Sex and its Problems... A Crash Course!! Part 2

Psychosomatic Sex Cycle (adapted from Bancroft (2009))

So we've briefly touched on the components of the sexual response. Let's explore now the problems and their prevalence in males and females.

1/ DISORDERS OF SEXUAL DESIRE

Impairment of sexual desire can occur in both men and women; however lack of desire most commonly affects females with 60-70% prevalence rate.

Sexual desire correlates with the testosterone:oestrogen ratio in both genders so that a higher ratio is associated with increased sexual desire. Inhibition or lack of interest is broadly either psychogenic or organic in origin. Psychological factors include early parental problems, society or past experiences eg rape/incest. Organic causes include hyperprolactinaemia due to a pituitary adenoma (if impaired sexual response co-exists with symptoms of headache and impairment of peripheral vision- think pituitary adenoma!!). Diminished testosterone:oestrogen ratio may lead to lack of desire.

Management includes assessment for an underlying organic problem. Psychological problems are far more common, and a good history taker would be able to identify how patient attitudes of past and current relationships, any guilt or indication of early childhood problems contribute to the problem. Relationship therapy and taught focus exercises might be of benefit.

2/ DISORDERS OF SEXUAL AROUSAL

This is represented by erectile difficulties in men and by lack of lubrication and of general sexual responsiveness in women.

IN MEN

About 85% of cases with erectile dysfunction are organic in origin. Risk factors include obesity, lack of exercise smoking, high cholesterol, hypertension and diabetes.

- organic causes;

VASCULAR= atherosclerotic change in penile blood vessels (accounts for half of cases)

NEUROLOGICAL= can be either central (eg in Parkinson's, MS, spinal cord syndrome) or peripheral in origin (eg peripheral neuropathy like diabetic neuropathy or GBS, alchoholism, uraemia).

HORMONAL= Hypoganadism, Cushing's and thyroid diseases, hyperprolactinaemia

ANATOMICAL= Peyronie's disease

DRUGS = beta blockers, diuretics, Cu channel blockers, hormonal agents eg cyptotenone acetate,LH releasing analogues, H2 antagonists eg cimeetidine, ranitidine.

2/Psychogenic causes

- psychosexual factors (can be general due to a disorder of sexual intimacy and lack of arousability or situational due to partner or stress)

-Psychiatric illness ( Generalized anxiety disorder, depression, alcohol dependency)

Management - involves

- history taking ( ask about current/past sexual relationships, current emotional status, erectile symptoms eg onset and duration, arousal ejaculation and orgasmic difficulties). don't forget drug and social history. Latter is important to look for drinking problems, smoking, home situation, difficulties at work/marriage.

-Investigations - blood glucose, U&Es, urinarlysis, LFTs if indicated. If patient also has reduced sexual drive or abnormal sexual characterization, check testosterone levels, LH/FSH, prolactine (especially in young men).

Treatment - correct the underlying cause whether organic or psychological. First line symptomatic treatment is with phosphodiesterase inhibitors (sidenafil, tadafil, vardarefil) or vacuum devices eg external cylinder - one study reported that 23% asked for a prescription after a 2-week trial and 52% reported satisfaction (suitable for older patients).

IN WOMEN

Lack of arousal may be caused by inability to respond to sexual stimulation with dilatation of venous vaginal plexuses and lubrication to reach orgasm.

The causes are;

1/psychosexual;

- inhibitions from learned attitudes, past experiences or marriage difficulties.

- situational anxiety eg about a baby, in parental house

- inadequate stimulation from an inexperienced lover is often a cause of early difficulties

2/ organic

- Causes include drug side effects, neurological problems (MS), vascular disease (Diabetes), postmenopause (low oestrogen).

- Inadequate stimulation or lack of arousal may accompany dyspareunia, which is pain during a sexual intercourse. Fear of pain with intercourse causes anxiety with or without sexual reponse leading to vaginismus (contraction of pelvic muscles resulting in failure of penetrative sex) and more painful intercourse thus creating a vicious cycle.

For medical students reading this, dyspareunia is not an uncommon history station in your OSCE. You have to think of a differential. This depends on the site of the pain, which classifies dyspareunia into introital, midvaginal or deep.

Introital dyspareunia is caused by

-inadequate lubrication or vaginitis (eg due to STI)

-vaginismus

Midvaginal caused by

- urethritis, congenital vaginal abnormalities

Deep dyspareunia caused by

- endometriosis (ectopic bleeding uterine tissue outside uterus), adenomyosis (bleeding uterine tissue within uterine muscle layer), leiomyomata (benign uterine cancer), pelvic inflammatory disease, uterine retroversion or ovarian cyst.

Management

- Take a good history; if patient reports painful intercourse, ask about onset, duration and site of pain, and whether pain occurs with arousal or at penetration. Ask about associated symptoms eg rash, irritation, smell (local aetiology), vaginal discharge (STI), heavy periods and menstrual irregularities (endometriosis) and menopausal symptoms and any dragging sensation (prolapse).

- pelvic and speculum examination

-treatment; to correct the underlying cause. The cycle of fear must be broken in order to stop the pain if no evidence of organic aetiology and anxiety/vaginismus induced dyspareunia is suspected. A specialized Kegel exercise of the pelvic muscle is taught to the patient to learn how to relax pelvic muscles during an intercourse. Lubricants may be used in case of indequate lubrication.

3/ ORGASMIC DYSFUNCTION

5-10% of females report anorgasmia, which can either be primary (never been able to achieve orgasm under any circumstances) or secondary (diminished ability to active orgasm despite previous successful attempts). A study by Kinsey in 1953 found that 9% remain unable to experience orgasm throughout their lives.

Psychosexual factors include fear from momentary loss of control experienced during orgasm and unable to relax and let go. Vaginismus can cause orgasmic dysfunction as well as impaired arousal. Other physical factors include lack of normal bulbo-cavernous reflex which causes failure to reach orgasm.

I hope this brief post made a useful introduction into medical problems affecting sexuality, which is normally a big and complicated area. For further reading, please explore the references below.

Information was adapted from;

- www.patient.co.uk (highly recommended for non-medical readers)

- John Bancroft, human sexuality and its problems. 3rd edition. 2009

- David Goldberg, Linda Gask and Richard Morris. Psychiatry in medical practice. 3rd edition. 2008