubricant, vibrators, vielle
28
What is sensate focus?
A staged programme of exercises to enable the couple to identify own and others sexual likes/dislikes and explore new techniques etc. Work with therapist to understand and overcome negative beliefs and unhelpful thinking patterns in relation to sexual behaviour
29
What is female orgasmic disorder?
Orgasm either does not occur or is markedly delayed
30
What are the physiological causes of female orgasmic disorder?
Chronic medical conditions -CVD, Diabetes Mellitus, neurological disorder, renal/liver problems Hormonal disorders - oestrogen and/or androgen insufficiency (e.g. post menopause), hypothyroidism Pelvic floor weakness or damage Ageing Prescribed medication especially SSRIs, specifically citolapram
31
What are the psychological causes of female orgasmic disorder?
``` Psychiatric conditions - depression, anxiety, substance misuse Previous abuse Couple script problems Couple relationship problems Cultural and religious issues Lack of understanding Environmental factors Stress ```
32
How can the menopause affect sexual function?
Vaginal or pelvic pain Vaginal Atrophy Dryness Change in self image, mood, memory, cognition Changes in desire Relationship, psychosocial and health factors play their part Physical discomfort – sleeplessness, night sweats
33
What is rapid ejaculation?
The inability to control ejaculation sufficiently for both partners to enjoy sexual interaction
34
What are the physiological causes of rapid ejaculation?
``` Genetic susceptibility (Neuroreceptor sensitivity) Penile hypersensitivity Hyperthyroidism Prostatitis Co-morbid sexual problems e.g. ED Sympathomimetic medication ```
35
What are the psychological causes of rapid ejaculation?
``` Anxiety states Early learned experiences Lack of experience/infrequent sexual activity Psychosocial and environmental factors Relationship issues Partner issues eg pain ```
36
What are the treatment options for rapid ejaculation?
Physical examination Topical local anaesthetic (e.g. stud 100 spray) Medication - Dapoxetine Couple psychosexual therapy - education, permission giving, normalising - manage partner expectations Behavioural Interventions: - Stop/start technique & Sensate Focus - Practice ‘point of inevitability’ - Kegel exercises
37
What is delayed ejaculation?
On almost or all occasions (75-100%) either generalised or situational, without the individual desiring delay: Marked delay in ejaculation Marked infrequency or absence of ejaculation May be lifelong or acquired, mild, moderate or severe.
38
What are the physiological causes of delayed ejaculation?
Congenital disorders Trauma or surgery Age Infectious disorders Neurological idsorders eg DM, spinal cord injury, alcohol neuropathy Depression Medication induced eg SSRI, phenothiazines, thiazides, some alpha blockers Low testosterone levels * Important to exclude retrograde ejaculation *
39
What is retrograde ejaculation?
Sensation of ejaculation, but ejaculating into bladder rather than out of the penis. Different to delayed or inhibited ejaculation
40
What are the psychological causes of delayed ejaculation?
Insufficient stimulation/poor sexual arousal Masturbation technique Individual vulnerability factors eg poor body image, history of sexual or emotional abuse. Outgrowth of psychic conflict eg fear, hostility Relationship factors eg poor communication, desire discrepancies Partner issues eg ill health, sexual problems Disguised desire disorder Secondary to other sexual problems eg pain disorder
41
What are the investigations for delayed ejaculation?
Physical examination – testes, epididymis, vasa, prostate Blood tests – FBC, Glucose, Testosterone, B12, Folate, PSA Urine sample for presence of spermatozoa and fructose (if retrograde ejaculation suspected)
42
How would you treat delayed ejaculation?
``` PSGP (Personal Sexual Growth Programme) Individual therapy Couples therapy Kegel exercises Use of vibration/superstimulation ```
43
What is vaginismus?
Spasm of the pelvic floor muscles that surround the vagina, causing occlusion of the vaginal opening. Penile entry is either impossible or painful.
44
What are the physiological causes of vaginismus?
