Sexual Problems (Lecture Note)

Sexual Problems Normal sexual response Desire – general level of interest. Hormone(testosterone) dependent in both sexes Central Arousal – response to sexual stimuli (real/imagined) in limbic system Genital response – vasocongestion & neuromuscular changes (Parasympathetic S2,3,4) + involvses vasoactive intestinal polypeptide (VIP – a potent vasodilator in penis & vagina). Penis erects due to engorgement of corpora cavernosa & testes elevate by cremaster muscle. Vagina is lubricated by transudate formed due to venous engorgement (bartholins glands not until late), can be irregular contractions in the lower 1/3 of vagina Peripheral arousal – rise in BP, general flushing of skin, change in HR, respiratory changes, papillary dilatation Plateau Phase – prolongation of pleasure before orgasm Orgasm – genital, muscular and sensory changes + CVS & RS responses. Contraction on rectus abdominis, pelvic thrusting, contraction of anal sphincter. Rise in systolic BP approx 25mmHg, hyperventilation, intense pleasure & altered consciousness. Male – smooth muscle contraction from epididymis to ampulla à feeling of imenent orgasm à ejaculation. Female – spasm of muscles surrounding lower 1/3 of vagina f.b. 5-8 rhythmic contractions. Resolution – gradual resolution & drainage of venous congestion with subjective feeling of relaxation Refractory phase – phase during which further stimulation cannot produce a response Female Sexual Dysfunction Impaired desire Primary – never felt interested in sex, can be impairment of arousal or orgasm, perception of sex etc Secondary – common after childbirth (parents devoting attention to baby), depression, bereavment, menopause (HRT can help), gynae investigation, loss of self esteem, can be poor communication with partner Orgasmic dysfunction Primary – never had an orgasm – may be due to inexperience or unrealistic expectations Secondary – usually accompanies secondary impaired desire & low self esteem Vaginismus Involuntary spasm of pelvic floor & perineal muscles provoked by attempted penetration. May be due to concerns about pain or childhood experiences (primary) or due to factors later in life (secondary) eg painful experience. Can be aided by counselling, vaginal dilators Dyspareunia Most common sexual problem. Superficial – pain at introitus usually makes full intercourse impossible Deep – pain in the pelvis on deep penetration – may be caused by infection, endometriosis or insuffient lubrication Male Sexual Dysfunction Impaired desire Libido is dependent on testosterone levels (check if low libido). If low supplements can help Also age dependent – men may be unable to accept that Erectile dysfunction Inability to achieve/maintain satisfactory erection (impotence) Usually psychological cause, if physical my be treatable Check if primary, secondary or situational, signs of systemic disease, examine genitalia for hypospadias etc. check testosterone (if low also check FSH & LH). Treatments include sildenafil (viagra), aloprostadil (PGE1 injection or MUSE pellet) & vacuum devices Ejaculatory dysfunction Premature ejaculation – normal earlier in life, strong links to anxiety can lead to vicious circle