Approach to the Patient with Sexual Dysfunction

Linda C. Shafer

There is an important relationship between one’s sexual life and emotional and physical well-being. With the advent of orally effective medication for treating erectile dysfunction and the increased interest in pharmacologic agents for treating female sexual disorders, the frequency of sexual dysfunction complaints in primary care practice has risen to nearly 15% to 20% of visits. However, the incidence of sexual problems in any medical practice is a function of the frequency with which physicians take a sexual history. Approximately 43% of women and 31% of men report some specific sexual dysfunction when questioned. Therefore, the primary care physician needs to know how to take a sexual history, perform an appropriate medical evaluation (see Chapters 115 and 132), and carry out basic types of sexual counseling and supportive therapy. More than 80% of sexual complaints can be treated successfully in the primary care setting.

DEFINITIONS (1, 2, 3, 4 and 5)

The consensus psychiatric definitions of sexual disorders are those specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Changes have been put forward in the just-released edition (DSM-5) and may differ from the terminology used here, but the basic elements remain the same. They are classified as primary when there has never been a period of satisfactory functioning and secondary when the difficulty occurs after adequate functioning had been obtained.

Male Disorders

Male Erectile Disorder

Erectile dysfunction (impotence) is defined as the inability of a male to maintain an erection sufficient to engage in intercourse and is considered a problem if it occurs in more than 25% of attempts.

Premature Ejaculation

This condition is defined as recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it (most often <2 minutes after penetration or on <10 thrusts).

Male Orgasmic Disorder

This disorder (“retarded ejaculation”) is defined as persistent delay or absence of orgasm following normal sexual excitement. It is often restricted to failure to reach orgasm in the vagina during intercourse. Orgasm can usually occur with masturbation and/or from a partner’s manual or oral stimulation. There is a persistent failure to ejaculate in the presence of a satisfactory erection.

Retrograde Ejaculation

Retrograde ejaculation is a physical impairment of internal vesicle sphincter activity. The bladder neck does not close off properly during orgasm, causing semen to spurt backward into the bladder.

Female Disorders

Frigidity is a term applied to a wide variety of conditions in the woman, from complete lack of any sexual response to various inadequacies in orgasmic response. Because it is nonspecific and has a derogatory connotation, the term has been eliminated.

Female Sexual Arousal Disorder

This disorder is defined as the inability to respond to sexual stimulation with lubrication and genital vasocongestion.

Female Orgasmic Disorder

This disorder (“orgasmic dysfunction”) is defined as a recurrent delay in, or absence of, orgasm following a normal sexual excitement phase, despite the ability to enjoy sexual intercourse and have normal sexual desire. Some women who can have orgasm with direct clitoral stimulation find it impossible to reach orgasm during intercourse. This is a normal variant of sensitivity requiring the pairing of direct clitoral contact with intercourse.

Vaginismus

Vaginismus is an involuntary spasm of the musculature of the outer third of the vagina, making penile penetration impossible.

Both Sexes

Dyspareunia

Dyspareunia is a condition defined as painful intercourse leading to avoidance of sexual contact.

Hypoactive Sexual Desire Disorder

This disorder (“low libido”) is defined as a deficit or absence of sexual fantasies and lack of desire to engage in sexual activity.

Sexual Aversion Disorder

This disorder is defined as an active avoidance of genital sexual contact with a sexual partner.

Hypersexual/Sexual-Addiction Disorder

Although not classified as a specific disorder in the DSM, this is viewed as an addiction, which can be a primary problem or a coping mechanism. There is excessive and/or compulsive sexual activity that affects the patient’s sexual and nonsexual functioning.

PATHOPHYSIOLOGY AND CLINICAL PRESENTATION (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12)

Pathophysiology

Organic conditions are responsible for between 50% and 85% of sexual problems in both sexes. This figure represents a dramatic shift in the understanding of the causes of sexual disorders that were once thought to be primarily of psychogenic origin. Neurogenic, hormonal, vascular, and drug-induced mechanisms are prominent (see Chapters 115 and 132). For example, diabetes mellitus is a particularly important cause of erectile dysfunction (see Chapter 102); selective serotonin reuptake inhibitor (SSRI) antidepressant use is associated with reduced libido. Recent research emphasizes increasing links between general and sexual health. Obesity, metabolic syndrome, and other cardiovascular risk factors are associated with erectile dysfunction as well as female sexual dysfunction. When the coexisting medical illness is treated or lifestyle factors addressed, sexual function will often concurrently improve.

