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Female Sexual Dysfunction

Assessing sexual dysfunction

• Purpose: assess association between activity and dysfunction, assess risk factors for STIs
• Partners: sexually active, number, gender
• Practices: types of insertive sexual intercourse
• Protection: yes/no, types, frequency
• STIs: history, screening
• Pregnancy: concerns, birth control
• Questionnaires: Can use FSFI (questions and answer key) and FSDS (cutoff for FSD is 11 points)

Female genital exam components

• Pubic hair: assess for thinning or unintentional loss
• Labia majora: assess for lichen sclerosus, erosions, erythema, atrophy, pain
• Labia minora: assess for atrophy
• Clitoris: assess for adhesions (lichen sclerosus or atrophy), pain/hypersensitivity (use Q-tip), can be easier with magnification
• Urethra: assess for caruncle/prolapse, pain/hypersensitivity (use Q-tip), Skene gland obstruction, SUI
• Vestibule: assess for atrophy, erythema, pain
• Vagina: assess for atrophy, discharge, friability, prolapse
• Pelvic floor: assess for pain/tenderness with contraction/relaxation

Female sexual interest disorder (Hypoactive sexual desire disorder + female sexual arousal disorder)

• DSM V combined HSDD + FSAD into FSID
• ~40% women will be affected at some point during lifetime
• Defined as decreased motivation, decreased desire, loss of interest, leading to personal distress, present for 6+ months
• Conditions that increase risk for low sexual desire: HTN, DM, thyroid dysfunction, hyperprolactinemia, CKD, SCI, MS, Parkinson, dementia, postmenopause, PCOS, breast cancer + treatments, depression
• Medications associated with low sexual desire: anticonvulsants, cardiac meds, hormonal therapy, NSAIDs, opioids, psychotropics, illicit drugs, antihistamines, KTZ, chemotherapy
• Physical exam and labs are not necessary but may be helpful to rule out specific causes
• Assess with the decreased sexual desire screen (DSDS)
• Manage with therapy, including behavioral, CBT, and mindfulness
• Flibanserin (Addyi): FDA-approved for premenopausal women with low sexual desire, 100mg PO QHS, side effects include dizzinesss, somnolence, nausea, fatigue, contraindicated with alcohol
• Bremelanotide (Vyleesi): melanocortin receptor agonist, 1.75mg subQ 45min prior to sexual activity, improves desire and decreases distress, 40% develop nausea, contraindicated if uncontrolled HTN or CVD, do not use more than daily, can cause hyperpigmentation if used > 8x/mo
• Ospemifene: SERM indicated for vulvovaginal atrophy and dyspareunia in postmenopausal women, 60mg daily
• Can consider testosterone after discussing androgenic side effects
• Consider bupropion (300-400mg daily) or buspirone (20-60mg daily)
• Consider clitoral suction to promote engorgement (similar to vacuum erection device)

Female orgasmic disorder

• Delayed, infrequent, absent, or less intense orgasm for 6+ months in 75-100% sexual interactions
• History is important to determine primary/secondary, situational, inciting/aggravating factors
• Management: sex therapy, patient + partner education, mindfulness, sensate focus, coital alignment, sex devices
• No clear evidence for hormones, PDE5i, oxytocin

Female persistent genital arousal disorder

• Spontaneous, intrusive, unwanted genital arousal in absence of sexual interest/desire
• Differentiate from hypersexuality (increased sexual thoughts/desires) and clitoral priapism (engorged clitoris associated with severe pain)
• Management: CBT, ECT, duloxetine, pregabalin, varenicline

Genitopelvic pain/penetration disorder

• Dyspareunia: pain during intercourse
• Vaginismus: involuntary vaginal muscle contractions interfering with intercourse
• Vulvodynia: vulvar discomfort in absence of physical exam findings
• Provoked vulvodynia: pain triggered by an external stimulus
• Pelvic floor dysfunction seen frequently in setting of vulvodynia
• Clitoral adhesions: hood can develop smegma buildup and lead to pain, may require lysis of adhesions (perform in clinic with topical anesthesia)
• 40% women with vaginal atrophy report dyspareunia
• No proven benefits to "vaginal rejuvenation" techniques
• Conservative therapies: patient education, biofeedback, dilators, massage, electrostimulation
• Estrogen applied to vestibule as opposed to vagina may be more beneficial for pain relief
• Ospemifene (SERM): indicated for vulvovaginal atrophy, 60mg daily, can cause hot flashes, vaginal discharge, and muscle spasms do not give if hx estrogen-mediated cancer, VTE, CVA, or MI
• Vestibulectomy indicated for refractory pain

Lower urinary tract symptoms and sexual dysfunction

• OAB, incontinence, prolapse, and pelvic floor dysfunction can have a negative impact on sexual function
• SUI surgical treatment may prevent coital incontinence but may lead to pain or altered vaginal sensation (concern for dissection in anterior vaginal wall), although studies do not demonstrate this (and some patients see improvement)
• Posterior colporrhaphy may narrow introitus leading to dyspareunia

Male Sexual Dysfunction

Normal male ejaculation

• Emission: contraction of SVs + vas + prostate, expelling sperm into posterior urethra, induced by both sympathetic and parasympathetic stimulation
• Expulsion: pulsatile contraction of bulbospongiosus, ischiocavernosus, and levator ani muscles expelling semen down the urethra, controlled by somatic signals through the pudendal nerve, also sympathetic closure of bladder neck
• Orgasm: cerebral interpretation of sensory signals from posterior urethra and verumontanum, and contraction of the organs

