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Overview |
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Broadly defined, sexual dysfunction is the general inability to enjoy sexual
intercourse. Sexual disorders include sexual desire (libido) problems, disorders
in the psychophysiologic processes of the sexual response cycle (desire,
excitement, orgasm, resolution), and pain with sexual intercourse. Sexual
dysfunctions are classified as primary (lifelong) or secondary (acquired after
normal sexual functioning) and may be generalized (not limited to certain
situations, partners, or stimulation) or situational. |
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Definition |
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This large group of vasocongestive and orgasmic disorders affects both males
and females and may affect more than half of all couples at some time. The major
subtypes are:
- Male erectile disorder (impotence)—the
inability to attain or maintain an erection for sexual intercourse
- Ejaculation disturbances—primarily premature
ejaculation in men
- Vaginismus—spasm of the vagina preventing
penetration and sometimes causing pain during coitus
- Sexual aversion disorder—the inhibition of
sexual arousal and excitement
- Orgasmic disorders—delayed or absent orgasm
in either males or females who otherwise have normal sexual desires and
arousal
- Dyspareunia—sexual pain disorders
- Sexual dysfunction due to general medical condition
- Substance-induced sexual
dysfunction
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Etiology |
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Psychological influences (e.g., anger, fear, guilt, depression, and anxiety);
interpersonal issues (e.g., marital discord and boredom); alcohol and drug use;
certain medications; neurologic insult and/or biological causes can be factors
in the etiology of sexual dysfunction. |
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Risk Factors |
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- Medical comorbidity (e.g., diabetes, pelvic cancer, genitourinary
disorders, urethral strictures, genital infections, endocrine and hormonal
disorders)
- Pharmacological (e.g., antihypertensive, antipsychotic, and
antidepressant medications)
- Alcohol or drug abuse
- Cigarette smoking (atherosclerosis of the penile artery may account
for nearly 50% of impotence cases in men over 50)
- Depression, anxiety, or issues of self-esteem
- Age 65 and over in men
- Stressful life events
- Vascular surgery
- Previous sexual trauma
- Cultural pressures and expectations
- Fatigue
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Signs and Symptoms |
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Dependent on the disorder:
- Premature or retarded ejaculation in men
- Inability to maintain an erection
- Pain during intercourse
- Lack or loss of sexual desire
- Difficulty achieving orgasm
- Anxiety and/or depression
- Inadequate vaginal lubrication in
women
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Differential
Diagnosis |
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- Sexual dysfunction due to a general medical condition
- Substance-induced sexual dysfunction
- Sexual dysfunction due to combined factors (e.g., psychological and
general medical condition)
- Sexual dysfunction not otherwise specified
- Personality disorder
- Relational problem
- Pseudodyspareunia
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Diagnosis |
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Physical Examination |
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Varies depending on the type of sexual dysfunction. Examples of physical
presentations include:
- Involuntary spasm in the perineal muscles surrounding the distal
third of the vagina (vaginismus)
- Structural abnormalities of the penis, such as genital infections,
Peyronie's disease, and lesions (dyspareunia and male erection disorder)
- Infectious vaginitis and atrophic vaginitis (female sexual arousal
disorder)
- Scars, vulvar inflammation, clitoral inflammation or adhesions, and
dermatitis (female dyspareunia)
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Laboratory Tests |
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Specific laboratory tests are available to aid diagnosis of sexual
dysfunctions resulting from underlying medical conditions; these are usually not
considered diagnostic alone. Blood tests, such as serum-free testosterone,
luteinizing hormone (if low testosterone level), and serum prolactin tests can
help detect hormonal problems and distinguish between psychological and organic
causes for sexual dysfunctions like impotence and sexual aversion
disorders. |
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Imaging |
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CTs and MRIs are helpful for differential diagnosis (e.g., evaluating the
sella turcica for pituitary tumors).
Duplex ultrasound can ascertain blood flow in cavernous arteries (erectile
dysfunction). |
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Other Diagnostic
Procedures |
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- Clinician interview—assess symptoms and
degree of severity; may include routine sexual history, modified sexological
examination (e.g., sensitivity of vulva to touch); gather information on ethnic,
cultural, religious, and social background, which may impact a patient's sexual
desires, expectations, and attitudes
- Evaluate for concurrent substance abuse, medical conditions,
psychiatric conditions
- Nocturnal penile tumescence measurements taken during REM sleep help
to differentiate between psychological and organic causes.
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Treatment Options |
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Treatment Strategy |
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Depending on the type, severity, and duration of the sexual dysfunction, one
or more of the following are recommended.
- Psychotherapy and sex therapy, especially interpersonal
therapy
- Behavioral therapy (e.g., dysfunctions like premature ejaculation and
vaginismus may stem from conditioned responses)
- Pharmacotherapy, and adjusting/alleviating existing
medications
- Surgery of penile venous system for severe cases in which venous
leakage occurs; NIH recommends procedure be performed in investigational setting
at medical centers
- Penile prostheses
- Vacuum/constrictive devices for erectile
dysfunction
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Drug Therapies |
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- Sildenafil citrate (Viagra)—enhances natural
response to sexual stimulation in men by blocking effect of enzyme that breaks
down cyclic guanosine monophosphate (cGMP); complications include serious
cardiovascular event (e.g., myocardial infarction and sudden cardiac death),
primarily in patients with preexisting risk factors; other side effects include
anxiety, priapism, and temporary vision loss or decreased vision;
contraindicated for patients taking nitrates
- Tricyclics or MAOIs—for treating panic
states leading to sexual aversion disorder
- Testosterone—for treating low androgen
levels in erectile dysfunction and impotence (200 mg IM every two weeks for
three to four months)
- Vasodilators—such as papaverine,
phentolamine, or prostaglandin E1 used alone or in combination and
administered via penile injections for erectile dysfunction; may cause priapism
and transient hypertension
- Nefazodone (Serzone) and other
antidepressants—may help decrease psychological side
effects of sexual dysfunction; contraindicated for use with MAOIs or in pregnant
women
- Dibucaine (1%) or lidocaine (1%)—ointment
applied externally for vulval distress
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Complementary and Alternative
Therapies |
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Sexual dysfunction that is secondary to decreased peripheral circulation,
hormonal imbalance, or depression and/or anxiety may be reduced with the use of
alternative therapies. Mind-body techniques such as meditation, progressive
muscle relaxation, yoga, tai chi, and stress management may be helpful in
relieving anxiety around sexual performance. |
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Nutrition |
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- Vitamin C (1,000 mg tid) to support vascular integrity.
