Sexual Dysfunction Clinical Trials, Diagnosis, and Treatment

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Sexual Dysfunction

Sexual dysfunction or sexual malfunction is difficulty during any stage of the sexual act (which includes desire, arousal, orgasm, and resolution) that prevents the individual or couple from enjoying sexual activity.

Current Research

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Onset

Sexual difficulties can begin early in a person's sex life or they may develop after an individual has previously experienced enjoyable and satisfying sex. A problem may develop gradually over time, or may occur suddenly as a total or partial inability to participate in one or more stages of the sexual act. The causes of sexual difficulties can be physical, psychological, or both.

Emotional factors affecting sex include both interpersonal problems (such as marital/relationship problems, or lack of trust and open communication between partners) and psychological problems within the individual (depression, sexual fears or guilt, past sexual trauma, sexual disorders, and so on).

Physical factors include drugs (alcohol, nicotine, narcotics, stimulants, antihypertensives, antihistamines, and some psychotherapeutic drugs); injuries to the back, problems with an enlarged prostate gland, problems with blood supply, nerve damage (as in spinal cord injuries); or disease (diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis); failure of various organ systems (such as the heart and lungs); endocrine disorders (thyroid, pituitary, or adrenal gland problems); hormonal deficiencies (low testosterone, estrogen, or androgens); and some birth defects.

Sexual dysfunction disorders are generally classified into four categories: sexual desire disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders.

Sexual desire disorders or decreased libido can be caused by a decrease in normal estrogen (in women) or testosterone (in both men and women) production. Other causes may be aging, fatigue, pregnancy, medications (such as the SSRIs) or psychiatric conditions, such as depression and anxiety. Loss of libido from SSRIs usually reverses after SSRIs are discontinued, but in some cases it does not. This is known as PSSD.
Sexual arousal disorders were previously known as frigidity in women and impotence in men, though these have now been replaced with less judgmental terms. Impotence is now known as erectile dysfunction, and frigidity has been replaced with a number of terms describing specific problems with, for example, desire or arousal.
For both men and women, these conditions can manifest as an aversion to, and avoidance of, sexual contact with a partner. In men, there may be partial or complete failure to attain or maintain an erection, or a lack of sexual excitement and pleasure in sexual activity.
There may be medical causes to these disorders, such as decreased blood flow or lack of vaginal lubrication. Chronic disease can also contribute, as well as the nature of the relationship between the partners. As the success of sildenafil (Viagra) attests, most erectile disorders in men are primarily physical, not psychological conditions.
Orgasm disorders are a persistent delay or absence of orgasm following a normal sexual excitement phase. The disorder can occur in both women and men. Again, the SSRI antidepressants are frequent culprits -- these can delay the achievement of orgasm or eliminate it entirely.
Sexual pain disorders affect women almost exclusively and are known as dyspareunia (painful intercourse) and vaginismus (an involuntary spasm of the muscles of the vaginal wall that interferes with intercourse). Dyspareunia may be caused by insufficient lubrication (vaginal dryness) in women.

Poor lubrication may result from insufficient excitement and stimulation, or from hormonal changes caused by menopause, pregnancy, or breast-feeding. Irritation from contraceptive creams and foams can also cause dryness, as can fear and anxiety about sex.

It is unclear exactly what causes vaginismus, but it is thought that past sexual trauma (such as rape or abuse) may play a role. Another female sexual pain disorder is called vulvodynia or vulvar vestibulitis. In this condition, women experience burning pain during sex which seems to be related to problems with the skin in the vulvar and vaginal areas. The cause is unknown.

Sexual dysfunctions are more common in the early adult years, with the majority of people seeking care for such conditions during their late twenties through thirties. The incidence increases again in the geriatric population, typically with gradual onset of symptoms that are associated most commonly with medical causes of sexual dysfunction.

Sexual dysfunction is more common in people who abuse alcohol and drugs. It is also more likely in people suffering from diabetes and degenerative neurological disorders. Ongoing psychological problems, difficulty maintaining relationships or chronic disharmony with the current sexual partner can also interfere with sexual function.

