Sexual disorder

Moderator: Dr. Vishal Sinha
Presentator: Dr. Ramashankar
SEXUAL DYSFUNCTION-1

NORMAL SEXUALITY
 It is the process by which
people experience and express
themselves as sexual beings.
 Sexuality has been a consistent
focus of curiosity, and interest,
to humankind.

 Determined by anatomy, physiology, the culture in which a
person lives, relationships with others, and developmental
experiences throughout the life cycle.
 It includes the perception of being male or female and
private thoughts and fantasies as well as behavior.
 Normal sexual behavior brings pleasure to oneself and one's
partner, involves stimulation of the primary sex organs
including coitus
 Devoid of inappropriate feelings of guilt or anxiety and is not
compulsive.

Four-phase cycle of Physiological Responses
Phase-1
Desire
Orgasm
ExcitementResolution Phase-2
Phase-3
Phase-4
Plateau phase
The sequence of responses
can overlap and fluctuate

PHASE 1: DESIRE
 The phase is characterized by sexual fantasies and the
conscious desire to have sexual activity.
 Desire may be biological driven OR
 Wish to bond sexually with particular partner

PHASE 2: EXCITEMENT
 Brought on by
 psychological stimulation (fantasy or the presence of a
love object) OR
 physiological stimulation ( Foreplays-stroking or kissing)
OR combination of the two.
 Consists of
o Subjective sense of pleasure
o Objective signs of sexual excitement.

PHASE 3: ORGASM
 Peaking of sexual pleasure,
 Release of sexual tension
 Rhythmic contraction of the perineal muscles and the pelvic
reproductive organs.
 A subjective sense of ejaculatory inevitability triggers men's
orgasms. The forceful emission of semen. 4 to 5 rhythmic
spasms of the prostate, seminal vesicles, vas, and urethra.

 In women, orgasm is characterized by 3 to 15 involuntary
contractions of the lower third of the vagina and by strong
sustained contractions of the uterus, flowing from the fundus
downward to the cervix.

PHASE 4: RESOLUTION
 Resolution consists of the disgorgement of blood from the
genitalia (detumescence). Body back to its resting state.
 If orgasm occurs: resolution is rapid, a subjective sense of
well-being, general and muscular relaxation.
 If orgasm does not occur : resolution may take from 2 to 6
hours and may be associated with irritability and discomfort.

 After orgasm, men have a refractory period (several minutes
to many hours)
 they cannot be stimulated to further orgasm.
 Women do not have a refractory period
 They are capable of multiple and successive orgasms.

SEXUAL DYSFUNCTION
 DEFINITION:
 An individual is “unable to participate in a sexual
relationship as he or she would wish”. *
* ICD-10 pg-150

 Sexual dysfunctions can be
 Lifelong or acquired,
 Generalized or situational,
 Result from psychological factors, physiological
factors, combined factors, and numerous stressors
including prohibitive cultural mores, health and partner
issues, and relationship conflicts.
 In DSM-5, the severity of the dysfunction is indicated by
whether the patient's distress is mild, moderate, or
severe .

 Sexual dysfunctions are diagnosed only when they
are a major part of the clinical picture.
 If more than one dysfunction exists, they should all
be diagnosed.

CLASSIFICATION (DSM-5)
 DESIRE, INTEREST, AND AROUSAL DISORDERS
 Male Hypoactive Sexual Desire Disorder
 Female Sexual Interest/ Arousal Disorder
 Male Erectile Disorder
 ORGASM DISORDERS
 Female Orgasmic Disorder
 Delayed Ejaculation
 Premature (Early) Ejaculation

 SEXUAL PAIN DISORDERS
 Genito-Pelvic Pain/Penetration Disorder
 SEXUAL DYSFUNCTION DUE TO A GENERAL MEDICAL
CONDITION/ SUBSTANCE USE
 OTHER SPECIFIED SEXUAL DYSFUNCTION
 UNSPECIFIED SEXUAL DYSFUNCTION

Changes in DSM-5 from DSM-IV
 Specifiers were introduced for severity of Sexual Dysfunctions
 Sexual Dysfunction Due to a General Medical Condition and the
distinction between psychological and combined factors in DSM-
IV were not included in DSM-5
 For Disorders of Sexual Desire and Arousal, women can be
diagnosed with Female Sexual Interest/Arousal Disorder
under DSM-5

Changes in DSM-5 from DSM-IV cont…
 Dyspareunia and Vaginismus were combined into Genito-
Pelvic Pain / Penetration Disorder.
 Male Hypoactive Sexual Desire Disorder has been introduced
 The diagnosis of Sexual Aversion Disorder was eliminated
in DSM-5
 Minimum duration of approximately 6 months and more precise
severity criteria in DSM-5.