- Vitamin E (400 IU/day), B6 (50 to 100 mg/day), and zinc (30 mg/day)
to support hormone production.
- Magnesium (200 mg bid) supports hormone production and is a
vasodilator.
- B-complex (50 to 100 mg/day) helps to reduce the effects of stress
and may improve symptoms of depression and/or
anxiety.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Consider the following herbs for sexual dysfunction related to vascular
insufficiency.
- Ginkgo (Ginkgo biloba, 50 to 100 mg/day) increases peripheral
circulation and may improve sexual function related to arterial insufficiency.
Long-term treatment (six months or more) may be required for best results.
Ginkgo should be used cautiously with other blood-thinning agents (e.g.,
coumadin).
- Hawthorn (Crataegus monogyna), rosemary (Rosmarinus
officinalis), ginger root (Zingiber officinale), and prickly ash bark
(Xanthoxylum clava-herculis) are circulatory stimulants. Use singly or in
combination, 3 cups of tea/day or 20 to 30 drops tincture tid.
- Yohimbe bark (Pausinystalia yohimbe) is used for sexual
dysfunction; however, because of its side effects it should not be used without
physician supervision.
Consider these herbs for sexual dysfunction secondary to hormonal imbalance.
- Chaste tree (Vitex agnus cactus) helps to normalize pituitary
function but must be taken long term (12 to 18 months) for maximum
effectiveness. Use only under physician supervision with hormone
therapy.
- Saw palmetto (Serenoa repens) may reduce excessive androgen
production.
- Damiana (Turnera diffusa) may support testosterone levels. It
is also tonifying to the central nervous system and may help alleviate anxiety
and depression in conjunction with sexual dysfunction.
- Milk thistle (Silybum marianum), dandelion root (Taraxacum
officinale), and vervain (Verbena officinale) support the liver and
may help restore hormone ratios. Use equal parts in a tea (1 cup before meals),
or tincture (15 to 20 drops before meals).
For sexual dysfunction associated with depression or anxiety, consider the
following.
- St. John's wort (Hypericum perforatum)
- Kava kava (Piper methysticum)
- Skullcap (Scutellaria lateriflora)
- Lemon balm (Melissa officinalis)
- Passionflower (Passiflora incarnata)
- Gotu kola (Centella asiatica)
Combine equal parts in a tea (one cup bid) or tincture (20 to 30 drops bid).
It may take up to six weeks to see best results. |
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency.
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Physical Medicine |
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Contrast sitz baths may relieve symptoms and promote circulation, relieving
pelvic vascular congestion. You will need two basins that can be comfortably sat
in. Fill one basin with hot water, one with cold water. Sit in hot water for
three minutes, then in cold water for one minute. Repeat this three times to
complete one set. Do one to two sets per day three to four days per week.
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Massage |
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Therapeutic massage may be beneficial in reducing the effects of stress and
increasing overall sense of well-being. |
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Patient Monitoring |
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Sexual dysfunctions tend to be chronic and episodic and require long-term
monitoring. |
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Other
Considerations |
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Prevention |
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In cases that are primarily psychological in nature, continued psychological,
behavioral, and interpersonal therapy decreases chances of a relapse. Men should
avoid smoking to help prevent vascular problems associated with erectile
dysfunction. |
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Complications/Sequelae |
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Drug side effects (e.g., androgen replacement therapy may have significant
health risks for men with normal testosterone levels, especially in cases of
unrecognized prostate cancer)
Sexual dysfunctions can adversely affect other areas of social
functioning. |
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Prognosis |
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Sexual disorders are usually recurrent and chronic; a spontaneous remission
occurs in 15% to 30% of patients with acquired erectile dysfunction; increased
sexual experience often leads to control of premature ejaculation in males.
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Pregnancy |
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Fluctuations in libido may be normal during and after pregnancy and should
not be treated. |
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References |
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American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association;
1994.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:383.
Conn RB, Borer WZ, Snyder JW. Current Diagnosis (No. 9). Philadelphia,
Pa: WB Saunders, Co; 1996:9.
Hoffman D. The New Holistic Herbal. New York, NY: Barnes & Noble
Books; 1995:195.
Murray MT. The Healing Power of Herbs: The Enlightened Person's Guide to
the Wonders of Medicinal Plants. Rocklin, Calif: Prima Publishing; 1995:127,
149-150.
Scalzo R. Naturopathic Handbook of Herbal Formulas. 2nd ed. Durango,
Colo: Kivaki Press; 1994:66.
Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis
& Treatment 1999. Stamford, Conn: Appleton & Lange;
1999. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |