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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