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Key Features

Essentials of Diagnosis

  • Large category of vasocongestive and orgasmic disorders

  • Often involve problems of sexual adaptation, education, and technique

General Considerations

  • Two most common conditions in men

    • Erectile dysfunction

    • Ejaculation disturbances

  • Two most common conditions in women

    • Orgasmic disorder

    • Hyposexual desire disorder

Erectile dysfunction

  • Often mentioned only after direct questioning

  • Patients sometimes use the term "impotence" to describe premature ejaculation

  • Causes can be psychological, physiologic, or both

  • A history of occasional erections—especially nocturnal tumescence—can demonstrate a psychological origin

Ejaculation disturbances

  • Ejaculation control is an acquired behavior that is minimal in adolescence and increases with experience

  • Sexual ignorance, anxiety, guilt, depression, and relationship problems may interfere with learning control

  • Interference with the sympathetic nerve distribution through surgery or radiation can be responsible

Orgasmic disorder

  • Sexual activity varies from active avoidance of sex to an occasional orgasm

  • Causes for the dysfunctions include poor sexual techniques, early traumatic sexual experiences, interpersonal disharmony (partner struggles, use of sex as a means of control), and intrapsychic problems (anxiety, fear, guilt)

  • Organic causes include

    • Conditions that might cause pain in intercourse

    • Pelvic pathology

    • Mechanical obstruction

    • Neurologic deficits

Hyposexual desire disorder

  • Although menopause may lead to diminution of sexual desire in some women, the relationship between menopause and libido is complicated and may be influenced by sociocultural factors

  • Alcohol, sedatives, opioids, marijuana, and some medications may affect sexual drive and performance

Clinical Findings

Symptoms and Signs

Erectile dysfunction

  • The inability to achieve an erection adequate for satisfactory intercourse

Ejaculation disturbances

  • Patients may not relate symptoms without direct questions regarding their sex lives

Orgasmic disorder

  • Difficulty in experiencing erotic sensation and lack of vasocongestive response

  • Should be differentiated from orgasmic dysfunction, in which varying degrees of difficulty are experienced in achieving orgasm

Hyposexual desire disorder

  • Consists of diminished or absent libido

  • May be a function of organic or psychological difficulties (eg, anxiety, phobic avoidance)

  • Hormonal disorders, including hypogonadism or use of antiandrogen compounds such as cyproterone acetate, and chronic kidney disease contribute to deterioration in sexual desire

Differential Diagnosis

  • Depression or anxiety

  • Underlying medical condition, eg, diabetes, peripheral vascular disease, hyperprolactinemia, hypogonadism

  • Dyspareunia or chronic pelvic pain

  • Drugs or substance use, eg, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, alcohol

Diagnosis

Diagnostic Procedures

  • Erectile dysfunction

    • Depression must be ruled out

    • Workup must differentiate between anatomic, endocrine, neurologic, and psychological causes

    • Even if an irreversible cause is identified, this knowledge may help the patient to accept the ...

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