Organically based sexual dysfunctions are usually compounded by psychological issues. There is a strong bidirectional association between depression and sexual dysfunction in both men and women. Although there are no rigid correlations between developmental factors and dysfunctional syndromes, sexual disorders can be related to prior experiences. Early sexual attitudes may be negatively shaped by parental communication that sex is bad, dirty, or sinful; by inadequate information about sex; or by myths and misconceptions such as the ever-ready penis or mutual climax. Other negative experiences range from unpleasant sexual encounters to childhood sexual abuse to rape. Intrapsychic conflicts extend from fear of sexual failure, to concerns about sexual identity, to profound depression.

Interpersonal issues of a sexual and nonsexual nature sometimes interfere with sexual functioning, especially in the setting of inadequate communication and lack of cooperation between partners. Sexual problems may develop from such nonsexual factors as situational stress and financial pressures. Finally, sexual difficulty may occur in the context of the anxiety generated by an organic illness, such as a post-heart attack fear of death.

Once a sexual problem ensues, regardless of the cause, a vicious cycle of fear of failure, anxiety, and guilt is likely to ensue and be self-perpetuating.

Clinical Presentation

Sexual dysfunction may present as the chief complaint or be an underlying or concurrent problem. Clinical presentations can be quite complex. For example, patients with sexual dysfunction may present with somatic complaints with no apparent medical cause (e.g., headache, low back pain, urinary symptoms, generalized pelvic pain, vulvar pruritus).

Male Erectile Disorder

Most normal men experience occasional erectile failure due to fatigue, too much alcohol, or any number of transient unfavorable circumstances. In the United States, it is estimated that up to 30 million men have erectile dysfunction, accounting for more than 500,000 ambulatory visits to health care professionals annually. Primary (lifelong) erectile dysfunction occurs in 1% of men younger than age 35 years. Secondary (acquired) erectile dysfunction occurs in 40% of men older than 60 years; this figure increases to 73% of men older than age 80 years. Erectile dysfunction may be the first symptom of vascular disease and should prompt further investigation. Primary impotence and long-standing secondary impotence are much more likely to be associated with medical disorders or more serious psychological issues, such as fears of intimacy, feelings of intense hostility toward women, and gender identity questions.

Premature Ejaculation

Premature ejaculation is the most common male sexual disorder, occurring in 30% to 40% of adult men. The lifetime prevalence of premature ejaculation is 15%. The psychological causes of the disorder range from early conditioning to ambivalence and hostility toward women. Its increasing frequency has been associated with women wanting more sexual satisfaction, particularly orgasm. Once premature ejaculation occurs, it can easily be reinforced by the negative attitudes expressed by the partner. In addition, prolonged periods of no sexual activity seem to make the problem worse. If premature ejaculation occurs over a long period of time and remains untreated, secondary impotence may result. It is often easily treated in the context of a good relationship.

Male Orgasmic Disorder

Retarded ejaculation occurs most often in younger, less sexually experienced men (usually younger than age 35 years). The lifetime prevalence is 2%. Its milder form is often related to
anxiety-provoking situations and has an excellent prognosis. When it is long-standing, the condition often signifies deeperseated psychopathology, such as significant fears of rejection involved with letting go. Issues of control and commitment may be involved, as well as unconscious conflicts regarding female genitals or pregnancy. Retarded ejaculation should be considered in a couple presenting with infertility of unknown cause. The male may not have admitted his lack of ejaculation to his partner.

Female Sexual Arousal Disorder

These women present with a complete avoidance of sexual activity or an aversion to sex, which is stoically endured. The disorder has a lifetime prevalence of 60%. The condition is linked to problems of sexual desire, and a lack of vaginal lubrication may lead to dyspareunia. There is often a deep-seated conflict about sexuality, which makes the outcome less favorable. Concomitant depression and interpersonal problems and a history of medications or pelvic pathology (see Chapter 115) are other important factors.

Female Orgasmic Disorder

Orgasmic dysfunction is among the most frequent of female sexual complaints and occurs more often during the early years of sexual activity. The disorder has a lifetime prevalence of 35%. Among affected women, 30% to 40% require clitoral stimulation during intercourse to achieve orgasm; 5% to 8% present with total anorgasmia. The capacity for orgasm appears to increase with sexual experience, and that includes the aging woman. Claims that stimulation of the Gräfenberg spot, or G spot, in a region in the anterior wall of the vagina will cause orgasm and female ejaculation have never been substantiated. Premature ejaculation in the male may contribute to female orgasmic dysfunction. Again, the psychological factors involved are variable, and the prognosis for the condition is a function of which factors are responsible. These range from fears of loss of control and unrealistic expectations about sexual performance to poor partner communication. Depression must not be overlooked.