DESIRE, INTEREST, AND AROUSAL
DISORDERS

MALE HYPOACTIVE SEXUAL DESIRE
DISORDER
Criteria DSM-5:
A. Persistently or recurrently deficient (or absent) sexual/erotic
thoughts or fantasies and desire for sexual activity.
The judgment of deficiency is made by the clinician, taking into
account factors that affect sexual functioning, such as age and
general and sociocultural contexts of the individual's Life.

Criteria DSM-5 cont…
B. The symptoms in Criterion A have persisted for a minimum
duration of approximately 6 months.
C. The symptoms in Criterion A cause clinically significant
distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual
mental disorder or as a consequence of severe relationship
distress or other significant stressors and is not attributable to the
effects of a substance /medication or another medical condition

 Desire depend on factor like:
o Biological drive
o Adequate self -esteem,
o Availability of an appropriate partner,
o A good relationship in nonsexual areas with a partner,
o Ability to accept oneself as a sexual person.
 Abstinence from sex for a prolonged period sometimes
results in suppression

PREVELENCE:
 Approx 6 % of younger men (ages 18-24 years) and 41% of older
men (ages 66-74 years)
 CONTRIBUTING FACTOR:
 1) partner factors (e.g., partner's sexual problems, partner's health status);
 2) relationship factors (e.g., poor communication, discrepancies in desire for sexual
activity);
 3) individual vulnerability factors (e.g., poor body image, history of sexual or emotional
abuse), psychiatric comorbidity (e.g., depression, anxiety), or stressors (e.g., job
loss, bereavement);
 4) cultural/religious factors (e.g., inhibitions related to prohibitions against sexual
activity; attitudes toward sexuality); and
 5) medical factors relevant to prognosis, course, or treatment

 RISK AND PROGNOSTIC FACTORS:
o Mood and anxiety symptoms -strong predictors of low de-
sire in men.
o past history of psychiatric symptoms
o emotional connection
o Alcohol use may increase the occurrence of low desire
o Hyperprolactinemia
o Age is a significant risk factor for low desire in men

 DIFFERENTIAL DIAGNOSIS:
o Nonsexual mental disorders
o Substance/medication use
o Another medical condition
o interpersonal factors
 COMORBIDITY:
 Depression and other mental disorders, as well as
endocrinological factors, are often comorbid disorder

TREATMENT PLAN:
 GOAL: increasing sexual desire
 1. somatic treatment
 2. psychosocial treatment
 3. combined treatment
 SOMATIC TREATMENT
 Most common is testosterone replacement therapy(TRT)
 Indicated only when level of T at morning below 8 nmol/l
( 2.3ng/ml or 230 ng/dl)

 Effect depends on constant blood concentration, minimal side
effects, etc..
 Transdermal delivery (gel ,patch, subcutaneous pellets.)
 Men who continue to have erectile problem despite a return of
sexual desire after TRT, combine PDE-5 (phosphodiesterase-
5) inhibitor therapy (Sildenadil, Tadalafil)
 evaluate for
 Pituitary tumor ( hyperprolactinemia)
 Hypothyroidism
 Medication like SSRI

 PSYCHOSOCIAL TREATMENTS:
 Consisting of cognitive, affective, behavioural, or relationship
building intervention.
 COMBINED TREATMENT:
 If low desire has been long standing

FEMALE SEXUAL INTEREST/ AROUSAL
DISORDER
 The women do not necessarily move stepwise from desire
to arousal.
 DIAGNOSTIC CRITERIA( DSM-5):
 A. Lack of, or significantly reduced, sexual
interest/arousal, as manifested by at least three of the
following:

CRITERIA ( DSM-5) conti….
 1. Absent/reduced interest in sexual activity.
 2. Absent/reduced sexual/erotic thoughts or fantasies.
 3. No/reduced initiation of sexual activity, and typically
unreceptive to a partner’s attempts to initiate.
 4. Absent/reduced sexual excitement/pleasure during sexual
activity in almost all or all (approximately 75%-100%) sexual
encounters
 5. Absent/reduced sexual interest/arousal in response to any
internal or external sexual/erotic cues (e.g., written, verbal,
visual).

