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SEXUAL PROBLEMS (Normal sexual response (5 phases) (arousal (3 components…

- - - - genital response
      - peripheral arousal
        
        sexual arousal causes
        
        HR inc or dec
        
        resp change
        
        general flushing of skin
        
        pupillary dilatation
        
        rise syst and diast bp
      - central arousal
        
        response to sexual stimuli
    - - prolong pleasure before orgasm
- - - - Resp
      - CV eg MI
      - Renal eg dialysis
      - Endocrine eg diabetes
      - Gynaecological eg vaginitis
      - neuro problems eg spinal cord injuries, MS, neuropathy
      - cancer - esp gynae
      - psychiatric illness
      - acute and chronic illness
    - - colostomy
      - gynaecological eg oopherectomy, episiotomy, vaginal repair
      - mastectomy
      - amputation
    - - anticonvulsants
      - antihypertensives
      - anticholinergics
      - antiinflammatories
      - hormones
      - hypnotics and sedatives
      - major tranquilizers eg antipsychotics
      - alcohol
      - opiates
      - antidepressants
  - - - infidelity
      - parnter's sexul dysfunction
      - childbirth
      - relationship problem - may be cause or effect
      - psychiatric illness
    - - poor communication
      - lack of foreplay
      - anxiety
      - depression
      - poor information
    - - poor sex education
      - sexual or physical trauma
      - repressed family attitudes to sex
  - - - PRIMARY
        
        never felt interested in sex
        
        impairment of arousal and orgasm
      - SECONDARY
        
        may occur after childbirth
        
        loss of libido following an interval apparently normal sex drive
        
        postnatal depression will exacerbate the problem
        
        other causes
        
        depression
        
        bereavement
        
        the menopause, medical causes or drugs
        
        gynaecological ix eg for an abnormal cervical smear
        
        loss of self esteem eg problems at work
        
        may be from childhood
    - - inability to achieve orgasm usually assoc with lack of interest in sex
      - PRIMARY
        
        never been orgasmic
        
        often education and reassurance about normal sexual behaviour is sufficient
        
        may not let go of defences so need psychological counselling
      - SECONDARY
    - - PRIMARY
        
        discovered during first attempt of intercourse
        
        may be apprehension, failure to control pelvic musculature, psychological
      - SECONDARY
        
        may follow a physically painful experience
      - involuntary spasm of pelvic floor muscles provoked by attempted penetration
      - MANAGE
        
        Dilators
    - - pain on intercourse
      - CAUSES
        
        SUPERFICIAL
        
        atrophic change, particularly after menopause
        
        vulval dystrophy
        
        infection eg candida, herpes
        
        vaginismus
        
        take vaginal and vulval swabs
        
        if cant find cause consider deep
        
        DEEP
        
        bowel dysfunction
        
        pelvic mass
        
        pelvic inflammatory disease
        
        unexplained pelvic pain
        
        endometriosis
        
        DEEP OFTEN ASSOCIATED WITH
        
        dysmenorrhoea
        
        persistent pelvic pain
        
        try allowing more time for arousal
        
        high fibre diet may help
        
        if deep dyspareunia assoc with unexplained pelvic pain - treat may be difficult and may require a combo of endocrine manipulation and psych support
        
        take high vaginal and cervical swabs
        
        laparoscopy necessary to diagnose or exclude endometriosis or PID
  - - - check whether situational - does he get early morning erection
      - often first sign of CVD = have CV risk assessed
      - smoking hx important
      - check signs of systemic disease
      - check serum testost, glucose and lipids
      - THERAPY
        
        Phosphodiesterase inhibitors - sildenafil (viagra)
        
        alprostadil (PGE1) - injected directly into corpora cavernosa or a urethral pellet which is less effective - more effective than sildanefil in erectile failure
        
        vacuum devices
        
        penile implants as last resort
      - PHYSICAL CAUSES OF ERECTILE FAILURE
        
        DRUGS
        
        antihypertensives
        
        antipsychotics
        
        PSYCH ILLNESS
        
        severe depression
        
        severe anxiety
        
        VASC DISORDERS
        
        ED an important warning of CVD
        
        dec sexual activity after MI and before heart attack
        
        HTN assoc with ED
        
        SURGERY
        
        prostatectomy need not cause impotence particularly if is tranurethral or retropubic route
        radical prostatectomy usually causes erectile failure
        
        NEURO DISORDERS
        
        MS
        
        spinal injury - may return after phase of spinal shock if sacral segments intact
        
        PHYSIOLOGICAL
        
        ageing reduces frequency of erections
        
        ENDOCRINE DISORDERS
        
        DM - either due to diabetic neuropathy or vasc disease
        
        hypogonadism - reduced plasm testost = loss of libido also
    - - use stop start technique
      - squeeze technique
      - premature
        
        usually seen in early sexual experiences
      - antidepressant drufs (sSRI - sertraline) used of flicence to delay orgasm and are very effective
      - LA on frenulum before sec may be helpful
    - - check serum testosterone