Vaginismus

Vaginismus is associated with a high incidence of pelvic pathology (see Chapter 115). The frequency of vaginismus is unknown, but the condition probably accounts for less than 10% of female sexual disorders. Lifelong vaginismus has an abrupt onset, at the first attempt at penetration, and has a chronic course. Acquired vaginismus may occur suddenly, following a sexual trauma or medical condition. A careful gynecologic examination is always warranted and, in fact, is the only definitive way to make a diagnosis. Vaginismus is one cause of dyspareunia. When related to psychological factors, vaginismus can be considered a conditioned response and treated behaviorally. There is often confusion about sexual anatomy and physiology, leading to fears of penetration and concerns about femininity. If the condition is long-standing, partners of these women can become seriously affected, developing secondary impotence. This disorder has been at the center of many cases of unconsummated marriages of long duration.

Dyspareunia

The overall prevalence for this condition is 20% (15% of women and 5% of men). Patients often seek medical treatment, but the physical exam is often unremarkable, with no genital abnormalities. The condition is usually chronic and results in avoidance of sex.

Hypoactive Sexual Desire Disorder

The lifetime prevalence of this condition is 40% for women and 30% for men. Low libido in one partner may reflect an excessive need for sexual expression in the other partner. Depression should be ruled out in all cases. Medical conditions causing pain, weakness, and disturbance of body image may be important triggers.

Sexual Aversion Disorder

The exact incidence is unknown, but this is a common disorder. Primary sexual aversion is higher in men, and secondary sexual aversion is higher in women. About 25% of patients meet the criteria for panic disorder. These individuals may have marital problems and may avoid sexual situations by covert strategies such as going to sleep early, traveling, neglecting personal appearance, using substances, or being overly involved at work. However, patients tend to respond naturally to sexual relations if they are able to overcome their high anxiety and initial dread.

Hypersexual/Sexual-Addiction Disorder

The ready availability of Internet pornography and “cybersex” activities has dramatically increased the opportunity for potentially adverse sexual behaviors. Sexual “addiction” is an emerging source of distress among patients and may be a primary problem or a coping mechanism. Excessive and/or compulsive sexual activities may affect the patient’s sexual and nonsexual functioning.

WORKUP (1,3, 4 and 5,7)

Sexual History

The sexual history should be an integral part of every medical evaluation, given the importance of sexual function to overall health, the central role that sexual dysfunction might play in somatic complaints and quality of life, and the need to review safer sexual practices. The history is most easily obtained in conjunction with performing the gynecologic and menstrual review of systems in women and the genitourinary review in men. In this way, sexual practices and concerns can be comfortably elicited in the context of routine history taking, especially if the physician displays an open, nonjudgmental, unembarrassed, and accepting attitude. One needs to take into account differences in social values, class, and age. Clinicians should be aware that sexual problems such as erectile dysfunction may be the presenting complaint in patients suffering from or at risk for numerous medical conditions including obesity and cardiovascular disease. In addition, careful inquiry about medication use, including herbal agents, may reveal potential side effects contributing to sexual problems (see also Chapters 115 and 132).

Helpful screening questions include “Does your present sexual functioning meet your expectations?” “Has there been a change in your sexual functioning?” “Would you like to change anything about your sexual functioning?” Additional routine questions to ask are “Have you been sexually active (or involved) with a partner in the last 6 months? (with women, men, or both?)” “Do you practice safe(r) sex?” Failure to ask HIV screening questions may result in criticism of inadequate treatment or even lead to a malpractice suit.

If a sexual problem is uncovered, the chief complaint should be explored in detail. Ask patients to describe the problem in their own words, noting its duration, circumstances, possible precipitating and alleviating factors, and severity. Avoid using “why” questions, which tend to make patients uncomfortable; use “what” questions instead. A thorough description sometimes helps to distinguish an organic from a functional etiology (see Chapters 115 and 132). For example, in the impotent male, preservation of erectile function on awakening suggests a psychological cause, as does erection with attempts at masturbation.

Only gold members can continue reading. Log In or Register to continue