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Dr. Maliheh Keshvari Assistant professor of Urology Fellowship in Female Urology Mashhad University of Medical Sciences 2
Female Sexual Function and Dysfunction 3
It was not until recently that urologists actually began to consider female sexual function as relevant to their practice. Based on the National Health and Social Life Survey, sexual dysfunction is actually more prevalent in women (43%) than in men (31%). 4
Genital anatomy The external genital organs include the mons pubis, clitoris, urethral meatus, labia majora, labia minora, vestibule, Bartholin glands, and Skene glands. 5
General and Peripheral Nervous System The skin of the anus, clitoris, and medial and inferior aspects of the vulva is supplied primarily by distal branches of the pudendal nerve. The vulvar region receives additional sensory fibers from three nerves. The anterior branch of the ilioinguinal nerve sends fibers to the mons pubis and the upper part of the labia majora. The genital femoral nerve supplies fibers to the labia majora, and the posterior femoral cutaneous nerve supplies fibers to the inferoposterior aspects of the vulva. 6
The female sexual response is mediated primarily via spinal cord reflexes that are under descending control from the brainstem. Serotonin inhibits spinal sexual reflexes. 7
Traditionally three sex steroids have been implicated in female sexual behavior: estrogens, progestins, and androgens. Recent research suggests that estrogen and progesterone have little direct influence on female desire. 8
However, administration of both estrogen and androgen in natural and surgically menopausal woman has been shown to restore normal levels of sexual desire. Indirectly, progesterone may affect female sexual behavior by increasing depressive moods. 9
Testosterone Premenopausal women also produce 0.3 mg of testosterone daily. 50% of testosterone production in women comes directly from the ovaries and the adrenal glands, with the remaining 50% produced by testosterone precursors such as androstenedione and dehydroepiandrosterone (DHEA) in peripheral tissues. 10
Several studies have documented the negative effects of oral contraceptives on sexual function. 11
In premenopausal women with regular menstrual cycles,testosterone and androstenedione rise in the late follicular and luteal phases Unlike estrogen and progesterone levels, which fall abruptly with menopause, testosterone levels diminish gradually throughout life. Decreased androgen levels associated with aging have been associated with decreased sexual function. 12
Hyperprolactinemia and adrenal insufficiency can cause hypogonadotropic hypogonadism and loss of libido. Cushing disease or endogenous or exogenous glucocorticosteroid excess leads to adrenal suppression and androgen insufficiency and indirectly inhibits sexual function. 13
Female normal sexual cycle Excitement Plateau Orgasm Resolution. 14
Classification and epidemiology Hypoactive Sexual Desire Disorder: Absent in sexual thoughts and motivations for attempting to become sexually arouse. 15
Subjective Sexual Arousal Disorder: Absent or markedly diminished feelings of sexual arousal from any type of sexual stimulation.however, vaginal lubrication or other signs of physical response still occur. Genital Sexual Arousal Disorder: Complaints of impaired genital sexual arousal, which may include minimal vulvar swelling or vaginal lubrication. However, subjective sexual excitement still occurs with nongenital sexual stimuli. Combined 16
Women s Orgasmic Disorder Dyspareunia: Persistent or recurrent pain with attempted or complete vaginal entry and/or penile-vaginal intercourse. 17
Vaginismus: Persistent or recurrent difficulties to allow vaginal entry of a penis, finger, or other object, despite the woman s desire to participate. Sexual Aversion Disorder: Extreme anxiety or disgust at the anticipation of or attempt at any sexual activity. 18
Female pelvic floor disorders incontinence, lower urinary tract symptoms, and pelvic organ prolapse) have also been shown to have a negative impact on female sexual function. Women with incontinence are up to three times more likely to experience decreased arousal, infrequent orgasms, and increased dyspareunia. 19
Diagnosis 3 basic questions 1. Are you sexually active? 2. Are there any problems? 3. Do you have pain with intercourse? 20
Vital signs, particularly blood pressure, peripheral pulses, and a neurologic evaluation, including a sensory assessment. For women with neurologic disorders, anal and vaginal tone, voluntary tightening of the anus, and bulbocavernosal reflexes should be evaluated. 21
The second portion of the physical examination is palpation. The levator ani muscles should be palpated to assess for vaginismus and levator ani myalgia. A bimanual examination should be done to assess for motion tenderness, adnexal masses, endometriosis, and fibroids. Finally, a speculum examination should be performed to evaluate for pelvic organ prolapse. 22
Laboratory testing A ph of 4.5 or more is suggestive of vaginitis, vaginosis, and/or atrophic vaginitis. If a patient is diagnosed with bacterial vaginosis it is important to also screen for gonorrhea and chlamydia 23
Hypoactive Sexual Desire Disorder This is the most common type of female sexual disorder, and the cause can be physiologic, psychological, or both. 24
Atherosclerotic changes lead to clitoral fibrosis, which interferes with normal smooth muscle relaxation and dilation to sexual stimulation. Indications for vascular testing include (1) Multiple vascular risk factors (2) Pelvic fractures (3) Unresponsive to other therapies Doppler ultrasonography, vaginal and clitoral photoplethysmography, and selective pudendal arteriography methods of vascular testing. 25
MRI MRI is one of the newest technologies which can be used to define the normal anatomic relationships of the female genital structures. 26
Treatment Initiating a sexual encounter in the morning instead of when exhausted at the end of a long day) - Smoking cessation - A healthy diet. - Adequate rest - Exercise Food and Drug Administration (FDA) approved pharmacologic treatment of any female sexual disorder is that of conjugated estrogens (Premarin Vaginal Cream) for moderate to severe dyspareunia. 27
Treatment HSDD is the most common type of female sexual disorder, and the cause can be physiologic, psychological, or both. Treatment should begin with educating the patient that it is normal for drive to decline with increasing age. The patient should be referred to a sex therapist or psychologist to discuss lifestyle changes, stress management, or couples therapy. 28
Exogenous testosterone therapy with tibolone (a synthetic steroid with selective estrogenic, androgenic, and progesterogenic properties) may be an appropriate option, particularly for postmenopausal women. 29
Contraindications to testosterone therapy include androgenic alopecia, hirsutism, seborrhea or acne, polycystic ovary syndrome, liver dysfunction, and estrogen depletion. 30
Arousal Disorders Estrogen: improving vaginal lubrication and blood flow. Bupropion: an aminoketone antidepressant: improve arousal in both premenopausal and postmenopausal women and both depressed and nondepressed women. Alprostadil: a topically prostaglandin under investigation. Arginmax: a nutritional supplement Phentolamine and yohimbine: α-androgenic antagonists Sildenafil: a selective phosphodiesterase-5 inhibitor 31
EROS: clitoral therapy device, an FDA-approved device that applies gentle suction to the clitoris, enhancing clitoral engorgement, has proven beneficial in women with arousal disorders 32
Orgasmic Disorders Primary: cognitive behavioral therapy sex education. Secondary : is often the result of antidepressant medications. 33
Surgical Therapy Vulvar Vestibulectomy Drainage of Sebaceous Cysts or Infected Bartholin or Skene Gland Cysts Correction of Female Pelvic Floor Disorders 34
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