CRITERIA ( DSM-5) conti….
 6. Absent/reduced genital or non-genital sensations during
sexual activity in sexual encounters
 Criterion A have persisted for a minimum duration of approximately
6 months.
 C. The symptoms in Criterion A cause clinically significant distress
in the individual.
 D. The sexual dysfunction is not better explained by a non-sexual
mental disorder or as a consequence of severe relationship distress
(e.g., partner violence) or other significant stressors and is not
attributable to the effects of a substance/medication or another
medical condition.

 CONTRIBUTING FACTOR:
 partner factors, relationship factors, individual vulnerability
factors, psychiatric comorbidity or stressors,
cultural/religious factors and medical factor
 Negative cognitions
 Attitudes about sexuality
 Past history of mental disorders
 Relationship difficulties, partner sexual functioning,
 Early relationships with caregivers and childhood stressors.
 Medical conditions

 DIFFERENTIAL DIAGNOSIS
 Nonsexual mental disorders
 Substance/medication use
 Another medical condition
 Interpersonal factors
 Inadequate or absent sexual stimuli
 Other sexual dysfunctions

MANAGEMENT PLAN:
 GOAL: Increase the desire and/or arousal to the extent that
it results in greater sexual satisfaction.
 SOMATIC TREATMENTS:
 Hormone replacement therapy (Estrogen alone or
estrogen-progestin)
 Adding testosterone in menopausal female appear to
increase sexual desire.
 Testosterone is not used in premenopausal female due to
increased risk of hirsutism, acne, alopecia, insulin resistance,
cardiovascular disease, metabolic syndrome, breast cancer

 Non hormonal t/t primarily act on CNS & vascularity.
 Flibanserin: agonist and antagonist to various serotonin
receptors
 Modest effect on sexual desire of women
 If pt taking SSRI for depression add bupropion.
 PSYCHOSOCIAL TREATMENTS(PST):
 Improvement in severity is better by PST is better as
compared to other sexual dysfunction in female. (Fruhauf et al. 2013)

 1. Increasing the reinforcing value of sexual activity.
 (via increasing in arousal, orgasm, pleasure, physical and
emotional satisfaction.)
 2. Improving the condition of non-sexual condition.
 COMBINED TREATMENTS:
For best results.

MALE ERECTILE DISORDER
 Historically called as impotence.
 More common in man with feeling of powerlessness,
helplessness and resultant low self-esteem
 May be lifelong or acquired
 Situational male erectile disorder: a man is able to have
coitus in certain circumstances but not in others

 AMED (Acquired male erectile dysfunction)
reported in 10-20% of all male
 1% of men younger than 35 year
 Alfred kinsey found 75% of all men were impotent by the age of
80 year
 Masters and Johnson claimed, have a fear of impotence,
reflected the masculine fear of loss of virility with advancing
age.
 The first sexual encounter "is a horse race between
excitement and anxiety.’’-Stephen Levine

INDIAN STUDIES
AUTHORS SETTING YEAR PREVALENCE
OF ED
Bagadia et.al Teaching hospital 1972 48%
Verma et.al Psychosexual clinic 1998 23.6%
Gupta et.al Skin OPD 2004 34%
S. Sathyanarayana Rao, M. S.
Darshan, Abhinav Tandon
South Indian rural
population
2015 15.77%

CRITERIA DSM-5
 A. At least one of the three following symptoms must be
experienced on almost all or all (approximately 75%-100%)
occasions of sexual activity
 1. Marked difficulty in obtaining an erection during sexual
activity.
 2. Marked difficulty in maintaining an erection until the
completion of sexual activity.
 3. Marked decrease in erectile rigidity.

