Sexual dysfunctions: Clinical practice
AssessmentsSexual dysfunctions: Clinical practice
USMLE® Step 2 style questions USMLE
A 50-year-old man comes to the office for a regular follow-up appointment. He tells the physician that he has been feeling depressed recently because he has not been able to have sexual intercourse with his wife due to an inability to maintain an erection. He feels that this is affecting his relationship with his wife. His medical history is significant for hypertension treated with hydrochlorothiazide and hyperlipidemia treated with simvastatin. Both of these medications were started at his last physical examination about 4 months ago. His examination is completely normal. Which of the following is the best treatment option?
Content Reviewers:Rishi Desai, MD, MPH
Contributors:Pauline Rowsome, BSc (Hons), Jake Ryan, Daniel Afloarei, MD
Sexual dysfunctions are a group of dysfunctions that prevent individuals from wanting or enjoying sexual activity. They can have a profound impact on a person’s life, and can lead to high levels of distress and anxiety.
There are many factors which may lead to sexual dysfunctions.
Emotional factors include depression, sexual fears or guilt, past sexual trauma, and anxiety.
Physical factors include pain and discomfort during sex.
Additionally, drugs, such as alcohol, nicotine, or narcotics, premenstrual syndrome, pregnancy, the postpartum period, and menopause can all affect a person’s libido and the ability to experience sexual pleasure.
Sexual dysfunctions can be divided into four subtypes: lifelong or acquired and generalized or situational.
Lifelong is when the sexual problem has been present from first sexual experiences; acquired applies to problems that develop after a period of relatively normal sexual function; generalized is when the problem occurs across many types of stimulation, situations, or partners; and situational refers to sexual difficulties that only occur in certain contexts.
In all the disorders, the sexual dysfunction should not be better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other stressors, and it shouldn’t be attributable to another medical condition.
Additionally, the symptoms must persist for at least 6 months and should cause significant distress.
Sexual dysfunctions can be further divided into three categories: male sexual disorders which include delayed ejaculation, erectile disorder, male hypoactive sexual desire disorder, and premature ejaculation; female sexual disorders which include female orgasmic disorder, female sexual interest or arousal disorder, and genito-pelvic pain or penetration disorder; and three common disorders, namely substance or medication-induced sexual dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction.
First up in male sexual dysfunctions, is delayed ejaculation, which causes either a marked delay in ejaculation, marked infrequency of ejaculation, or absence of ejaculation.
The delay shouldn’t be intentional, and should occur almost every time the individual has sex.
Second is erectile disorder which causes marked difficulty in having an erection during sex; difficulty in maintaining an erection until the end of sex; or a decrease in erectile rigidity.
Some common factors that can cause this problem include factors like the health of the relationship; poor body image or a history of sexual or emotional abuse; a psychiatric comorbidity or stressors; the individual’s cultural or religious background; and medical factors.
Third is male hypoactive sexual desire disorder which is when there are few or no sexual thoughts or fantasies and a low or absent desire for sexual activity.
A "desire discrepancy," in which individuals have a lower desire for sexual activity than their partners is not sufficient to diagnose male hypoactive sexual desire disorder.
The fourth male-related condition is premature ejaculation.
It’s when ejaculation occurs within 1 minute of vaginal penetration and before the individual wishes it.
There are three levels of severity: mild when ejaculation occurs within 30 seconds to 1 minute, moderate when it occurs within 15 to 30 seconds, and severe when it occurs before individuals even start having sex, at the start of sexual activity, or within 15 seconds of penetration.
Next up are the female sexual dysfunctions. First, female orgasmic disorder causes a delay in, infrequency of, or absence of orgasm, alternatively it can cause reduced or absent orgasmic sensations.
The symptoms are experienced in most or all occasions of sexual activity.
Many individuals require clitoral stimulation to reach orgasm, with only a minority of females being able to consistently experience an orgasm during penile-vaginal intercourse.
So experiencing orgasm through clitoral stimulation, but not during intercourse does not meet criteria for female orgasmic disorder.
Second, there’s female sexual interest or arousal disorder, and that is diagnosed when there are at least three of the following six symptoms.
First, there’s little or no interest in sex.
Second, few or no sexual or erotic thoughts or fantasies.
Third, they rarely initiate sex and often refuse when others initiate it.
Fourth, they usually feel little or no sexual excitement or pleasure during sex.
Fifth, there’s little or no sexual interest or arousal in response to sexual cues that may be written, verbal, or visual.
And sixth there’s reduced or absent genital or nongenital sensation during sexual activity.
Third, there’s genito-pelvic penetration disorder which causes problems in one or more of the following four situations.
First is difficulty with vaginal penetration during intercourse or with tampon insertion, and this can occur only in some situations or in all situations.
Second, there’s vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
Third, there’s fear or anxiety about vulvovaginal or pelvic pain related to vaginal penetration.
And fourth, the pelvic floor muscles are tense or tighten during vaginal penetration.
A disorder common to both males and females is a substance or medication-induced sexual dysfunction.
Usually there’s either evidence that the dysfunction developed during or soon after substance intoxication or withdrawal or after exposure to a medication; and that the substance is capable of producing the disturbances.
Also, the disturbance shouldn’t occur exclusively during the course of an episode of delirium.
Other specified sexual dysfunction applies to presentations in which symptoms characteristic of a sexual dysfunction cause distress and impairment but do not meet the full criteria for any of them, and the clinician chooses to communicate the specific reason they don’t.
If the clinician chooses not to specify the reason, diagnosis is unspecified sexual dysfunction.
Treatment for sexual dysfunctions can involve behavioral and psychological therapies, lifestyle changes, and medication.
Behavioral and psychological therapies are designed to achieve a number of goals: treat sex-related anxiety, improve self-confidence and communication in the relationship and, ultimately, improve the individual’s sex life.
First treatment option is cognitive-behavioral therapy which focuses on dysfunctional thoughts, unrealistic expectations, behavior that decreases desire for intercourse, and insufficient physical stimulation. These sessions can include both partners and homework assignments are often used.
Psychodynamic sex therapy, which addresses underlying developmental and identity issues that impact sexual desire, is a short-term form of counseling, generally involving five to 20 sessions with a sex therapist. A typical session may be one hour every week or every other week.
Other options include group therapy, talk therapy, and sex education.
Second, regular physical activity, at least 60 minutes per day, has been associated with improved blood flow to the genital area, psychosocial well-being, and improved sex performance.
Fatigue and stress can contribute to low libido and sexual problems for all sexes so addressing these issues through mindfulness, yoga, or other relaxation techniques, often results in improved sexual interest and satisfaction.
- "Clinical Practice Guidelines for Management of Sexual Dysfunction" Indian J Psychiatry. (2017 Jan)