Medical conditions where the vulva is sore to touch (e.g. thrush) Other pain conditions or where pain is anticipated Female Genital Mutilation Congenital abnormality
45
What are the psychological causes of vaginismus?
Misinformation and mistaken beliefs - vagina too small, no opening, first intercourse will be painful Religious or cultural issues Fear of pregnancy Previous sexual abuse/trauma, or unpleasant first sexual experience or gynaecological examination Fear or dislike of partner Relationship dissatisfaction Situational
46
What is dyspareunia?
Dyspareunia (or pain during intercourse) occurs in both women and men. It can often be attributed to local pathology and should then be properly categorised under the pathological condition. This category is to be used only if there is no primary nonorganic sexual dysfunction (e.g. Vaginismus or vaginal dryness)
47
What are the physiological causes of dyspareunia?
Manipulation - infection, injury, irritation, lesions, hypersensitivity Introitus (pain on entry) - episiotomy/circumcision, recurrent infection, herpes, allergies, Bartholin’s cyst, interstitial cystitis, urethritis, vaginal atrophy, menopause, post-radiotherapy, poor lubrication, insufficient sexual arousal, effects of a substance (drug/medication), penis size Mid-deep vaginal pain - endometriosis, congenital shortened vagina, fixed uterine retroversion, pelvic tumours, surgical adhesions, irritable bowel, constipation
48
What are the psychological causes of dyspareunia?
Previous experience of pain Previous sexual abuse Poor sexual education Poor understanding of anatomy and physiology Insufficient relaxation Painful or unpleasant Gynaecological examination
49
What are the relationship causes of dyspareunia?
Poor technique of partner Speed / timing of partner Fear of intimacy Anger / resentment towards partner
50
How do you treat dyspareunia?
Examination by specialist doctor or nurse Repeat bloods, testosterone replacement Couple Therapy Personal Sexual Growth program (both) Sensate focus to (re)start and (re)learn sexual contact with the addition of pain and how it can be managed in a sexual context
51
What are the main relationship issues?
``` Communication issues Timetabling Conflict Difficulties with compromise Power issues Trust issues Sexual problems ```
52
Which extra things need to be addressed in sexual medicine and psychosexual therapy?
The relationship between sexual and relationship problems Our professional and personal values and beliefs Issues of diversity Changes in relationships brought about by the internet and technology Awareness of relationship therapy and what it can help with.
53
What are the effects of our professional values and beliefs?
Ideas about appropriate treatment Environment of costings and scarce resources Deserving and undeserving categories Ideas about what is ok and not ok in sex Beliefs about how couple relationship should operate General ethical and moral positions
54
How can we alter or manage our professional values and beliefs?
We need to recognise that there are issues for us as well and not just for patients We need to be able to deal with the interface between our values and beliefs and those of patients We need to be able to monitor the ways in which we communicate to patients our personal values and expectations
55
How do you address patients values and beliefs?
Assess the degree to which patients are being pressurised about what is normal or what constitutes a problem Be aware of ideas and beliefs that may impact on advice or treatment
56
What does working with diversity involve?
Being aware of the diversity issues in the geographical and clinical areas in which we work Taking account of the variety and complexity of the couple arrangements in contemporary society compared with the past Seeing couples in the context of wider family values and culture and the variable importance of these Taking account of ethnicity and culture Addressing the effects of illness on relationships
57
What does taking account of ethnicity and culture involve?
Not making assumptions around couple arrangements and sexual practices Knowing about and taking account of issues around couple arrangements and sexual practices in consultations Addressing religion where relevant It is important to find out from patients about their beliefs
58
How does religion effect sexual medicine?
Religious patients fear their belief system will be seen as at best unusual and at worst unhealthy Personal discomfort with discussing religious topics is the sole predictor of clinical religious behaviour Patients would welcome a discussion about religious beliefs and their relationship to health matters
59
What are Petok's four principles?
Ask about religious beliefs during the initial visit Ask about religious teachings regarding sexual behaviour When in doubt, consult with a religious expert Help couples set reasonable expectations consistent with their beliefs
60
What are the main factors in the impact of chronic illnesses on relationships?