CRITERIA DSM-5 CONTI..
 B. The symptoms in Criterion A have persisted for a minimum
 C. The symptoms in Criterion A cause clinically significant
 D. The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of severe
relationship distress or other significant stressors and is not at-
tributable to the effects of a substance/medication or another
medical condition.

 Life long, in which erection cannot be achieved from the outset
of sexual desire,
 Acquired, in which ED begins after a period of normal erectile
and sexual activity .
 If a man reports having spontaneous erections at times when
he does not plan to have inter course, having morning
erections, or having good erections with masturbation or with
partners other than his usual one, the organic causes of his
erectile disorder can be considered negligible.

Types of ED and associated causes
CLASSIFICATION CAUSES
Psychogenic Physical and mental health problems
Psychological trauma
Relationship problems/partner dissatisfaction
Family/social pressures
Depression
Organic
Neurologic
Vasculogenic
Central nervous system—spinal cord injury, multiple sclerosis, stroke
Peripheral nervous system—neuropathy
Arterial insufficiency/peripheral arterial disease
Veno-occlusive disease
Hypertension
Trauma
Medical disorders Hepatic insufficiency
Dyslipidemia
Renal insufficiency
Chronic obstructive pulmonary disease
Sleep apnea

Penile factors Cavernous fibrosis
Peyronie's disease
Penile fracture
Endocrine Hypogonadism
Hyperprolactinemia
Diabetes mellitus
Thyroid disorders
Urologic disorders Benign prostatic hypertrophy
Lower urinary tract symptoms
Drug-induced Antihypertensive
Antidepressants
Antiandrogens
Marijuana
Heroin
Iatrogenic Drug-induced
Postoperative
Postradiation

 Neurotic personality traits may be associated with erectile
problems in college students
 Alexithymia is common in men diagnosed with
"psychogenic" erectile dysfunction
 Depression and posttraumatic stress disorder
 Age, smoking tobacco, lack of physical exercise, diabetes,
and decreased desire Hypertension
 Obesity/sedentary lifestyle

 Nonsexual mental disorder
 Normal erectile function
 Substance/medication use
 Another medical condition
 COMORBIDITY:
 lower urinary tract symptoms related to prostatic hypertrophy,
dyslipidemia, cardiovascular disease, hypogonadism, multiple
sclerosis, diabetes mellitus, and other diseases that interfere
with the vascular, neurological, or endocrine function necessary
for normal erectile function.

MANAGEMENT:
 HISTORY AND PHYSICAL EXAMINATION
 any sexual problem requires a detailed history
 medical history, sexual history, psychosocial assessment including
quality of life and relationship quality, confidence, self esteem, and
depression
 The Sexual Health Inventory for Men (SHIM) is one of the most
commonly used validated instruments for evaluation of ED
severity

Cappelleri JC, Rosen RC. The Sexual Health Inventory for Men (SHIM): a 5year review of research and
clinical experience. Int J Impot Res. 2005; 17(4): 307–19.

LABORATORY TESTING:
 Hemoglobin A1C
 Testosterone
 Prolactin
 Lipid profile
 Thyroid function tests
Penile duplex ultrasonography
Men with arteriogenic ED demonstrate a peak systolic velocity
(PSV) of <25mL/s, which has 100% sensitivity and 95%
specificity in men*
* Lewis RW , King BF . Dynamic colour Doppler sonography in the evaluation of penile erectile disorders. Int J Impot Res. 1994; 6:A30.

 Veno-occlusive dysfunction, in contrast, demonstrates a
PSV of 25 mL/s or greater, but with a persistent end diastolic
velocity (EDV) of >5 mL/s, with a sensitivity of 90% and
specificity of 56%*
 Resistive index (RI) (RI = PSV−EDV/ PSV)**
 RI of ≥0.9 indicative of normal function and a value of ≤0.75
indicative of venous leak
 ** Naroda T,Yamanaka M, Matsushita K, et al .Evaluation of resistive index of the cavernous artery with color Doppler
ultrasonography for venogenic impotence. Int J Impot Res. 1994; 6:D 62

TREATMENT OF ERECTILE DYSFUNCTION
 Psychosexual
therapy, lifestyle
modifications,
and medical
and surgical
management.

