Diagnosis and management of sexual dysfunction. Dr Chris Simpson Consultant Psychiatrist
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1 Diagnosis and management of sexual dysfunction Dr Chris Simpson Consultant Psychiatrist
2 What are we talking about? Male Erectile dysfunction Premature ejaculation Delayed ejaculation Sexual aversion Paraphilia Gender identity disorder
3 What are we talking about? Female Vaginismus Sexual arousal disorder Sexual desire disorder Dyspareunia Paraphilia Gender identity disorder
4 General principles Physical v psychological Vocabulary The relationship Performance anxiety Sensate focus / sex therapy Cognitive therapy Information/education Testosterone Specific treatments
5 Physical v psychological Both History, examination, investigation, diagnosis History detailed, relationship, alcohol, drugs Examination hair distribution, liver, genitals, chaparone Investigations physical, psychological and social Diagnosis determines treatment Aetiology does not necessarily lead to treatment
6 Vocabulary Use specific terminology Use clinical terms Patient terminology may be inaccurate Put patient at ease
7 The Relationship You are not a relationship counseller Are you treating The organ The person The relationship? Involve partner
8 Performance anxiety May be a cause May be a maintaining factor
9 Sensate focus / sex therapy Masters and Johnson (1966) A behavioural treatment Removes performance anxiety
10 Sensate focus Stage 1 Touching with no genital contact separately for your own pleasure
11 Sensate focus Stage 2 Touching with no genital contact separately but for your own and partners pleasure
12 Sensate focus Stage 3 Touching with genital contact
13 Sensate focus Stage 4 touching with genital contact and simultaneous carressing
14 Sensate focus Stage 5 vaginal containment
15 Sensate focus Stage 6 vaginal containment with movement
16 Cognitive therapy/techniques Explore thoughts about and during intercourse Challenge Distract
17 Education / information Often this is all that is required
18 Testosterone Male and female Free testosterone so SHBG needs measuring
19 Clinical picture of testosterone deficiency 1 Emotional Depression Reduced well-being Low self esteem Poor concentration/drive General body effects Decreased muscle bulk/power Abdominal obesity Loss of libido Hot flushes/palpitations Decreased body hair Anaemia Complications Osteoporosis Lipid metabolism Insulin resistance Sarcopaenia Reproductive system Subfertility Decreased genital size Thinning/loss of pubic hair Erectile dysfunction Sexual dysfunction 1. Nieschlag E and Behre HM. Testosterone: action, deficiency, substitution (3 rd Edition). Cambridge University Press; 2004.
20 Measurement of Testosterone 1 Free T (~2%) Bound to SHBG* (~60%) Bound to albumin (~38%) Bioavailable testosterone *Sex hormone binding globulin 1. Jockenhovel F in Male Hypogonadism UNI-MED 2004
21 Testosterone levels requiring substitution 1 Total T Free T Testosterone substitution not required 12 nmol/l* 250 pmol/l* Consider trial of treatment if other causes of symptoms have been excluded 8 nmol/l* 180 pmol/l* Testosterone substitution required * Cut-off values may have to be adjusted according to laboratory reference values 1. Nieschlag et al. Eur Urol 2005, 48: 1-4.
22 Testosterone preparations Oral Buccal Transdermal Gel Subdermal Intramuscular Short-acting Long-acting
23 Specific Treatments ERECTILE DYSFUNCTION
24 Prevalence in population (%) Prevalence of Impaired Erectile Function The Massachusetts Male Aging Study (MMAS) Degree of ED Minimal Moderate Complete The combined mean prevalence of minimal, moderate, and complete erectile impairment was 52% Age (mid point) 8% of men in their 40s report moderate or complete ED and this approaches a mean of 40% in men aged yrs 2 1 Feldman et al. J Urol. 1994; 151: McKinlay. Int J Impot Res. 2000;12(suppl 4):S6-S11
25 Possible Causes of Erectile Dysfunction (ED) 1 Organic Diabetes Vascular disease CHD Pelvic surgery Peyronie s disease O V E R L A P Psychogenic Performance anxiety Relationships Depression Stress Eardley I, Sethia K: Erectile Dysfunction, Current Investigation and Management Second Edition 2003
26 Anatomy of the Penis
27 Sinusoidal Anatomy Flaccid Penis Erect Penis Sinusoids lined with smooth muscle cells
28 Veno-occlusive mechanism of erection
29 Factors Affecting Erectile Function/Dysfunction 1 Signals from brain induced by sexual stimulation Blood supply Atherosclerosis NO from vascular endothelium NO from NANC nerves Surgery Trauma Diabetes Endothelial dysfunction NO from trabecular smooth muscle Eardley I, Sethia K: Erectile Dysfunction, Current Investigation and Management Second Edition 2003
30 Therapeutic Options for Erectile Dysfunction 1 Generic Brand Co. Oral Intraurethral Intracavernosal Vardenafil Levitra BHC Sildenafil Viagra Pfizer Tadalafil Cialis Lilly/ICOS Alprostadil MUSE Meda Alprostadil Caverject Pfizer 1. MIMS July 2008
31 Intraurethral (IU) therapy - alprostadil MUSE (Medicated Urethral System for Erection) Pellet of alprostadil inside the urethra Applicator for intraurethral delivery of alprostadil. Depressing the end releases the pellet into the urethra.
32 Intracavernosal Injection e.g. alprostadil Cross-section of the shaft of the penis Drug injected directly into the corpus away from midline Midline Corpus cavernosum
33 Vacuum Erection Devices
34 Inflatable Penile Prosthesis
35 Penile prosthesis Reservoir Cylinders Multi- part inflatable prosthesis Pump
36 Mechanism of action of PDE5 inhibitors
37 PDE5 Inhibitor Pharmacokinetics* T max T 1/2 Vardenafil Sildenafil Tadalafil Median 60 minutes Median 60 minutes Median 120 minutes 4 5 hours 3 5 hours hours *Based on SmPC for each product
38 PDE5 inhibitors BEWARE Interaction with nitrates prescribed and abused Exertion Headache
39 Specific Treatments PREMATURE EJACULATION SSRIs Condom/ local anaesthetics Stop/start technique Squeeze technique
40 Specific Treatments VAGINISMUS Trainers
41 Mr A 50 yr old with erectile dysfunction Mother died, trip to Thailand Able to maintain an erection with vardenafil Rx Physical examination Ix Sensate focus
42 Mr B 25 yr old man with premature ejaculation Hx primary Examination and Ix normal Rx Psychological stop start, squeeze, sensate focus Physical - SSRIs
43 Mr C 51 yr old with erectile dysfunction PTSD, severe back pain, responds to sildenafil Ix smoker, normal testosterone but low free testosterone as SHBG high. Not responded to testosterone Rx no erection with masturbation, so sensate focus not likely to work Needs sildenafil and stop smoking
44 Case Examples 1. A 40 year old man comes into the surgery saying he cannot get an erection. What are you going to do? 2. An 18 year old man attends the surgery saying he ejaculates too early. What are you going to do? 3. A 35 year old woman had her first baby vaginally and now 6 months later she finds intercourse painful. What are you going to do? 4. A 30 year old woman with 2 children says she has no interest in sex. This is causing problems between her and her partner. What are you going to do?
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