Sexual Dysfunction

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

  • Hypoactive desire disorder

Erectile dysfunction

• Often mentioned only after direct questioning

• Patients sometimes use the term "impotence" incorrectly 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

Hypoactive sexual desire disorder

• Menopause may lead to diminution of sexual desire in some women

• 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

Hypoactive sexual 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 ...