 1. LIFE STYLE MODIFICATION
 2. HYPOGONADISM
 testostérone supplémentation recommended
 Normal 270-1070 ng/dL…. Average 680 ng/dL
 levels correlate with sexual symptom onset, decrements
in libido at ~430ng/dL
ED at 230–300 ng/dL
Response after 4–12 weeks of initiation

3. ORAL THERAPIES:
 Phosphodiesterase 5 inhibitors are first line medical therapy
 Sildenafil, vardenafil, tadalafil etc.
 All PDE 5 is inhibit PDE 5, found in high concentrations in the
corpora cavernosa, thus blocking 3′ 5′ cGMP cleavage in the
corpora cavernosa and promoting erection.
 PDE 5 is only work with sexual stimulation, as this generates 3′
5′ cGMP.
 Contraindication: pts on nitrates, recent MI, recent stroke,
unstable angina

4. TRANSURETHRAL THERAPIES
 transurethral alprostadil (prostaglandin E1(PGE1)) is used.
 response rates of 27–53% when compared with 66-96% for
intracavernosally injected alprostadil
 penile pain in 25–43% of patients
 5.INTRACAVERNOSAL THERAPIES
 second line ED treatment
 bypass the need for intact neurological pathways for erection
 When used alone, PGE1 used.
 combination of papaverine and phentolamine- bimix
 combination of papaverine 30 mg, phentolamine 1 mg, and PGE1 40
μg, trimix

VACUUM ERECTION DEVICES
uses vacuum
chamber, pump and
constriction device to
increase blood flow
into the penis and
maintain rigidity via
constriction band

SURGICAL THERAPY
• third line therapy for
ED, used after patients
fail medical therapies
• available in semi rigid
and inflatable forms

Moderator: Dr. Vishal Sinha
Presentator: Dr. Ramashankar
SEXUAL DYSFUNCTION-ii

FEMALE ORGASMIC DISORDER (FOD)
 DIAGNOSTIC CRITERIA (DSM-5):
 A. Presence of either of the following symptoms and
experienced on almost all or all (approximately 75%-100%)
occasions of sexual activity (in identified situational contexts or, if
generalized, in all contexts):
 1. Marked delay in, marked infrequency of, or absence of
orgasm.
 2. Markedly reduced intensity of orgasmic sensations.

DIAGNOSTIC CRITERIA (DSM-5) CONTI…
relationship distress (e.g., partner violence) or other
significant stressors and is not attributable to the effects of
a substance/medication or another medical condition.

 PREVALENCE:
 From 10% to 42%, depending on multiple factors (e.g.,
age, culture, duration, and severity of symptoms)
 Approximately 10% of women do not experience orgasm
throughout their lifetime.
 Anxiety and concerns about pregnancy
CONTINUE…

RISK AND PROGNOSTIC FACTORS CONT..
 Relationship problems, physical health, and mental health in
women
 Sociocultural factors
 Conditions such as multiple sclerosis, pelvic nerve damage
from radical hysterectomy, and spinal cord injury
 SSRI
 Vulvovaginal atrophy
 DECENT WOMEN Many women have grown up to
believe that sexual pleasure is not a natural entitlement.

 Nonsexual mental disorders
 Substance/Medication-induced sexual dysfunction
 Interpersonal factors
 COMORBIDITY:
 Arousal difficulties, major depressive disorder

TREATMENT PLAN
 GOALS : instatements of orgasm or its facilitation
 SOMATIC TREATMENT:
o No approved medication for FOD
o Testosterone is helpful in postmenopausal women
o Herbal based products (eg. Zestra, ArginMax)
o Focus on SSRI
o Sildenafil has no effects on FOD

o Promoting sex positive thought & attitude
o ↓ anxiety
o ↑ competence of sexual stimulation
o Use of sex aids can be helpful.

DELAYED EJACULATION
 DIAGNOSTIC CRITERIA (DSM-5)
 A. Either of the following symptoms must be experienced on
almost all or all occasions (approximately 75%-100%) of
partnered sexual activity (in identified situational contexts or, if
generalized, in all contexts), and without the individual desiring
delay:
 1. Marked delay in ejaculation.
 2. Marked infrequency or absence of ejaculation.

DIAGNOSTIC CRITERIA (DSM-5) CONT…
relationship distress or other significant stressors and is not
attributable to the effects of a substance/medication or
another medical condition.

 Also called as retarded ejaculation
 The problem is rarely present with masturbation, but
appears as a problem during partnered sex.
 PREVALENCE:
 Less than 1% of men will complain of problems with
reaching ejaculation that last more than 6 months.

 Age-related loss of the fast-conducting peripheral sensory
nerves
 age-related decreased sex steroid secretion
 Another medical condition.
Traumatic surgical injury, retrograde ejaculation, lumbar
sympathectomy, neuro degenerative diseases.
 Substance/medication use.
 Dysfunction with orgasm

 TREATMENTS PLAN:
 GOAL: reduce latency to a level that is acceptable to the
patient and his partner
o No approved pharmacological T/t
o Anti-serotonergic agents (Cyproheptadine)
o Dopamine agonist (Amantadine)
o Switch the antidepressant to Bupropion

 PSYCHOLOGICAL TREATMENTS:
 Explore the stimulation preferences
 Orgasm is not the goal of these exploratory exercise
 Focus on pleasure without the pressure of achieving
ejaculation
 Reducing or discontinuing masturbation
 Change in the patients masturbation style
 Resolve the relational factor

PREMATURE (EARLY) EJACULATION
DIAGNOSTIC CRITERIA (DSM-5):
 A. A persistent or recurrent pattern of ejaculation occurring during
partnered sexual activity within approximately 1 minute following
vaginal penetration and before the individual wishes it.
 Note: Although the diagnosis of premature (early) ejaculation may
be applied to individuals engaged in non vaginal sexual activities,
specific duration criteria have not been established for these
activities.
 B. The symptom in Criterion A must have been present for at least
6 months

 C. The symptom in Criterion A causes clinically significant
relationship distress or other significant stressors and is not at-
tributable to the effects of a substance/medication or another
medical condition.
 Mild – 30 sec -1 min, Mod- 15-30 sec, severe < 15 sec.

 PREVALENCE:
 1%-3% of men
 Prevalence may increase with age.
 Some men may experience premature (early) ejaculation during
their initial sexual encounters but gain ejaculatory control over
time.
 If problems for longer than 6 months, the diagnosis of pre-
mature (early) ejaculation (PE).

 More common in men with anxiety disorders, especially social
anxiety disorder
 May be associated with dopamine transporter gene
polymorphism or serotonin transporter gene polymorphism
 Thyroid disease, prostatitis, and drug withdrawal are associated
with PE.

 Substance/medication-induced sexual dysfunction
 Ejaculatory concerns that do not meet diagnostic criteria
 who desire longer ejaculatory latencies
 episodic premature (early) ejaculation

MANAGEMENT PLAN:
 GOAL: To increase latency
 Tropical agents to diminish penile sensitivity
 SSRI better than TCA
 Fluoxetine, paroxetine, fluvoxamine sertraline
 Dapoxetine(30-60)mg a potent SSRI specifically
developed for the T/t of PE
 If PE is combined with erectile dysfunction then PDE-5 is
also indicated

o Counselling on self-esteem, confidence & relationship
o STOP-SQUEEZ & START-STOP method

GENITO-PELVIC PAIN/PENETRATION
DISORDER (GPPPD)
 DIAGNOSTIC CRITERIA (DSM-5):
 A. Persistent or recurrent difficulties with one (or more) of the
following:
 1. Vaginal penetration during intercourse.
 2. Marked vulvovaginal or pelvic pain during vaginal
intercourse or penetration attempts.
 3. Marked fear or anxiety about vulvovaginal or pelvic pain in
anticipation of, during, or as a result of vaginal penetration.
 4. Marked tensing or tightening of the pelvic floor muscles
during attempted vaginal penetration.

nonsexual mental disorder or as a consequence of a severe
relationship distress (e.g., partner violence) or other significant
stressors and is not attributable to the effects of a
substance/medication or an other medical condition.