Life-threatening illness can lead to withdrawal Tiredness, low mood, anxiety Disturbance of body image Disturbance of roles and life narratives Limitations on mobility and social contact Disturbance of mental functioning Postponement of relationship breakdown
61
What are the general principles of couples therapy?
Create a working alliance with the couple Offer insight and understanding into problem and their origins Enable feelings to be tolerated and managed Facilitate more effective communication Change dysfunctional thought patterns Help resolve conflict and enable compromise Help shift major dysfunctional dynamics eg intimacy and power
62
What are the four main couple therapy approaches?
Cognitive-Behavioural Psychodynamic Systemic Integrative
63
What does cognitive behavioural couples therapy involve?
Focusses on dysfunctional patterns of belief and behaviour in the here-and-now
64
What does psychodynamic couples therapy involve?
Focuses on the relationship between current problems and earlier patterns of response and behaviour from earlier life and takes into account unconscious processes
65
What does systemic couples therapy involve?
Focuses on process and context rather than and content to bring about change which is not necessarily based on understanding and intent
66
What does integrative couples therapy involve?
Uses understanding and interventions from more than one approach Can appear to offer the best of possible worlds but has risks and limitations
67
What are the rational for psychosexual therapy referral?
1. Maximize a person’s overall psychological well-being, quality of life and self-fulfilment. 2. Explore sexual and/or relationship concerns and find ways to address dysfunctions, symptoms or difficulties. 3. Achieve long term comfort in their sexual and relationship identity and expression. 4. Clarifying and exploring sexual and/or relationship concerns. 5. Address co-existing mental and/or physical health concerns identified during assessment, where this is impacting on sexual and relationship functioning, and in collaboration with other health service providers 6. Facilitate development of an individualized plan with specific goals and timelines relating to sex and relationship satisfaction. 7. Provide a space for patients to express themselves and find a way to overcome fears. 8. Provide stability and satisfaction with their sense of sexual identity.
68
What is gender identity?
Intrinsic sense of being "male‟/‟female‟/‟alternative‟
69
What is gender role/expression?
Personality, appearance and behaviour (cultural & historical context)
70
What are primary sexual characteristics?
Present before, during and after puberty. MALE : penis, scrotum and testes FEMALE: Vagina and other internal genitalia, vulva and other internal genitalia, ovaries
71
What are secondary sexual characteristics?
Present during and after puberty. MALE: enlargement of genitalia, lowering of voice pitch, redistribution of muscle tissue and fat, pubic, facial, body and armpit hair FEMALE: enlargement of genitalia, development of breast, pubic and armpit hair
72
What is transgender?
Diverse gender variance, including transsexual/genderqueer/agender
73
What is gender dysphoria?
Distress due to incongruence between gender identity and sex assigned at birth
74
What is transsexual?
Individuals who seek to change or have changed their primary &/or secondary sex characteristics
75
What is transmale?
Female at birth changing or changed to male role/body
76
What is transfemale?
Male at birth changing or changed to female role/body
77
What is sexual orientation?
Sex of person/s to whom sexual fantasies, arousal and activities directed
78
Does every embryo grow up to be male or female?
Female
79
When do the external genitalia and gonads develop?
8 weeks
80
What are the consequences that transphobia could lead to ?
Vulnerable to lack of family & social acceptance & support, discrimination at work, access to services, higher risk of anxiety, low mood, self harm and substance misuse, higher levels of suicide attempt
81
How can you manage transmale?
``` Assessment & diagnosis Social transition +/- psychotherapy/OT • Fertility options Androgens +/- GNrH analogue Voice & communication Male chest reconstruction Hysterectomy & b/l oophorectomy Phalloplasty/metoidoplasty ```
82
How can you manage transfemale?
``` Assessment & diagnosis Social transition +/- psychotherapy/OT • Fertility options Oestrogens +/- antiandrogens Voice & communication Facial hair removal Vaginoplasty Augmentation mammoplasty Facial feminisation surgery ```

1 - Psychiatry AE (6 decks)

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