Sexual dysfunction resident survival guide
Synonyms and Keywords: Approach to sexual dysfunction, Approach to dyspareunia
|Sexual dysfunction Resident Survival Guide Microchapters|
Sexual dysfunction is defined as recurrent and persistent issues with sexual response, desire, experience of pain or achieving orgasm. Sexual dysfunction often causes distress to the partners in a relationship. Sexual dysfunction conditions are broadly classified into disorders of sexual desire, arousal, orgasm and pain disorders. Treatment often includes identifying the underlying cause and treatment along with counselling and supportive care.
Disorders of sexual desire
- Psychological disorders or stress
- Advanced age
- Emotional distress
- Medications such as antidepressants, anxiolytics, antihypertensives
Disorders of sexual arousal
- Chronic disorders such as diabetes, multiple sclerosis
- Previous genital surgery
Disorders of orgasm
- History of sexual or emotional abuse
- Medication such as antihypertensives, anxiolytics
- Previous trauma or surgery
Disorders of sexual pain
- Pelvic inflammatory disease
- Decreased vaginal lubrication
- Sexually transmitted infections
Shown below is an algorithm summarizing the diagnosis of Sexual dysfunction according the the Journal of Sexual Medicine 2017 Opinion paper on The Diagnosis/Classification of sexual arousal concerns in women and the American College of Obstetricians and Gynecologists' Committee Practice Bulletin Summary on Sexual Dysfunction. 
Seek proper history, ask patients to describe in their own words, what do they mean by sexual dysfunction?
This will help distinguish the various causes of sexual dysfunctionThe history should also determine the characteristics, severity, and frequency of dysfunction:
❑ Onset – Abrupt or gradual, relationship to illness or life event
❑ Course – Stable, improving, or worsening
❑ Duration and pattern
❑ Factors that alleviate or exacerbate it
❑ Impact on life – Causing emotional or psychological distress, marital discord?
❑ Any recent changes that the patient has made such as change in contraceptive, any other medication
❑ Menstrual history including menopausal status
|Persistent lack of interest in sexual arousal||Difficulty in becoming sexually aroused or maintaining sexual arousal||Diminished ability in achieving orgasm||Pain associated with sexual activity||Other sexual concerns|
Difficulty in maintaining sexual excitement
Vaginal dryness/difficulty with lubrication
|Proper sexual education and counselling|
|Subjective Arousal disorder||Genital Sexual Arousal disorder||Painful intercourse||Pain associated with sexual stimulation||Pain with vaginal entry|
|Does nongenital stimulation (visual, mental) cause sexual arousal?||Dyspareunia||Non coital pain disorder||Vaginismus|
|High arousal but no orgasm/very delayed orgasm||Poor arousal and no orgasm||Orgasm present but minimal/low intensity|
|Genital female sexual arousal disorder||Missed diagnosis of female sexual arousal disorder|
|Female orgasmic disorder||Female sexual arousal disorder||Consider other investigations/diagnoses|
|Lack of sexual desire in response to sexual stimulation||Lack of spontaneous sexual desire|
|Sexual desire or Sexual interest disorder||May be normal under certain circumstances|
Shown below is an algorithm summarizing the treatment of sexual dysfunction.
|Identify the cause of sexual dysfunction with thorough history and physical exam|
|Disorders of sexual desire||Disorders of orgasm||Disorders of sexual arousal||Disorders of sexual pain|
|Sexual interest/Sexual desire disorder||Genital female sexual arousal disorder|
❑ Encourage communication among partners
❑ Educate patients about healthy lifestyle choices
❑ Counselling sessions with therapists who specialize in sexual dysfunction
❑ Flibanserin can be used in cases of low sexual desire/interest
|Female orgasmic disorder||Female orgasmic disorder +/- arousal disorder|
Non coital pain disorder
❑ Mulitmodal approach involving a
* Expert in pain management
* Mental health professional
❑ Tricyclic antidepressants
❑ Hormone replacement
❑ Cognitive behavioural therapy
❑ Vaginal dehydroepiandrosterone in post-menopausal patients
❑ Dyspareunia in post partum patients can be treated with
* vaginal lubricants and
* scar tissue massage
❑ Botulinum toxin injection
❑ Physical therapy of pelvic floor
❑ Adesiolysis in cases of adhesions
- Encourage patients to discuss sexual health with their primary care provider or obgyn.
- Referral to a psychiatrist may be needed to alleviate patient distress.
- Pelvic floor rehabilitation must be done in patients with dyspareunia.
- Encourage non coital behaviours such as massages to improve communication and understanding between partners.
- Education about sexually transmitted infections must be done to all patients.
- Early identification and treatment can help prevent PID and associated cervical motion tenderness, dyspareunia and even subsequent infertility.
- Don't forget to do an endocrine/hormonal evaluation in patients with sexual dysfunction.
- Oral contraceptive use can cause vaginal dryness which leads to sexual dysfunction. Don't treat patients without taking a proper and thorough drug history.
- Do not do counselling on patients alone, both involved partners must be encouraged to undergo sex education and counselling.
- Do not proceed to genital examination without properly explaining to the patient about the procedure to be done. Some patients might have severe discomfort due to vaginismus or prior trauma.
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