PREVALENCE:
 Approximately 15% of women
 Sexual and/or physical abuse, long use of OCP, UTI,
 Pain during tampon insertion or the inability to insert tampons
before any sexual contact
 Another medical condition (e.g., lichen sclerosus, endometriosis, pelvic
inflammatory disease, vulvovaginal atrophy)
 Somatic symptom and related disorders
 Inadequate sexual stimuli

MANAGEMENT:
 GOAL: to eradicate the pain and difficulties with vaginal
penetration
 Minimal invasive tropical application to maximum invasive
genital surgery
 Low dose TCA show improvements in 60% pt.
 Other lignocaine, fluconazole, carbamazepine can used
 Vestibulectomy

SUBSTANCE/MEDICATION-INDUCED
SEXUAL DYSFUNCTION

DIAGNOSTIC CRITERIA (DSM-5):
 A. A clinically significant disturbance in sexual function is
predominant in the clinical picture.
 B. There is evidence from the history, physical examination, or
laboratory findings of both (1)and (2):
o 1. The symptoms in Criterion A developed during or soon after
substance intoxication or withdrawal or after exposure to a
medication.
o 2. The involved substance/medication is capable of producing the
symptoms in Criterion A.

C. The disturbance is not better explained by a sexual dysfunction
that is not substance/medication-induced. Such evidence of an
independent sexual dysfunction could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial
period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there
is other evidence suggesting the existence of an independent non-substance/medication-induced sexual
dysfunction (e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of
a delirium.
E. The disturbance causes clinically significant distress in the
individual.

 Specify if
 With onset during intoxication
 With onset during withdrawal
 With onset after medication use
 Specify current severity:
 Mild: Occurs on 25%-50% of occasions of sexual activity.
 Moderate: Occurs on 50%-75% of occasions of sexual activity.
 Severe: Occurs on 75% or more of occasions of sexual activity.

ANTIPSYCHOTIC DRUGS
 Elevate serum prolactin, block dopamine, and block adrenergic
and cholinergic receptors
 Haloperidol, risperidone, and amisulpride are classed as
prolactin elevating antipsychotics,
 Olanzapine, clozapine, quetiapine, ziprasidone, and aripiprazole
are classed as prolactin sparing drugs.
 In rare cases of priapism have been reported with
antipsychotics

 Chlorpromazine, thioridazine, trifluoperazine and haloperidol
are potent anticholinergic agents that impair erection and
ejaculation in men and inhibit vaginal lubrication and orgasm
in women.
 Thioridazine has a particular adverse effect of causing
retrograde ejaculation

DRUG EFFECT PHYSIOLOGICAL EFFECT SEXUAL FUNCTION EFFECT
Histamine receptor antagonism
Impaired arousal
Sedation Impaired arousal
Dopamine receptor antagonism Inhibition of motivation and
reward
Decreased libido
Dopamine D2 receptor
antagonism (tuberoinfundibular
pathway)
Hyperprolactinaemia Decreased libido, impaired
arousal, impaired orgasm
Cholinergic receptor antagonism Reduced peripheral
vasodilation
Erectile dysfunction
a-Adrenergic a receptor
antagonism
Reduced peripheral vasodilation Decreased erection/lubrication,
abnormal ejaculation

SELECTIVE SEROTONIN REUPTAKE INHIBITORS
 Adverse sexual effects due increased serotonin concentration
 80% of serotonin is localized in the periphery, where when
elevated, it directly reduces sensation in the anatomical
structures of the reproductive system as well as diminishing
erection, vaginal lubrication, ejaculation and orgasm.
 Serotonin also inhibits nitric oxide production
 sexual adverse effects paroxetine > fluoxetine and the least
with sertraline.
 Similar symptoms have been associated with fluvoxamine,
citalopram and escitalopram

HETEROCYCLIC ANTIDEPRESSANTS
 The anticholinergic effects that interfere with erection and
delay ejaculation
 Some men report a pleasurable increased sensitivity of the
glans
 In some cases, however, the tricyclic drug causes a painful
ejaculation