Symptoms

Psychological Sexual Disorders

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders lists the following psychological sexual disorders:

Hypoactive sexual disorder (see also asexuality)
Sexual aversion disorder (avoidance of or lack of desire for sexual intercourse)
Female sexual arousal disorder (failure of normal lubricating arousal response)
Male erectile disorder
Female orgasmic disorder (see Anorgasmia)
Male orgasmic disorder (see Anorgasmia)
Premature ejaculation
Dyspareunia
Vaginismus
Secondary sexual dysfunction
Paraphilias
Gender identity disorder
PTSD due to genital mutilation or childhood sexual abuse

Clinical Studies

Since people tend not to talk to one another about their sexual problems, many people imagine that they are "abnormal", or that their sexual problems are unique or shameful. Images of sexuality presented by society and the media often present people with unrealistic ideals of sexual behavior, whether of the ideals of chastity and sexual fidelity presented by religion, or the ideal of sexual inexhaustibility and promiscuous availability presented by pornography. Neither image appears to be representative of human behavior in real life: this has been summed up in the phrase "everyone lies about sex".

The genuine clinical study of sexual problems is usually dated back no further than 1970 when Masters and Johnson's Human Sexual Inadequacy was published. It was the result of over a decade of work at the Reproductive Biology Research Foundation in St. Louis, involving 790 cases. The work grew from Masters and Johnson's earlier Human Sexual Response (1966).

Prior to Masters and Johnson the clinical approach to sexual problems was largely derived from the thinking of Freud. It was held with psychopathology and approached with a certain pessimism regarding the chance of help or improvement. Sexual problems were merely symptoms of a deeper malaise and the diagnostic approach was from the psychopathological. There was little distinction between difficulties in function and variations nor between perversion and problems. Despite work by psychotherapists such as Balint sexual difficulties were crudely split into frigidity or impotence, terms which too soon acquired negative connotations in popular culture.

The achievement of Human Sexual Inadequacy was to move thinking from psychopathology to learning, only if a problem did not respond to educative treatment would psychopathological problems be considered. Also treatment was directed at couples, whereas before partners would be seen individually. Masters and Johnson saw that sex was a joint act. They believed that sexual communication was the key issue to sexual problems not the specifics of an individual problem. They also proposed co-therapy, a matching pair of therapists to the clients, arguing that a lone male therapist could not fully comprehend female difficulties and vice versa.

The basic Masters and Johnson treatment program was an intensive two week program to develop efficient sexual communication. Couple-based and therapist led the program began with discussion and then sensate focus between the couple to develop shared experiences. From the experiences specific difficulties could be determined and approached with a specific therapy. In a limited number of male only cases (41) Masters and Johnson had developed the use of a female surrogate, an approach they soon abandoned over the ethical, legal and other problems it raised.

In defining the range of sexual problems Masters and Johnson defined a boundary between dysfunction and deviations. Dysfunctions were transitory and experience by the majority of people, dysfunctions bounded male primary or secondary impotence, premature ejaculation, ejaculatory incompetence; female primary orgasmic dysfunction and situational orgasmic dysfunction; pain during intercourse (dyspareunia) and vaginismus. According to Masters and Johnson sexual arousal and climax are a normal physiological process of every functionally intact adult, but despite being autonomic it can be inhibited. Masters and Johnson treatment program for dysfunction was 81.1% successful.

Despite the work of Masters and Johnson the field in the US was quickly over-run by ethusiastic rather than systematic approaches, blurring the space between 'enrichment' and therapy. Although it has been argued that the impact of the work was such that it would be impossible to repeat such a clean experiment.

(adapted from Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Sexual_dysfunction)

Findings From Current Research

Comorbid LUTS and Erectile Dysfunction: Optimizing Their Management.

Authors: Kaminetsky J.

Department of Urology, New York University School of Medicine, New York, NY 10016, USA. jckammd@att.net

BACKGROUND AND SCOPE: Lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH), and sexual dysfunction such as erectile dysfunction (ED), are highly prevalent in men over the age of 50. LUTS and ED have a negative impact on sexual function and when comorbid, result in reduced quality of life. The goal of this article is to discuss the relationship between ED and LUTS, describe the diagnostic workup of these disorders, explore the current treatment options, and examine how treatments may affect this population. Medline (1980-2006), Cochrane reviews, and the American Urological Association 2006 General Meeting abstracts were searched for relevant clinical trials and reviews with the terms: benign prostatic hyperplasia, lower urinary tract symptoms, erectile dysfunction, sexual dysfunction, alpha-adrenergic receptor antagonists, alpha-blockers, 5alpha-reductase inhibitors, phosphodiesterase type-5 inhibitors, transurethral resection of the prostate, transurethral microwave thermotherapy, transurethral needle ablation, adverse events, alfuzosin, doxazosin, tamsulosin, terazosin, dutasteride, finasteride, sildenafil, tadalafil, vardenafil. However, because of the volume of literature, this article is not a systematic review. FINDINGS: Although age is an independent risk factor for both LUTS and ED, studies report that LUTS is also an independent risk factor for ED. Treatments for LUTS include pharmacologic, minimally invasive, and surgical therapies. Among pharmacologic options, alpha1-adrenergic receptor (alpha1-AR) antagonists provide effective treatment with a low risk of sexual side-effects; some of these drugs have been reported to improve sexual function. The treatment of LUTS may improve ED. Phosphodiesterase type 5 inhibitors (PDE-5s) are considered first-line therapy for ED. Comorbid LUTS and ED are treated with an alpha1-AR antagonist and a PDE-5; however, this combination must be used with caution because of vasodilatory adverse events associated with both classes of drugs. CONCLUSIONS: Optimal management includes screening to identify patients with comorbid LUTS and ED, and the use of treatments that minimize both vasodilatory and sexual side-effects.

