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For further information, see CMDT Part 25-09: Psychosexual Disorders

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 sexual desire disorder

Erectile dysfunction

  • Often mentioned only after direct questioning

  • Causes can be psychological, physiologic, or both

  • Most likely to have an organic basis

  • Majority are pathophysiologic and, to varying degrees, treatable

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

Ejaculation disturbances

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

  • Pathogenic factors that interfere with learning control include sexual ignorance

  • Intrapsychic factors include

    • Anxiety

    • Guilt

    • Depression

    • Relationship problems

  • Organic factors include

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

    • Effects of pharmacologic agents (eg, SSRIs, sympatholytics)

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)

    • 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

  • Causes include organic and psychological difficulties

    • Chronic illness

    • Aging and menopause

    • Hormonal disorders, including hypogonadism or use of antiandrogen compounds such as cyproterone acetate

    • Chronic kidney disease

    • Use of alcohol, sedatives, opioids, marijuana, and some medications

    • Anxiety

    • Phobic avoidance

  • 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

Clinical Findings

Symptoms and Signs

Erectile dysfunction

  • The inability to achieve or maintain an erection firm enough for satisfactory intercourse

Ejaculation disturbances

  • Ejaculation disturbances include

    • Premature ejaculation

    • Inability to ejaculate

    • Retrograde ejaculation

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

Orgasmic disorder

  • Difficulty in experiencing erotic sensation and lack of vasocongestive response

  • Orgasmic dysfunction—in which a woman has a vasocongestive response but varying degrees of difficulty in reaching orgasm—is sometimes differentiated from anorgasmia

Hypoactive sexual desire disorder

  • Consists of diminished or absent libido

Differential Diagnosis

  • Depression or anxiety

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

  • Dyspareunia or chronic pelvic pain

  • Drugs or substance use, eg, ...

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