MONOAMINE OXIDASE INHIBITORS
 They produce impaired erection, delayed or retrograde
ejaculation, vaginal dryness, and inhibited orgasm.
 LITHIUM
 Regulates mood and, in the manic state,
 May reduce hyper sexuality, possibly via dopamine
antagonism.
 Some patients have reported impaired erection

PSYCHOSTIMULANTS
 Amphetamine and methylphenidate
 Raise plasma concentrations of norepinephrine and
dopamine
 Libido is increased; however, with prolonged use, men may
experience a loss of desire and erections

Α-ADRENERGIC AND Β-ADRENERGIC RECEPTOR
ANTAGONISTS
 Used to treat hypertension, angina, and certain cardiac
arrhythmias
 Diminish tonic sympathetic nerve outflow from vasomotor
centres in the brain
 It can cause impotence, decrease the volume of ejaculate, and
produce retrograde ejaculation
 ANTICHOLINERGICS
 Can produce dryness of the mucous membranes (including
those of the vagina) and erectile dysfunction

ANTIHISTAMINES
 Diphenhydramine have anticholinergic activity
 Cyproheptadine, It has potent activity as a serotonin
antagonist.
 used to block the serotonergic adverse sexual effects
produced by SSRIs.
 ANTIANXIETY AGENTS
 They diminish anxiety, thus improving sexual function in
individuals inhibited by anxiety

ALCOHOL
 Alcohol suppresses CNS activity generally and, hence, can
produce erectile disorders in men
 Decreases testosterone concentrations in men;
 Paradoxically, it can produce a slight increase in testosterone
concentrations in women
 Long-term use of alcohol reduces the ability of the liver to
metabolize estrogenic compounds.
OPIOIDS: Erectile failure and decreased libido.

CANNABIS
 May enhance sexual pleasure for some individuals.
 Its prolonged use depresses testosterone concentrations.
HALLUCINOGENS:
 These drugs cause loss of contact with reality and an expanding
and heightening of consciousness.
 Some users report that the sexual experience is similarly
enhanced;
 Others experience anxiety, delirium, or psychosis, which clearly
interferes with sexual function.

MANAGEMENTS:
 The first step in management is to define the actual complaint
and then attempt to determine the aetiology
 Eliminating confounding factors for sexual dysfunction, eg, age or
alcohol/substance use
 Excluding a comorbid physical complaint, eg, side effects of drugs
used to manage diabetes or hypertension central and peripheral
nervous system disease,
 Exclude ongoing, or residual, symptoms of depression.

 In case of antidepressants, there are 5 possible
strategies.
 1. Wait for spontaneous resolution.
 2. Dose reduction
 3. Drug holidays
 4. Substitute other agents which have no sexual side
effects
 5. Adding antidote

 WAIT FOR SPONTANEOUS RESOLUTION
 19-30% of patients with antidepressant-induced sexual
dysfunction have moderate to total regain of their sexual
functions after 6 months of using antidepressants.
Serretti and Chiesa (2009) and Montejo-González et al (1997).

 DRUG HOLIDAY
 Rothschild (1995) concluded that holding the antidepressant
during the weekend for those on paroxetine or sertraline (but
not fluoxetine) significantly improved sexual functioning
without significant worsening of depressive symptoms.
 Maudsley prescribing guidelines in psychiatry doesn’t prefer
this strategy as it may carry a risk for relapse of depression or
experiencing antidepressant discontinuation symptoms.

 DECREASE THE DOSE
 Antidepressant -induced sexual
dysfunction appears to be dose-related.
Zajecka (2001)
 In a prospective observational study,
77% had moderate to complete
improvement in sexual functioning when
antidepressant dose was reduced by
50%.
Montejo-González et al (1997).

 SWITCH TO ANOTHER ANTIDEPRESSANT:
 Bupropion
 Agomelatine
 Mirtazapine
 Nefazodone
 Moclobemide
 Selegiline

 AUGMENTATION:
 Bupropion
 Phosphodiesterase-5 inhibitors
 Mirtazapine
 Ginkgo biloba
 EXERCISE

Side effect due to anti-psychotic medication can be reduced by
drug substitution.
Eg. Aripiprazole, olanzapine, quetiapine,
Can be reduced by adding some antidote like..
PDE-5 inhibitor, amantadine, bromocriptine

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