Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 25-09: Psychosexual Disorders + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 condition Other conditions Clinical diagnosis + Treatment Download Section PDF Listen +++ +++ Medications +++ Erectile dysfunction ++ Sildenafil (25–100 mg orally), vardenafil (2.5–20 mg orally), or tadalafil (5–20 mg orally) 1 hour before intercourse is useful Sildenafil, vardenafil, and tadalafil must not be used concurrently with nitrates owing to a risk of hypotension leading to sudden death +++ Ejaculation disturbances ++ SSRIs have been effective because of their common effect in delaying ejaculation +++ Hypoactive sexual desire disorder ++ Flibanserine A 5-HT1A agonist/5-HT2 antagonist that is FDA approved for the treatment of female hypoactive sexual desire disorder Dose is 100 mg orally nightly to circumvent side effects of dizzinesss, sleepiness, and nausea Interacts with alcohol, causing hypotensive events, so patients need to be educated about this risk Bremelanotide Approved by the FDA in 2019 It is self-administered by injection to the thigh or abdomen about 45 minutes before anticipated sexual activity +++ Therapeutic Procedures ++ Anxiety and guilt about parental injunctions against sex may contribute to sexual dysfunction +++ Erectile dysfunction ++ The effect of this problem on relationships must be considered and addressed +++ Ejaculation disturbances ++ Psychotherapy is best suited to cases in which interpersonal or intrapsychic problems predominate A combined behavioral-psychological approach is most effective +++ Orgasmic disorder and hypoactive sexual desire disorder ++ Masters and Johnson have used behavioral approaches in all of the sexual dysfunctions, with concomitant supportive psychotherapy and with improvement of the communication patterns of the couple Organic causes (conditions causing dyspareunia, pelvic pathology, mechanical obstruction, and neurologic deficits) and contributing intrapersonal issues must be uncovered and addressed As with other psychosexual disorders, behavioral approaches with supportive psychotherapy and improved communication within couples can be effective + Outcome Download Section PDF Listen +++ +++ Prevention ++ The proximity of other people (eg, mother-in-law) in a household is frequently an inhibiting factor in sexual relationships; some social engineering may alleviate the problem + References Download Section PDF Listen +++ + +Dhillon S et al. Bremelanotide: first approval. Drugs. 2019 Sep;79(14):1599–606. [PubMed: 31429064] + +Hadj-Moussa M et al Evaluation and treatment of gender dysphoria to prepare for gender confirmation surgery. Sex Med Rev. 2018 Oct;6(4):607–17. [PubMed: 29891226] + +Jaspers L et al. Efficacy and safety of flibanserin for the treatment of hypoactive sexual desire disorder in women: a systematic review and meta-analysis. JAMA Intern Med. 2016. Apr;176(4):453–62. [PubMed: 26927498] + +Simopoulos EF et al. Male erectile dysfunction: integrating psychopharmacology and psychotherapy. Gen Hosp Psychiatry. 2013 Jan;35(1):33–8. [PubMed: 23044247]