Sexual dysfunction resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[2]

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

Disorders of sexual arousal

Disorders of orgasm

Disorders of sexual pain


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. [11][12]

❑ 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 dysfunction.
❑ The 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 <be> ❑ 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 <be> ❑ Menstrual history including menopausal status
Rule out medical conditions such as
❑ Chronic diabetes mellitus
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?
Non coital pain disorder
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
Hormone therapy in cases of low estrogen
❑ If the patient is on an antidepressant, changing the dose might help
❑ Counselling with the help of a sex-therapist
Bremelanotide is a nasal spray which is used in sexual arousal disorder
Female orgasmic disorder
Female orgasmic disorder +/- arousal disorder
Cognitive behavioural therapy
❑ Psychodynamic sex therapy
Estrogen therapy in post menopausal women
Testosterone therapy is experimental and has been used in some[13]
Cognitive behavioural therapy
Hormone therapy with estrogen
❑ Review of medication list, change in dosage of antidepressants
❑ Counselling
Non coital pain disorder
❑ Sex therapy and counselling
Vaginal dilators
Kegel exercises
❑ Mulitmodal approach involving a
* Gynecologist
* 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.[14]
  • 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.[15]
  • Early identification and treatment can help prevent PID and associated cervical motion tenderness, dyspareunia and even subsequent infertility.[16]


  • 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.[17]
  • 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.


  1. Goldstein I, Kim NN, Clayton AH, DeRogatis LR, Giraldi A, Parish SJ; et al. (2017). "Hypoactive Sexual Desire Disorder: International Society for the Study of Women's Sexual Health (ISSWSH) Expert Consensus Panel Review". Mayo Clin Proc. 92 (1): 114–128. doi:10.1016/j.mayocp.2016.09.018. PMID 27916394.
  2. Kucukdurmaz F, Inanc Y, Inanc Y, Resim S (2018). "Sexual dysfunction and distress in premenopausal women with migraine: association with depression, anxiety and migraine-related disability". Int J Impot Res. 30 (5): 265–271. doi:10.1038/s41443-018-0049-z. PMID 30068979.
  3. Greenberg DR, Khandwala YS, Breyer BN, Minkow R, Eisenberg ML (2019). "Genital Pain and Numbness and Female Sexual Dysfunction in Adult Bicyclists". J Sex Med. 16 (9): 1381–1389. doi:10.1016/j.jsxm.2019.06.017. PMID 31402178.
  4. Tamás V, Kempler P (2014). "Sexual dysfunction in diabetes". Handb Clin Neurol. 126: 223–32. doi:10.1016/B978-0-444-53480-4.00017-5. PMID 25410225.
  5. Na Y, Htwe M, Rehman CA, Palmer T, Munshi S (2020). "Sexual dysfunction after stroke-A biopsychosocial perspective". Int J Clin Pract. 74 (7): e13496. doi:10.1111/ijcp.13496. PMID 32100415 Check |pmid= value (help).
  6. Tunuguntla HS, Gousse AE (2006). "Female sexual dysfunction following vaginal surgery: a review". J Urol. 175 (2): 439–46. doi:10.1016/S0022-5347(05)00168-0. PMID 16406967.
  7. Bornefeld-Ettmann P, Steil R, Lieberz KA, Bohus M, Rausch S, Herzog J; et al. (2018). "Sexual Functioning After Childhood Abuse: The Influence of Post-Traumatic Stress Disorder and Trauma Exposure". J Sex Med. 15 (4): 529–538. doi:10.1016/j.jsxm.2018.02.016. PMID 29550460.
  8. La Rosa VL, De Franciscis P, Barra F, Schiattarella A, Tropea A, Tesarik J; et al. (2020). "Sexuality in women with endometriosis: a critical narrative review". Minerva Med. 111 (1): 79–89. doi:10.23736/S0026-4806.19.06299-2. PMID 31726815.
  9. Brunham RC, Gottlieb SL, Paavonen J (2015). "Pelvic inflammatory disease". N Engl J Med. 372 (21): 2039–48. doi:10.1056/NEJMra1411426. PMID 25992748.
  10. Simonelli C, Eleuteri S, Petruccelli F, Rossi R (2014). "Female sexual pain disorders: dyspareunia and vaginismus". Curr Opin Psychiatry. 27 (6): 406–12. doi:10.1097/YCO.0000000000000098. PMID 25211497.
  11. Althof SE, Meston CM, Perelman MA, Handy AB, Kilimnik CD, Stanton AM (2017). "Opinion Paper: On the Diagnosis/Classification of Sexual Arousal Concerns in Women". J Sex Med. 14 (11): 1365–1371. doi:10.1016/j.jsxm.2017.08.013. PMID 28958593.
  12. "Female Sexual Dysfunction: ACOG Practice Bulletin Summary, NUMBER 213". Obstet Gynecol. 134 (1): 203–205. 2019. doi:10.1097/AOG.0000000000003325. PMID 31241595.
  13. Vegunta S, Kling JM, Kapoor E (2020). "Androgen Therapy in Women". J Womens Health (Larchmt). 29 (1): 57–64. doi:10.1089/jwh.2018.7494. PMID 31687883.
  14. Ghaderi F, Bastani P, Hajebrahimi S, Jafarabadi MA, Berghmans B (2019). "Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial". Int Urogynecol J. 30 (11): 1849–1855. doi:10.1007/s00192-019-04019-3. PMC 6834927 Check |pmc= value (help). PMID 31286158.
  15. Petrova D, Garcia-Retamero R (2015). "Effective Evidence-Based Programs For Preventing Sexually-Transmitted Infections: A Meta-Analysis". Curr HIV Res. 13 (5): 432–8. doi:10.2174/1570162x13666150511143943. PMID 26149164.
  16. Curry A, Williams T, Penny ML (2019). "Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention". Am Fam Physician. 100 (6): 357–364. PMID 31524362.
  17. Mares P, Hoffet M, Rousseau O, Ripart-Neveu S (2001). "[Vaginal dryness]". Rev Prat. 51 (2): 155–8. PMID 11252940.

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