Premature ejaculation

• Definition: some variety of ejaculation within 1 minute or prior to vaginal penetration, inability to delay ejaculation, and subsequent negative emotions
• Types: lifelong (never normal latency) vs acquired (previously normal latency), variable (occurs sometimes with other normal latency periods) vs or subjective (patient-perceived with normal latency times)
• Data: minimal research performed in situations other than with vaginal intercourse
• Accuracy of patient reporting: patient's subjective timing is relatively accurate compared to objective timing of latency period
• History: assess frequency, severity, average time-to-ejaculation, associated factors, partners vs masturbation
• Associated conditions: anxiety, ED (trying to rush intercourse before losing erection), prostatitis, hyperthyroid, drug withdrawal
• Additional tests: not necessary if lifelong, consider checking T, HbA1c, thyroid panel, prolactin, B12, Vit D
• Psychosexual therapy: recommended, can be beneficial for both patient and partner
• Squeeze technique: stop sexual activity and squeeze glans until urge to ejaculate goes away
• Start/stop technique: stop penile stimulation when ejaculation about to occur, then restart once urge goes away
• "Quiet vagina:" female partner stops moving when patient nearing ejaculation, then resume when urge goes away
• Sensate focus: progressing from non-sexual touching to sexual touching to penetrating intercourse to help with self-awareness
• Daily SSRI (off label): paroxetine 10-40mg (recommended choice), clomipramine 12.5-50mg (most side effects, lowers seizure threshold), sertraline 50-200mg, fluoxetine 20-40mg, citalopram 20-40mg (least effective), takes 2-3 weeks for full effect, taper off after 6-8 weeks, watch for agitation, hypomania, and potential increased risk of suicidal ideation
• Topical therapies: EMLA cream (2.5% prilocaine + 2.5% lidocaine), can be applied 5-min prior to intercourse (use with condom) or 20-30min prior (place on penis, wipe off, use without condom)
• PDE5i not recommended

Delayed ejaculation

• Definition: any disorder resulting in delayed/absent ejaculation 75-100% of sexual interactions
• Most common causes: psychogenic, aging, hypogonadism, hypothyroid, diabetes, SSRI, prior prostate/pelvic surgery, prior radiation
• Cutaneous nerve testing: assess sensory function of the penis, may indicate sensory neuropathy
• Labs: recommended to check testosterone levels, consider evaluating DM or hypothyroid
• Management: switch SSRIs or other meds, psychosexual therapy (helpful to include partner in discussion), consider vibratory stimulation, altering sexual practices
• Medications: options include cabergoline, pramiprexole, amantadine, bupropion, pseudoephedrine, reboxetine, buspirone, cyproheptadine, oxytoxcin, but have limited evidence and are indicated for patient-specific situations

Painful ejaculation

• Location: may be penile, scrotal, perineal
• Causes: infection, stricture, prior vasectomy, prior hernia repair, ejaculatory duct obstruction, seminal vesicle calculi, prior XRT
• Exam: assess location of pain, perform DRE (check for BPH/cancer and pelvic floor dysfunction)
• Pelvic pain during orgasm + anejaculation: may indicate ejaculatory duct obstruction
• Pelvic floor dysfunction: patients may also report pain with urination and bowel movements in addition to sexually-related pain
• Treatment: depends on underlying cause, a-blockers may actually increase pain

Anejaculation + Retrograde ejaculation

• Sympathetic nerve injury: RPLND, spinal cord injury (< 5% can ejaculate), colorectal/vascular surgery
• Bladder neck closure failure: TURP (other BOO procedures), diabetes
• Prostate cancer: hx surgery or radiation
• Medications: a-blockers, B-blockers, SSRIs, MAOis, TCAs, benzos, antipsychotics, Amicar (aminocaproic acid)
• Diagnosis: post-ejaculate urinalysis differentiates retrograde ejaculation (sperm present in urine) from anejaculation (sperm absent in urine)

a-agonists for retrograde ejaculation

• Dosing: pseudophedrine 60mg QD-QID or ER 120mg BID, imipramine 25mg BID, ephedrine 50mg QID
• Success: 58% diabetic men had antegrade ejaculation after 120mg QID day before and BID on day of intercourse
• Side effects: HTN, arrhythmias, urinary retention
• Contraindications: narrow angle glaucoma, HTN, CAD, CHF, arrhythmias, recent MI, urinary retention, DM, hyperthyroid, MAOi, hx seizures

a-agonists: assess underlying cause and manage

Hematospermia

• Causes: infection, stones, prior trauma, constipation, obstruction, cysts, cancer, vascular abnormalities, recent GU instrumentation/surgery
• Malignancy risk: 1.4% if < 40yo, 6.2% if > 40yo, cause is almost always benign
• Evaluation: risk factors, GU exam, DRE, urinalysis, may require STI and Tb testing, consider PSA testing if > 40yo
• Adjunct testing: consider TRUS, semen culture, cystoscopy, pelvic MRI
• Management: often self-limiting, can aspirate or unroof cysts, consider embolization/excision if severe uncontrolled bleeding

Other male sexual dysfunctions

• Ejaculatory anhedonia: minimal pleasure with ejaculation/orgasm, check hormone levels and history, consider psychotherapy or treatment of hormonal causes
• Post-SSRI sexual dysfunction: reported 5-15%, may persist for months/years and spontaneously resolve
• Postorgasmic illness syndrome: rare, may be due to hypersensitivity reaction with their own semen

Obtaining sperm in setting of anejaculation

• Retrograde ejaculation: urinary sperm retrieval/washing, success 20-50% per cycle
• Penile vibratory stimulation or electroejaculation: useful for MS, SCI, DM, or psychogenic causes, causes ejaculation 65-83% (PVS) and 80-97% (electro), electroejaculation requires general anesthesia, can induce autonomic dysreflexia
• Step-by-step video from Fertility & Sterility