Background
Sexual problems are spectrum of disorders afflicting males as well as women. It can develop from psychological or physical factors or from both taken together. As the third National Survey of Sexual Attitudes and Lifestyles (NATSAL-3) shows—more than 40% of men and more than 50% of women reported having sexual response difficulties in the previous year—problems with sexual function are rather frequent.
Assessment
The past medical and surgical history as well as the drug history should be part of a comprehensive history. The sexual history should cover sexual orientation as well as present and former relationship status. The social history should include questions on smoking, alcohol, illegal drug usage, and any stress at home or at business.
Sexual dysfunction in males
Erectile dysfunction (ED) is the ongoing inability to get and/or sustain an erection adequate for sexual performance.
It is rather prevalent affecting ≥1 in 10 men in the UK. Older guys have far higher prevalence. Obesity and a lazy lifestyle are among the risk factors for ED that resemble those of cardiovascular disease (CVD). Since ED may show a generalized arteriopathy linked with cardiovascular illness, it could be the first presentation of a major underlying medical issue, say HBP. Physical examination should cover BMI, waist circumference, heart rate, blood pressure. One should advise a genital check-up.
Men should have serum lipids, fasting blood glucose, HbA1c, and serum testosterone—measured on a blood sample obtained between 8 a.m. and 11 a.m. Measuring prostate specific antigen (PSA) both before and during testosterone treatment is advised. Referral for additional CVD assessment and management advice could be advised. Management: lifestyle changes; psychosexual counseling; diagnosis and treatment of any treatable ED cause. Men with low total serum testosterone (<12 nmol/L) may consider trial of testosterone replacement therapy. Anatomical anomalies may call for surgery.
Premature ejaculation (PE): Characterized by ejaculation either always or nearly always occurring prior to or within roughly one minute following vaginal penetration and unable to prolong this, premature ejaculation (PE) has related negative repercussions, e.g., stress. One could find as high as 25% in self-reported PE frequency. Although indicates a tendency for younger men, it is among the most prevalent male sexual issues and can affect any age. One can either get lifetime (main) or secondary PE. The aetiology can be separated into organic causes, e.g. chronic prostatitis, pelvic injury; and psychogenic factors, e.g. anxiety, relationship problems. Treatment consists in psychotherapy, behavioural therapy, and pharmacotherapy. These taken together have been found to be better than individual therapies,
Delayed or retarded ejaculation is the recurring or persistent difficulty that results from either absence of or delay in obtaining orgasm (which creates personal distress). It can have an organic aetiology, such as spinal cord injury, diabetes mellitus or medication therapy, or a psychological one. Psychosexual therapy forms the backbone of management.
Sexual problems in females
Women often have sexual issues. They can be generally categorized as disorders of sexual interest/arousal; orgasm; and disorders related with pain.
Sexual problems can be acquired or lifelong, generalized or limited to particular circumstances. Many disorders can coexist; dyspareunia, for instance, can cause arousal difficulties.
Commoner with aging are disorders of sexual desire and arousal; these can be influenced by hormones, including the menopause. Important roles are also played by psychological elements including stress, depression, and relationship difficulties.
Peripheral neuropathy and spinal cord damage can be linked to failure to get physically aroused. Younger women more often suffer with anorgasmia. Often occurring concurrently, dyspareunia and vaginismus are among the sexual pain syndromes. To rule out organic pathology, a genital examination is required; but, before the ladies are ready for this, multiple consultations could be needed. Vaginisimus should be treated as a kind of sexual pain syndrome.
Despite the woman’s apparent intention to enable vaginal access of a penis, a finger and/or any object, vaginismus is the chronic or repeated difficulty of the woman allowing this. Often there is involuntary pelvic muscular contraction (of levator ani) and pain expectation. Vaginisimus has been linked to things like unfavorable ideas about sexuality, trauma from occurrences like difficult childbirth. For diagnosis, a brief sexual history and discussion of the woman’s opinions on genital inspections might be quite beneficial.
Most usually described as a searing sensation in the absence of pertinent visual symptoms or a specific, clinically identifiable, neurological condition, vulvodynia has been defined as vulval discomfort. Vulval Diseases International Society (ISSVD) 2007.
Classification:
either provoked, unprovoked, or mixed. either generalized or localized.
Known aetiology but most likely multifactorial; provoked vulvodynia
One could have a trigger factor, say a history of vulvovaginal candidiasis.
Vulval pain usually felt at penetration, or during SI or tampon insertion, mostly at the introitus. There are no indications of acute inflammation; gentle touch with a cotton bud or swab can show focal pain.
Diagnosis: clinical; also exclude other causes e.g. dermatoses.
Investigations: ± skin swabs; STI screen as suitable.
Complications: depression, vaginismus, interpersonal issues.
Management of sexual problems:
One can find great benefit from combining treatments. Sitting causes pain; this could be pudendal neuralgia and referral to the pain specialists would help. Up to 50% of people diagnosed a year later may experience spontaneous remission. One could call for psychosexual referral.
Unprovoked vulvodynia: Not known aetiology. Symptoms: searing discomfort usually long-standing and inexplicable. It is more common in women going postmenopausal. Signs: a regular vulva. Complications, diagnosis, and research follow the pattern of induced vulvodynia. Management: Initially treatment should take into account best managed as a chronic pain syndrome and painkillers in a titrating dose. Resistant unprovoked vulvodynia could call for referral to a pain clinic.
Feminine management of sexual problems
Any underlying reason should be addressed; for vaginal atrophy, this includes oestrogen.
Licenced for postmenopausal women’s loss of desire treatment is tibolone.
In postmenopausal women without another clear cause of lowered sexual desire, testosterone treatment can also be employed. Often in management, behavioral therapy and psychosexual therapy play a part; some couples will need counseling for their relationships.
Editor Choice: Reproductive Health and Sexual Health : Fundamentals