Journal: Curr Med Res Opin. 2006 Dec;22(12):2497-506.
Adapted from PubMed; click here to access full journal article.

Female Sexual and Hormonal Status in Patients with Bronchial Asthma: Relationship with Respiratory Function Tests and Psychological and Somatic Status.

Authors: Basar MM, Ekici A, Bulcun E, Tuglu D, Ekici MS, Batislam E.

Department of Urology, University of Kirikkale Faculty of Medicine, Kirikkale, Turkey. mmbasar@hotmail.com

OBJECTIVES: To assess the relationship among the sexual, hormonal, physical, and psychological status of women with bronchial asthma (BA) compared with that of healthy volunteers. METHODS: Thirty-eight women with BA were enrolled in the study. The patients were asked to complete the Female Sexual Function Index, General Health Questionnaire, and Medical Outcomes Study Short Form 36-item Health Survey (SF-36). Using the answers on the SF-36, the mental and physical component summary scores were calculated. A total of 20 healthy women were enrolled in the study as the control group. The same questionnaires were given to this group as well. Statistical analysis was performed using the Mann-Whitney U test and Pearson correlation tests. RESULTS: At the end of the study, statistically significant differences were observed for all questionnaire scores (P <0.05). The most common female sexual dysfunction was diminished arousal (n = 30, 78.9%) in women with BA. In the correlation analysis, the total Female Sexual Function Index score had a statistically significant and positive correlation with the mental component summary score (r = 0.503, P = 0.001) and a negative correlation with the General Health Questionnaire score (r = -0.380, P = 0.020). CONCLUSIONS: The results of our study have shown that BA, as a chronic medical condition, can be a cause of female sexual dysfunction with mental and psychiatric mechanisms.

Journal: Urology. 2007 Mar;69(3):421-5.
Adapted from PubMed; click here to access full journal article.

The Effects of False Positive and False Negative Physiological Feedback on Sexual Arousal: A Comparison Women with or without Sexual Arousal Disorder.

Authors: McCall KM, Meston CM.

Department of Psychology, University of Texas at Austin, One University Station A8000, Austin, 78712, Texas, USA, meston@psy.utexas.edu.

The effects of false positive and false negative physiological feedback (vaginal photoplethymograph response print-out) on women's sexual arousal were examined. Participants included women without sexual dysfunction (n=16) and women with Sexual Arousal Disorder (SAD; n=15). Measures of subjective sexual arousal, physiological sexual arousal (vaginal pulse amplitude), expectancies, affect, and anxiety were obtained in response to viewing an erotic film. Results indicated that false positive feedback significantly increased subjective levels of sexual arousal, whereas false negative feedback significantly decreased subjective levels of sexual arousal in both groups. Sexually functional women had overall higher expectancies for sexual arousal than women with SAD. Unexpectedly, false positive feedback did not significantly impact physiological sexual arousal in sexually functional women; however, it resulted in significantly decreased responses in physiological sexual arousal in women with SAD. False negative feedback had no significant effect on physiological sexual response in sexually functional women or women with SAD.

Journal: Arch Sex Behav. 2007 Feb 27;
Adapted from PubMed; click here to access full journal article.

Risk of Sexual Dysfunction in a Randomly Selected Nonclinical Sample of the Swedish Population.

Authors: Steel JL, Herlitz CA.

Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA. steelj@msx.upmc.edu

OBJECTIVE: To investigate the risk of sexual dysfunction as a result of childhood sexual abuse or sexual assault in a randomly selected nonclinical sample of men and women. METHODS: In 1996, a randomly selected sample of 2,810 Swedish males and females completed a 322-item interview and questionnaire. Age-adjusted odds ratios (ORs) were calculated to assess risk of sexual dysfunction and analysis of variance was employed to test differences by gender and abuse or assault history in regard to seeking assistance for sexual dysfunction. RESULTS: For females with a history of childhood sexual abuse, an increased risk of anorgasmia for more than 12 months was found for women aged between 31 and 45 years (OR 1.21, P=.009). For females with a history of sexual assault; an increased risk for hypoactive sexual desire disorder was found for women who between the ages of 16 and 30 years (OR 1.51, P=.03), 31 and 45 years (OR 1.28; P=.02), 46 and 60 years (OR 1.21, P=.03), and 61 and 84 years (OR 1.62, P=.04); lubrication problems in the past year for women between 46 and 60 years (OR 1.28, P=.02) and for more than 12 months (OR 1.38, P=.02). No statistically significant increased risk of sexual dysfunction was found for males with a history of childhood sexual abuse. Males who reported a history of sexual assault as an adult had a significant increased risk of retarded ejaculation in the last 12 months if they were between the ages of 31 and 45 years (OR 2.00, P=.008) or 46 and 60 years (OR 2.11, P=.02). Women most often reported sexual dysfunction to their gynecologists (18%) or midwives (8.4%), whereas men reported their sexual dysfunction to their physicians (5.6%) or urologists (4.3%). CONCLUSION: Future research should focus on predictors of sexual dysfunction and resilience subsequent to childhood sexual abuse and sexual assault as an adult. LEVEL OF EVIDENCE: III.

Journal: Obstet Gynecol. 2007 Mar;109(3):663-8.
Adapted from PubMed; click here to access full journal article.

Sexual Function in Hypertensive Patients Receiving Treatment.

Authors: Reffelmann T, Kloner RA.

University of Southern California, The Heart Institute, Good Samaritan Hospital, Division of Cardiovascular Medicine, Keck School of Medicine, Los Angeles, CA 90017-2395, USA.

In many forms of erectile dysfunction (ED), cardiovascular risk factors, in particular arterial hypertension, seem to be extremely common. While causes for ED are related to a broad spectrum of diseases, a generalized vascular process seems to be the underlying mechanism in many patients, which in a large portion of clinical cases involves endothelial dysfunction, ie, inadequate vasodilatation in response to endothelium-dependent stimuli, both in the systemic vasculature and the penile arteries. Due to this close association of cardiovascular disease and ED, patients with ED should be evaluated as to whether they may suffer from cardiovascular risk factors including hypertension, cardiovascular disease or silent myocardial ischemia. On the other hand, cardiovascular patients, seeking treatment of ED, must be evaluated in order to decide whether treatment of ED or sexual activity can be recommended without significantly increased cardiac risk. The guideline from the first and second Princeton Consensus Conference may be applied in this context. While consequent treatment of cardiovascular risk factors should be accomplished in these patients, many antihypertensive drugs may worsen sexual function as a drug specific side-effect. Importantly, effective treatment for arterial hypertension should not be discontinued as hypertension itself may contribute to altered sexual functioning; to the contrary, alternative antihypertensive regimes should be administered with individually tailored drug regimes with minimal side-effects on sexual function. When phosphodiesterase-5 inhibitors, such as sildenafil, tadalafil and vardenafil, are prescribed to hypertensive patients on antihypertensive drugs, these combinations of antihypertensive drugs and phosphodiesterase 5 are usually well tolerated, provided there is a baseline blood pressure of at least 90/60 mmHg. However, there are two exceptions: nitric oxide donors and alpha-adrenoceptor blockers. Any drug serving as a nitric oxide donor (nitrates) is absolutely contraindicated in combination with phosphodiesterase 5 inhibitors, due to significant, potentially life threatening hypotension. Also, a-adrenoceptor blockers, such as doxazosin, terazosin and tamsulosin, should only be combined with phosphodiesterase 5 inhibitors with special caution and close monitoring of blood pressure.

Journal: Vasc Health Risk Manag. 2006;2(4):447-55.
Adapted from PubMed; click here to access full journal article.

Sexual Dysfunction in Men and Women with Endocrine Disorders.

Authors: Bhasin S, Enzlin P, Coviello A, Basson R.

Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston Medical Center, Boston, MA 02199, USA. bhasin@bu.edu

Endocrine disease frequently interrupts sexual function, and sexual dysfunction may signal serious endocrine disease. Diabetic autonomic neuropathy and endothelial dysfunction impair erectile function, and phosphodiesterase inhibition produces only moderate benefit. The effect of diabetes on women's sexual function is complex: the most consistent finding is a correlation between sexual dysfunction and depression. Reductions in testosterone level in men are associated with low sexual desire and reduced nocturnal erections and ejaculate volume, all of which improve with testosterone supplementation. The age-dependent decline in testosterone production in men is not associated with precise sexual symptoms, and supplementation has not been shown to produce sexual benefit. In women, sexual dysfunction has not been associated with serum testosterone, but this may be confounded by limitations of assays at low concentrations and by the greater importance of intracellular production of testosterone in women than in men. Testosterone supplementation after menopause does improve some aspects of sexual function in women, but long-term outcome data are needed. More research on the sexual effects of abnormal adrenal and thyroid function, hyperprolactinaemia, and metabolic syndrome should also be prioritized. We have good data on local management of the genital consequences of estrogen lack, but need to better understand the potential role of systemic oestrogen supplementation from menopause onwards in sexually symptomatic women.

Journal: Lancet. 2007 Feb 17;369(9561):597-611.
Adapted from PubMed; click here to access full journal article.

Testosterone Treatment for Hypoactive Sexual Desire Disorder in Postmenopausal Women.

Authors: Kingsberg S.

Case Western Reserve University School of Medicine, Cleveland, OH, USA.

Introduction. The reduced levels of testosterone in postmenopausal women are associated with loss of libido, decreased sexual activity, diminished feelings of physical well-being, and fatigue. A bilateral oophorectomy can lead to decreases in sexual desire in 50% of cases by removing ovarian contribution to the circulating levels of testosterone. Testosterone therapy is an option for the restoration of sexual drive. Aim. Transdermal testosterone administration may bypass the effects of first pass hepatic metabolism. To this end a series of studies have been carried out using a novel transdermal testosterone system. A review of the results from these studies are presented here. Main Outcome Measures. A key feature of these studies was the use of validated study instruments to measure sexual function: Sexual Activity Log((c)) (SAL((c))), Profile of Female Sexual Function((c)) (PFSF((c))) and Personal Distress Scale((c)). Methods. The data from the Phase III studies, known as the Investigation of Natural Testosterone in Menopausal women Also Taking Estrogen in Surgically Menopausal women (INTIMATE SM) 1 and 2 were reviewed and the salient information is presented here. Results. Both INTIMATE 1 and 2 showed a significant increase in total satisfying sexual activity, via the SAL((c)) in those women receiving testosterone, compared with those women in the placebo group. Total satisfying sexual activity increased by 74% and 51% for INTIMATE 1 and 2, respectively. The PFSF((c)) instrument demonstrated significant improvements in INTIMATE 1 and 2 in all domains of sexual function in testosterone-treated women compared with the placebo patients. In both studies, personal distress decreased in those patients receiving testosterone, compared with the placebo group. The most commonly reported adverse events were application site reactions. Eight-five percent of patients said they would probably or definitely continue treatment. Conclusions. The transdermal testosterone patch is an effective treatment for hypoactive sexual desire disorder in surgically postmenopausal women receiving concomitant estrogen therapy. The treatment has a favorable safety profile.

Journal: J Sex Med. 2007 Mar;4 Suppl 3:227-34.
Adapted from PubMed; click here to access full journal article.

Sexual Dysfunctions: Classifications and Definitions.

Authors: Hatzimouratidis K, Hatzichristou D.

2nd Department of Urology and Center for Sexual and Reproductive Health, Aristotle University of Thessaloniki, Greece. hatzichr@med.auth.gr

Sexual classification systems are based on precise and understandable definitions of sexual dysfunctions and are needed for investigative research, determination of diagnostic standards, and delineation of treatment strategies. The four major categories of sexual dysfunctions include disorders of sexual desire/interest, arousal, orgasm, and sexual pain. The purpose of this article is to review the major features, differences, and similarities of the six classification systems widely used in sexual medicine, including the International Classification of Diseases, the Diagnostic and Statistical Manual of Mental Disorders, the National Institute of Health Consensus Conference on Impotence, the American Foundation for Urologic Diseases, International Consensus Conference on Women's Sexual Dysfunction, and the First and Second International Consultations on Sexual Dysfunctions.

Journal: J Sex Med. 2007 Jan;4(1):241-50.
Adapted from PubMed; click here to access full journal article.

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